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21,835
| 159,268
|
9155+55991
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-10-18**] Discharge Date: [**2176-10-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Transfusion of packed red blood cells
Upper endoscopy
History of Present Illness:
Mr. [**Known lastname **] is an 88 year old male with history of atrial
fibrillation (on coumadin), coronary artery disease, chronic
obstructive pulmonary disease, and diverticulosis who presented
with chest discofort and was found to have a gastrointestinal
bleed. In brief, the patient presented to the ED on [**10-17**] with
right-sided, typical chest pain. The pain was exacerbated by
exertion, but he did not have any associated heart failure
symptoms. Mr. [**Known lastname **] [**Last Name (Titles) 15797**] any nausea, diaphoresis, melena or
hematochezia. In the ED, he was found to have melena with a Hct
of 21. There, he had a positive NG lavage, and ischemic changes
were noted on his EKG in the inferior and lateral leads.
Cardiology saw the patient and recommended aspirin.
.
Due to his bleeding and INR of 2.5, he was given 2 U prbc, 2 U
FFP, and 10 mg SC Vitamin K, and he was admitted to the ICU.
After receiving blood, he had resolution of ECG changes. In the
ICU, he was placed on a PPI and his hematocrit remained stable
overnight. He had an EGD performed on [**10-18**] that showed healing
duodenal ulcer with no sign of recent bleeding. After this
finding, GI recommended only PPI [**Hospital1 **] for one month then lifelong
PPI should he need to remain on his aspirin. Over the course of
[**2180-10-17**], he required a total of 5U PRBC's to maintain Hct > 28.
After his reassuring EGD and stabilization of his hematocrit, he
was transferred to the floor.
.
On my interview, the patient denies any chest pain, respiratory
difficulty, abdominal pain, further dark stools, nausea or
vomiting, or any other concerns. In fact, he says he fells quite
well. His daughter reports to me that he is reluctant to
complain of any symptoms.
Past Medical History:
1. Atrial fibrillation: history of slow ventricular response, on
Coumadin
2. Hypertension
3. CAD: [**1-11**] stress-MIBI showing ischemic EKG changes in
inferior and lateral leads and MIBI showing a mild reversible
inferior wall defect, medical management only
4. CHF: ischemic cardiomyopathy (mildly depressed EF 50-55%)
5. ?COPD: documented in notes but no PFTs
6. Melanoma: s/p excision [**4-11**] & [**2174-10-3**] R posterior
auricular region, + radiation treatments (last in [**12-14**]),
concern for recurrence in [**3-13**] but pt refused further w/u
7. Basal cell carcinoma: s/p excision on [**12-12**] & [**4-11**]
8. Diverticulosis
9. Glaucoma
10. Venous insufficiency
11. Hearing impairment
12. Irritable bowel syndrome
13. Macular degeneration
Social History:
Mr. [**Known lastname **] is from [**Country 4754**] and is recently widowed with
significant grief reaction per past notes. He lives with his
granddaughters who assist with [**Name (NI) 4461**] and meds. His daughter is
also involved in his care, and he is able to ambulate around his
apartment freely. He is a prior smoker, 10cig/d x 20y, quit
years ago. He denies EtOH and drugs.
Family History:
NC
Physical Exam:
T 100.4 HR 50 BP 135/75 RR 14 O2 sat 96% on RA
HEENT-PERRL, no elevated JVP, MM dry
Hrt-irreg irreg nS1S2 [**2-12**] SM at RUSB
Lungs-poor air movement, crackles at bases bilat
Abd-soft, NT, ND no HSM, no renal bruits
Neuro-CNII-XII intact, [**4-12**] UE and LE strength, 2+DTR at [**Name2 (NI) 31507**]
and achilles bilat
Extrem-2+rad, 2+ dp pulses, trace ankle edema bilat
Skin-no rashes or lesions anteriorly on brief exam
Pertinent Results:
Labs on admission: WBC 10 (85% neutrophils, 10% lymphs, 4%
monos), Hgb 6.7, Hct 20.8, Plt 212,000
BMP remarkable for glucose 168, BUN 98, creatinine 1.7,
potassium 5.2
Coags with PT 24.5, PTT 28.7, INR 2.5
CK in 50s X 3 sets
Troponins 0.06 --> 0.04 --> 0.05
.
EGD ([**10-18**]): Erosion in the antrum compatible with non-steroidal
induced gastritis. Healing ulcer in the posterior bulb. Mucosa
suggestive of Barrett's esophagus. Otherwise normal EGD to
second part of the duodenum
Recommendations: PPI [**Hospital1 **] for one month. Discuss with cardiology
if need for both aspirin & warfarin; if needs aspirin will
require life-long PPI. Consider follow-up EGD & colonoscopy.
.
CXR ([**10-17**]):: Interval improvement in the previous possible
lingular opacity with no evidence of acute cardiopulmonary
process.
.
CXR ([**10-19**]): Vague left lingular opacity, unchanged.
.
ECG ([**10-17**]): Atrial fibrillation with a slow ventricular
response. Right bundle-branch block. Diffuse non-specific ST-T
wave changes. Compared to the previous tracing ST-T wave changes
are now present.
.
Urinalysis & urine culture ([**10-21**]): Negative.
.
Labs on discharge: Hct 28.9
BMP remarkable for creatinine 1.6
INR 1.1
Brief Hospital Course:
Mr. [**Known lastname **] is an 88 year old gentleman who presented with chest
pain and likely demand ischemia in the setting of a hematocrit
of 21 due to gastrointestinal bleeding, now with stable
hematocrit and free of chest pain after transfusions.
.
# Gastrointestinal bleed: The patient's EGD showed healing
ulcers and changes consistent with gastritis. His hematocrit did
stabilize, and the gastroenterology team did not feel that a
colonoscopy was necessary at this time. He had a colonoscopy in
[**2169**] which showed diverticulosis as well as a single polyp. The
patient was instructed to speak with his primary care physician
regarding [**Name Initial (PRE) **] repeat EGD (due to concern for Barrett's) and
potentially a colonoscopy within the next 2-3 months. The
patient should remain on a [**Hospital1 **] PPI for one month; after that,
because he is to stay on his aspirin, he should continue on a
once daily PPI for life.
.
Due to his low risk for rebleeding, the gastroenterology team
felt comfortable with Mr. [**Known lastname **] [**Last Name (Titles) 9533**] both his aspirin and
coumadin. He is to follow up with his PCP later this week. A
hematocrit should be checked at that time to ensure that he is
maintaining a hematocrit of 28-29 as he did in the hospital. He
did receive a total of 6 units of packed red blood cells as
mentioned above. Our goal for transfusion was hematocrit greater
than 28. The patient will also have VNA services at home. The
VNA should further instruct the patient regarding signs and
symptoms of further bleeding. Mr. [**Known lastname **] was discharged with a new
prescription for ferrous gluconate to take daily at the
recommendation of the GI team. At the time of discharge, the
patient was hemodynamically stable, afebrile, and comfortable on
room air.
.
# Atrial fibrillation: The patient is well rate controlled
naturally, with his usual pulse in the 50s range. He did have
some bradycardia to the high 30s while sleeping. This was
asymptomatic. He was instructed to resume his usual coumadin
regimen upon discharge with repeat INR due at the end of this
week when he sees his PCP.
.
# CHF and CAD: On the day after arrival on the floor, the
patient's home regimen of ACEi, nitrate, and lasix were
restarted. The patient remained chest pain free. It is likely
that Mr. [**Known lastname **] has fixed coronary lesions with demand ischemia
which manifested itself when his hematocrit was so low. He was
instructed to continue on his aspirin with PPI for life ([**Hospital1 **] for
one month then once daily).
.
# COPD: The patient does not have any wheezing on exam. He is
not on any outpatient medications so this history should be
clarified.
.
# Fever: The patient did have low grade fevers on transfer to
the floor without an elevated white blood count. He does have
some [**Last Name (LF) **], [**First Name3 (LF) **] a chest x-ray was checked to ensure that he did
not aspirate during his EGD. His chest x-ray is unchanged from
last month with a vague lingular opacity but no other
significant findings. A urinarlysis was also sent which was
negative. At the time of discharge, his temperature was 98.4. It
is possible that this low grade temperature is due to
atelectasis.
.
# FEN: Prior to discharge, the patient was tolerating a regular
diet without problem. [**Name (NI) **] did not receive IV fluids on the floor.
His electrolytes were repleted as necessary.
.
# Prophylaxis: The patient wore pneumoboots for DVT prophylaxis
and was ambulatory prior to discharge. He also received a PPI.
.
# Code status: Full, discussed with daughter.
Medications on Admission:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
6. Warfarin 4 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 months.
Disp:*180 Tablet(s)* Refills:*0*
8. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gastrointestinal bleed, likely secondary to gastritis
Atrial fibrillation
Coronary artery disease
Discharge Condition:
Hemodynamically stable, afebrile, and comfortable on room air
Discharge Instructions:
Please take all your medications as prescribed.
Please call your doctor or return to the emergency room should
you experience any of the following symptoms: chest pain, blood
in your urine, stools, or vomiting, difficulty breathing,
abdominal pain, pain with urination, productive [**Hospital **], fever >
100.5, or any other concerns.
You will be [**Hospital 9533**] your coumadin this evening. Please have
your INR checked later this week (at your outpatient
appointment).
Followup Instructions:
You should follow up this coming Friday with the nurse
practitioner at Dr.[**Name (NI) 6844**] office. Your appointment is
Friday, [**10-25**], at 1:00 pm. After that, you should schedule
another appointment to see Dr. [**Last Name (STitle) **] at an interval of their
discretion. At this appointment, you should ask Dr. [**Last Name (STitle) **]
about a need for a repeat endoscopy and/or a colonoscopy within
the next few months.
Completed by:[**2176-10-23**] Name: [**Known lastname 3567**],[**Known firstname 3206**] Unit No: [**Numeric Identifier 5433**]
Admission Date: [**2176-10-18**] Discharge Date: [**2176-10-21**]
Date of Birth: [**2088-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5434**]
Addendum:
GI also recommended that Mr. [**Known lastname **] should have H. pylori
serologies checked. This was not done during his
hospitalization. I have contact[**Name (NI) **] his PCP to get this
accomplished as an outpatient.
Thanks.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Last Name (NamePattern4) 5435**] MD [**MD Number(2) 5436**]
Completed by:[**2176-10-23**]
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66,232
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Discharge summary
|
report
|
Admission Date: [**2137-10-31**] Discharge Date: [**2137-11-8**]
Date of Birth: [**2097-11-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
s/p fall, alcohol withdrawal
Major Surgical or Invasive Procedure:
endotracheal intubation
cardiopulmonary resuscitation
History of Present Illness:
Mr [**Known lastname 3517**] is a 39M with hx EtOH abuse, hx seizures, tx from
[**Location (un) 620**] for EtOH withdrawal and s/p fall. last drink was 2 days
ago. Per ED report, he was found down after an unclear period of
time by his father, and there was concern that he ahd a seizure
at top of 13 stairs and fell to the bottom. In the eedham ED, he
had a lactate fo 11. CT head, cervical spine, and
torso were done given fall history, with no acute findings. He
was transferred to [**Location (un) 86**] given "concerning mechanism for fall".
He was given KCl prior to transfer.
.
In the [**Hospital1 **] [**Location (un) 86**] ED, the patient was awake, alert, with mild
confusion, complaining of chest, back and L ankle pain. Exam was
notable for tongue lac (nonsuturable), neck nontender, c-spine
cleared. He continued to be tachy to 130 despite 20mg IV valium.
Ankle swelling was noted, therefore ankle films were repeated
and showed no obvious fracture. He was given 3 additional L of
fluid, lactate went from 11 to 1.8, also got an additional 4 mg
ativan in IV. Vitals on transfer were HR 140s, 132/80, r 23. He
was initially placed in a sling out of concern for small
fracture of humerus seen on shoulder films.
.
In the MICU, Pt was initially aao x1, states he is in pain in
his R shoulder and back. Was drinking one pint of vodka/day,
last drink [**2137-10-28**]. In the MICU, Pt initially had a Hct of 19
and was transfused 2 x PRBCs plus 6 pack of platelets. Pt had
coffee grounds on suctioning and was started on pantoprazole [**Hospital1 **]
before being switched to omeprazole. Pt also desaturated to 60s
and was pulseless for 30 seconds, requiring 30 seconds of CPR
and was intubated on [**2137-10-31**]. Pt was extubated without incided
on [**2137-11-2**] w/ no issues. Pt may have had an apiration event but
Pt has not been febrile, and CXR is not concerning. While
intubated, Pt had continuous recording EEG but no seizure
activity was noted. On presentation, pt was seizing, but has
been very stable and only [**Doctor Last Name **] 0-1 on CIWA scale on day of
transfer. Pt did not have repeat EGD due to [**2137-7-22**] EGD at
[**Hospital1 **] [**Location (un) 620**] showing portal gastropathy and gastritis but no
varices. Of note, Pt also has a R humerus greater tuberosity
fracture. Per MICU staff, orthopedics was not formally consulted
but recommended no sling and outpatient followup.
.
Pt was transferred to floor on [**2137-11-3**]. On arrival to the
floor, Pt's vitals were:
.
Review of sytems: Prior to admission, but had no fevers, no
chills, no weight loss, no nightsweats. No nausea or vomiting,
no diarrhea or constipation. No chest pain or dyspnea. No
palpitations. No focal numbness or weakness. No urinary
symptoms. No abdominal pain.
Past Medical History:
HTN
PUD
EtOH abuse complicated by withdrawal seizures, multiple prior
aborted attempts at detox
psoriasis (no formal diagnosis)
depression
Social History:
Pt lives in [**Location 620**] with his father. Not currently working.
Previously contractor / landscaper. 1 pt vodka/day, no tobacco,
no illicits, no iv drug use.
Family History:
mother had breast cancer. Father diabetes.
Physical Exam:
Vitals: T:99.7 BP:134/64 P:145 R: 18 O2:97% RA
General: Alert, orient x1.5, appears uncomfortable
HEENT: Sclera icteric, oropharynx clear, tongue bruised, eyes
with saccadic movements and rolling back into the head during
the exam
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse upper airways sounds, no rhonchi/rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Skin: erythematous plaques with silver scale on legs, bruising
on extremities and back
Pertinent Results:
Admission labs:
[**2137-10-30**] 11:40PM GLUCOSE-140* UREA N-8 CREAT-0.6 SODIUM-137
POTASSIUM-3.0* CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
[**2137-10-30**] 11:40PM ALT(SGPT)-19 AST(SGOT)-136* CK(CPK)-350* ALK
PHOS-211* TOT BILI-10.6* DIR BILI-7.4* INDIR BIL-3.2
[**2137-10-30**] 11:40PM LIPASE-22
[**2137-10-30**] 11:40PM cTropnT-<0.01
[**2137-10-30**] 11:40PM CK-MB-6
[**2137-10-30**] 11:40PM CALCIUM-7.7* PHOSPHATE-1.1* MAGNESIUM-1.3*
[**2137-10-30**] 11:40PM WBC-11.0 RBC-2.98* HGB-8.9* HCT-27.8* MCV-94
MCH-30.0 MCHC-32.1 RDW-19.3*
[**2137-10-30**] 11:40PM NEUTS-89.6* LYMPHS-5.5* MONOS-3.8 EOS-0.9
BASOS-0.2
[**2137-10-30**] 11:40PM PLT SMR-VERY LOW PLT COUNT-44*
[**2137-10-30**] 11:40PM PT-17.7* PTT-32.2 INR(PT)-1.6*
[**2137-10-30**] 11:40PM URINE COLOR-DkAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-10-30**] 11:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-7.5 LEUK-TR
[**2137-10-30**] 11:40PM URINE RBC->182* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
[**2137-10-30**] 11:45PM LACTATE-1.8
Trauma plain films:
Ankles: IMPRESSION: Significant medial soft tissue swelling with
no fracure. Mild lateral clear space widening.
Right shoulder:
RIGHT SHOULDER, FOUR VIEWS: There is a fracture of the greater
tuberosity,
impacted and slightly comminuted. No other fracture. No
dislocation. Minimal AC joint spurring. The visualized portions
of the right lung and ribs are unremarkable.
Head CT: IMPRESSION:
1. Resolved small falcine subdural hematoma.
2. No acute intracranial abnormality.
[**Hospital1 18**]:
[**2137-11-1**] Radiology CT HEAD W/O CONTRAST
1. Resolved small falcine subdural hematoma.
2. No acute intracranial abnormality.
.
[**2137-11-1**] Radiology DUPLEX DOPP ABD/PEL
FINDINGS: Echogenicity of the liver is within normal limits with
no focal lesion identified. No intra- or extra-hepatic biliary
dilation is seen. The CBD measures 3 mm. The gallbladder is
mildly distended however no wall thickening or pericholecystic
fluid is seen. No evidence of cholelithiasis. The spleen is
enlarged measuring up to 14.5 cm. No free fluid is seen. The
kidneys appear normal. The right kidney measures 11.6 cm and the
left 12.9 cm. Limited views of the pancreas are normal though
the distal tail is obscured by overlying bowel gas. The aorta is
not well assessed due to overlying bowel gas. Doppler evaluation
of the liver was performed. There is reversal of flow in the
main portal vein as well as the anterior right portal vein. The
left portal vein and posterior right portal vein demonstrates
hepatopetal flow. The hepatic artery and major branches appear
normal. The hepatic veins appear normal though the right hepatic
vein cannot be followed in its entirety. The IVC, where
visualized, appears normal. The splenic vein is patent. There is
recanalization of the umbilical vein. There may be a small right
pleural effusion, partially imaged. IMPRESSION: Findings
consistent with cirrhosis and portal hypertension including
recanalized umbilical vein and splenomegaly. There is reversal
of flow in the main portal vein and anterior right portal vein.
No free fluid is seen.
.
- CT Cspine: mild C3-4 intervetebral disc herniation
- CT torso: acute fracture of greater tuberosity of R humerus, R
gluteal hematoma, cirrhosis with splenomegaly, esophageal
varices, no ascites, unchanged from [**4-1**]
Discharge labs:
[**2137-11-8**] 06:25AM BLOOD WBC-8.9 RBC-2.90* Hgb-8.9* Hct-28.4*
MCV-98 MCH-30.8 MCHC-31.4 RDW-20.3* Plt Ct-140*
[**2137-11-8**] 06:25AM BLOOD PT-16.6* INR(PT)-1.5*
[**2137-11-8**] 06:25AM BLOOD Glucose-83 UreaN-12 Creat-0.6 Na-135
K-3.7 Cl-102 HCO3-23 AnGap-14
[**2137-11-8**] 06:25AM BLOOD TotBili-9.2*
[**2137-11-8**] 06:25AM BLOOD Mg-1.9
Brief Hospital Course:
39 yo gentleman admitted with EtOH withdrawal, s/p fall likely
due to seizure, now with concern for ongoing seizure activity.
.
#. EtOH withdrawal: Patient with chronic EtOH abuse and a
history of withdrawal seizures, presented 2 days after last
drink with evidence of seizures. Story of fall downstairs was
highly suspicious for seizure. Given IV thiamine and IV ativan
in ED. On arrival to the ICU, the patient was confused and
tremulous. Around 7:30am the morning of admission, the patient
became minimally responsive with his eyes rolling up. He was
receiving boluses of IV ativan for withdrawal and began having
difficulty protecting his airway, so the decision was made to
intubate. He was difficult to intubate and became severely
hypoxemic. He was pulseless for about 1 minute, during which
time he received CPR. After intubation, his oxygenation
improved. He was started on multivitamin, thiamine and folate.
He was then continued on a midazolam infusion for sedation and
control of seizures. Continuous EEG monitoring showed just slow
wave forms without further seizures. His mental status improved,
and the next day he was able to be extubated. He did not require
further benzodiazepenes. Given that his seizures were in the
setting of withdrawal, he was not started on antiepileptics. Pt
also did not show any alcohol withdrawal symptoms since [**2137-11-2**]
and did not require benzodiazepenes for withdrawal. Pt's
electrolytes were repleted as needed, and he was treated with
thiamine, multivitamins, and folate daily.
.
#. GI bleed / anemia: after OG tube placement, patient had
coffee grounds on suction. Likely chronic from long-term
alcoholism, and portal gastropathy. Clinically stable. [**Month (only) 116**] be
exacerbated by gastritis. Started on pantoprazole 40mg [**Hospital1 **] IV
and continuous octreotide for 72 hours. Hematocrit went down to
19, requiring transfusion of 2 units PRBC. Patient had a recent
endoscopy at [**Hospital1 **] [**Location (un) 620**] that did not have esophageal varices, so
the decision was made to not do urgent endoscopy. His hematocrit
stabilized and OG suction mostly cleared prior to extubation.
Pt's Hct was stable at 24 for several days and improved to 28 by
day of discharge. Pt was started on nadolol 40mg daily to try to
decrease his portal hypertensive gastropathy. Pt did continue to
have blood-coated bowel movements due to his chronic
hemorrhoids, which improved with his home nightly hydrocortisone
suppositories.
.
# Transaminitis: also with severely elevated bilirubin,
consistent with alcoholic hepatitis. Has a history of repeated
episodes of alcoholic hepatitis. Hepatology service was
consulted. Discriminant function of 37 suggests suggested a
benefit from steroid therapy, so once his blood cultures and
hepatitis serologies were negative, he was started on prednisone
40mg daily, which was continued with plateau of Tbili at ~11. Pt
was therefore felt to be likely to benefit from full 4 week
course of steroids and was continued on prednisone 40mg daily.
However, given his rapid improvement, prednisone was
discontinued on [**2137-11-6**] and bilirubin continued to downtrend to
9.2 on day of discharge. Pt was also treated for several days
with aggressive nutrition via NG feeding tube. Nutrition consult
did a calorie count and estimated that Pt was consuming ~ 800
calories per meal. Since our goal for alcoholic hepatitis was ~
[**2125**] calories per day, tube feeds were not deemed necessary, and
feeding tube was discontinued no day of discharge. Pt was
instructed to eat large nutritious meals for the next few weeks
to aid his recovering liver. Pt was instructed not to restart
his pentoxyfiline on discharge.
.
# s/p fall, R humeral greater tuberosity fracture: Patient
arrived with multiple ecchymoses consistent with fall. Right
shoulder films showed a small fracture of the greater tuberosity
of the humerus. Orthopedics was formally consulted and suggested
sling and non-weightbearin status on R arm until he is seen in
outpatient orthopedic clinic on [**11-13**]. Pt was started on
vitamin D and calcium.
.
# Possible subdural hematoma: CT head from [**Hospital1 **] [**Location (un) 620**] showed a
possible subdural hematoma in the falx cerebri. Repeat imaging
at [**Hospital1 18**] showed resolution. Pt did not have any further
seizures. Pt did not have any focal neurological deficits.
.
# ? PNA: OSH CT reportedly with features concerning for
multilobular PNA. Pt certainly at risk for aspiration but did
not have fever or leukocytosis. Chest XR's at [**Hospital1 18**] did no show
any focal opacities or infiltrates. No antibiotics were given.
Pt remained afebrile and w/out any respiratory symptoms.
.
# ST depressions on EKG: Patient had ST depressions in V2-V4
without any symptoms concerning for ACS although pt unable to
clearly articulate. Likely rate related. Repeat EKG showed
resolution, and troponins remained negative. Pt did not have any
further concerning ECG changes or cardiac symptoms.
.
TRANSITIONAL ISSUES:
-Pt needs to stop drinking alcohol. Pt was given several choices
for detox programs. 1) [**Hospital 83176**] Hospital in [**Location (un) **], which
is an outpatient 5 days/week program. Contact [**Name (NI) **] at [**Telephone/Fax (1) 83177**]. 2) [**Hospital1 12671**] in [**Hospital1 1559**], which is an inpatient program.
Contact [**Name (NI) 41215**] at [**Telephone/Fax (1) 83178**]. He is supposed to call one of
these programs on Monday, [**11-11**], and [**Hospital1 18**] social worker
[**Name (NI) 501**] [**Name (NI) 56051**] will contact him to ensure he follows through.
-Pt needs to see orthopedics regarding further management of his
small R humeral fracture.
-Pt needs derm follow-up / workup of his extensive rash
-Pt has a murmur of unclear etiology and states that he has
never had any workup.
Medications on Admission:
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
PENTOXIFYLLINE - (Prescribed by Other Provider) - 400 mg Tablet
Extended Release - 1 Tablet(s) by mouth three times a day
Medications - OTC
MAGNESIUM OXIDE - (OTC) - 250 mg Tablet - 1 Tablet(s) by mouth
once a day
MILK THISTLE [MILK THISTLE EXTRACT] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for sbp < 90 or hr < 55.
Disp:*60 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Suppository Rectal QHS (once a day (at bedtime)).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for psoriasis.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
alcoholic hepatitis
alcohol withdrawal
fracture of right greater tuberosity of humerus
Secondary:
hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 3517**],
You were originally brought to the hospital by your father after
he found you down at the bottom of the stairs. You most likely
had an alcohol withdrawal seizure. You were transferred to [**Hospital1 18**]
for further care. You had to be intubated during your stay in
the ICU and you briefly needed cardiopulmonary resuscitation
(CPR). Your clinical condition improved with aggressive
nutrition and with steroids. You will need to see a liver
specialist (Hepatologist) about your alcoholic hepatitis. You
also had a small fracture of your right upper arm and you were
seen by our orthopedic specialists, who wanted to treat your
fracture with a sling for one week followed by arm exercises.
You should continue to wear your right arm sling until you see
your orthopedic surgeons on [**11-13**] (see below). You should also
see a dermatologist because your skin lesions may not be
psoriasis. YOU MUST STOP DRINKING ALCOHOL, or you will likely
shortly succumb to your disease.
We have made the following changes to your medications:
-Start nadolol 40mg tablets, 1 tab daily
-Start vitamin d and calcium
-start tramadol for pain, you can take it up to every six hours
-stop pentoxyfiline
Followup Instructions:
Department: ORTHOPEDICS
When: WEDNESDAY [**2137-11-13**] at 1:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2137-11-13**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: THURSDAY [**2137-11-21**] at 4:50 PM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: Gastroenterology
Name: [**First Name4 (NamePattern1) 5987**] [**Last Name (NamePattern1) 41573**], MD
When: Tuesday [**2137-12-17**] at 2:30 PM
Location: [**Hospital 864**] [**Hospital3 249**]
Address: [**2137**] [**Apartment Address(1) 44649**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 44650**]
Department: Dermatology
Notes: The Dermatology Department in [**Location (un) 620**]/ [**Location (un) 55**] is
working on a hospital follow up appointment in 1 month after
your hospital discharge. If you have not heard from the office
in 2 business days please call the number listed below.
Phone: ([**Telephone/Fax (1) 31239**]
Completed by:[**2137-11-8**]
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5,696
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19049
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Discharge summary
|
report
|
Admission Date: [**2165-2-20**] Discharge Date: [**2165-3-18**]
Service: MEDICINE
Allergies:
Tramadol / Advil / Nsaids / Hydrocodone
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Colonoscopy with electrocautery of polypectomy site.
History of Present Illness:
86yo man with PMH significant for duodenal ulcer bleed, s/p
polypectomy 2 wks ago, s/p R hip arthroplasty [**11-17**], presented
with blood clots per rectum, maroon stools. He had a recent
admission in [**11-17**] for hematemesis, at which time he was found
to have a duodenal ulcer bleed, initially resolving with
embolization, but recurrent bleeding with resolution after
exploratory laparotomy, duodenotomy, oversewn ulcer, and J-tube
placement. At the time, he also had a biopsy of a liver mass and
an IVC filter placed for peripheral venous clots. In [**1-18**] he had
a colonoscopy which showed cecal polyps, Grade 1 internal
hemorrhoids, and diverticulosis of the sigmoid colon.
.
In the ED, NG lavage was negative. He denied abdominal pain.
Past Medical History:
1. Hypertension
2. Chronic obstructive pulmonary disease
3. Osteoarthritis
4. Osteopenia
5. Dementia
6. Depression
7. Status post bilateral inguinal hernia repair
8. Status post bilateral cataract surgery
9. Status post right total hip replacement
Social History:
lives in [**Hospital3 **] facility (came from [**Hospital **] rehab);
never smoked; no alcohol or IVDU; has 2 sons.
Family History:
noncontributory
Physical Exam:
T 97.6 P 109, BP 140/55, RR 18, 100% on 3L
Gen: pale elderly man lying flat in bed
HEENT: anicteric, R surgical pupil 4mm and nonresponsive, L
pupil 2mm, nonresponsive; OP clear w/ MMM, no JVD
CV: [**2-18**] holosystolic murmer at LLSB
Pulm: CTA anteriorly, no crackles or wheezes
Abd: obese, +BS, soft, NT, ND
Ext: warm, faint DP B, no edema
Neuro: able to answer most questions but mildly confused
Pertinent Results:
Admission labs:
CBC: WBC-11.2* RBC-4.01*# Hgb-10.1* Hct-30.6* MCV-76*#
MCH-25.2*# MCHC-33.0 RDW-17.4* Plt Ct-373
Diff: Neuts-78.1* Lymphs-15.4* Monos-4.9 Eos-1.5 Baso-0.1
Coags: PT-12.8 PTT-22.7 INR(PT)-1.1
Chem 10: Glucose-110* UreaN-17 Creat-0.6 Na-139 K-4.3 Cl-104
HCO3-24
Calcium-8.8 Phos-3.4 Mg-1.9
LFTs: ALT-18 AST-17 AlkPhos-128* Amylase-42 TotBili-0.1
.
More recent labs:
CBC: WBC-7.7 RBC-4.14* Hgb-11.1* Hct-33.0* MCV-80* MCH-26.7*
MCHC-33.5 RDW-17.2* Plt Ct-323
Coags: PT-13.3* PTT-22.8 INR(PT)-1.2*
Chem 10: Glucose-107* UreaN-6 Creat-0.5 Na-142 K-3.0* Cl-108
HCO3-24
Calcium-8.0* Phos-2.9 Mg-1.7
.
Imaging:
GIB study: Technically inadequate exam due to poor labeling.
This study could be repeated if necessary in 24 hours.
[**Last Name (un) **]: Diverticulosis of the sigmoid colon and distal descending
colon. Polyp in the cecum. Grade 1 internal hemorrhoids.
Brief Hospital Course:
Assessment: 86yo man with past medical history significant for
recent duodenal bleed s/p exploratory laparotomy with
duodenectomy and oversewn ulcer, s/p polypectomy 2 weeks ago,
presented with lower GI bleed thought secondary to polypectomy,
now s/p cauterization with stable hematocrit.
.
Hospital course is reviewed below by problem:
.
1. Gastrointestinal bleed: He was admitted to the MICU, where he
was thought to have a lower GI bleed. He was transfused two
units PRBCs. A GIB study was technically inadequate. He had a
colonoscopy, which showed diverticulosis of the sigmoid and
distal descending colon, a cecal polyp, and grade 1 internal
hemorrhoids. The cecal polyp was cauterized. He remained
hemodynamically stable and his hematocrits remained stable after
the procedure. He was treated with [**Hospital1 **] protonix.
.
2. Clostridium difficile infection - On [**2-25**], he was noted to
have green diarrhea. This was positive for c. diff. He was
started on a 14 day course of flagyl. By day 10, he was still
having diarrhea and began to spike fevers again. Vancomycin po
was started on [**3-6**]. He was discharged with instructions to
complete a course of PO vancomycin and Flagyl ending on [**2165-3-20**].
.
3. Hypertension - Lopressor was held secondary to GI bleed, then
restarted once he was stable with good blood pressure control,
and converted to Toprol XL prior to discharge.
.
4. Chronic obstructive pulmonary disease - The patient was
maintained on albuterol prn.
.
5. Depression - Seroquel was changed to Celexa during
hospitalization.
.
6. Nutrition - He had a speech and swallow evaluation, and was
continued on aspiration precautions. He needed observation for
meals. Medications were crushed in applesauce. He had a kosher
ground diet, with nectar thickened liquids. Tube feeds at the
time of discharge were Promote w/ fiber Full strength. He was
also started on ascorbic acid and zinc sulfate supplements to be
taken for 2 weeks, per nutrition recs.
.
7. Left thumb swelling - During the hospitalization, he was
noted to have left thumb swelling. He had no evidence of trauma,
and had no clear history of thumb swelling previously. He was
treated with a short course of colchicine, rest, elevation.
NSAIDs were not given due to his GI bleed. The rheumatology
service was consulted, who felt that he had no clear indication
of any inflammatory crystal disease, and that the thumb was not
amenable to tap. An x-ray showed no evidence of fracture. It may
have been secondary to unwitnessed minor trauma. It resolved
with conservative management during hospitalization.
.
8. Code status - full
Medications on Admission:
1. flomax 0.4mg po daily
2. dulcolax prn
3. ferrous sulfate 300mg
4. Folvite 1mg
5. colace
6. lactulose prn constipation
7. tylenol
8. Lopressor 12.5 [**Hospital1 **]
10. Seroquel 12.5mg 2pm and 8pm and prn
11. zinc ointment
12. Bacitracin
13. Beconase nasal spray [**Hospital1 **]
14. Ocean nose spray
15. MVI
16. Prevacid 30mg [**Hospital1 **]
17. thiamine
18. Albuterol nebs prn
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
BID (2 times a day) for 10 days.
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
16. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. heparin Sig: 5000 (5000) units Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
1. Lower gastrointestinal bleed
2. Coronary artery disease
3. Hypertension
4. Clostridium difficile infection
Discharge Condition:
Good; the patient is hemodynamically stable with stable serial
hematocrits.
Discharge Instructions:
Take all medications as prescribed below.
.
Please follow up with Dr. [**Last Name (STitle) 1603**] in the next week.
.
Call your doctor or go to the emergency room if you have any
lightheadedness, dizziness, large black bowel movements, red
blood in your bowel movements, loss of consciousness, nausea,
vomiting, abdominal pain, chest pain, shortness of breath, or
any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1603**] at [**Telephone/Fax (1) 719**] to make a follow up
appointment.
Completed by:[**2165-3-18**]
|
[
"V43.64",
"294.8",
"496",
"E878.8",
"311",
"285.1",
"401.9",
"707.07",
"562.10",
"V55.4",
"707.03",
"729.81",
"998.11",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7399, 7469
|
2857, 5480
|
254, 309
|
7623, 7701
|
1960, 1960
|
8146, 8287
|
1507, 1524
|
5913, 7376
|
7490, 7602
|
5506, 5890
|
7725, 8123
|
1539, 1941
|
208, 216
|
337, 1087
|
1976, 2834
|
1109, 1358
|
1374, 1491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,225
| 125,681
|
4299+55572
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-11-5**] Discharge Date: [**2175-12-27**]
Date of Birth: [**2147-8-13**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old
female with SLE/lupus, nephritis, end-stage renal disease
status post cadaveric renal transplant [**2175-9-1**],
complicated by delayed graft function/ATN, biopsy done
intraoperatively during reexploration post transplant for
bleeding requiring multiple transfusions. The patient has had
multiple admissions in the past since her transplant for
abdominal pain and dehydration. On [**2175-11-5**], the
patient was admitted for respiratory distress.
The patient was found to have agonal
breathing/unresponsiveness. At that time, fingersticks were
less than 20. The patient was treated with 1.5 amps of D50
but still not adequately awake. The patient was intubated in
the emergency room for airway protection. At that time, her
heart rate was in the 100s. Systolic blood pressure was 90-
100.
The patient was transferred to the ICU, and labs demonstrated
that the patient had a hematocrit of 14, sodium of 125,
potassium 8.3, chloride 95, bicarb 11, BUN and creatinine of
37 and 6.6.
In the ICU a line was placed, and a central line was placed.
The patient was transfused with 2 units of packed red blood
cells, 2 units of FFP, 1 unit of platelets and bicarb in the
setting of severe acidosis. The patient remained
hemodynamically stable.
PAST MEDICAL HISTORY:
1. SLE diagnosed in [**2166**] complicated by lupus/nephritis,
anemia, serositis and ascites, currently in remission.
2. End-stage renal disease on hemodialysis Monday, Wednesday
and Friday secondary to lupus.
3. History of VSD status post corrective surgery at age 13.
4. Hypertension.
5. ITP.
6. MSSA endocarditis.
7. [**Year (4 digits) **] cell trait.
8. Status post left oophorectomy related to IUD-associated
infection.
9. Restrictive lung disease noted on PFTs from [**2166**]. In [**2173**]
chest CT was with diffuse ground glass opacities.
10. GERD in [**2172**].
11. History of domestic violence.
12. Most recently is status post cadaveric renal on [**8-31**], [**2174**], complicated by delayed graft function.
ALLERGIES: Levaquin, cephalosporin, Unasyn, vancomycin and
derivative, Demerol and meperidine.
MEDICATIONS ON ADMISSION: Prednisone 5 mg daily, Bactrim SS
1 tablet daily, Valcyte 450 mg every other day, __________
2.5 mg daily, nifedipine 90 mg sustained release daily,
Protonix 40 mg daily, Dronabinol 2.5 b.i.d., Mirtazapine 15
mg q.h.s., MMF 500 mg b.i.d., nystatin suspension 5 ml
q.i.d., Epogen injection 3000 units Monday, Wednesday and
Friday, Percocet [**12-11**] 5/325 mg tablets 1 tablet q.4-6 hours
p.r.n., Labetalol 400 t.i.d., Linezolid 600 q.12 for a total
of 7 days, Reglan 5 mg q.i.d., sodium bicarb 650 mg tablets 4
tablets t.i.d., Coumadin 5 mg 1 p.o. daily for a left
axillary thrombus, Rapamune 6 mg once a day, the patient at
that time was on Linezolid because of a gram-negative staph
urinary tract infection, and on Coumadin for a non-occlusive
thrombus of left axillary vein that was documented on
[**2175-10-24**].
In the emergency room was intubated and sedation. CT of the
abdomen was performed demonstrating a large right-sided
hematoma displacing the transplanted kidney anteromedially
and inferiorly. The hematoma is larger compared to the CAT
scan that was performed on [**2175-6-29**], but appears smaller
compared to the CAT scan on [**2175-9-11**].
The transplanted kidney is barely discernable. The UV
catheter is noted in situ. A 3.8 cm heterogenous lesion,
likely arising from the uterus and probably a fibroid was
noted. There was also diffuse thickening of small bowel wall
with a differential of wide and intramural hemorrhage, and
there was massive ascites.
PREOPERATIVE DIAGNOSIS:
1. Anemia.
2. Acute renal failure.
3. Hyperkalemia.
4. Metabolic acidosis.
5. Coagulopathy.
6. Sepsis.
The patient was rushed to the OR where surgery was performed
on the morning of [**2175-11-6**], performed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Exploratory laparotomy and transplant nephrectomy
was performed due to a ruptured kidney.
A French [**Doctor Last Name 406**] drain was brought out through a separate
incision and sutured in place with 3-0 nylon.
The patient remained intubated and was taken to the ICU in
stable and satisfactory condition.
Postoperatively the patient was febrile. The patient had a
right femoral arterial line and left triple lumen. Cultures
were obtained on [**2175-11-7**], because the patient
became febrile which grew out pseudomonas.
The renal consulting team followed the patient closely.
The patient continued with hemodialysis Monday, Wednesday and
Friday. CAT scan was obtained postoperatively on [**2175-11-8**], to evaluate the abdomen and hematoma which demonstrated
interval removal of the transplant kidney with extravasation
of right extraperitoneal __________ . At the surgical site
remains an ill-defined collection consisting of residual
hemorrhage and gas and hyperdense perihepatic fluid probably
hemoperitoneum. There was free air present which may be
related to surgery. According to the radiologist, there was
nonspecific cecal thickening, new bibasilar consolidations
and new gallbladder distention.
The patient continued to be intubated. He was placed for tube
feeds, and tube feeds were started for nutrition. The patient
remained intubated. Tube feeds were continued. The patient
was continued on antibiotics, Linezolid day 16, Zosyn day 13.
The patient was also continued on a Fentanyl patch for pain
control.
At that time, [**2175-11-20**], she was assist control 40%,
PEEP of 10, 45 x 25.
Infectious disease was consulted for ongoing fever despite
being on multiple antibiotics. The patient had a radial
peroneal abscess that was drained. Infectious disease closely
followed the patient and made recommendations without
switching antibiotics.
On [**2175-11-14**], central line change was performed
complicated by a large left apical and basilar hemothorax.
Chest tube was placed that evening. Another chest x-ray was
performed demonstrating marked decrease of left-sided
pneumothorax, residual small left apical and basilar
pneumothorax.
The patient had another CAT scan on [**2175-11-16**], because
of ongoing abdominal pain. The patient required another
catheter for drainage of collection. CAT scan demonstrated 1)
interval improvement in bilateral basal consolidations, 2)
there was a collection along the right flank, decreased in
size compared to the prior study with catheter in adequate
position, 3) there was reduction of gallbladder distention,
4) stable small collection to the right of the uterus
consistent with resolving hematoma, 5) stable splenic
infarcts.
The patient hemodynamically stable. The patient did complete
a 7-day course for a possible mucocutaneous HSV. Antibiotics
were changed to Meropenem. Linezolid and gentamicin were
discontinued.
TPN was discontinued. Nepro tube feeds were started per
recommendations from nutrition.
The patient was slowly weaning from the vent. Tube feeds were
advanced.
On [**2175-11-20**], the patient needed central venous
access, and there was successful placement of an 8.5 French
16 cm long four-lumen catheter via the left common femoral
vein. Also the venogram demonstrated occlusion of the left IJ
and the left subclavian vein with multiple collaterals, and
also the right IJ was shown to be occluded on ultrasound
scan. Therefore the left femoral line was in place and ready
to use for central access.
On [**2175-11-24**], the patient had a bronchoscopy to
evaluate and assess airway patency. Using an endotracheal
tube, which was flexible, it was documented that her airway
was clear. There were no complications.
The patient continued with the dialysis 3 days a week. Renal
continued to follow the patient.
On [**2175-11-30**], the patient had an open tracheostomy
performed by Dr. [**Last Name (STitle) **] because of respiratory failure and
failure to wean off the ventilator status post tracheostomy
tube with a 7 French non-fenestrated tracheostomy tube. The
patient ventilated well, and the patient was transferred back
to the recovery room in stable condition.
On [**2175-12-2**], the patient had another CAT scan
because of abdominal pain and persistent fever. The case was
discussed with Dr. [**Last Name (STitle) 816**] who requested drainage of subhepatic
fluid collection.
1. The size of the subhepatic fluid collection within an
enhancing wall has decreased slightly since the prior
study. This was drained with an 8 French pigtail catheter
which was left in place.
2. There was a JP drain in the right pericolic fluid
collection which was in good position. The size of the
fluid collection was essentially [**Last Name (STitle) 1506**] from the prior
study of [**2175-11-23**].
3. There was a stable appearance of a cystic collection deep
within the pelvis to the right of the uterus not easily
amendable to percutaneous drainage.
4. There was anasarca with ascites.
5. There was bilateral lower lobe consolidation which was
[**Year (4 digits) 1506**].
6. There were splenic infarcts, which was [**Year (4 digits) 1506**].
We continued to check her labs which included CBC,
electrolytes daily and were replaced as needed.
The patient was evaluated for rehab.
Another CAT scan was performed on [**12-22**] at 1 a.m.
because of abdominal pain, and was documented:
1. Persistent, although smaller multiloculated fluid
collection along the right flank, status post removal of
drainage catheter. The presence of infection cannot be
excluded.
2. There was a similar uterine mass.
3. There was ascites and edema.
4. Improving bilateral lower lobe consolidations.
5. Continued splenic infarcts, not well appreciated on that
particular study.
The patient continued on antibiotics for pseudomonas coverage
and VRE bacteremia related to lines and questionable
abdominal fluid collections.
Later that day on [**2175-12-22**], the patient had a CT-
guided abdominal drainage using CT fluoroscopic guidance. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 4300**] needle was advanced to the right flank collection.
Approximately 40-50 ml of blood-tinged fluid was aspirated.
Postprocedural films demonstrated that the right flank
collection appears in good position. The patient tolerated
the procedure well. There were no immediate complications.
The 8 French catheter remained in place after the CT was
completed.
On [**2175-12-12**], the patient was evaluated for a Passy-
Muir valve evaluation, and it was observed that she did
tolerate wearing the PMV for 20 minutes with no oxygen
desaturation and was able to speak with a clear voice and
intelligible speech; however, she then began to cough at the
end of the evaluator's exam suggesting either
dryness/irritation or possibility of aspiration secretions.
Physical therapy and occupational therapy met with the
patient for evaluation and treatment and definitely felt that
the patient needed to go to rehab. The patient continued with
hemodialysis.
On [**2175-12-21**], the patient had a chest x-ray because of
ongoing fevers, and the radiologist documented the chest x-
ray report as a long-standing interstitial abnormality in the
right lower lobe present since [**5-19**]. This probably
represents irreversible changes of previous edema, pulmonary
hemorrhage, vascular congestion or interstitial lung disease,
not an acute process. Top-normal heart size and dilatation of
pulmonary arteries and left atrium are long standing. There
are no findings to suggest further cardiovascular
decompensation or current enterothoracic infection. Feeding
tube ends at the pylorus. Tracheostomy tube in standard
placement. No pleural effusion.
Pigtail catheter was removed on [**2174-12-21**], and
tracheostomy was downsized, and there were no adverse events
over night. She was afebrile with vital signs stable. P.O.
intake 640, tube feeds 710; does not void. The patient had JP
drainage of 35 cc.
Infectious disease had recommended to continue tobramycin,
p.o. vancomycin and Cipro until her follow-up appointment
with infectious disease on [**2176-1-9**]. At that time,
abdominal/pelvic CT will be obtained to assess fluid
collections to help define further duration of antibiotics.
On [**2175-12-22**], another CAT scan was performed to
evaluate the abdominal collections after the drains have been
removed.
On [**2175-12-23**], pain service was consulted requires
multiple narcotics. The pain service had stated to continue
the Fentanyl patch, to change her p.o. Dilaudid regimen and
to discontinue her IV Dilaudid.
Currently the patient is on Cipro for pseudomonas. The
patient is also on linezolid for enterococcus and history of
VRE. The patient continues on vancomycin for prior C-diff.
She is also receiving tobramycin.
She has 2 pending cultures from blood cultures that were
obtained on [**2175-12-24**].
Her labs on [**2175-12-26**], revealed the following: WBC
9.4, hematocrit 26.8, platelets 111; PTT 30.5, INR 1.1;
sodium 131, 3.6, 95, 28, BUN and creatinine of 20 and 3.5,
glucose 88, calcium 9.6, phos 2.5, magnesium 0.7, albumin
2.6. The patient had a tobramycin level of 1.1 on [**2175-12-26**].
When the patient goes to rehab, the patient will need daily
CBC, CHEM10 at least once-a-week. The patient will need to
have a CBC with diff and a post dialysis tobramycin level.
Those results need to be faxed to infectious disease [**Telephone/Fax (1) 18624**].
The patient has a follow-up appointment with Dr. [**First Name (STitle) 2505**] on
[**2176-1-9**], from infectious disease, [**Telephone/Fax (1) 457**]. This
appointment is for [**2176-1-9**], at 9 a.m. If you have
any questions or problems with the appointment please Dr.[**Name (NI) 18625**] office immediately. Also the facility should make an
appointment with transplant surgery potentially on the same
day; please call [**Telephone/Fax (1) 673**].
DISCHARGE MEDICATIONS: Prednisone 5 mg daily, Mucomyst
solution q.4-6 hours as needed, heparin 5000 units subcu
b.i.d., vancomycin 125, which is the oral liquid, q.6 hours,
Prevacid 30 mg suspension 1 tablet daily, Albuterol aerosol
puff inhalation 1-2 puffs q.6 hours, Lopressor 4.5 b.i.d.,
Fentanyl patch 100 mcg, please change every 72 hours,
__________ 750 q.24 hours, Colace 100 mg b.i.d., Dilaudid 2
mg tablets 1-3 tablets q.2 hours p.r.n., Linezolid 600 mg
q.12 hours, Ativan 1 mg IV q.6 hours, tobramycin as needed,
the last dose was 140 mg, but please check level prior to
giving dose. If there are any questions in regards to the
tobramycin, call infectious disease at [**Telephone/Fax (1) 457**].
The patient is on tube feeds, Nepro 3/4 strength, goal rate
of 40 cc/hr. Please check residuals q.4 hours and hold tube
feeds for residuals greater than 100 ml. Please flush with 50
cc of water q.8 hours. The patient should also receive
calorie counts and have a dietician following the patient.
The patient could be possibly transitioned from tube feeds to
a regular diet.
FINAL DIAGNOSIS: This is a 28-year-old woman with lupus
nephritis status post renal transplant on [**2175-9-1**],
with acute rejection and subsequent graft rupture.
SECONDARY DIAGNOSIS:
1. Pseudomonas bacteremia.
2. Peritoneal abscess/necrotizing fascitis.
3. Left IJ and left subclavian vein occlusion.
4. Left pneumothorax requiring chest tube placement.
5.
Respiratory failure requiring tracheostomy.
6. Intra-abdominal fluid collection status post drainage.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2175-12-27**] 12:32:23
T: [**2175-12-27**] 14:04:32
Job#: [**Job Number 18626**]
Name: [**Known lastname 2797**], [**Known firstname 2798**] Unit No: [**Numeric Identifier 2799**]
Admission Date: [**2175-11-5**] Discharge Date: [**2175-12-27**]
Date of Birth: [**2147-8-13**] Sex: F
Service: [**Last Name (un) **]
ADDENDUM:
Additional bits of information:
1. In regard to the Tobramycin, please obtain a trough level
prior to dialysis, and then also get a peak and trough
after dialysis. Again if there are any questions please
contact the infectious disease attending which I have had
previously given in the first dictation.
2. Patient does have a sacral pressure ulcer that needs to
be cleansed with saline and changed with a dressing.
Please apply a thin layer of DuoDerm gel to the base of
wound. Also apply foam dressing called Alleyden foam
dressing. Please change every 2 days and as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3067**]
Dictated By:[**Last Name (NamePattern1) 3068**]
MEDQUIST36
D: [**2175-12-27**] 13:09:37
T: [**2175-12-27**] 13:27:35
Job#: [**Job Number 3069**]
|
[
"008.45",
"054.9",
"593.89",
"616.50",
"599.0",
"996.62",
"616.4",
"996.81",
"276.2",
"682.2",
"584.5",
"038.43",
"518.81",
"453.8",
"285.1",
"585.6",
"512.1",
"286.9",
"710.0",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.04",
"99.15",
"96.6",
"00.14",
"71.3",
"48.81",
"38.93",
"39.95",
"31.1",
"55.53",
"54.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14177, 15239
|
2391, 14153
|
15257, 15406
|
177, 200
|
229, 1498
|
15427, 17139
|
1520, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,729
| 162,647
|
27092
|
Discharge summary
|
report
|
Admission Date: [**2102-3-8**] Discharge Date: [**2102-4-10**]
Date of Birth: [**2051-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
tracheobronchial malacia
Major Surgical or Invasive Procedure:
rigid bronch with Y stent removal [**2102-3-8**]
[**2102-3-12**] rigid bronch w/ Y stent replacement
History of Present Illness:
50 yr old male w/ sever tracheobronchial malacia managed by y
stnt which resulted in growth od granulation tissue and airway
occlusion. Admitted for removal of Y stent and excision of
granulation tissue on [**2102-3-8**].
Past Medical History:
tracheobronchomalacia, schizophrenia, mood d/o, anxiety,
allergies, h/o mitral valve prolapse (discovered '[**00**]), chronic
pneumonias
Social History:
lives in own apt w/ daily supportive care.
Counselor: [**Doctor First Name **] [**Telephone/Fax (1) 66549**] (pt makes his own decisions, has no
proxy)
[**Name (NI) 66550**] (sister): H [**Telephone/Fax (1) 66551**], C [**Telephone/Fax (1) 66552**]
Family History:
non contributory
Physical Exam:
General: well appearing, cooperative schizophrenic male in NAD.
Reports decreased dyspnea and improved performance w/ Y stent.
resp: lungs course w/ barking cough, difficulty clearing
secretions.
COR: RRR S1, S2
ABD: soft, NT, ND, +BS
Extrem; no C/C/E
Neuro: A+OX3. approp.
Pertinent Results:
CXR [**2102-4-4**]: CHEST PA AND LATERAL: Compared to the study from
[**2102-4-1**]. There is improved aeration of the right lung.
Improvement is seen in the subcutaneous emphysema over the right
neck. There is interval removal of the right IJ line. The heart
size, mediastinal and hilar contours are unremarkable. A small
right effusion is noted.
SPECIMEN SUBMITTED: LT MAIN STEM TUMOR.
DIAGNOSIS:
Left mainstem mass, biopsy:
Granulation tissue with respiratory mucosal lining, squamous
metaplasia, and acute and chronic inflammation
ECHO: [**2102-3-10**]
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion
abnormality cannot be fully excluded.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
is seen.
3. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2102-3-10**] 16:49.
[**Location (un) **] PHYSICIAN: [**Name Initial (NameIs) **]
Brief Hospital Course:
Pt was admitted for evaulation of TBM. A rigid bronch was done
which showed Y stent w/ obstructing granulation tissue of LMSB.
Y stent was removed and granulation tissue was mechanically
cleared. There was significant TBM (80-90% of proximal left and
right main stem seen after Y stent removal. Thick copious
secretions were removed and pt was started on IVAB for post
obstructive PNA. Became increasingly more hypoxic requiring
transfer to ICU for management.
Became septic w/ decreased mental status requiring transfer to
ICU for pressor support. Psych was called to eval mutliple psych
meds which were tapered to increase level of alertness and to
eval for suggestions re: post op management when unable to take
po meds. Level of alertness improved w/ management of PNA w/ ABx
and alteration of psych medications. Head CT was done d/t
decreased mental status and was unremarkable for acute event.
Baseline HCt 24-26- did rec transfusions of PRBC to maintain
baseline. Weaned of pressors w/ stable hemodynamics.
Once PNA resolved and pt afebrile he was taken to the OR for a
rigid bronch to have y stent removed on [**2102-3-21**] in preparation
for tracheobroncheoplasty on [**2102-3-24**]. Pt remained intubated after
stent removal as a precaution.
He underwent a tracheobroncheoplasty on [**2102-3-24**].
Managed in the ICU post op -intubated for airway secretion
management, bronched on POD#1 for minimal secretions and open
trachea and bronchus s/p plasty. Found to have laryngeal
edema-placed on steriods. Cont'd w/ serial bronch's for secteion
management. Extubated on POD#3 ([**2102-3-27**]). Throughout [**Hospital **]
hospital course he was followed daily by psych for pharmacologic
management. Remained in ICU post extubation until mental status
near baseline and pt could protect his airway.
transferred to surgical floor for continued psych, surgical and
rehab management.
At the time of discharge, pt was pain free, [**Last Name (un) 1815**] reg diet,
ambulatory and per his outpt psych team, at his psychiatric
baseline.
Pt was escorted home by his community mental health nurse [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66553**].
Medications on Admission:
albuterol, baclofen 5"', buspar 10"', claritin, clozapine 200
qhs, cogentin 2 [**Hospital1 **], depakote [**Telephone/Fax (1) 36883**], feosol 325", feodon
160", klonopin 0.5", mvt, protonix 40', cingulair 10', tylenol
prn
Discharge Medications:
1. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Clozapine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*60 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. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-19**] Inhalation qid
prn.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
tracheobronchial malacia
s/p Y stent removal [**2102-3-8**], replacement [**2102-3-12**], and removal
for tracheobroncheolplasty [**2102-3-24**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up
appointment after you are discharged from rehab or if you have
increased cough, fever, chills, shortness of breath.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 952**] ([**Telephone/Fax (1) 170**])
on [**4-27**] at 3:30pm in the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
Completed by:[**2102-4-10**]
|
[
"519.1",
"466.0",
"584.9",
"293.9",
"295.90",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.79",
"96.05",
"33.24",
"32.01",
"96.6",
"38.93",
"33.48",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
5638, 5644
|
2587, 4758
|
318, 420
|
5833, 5840
|
1442, 2501
|
6084, 6313
|
1115, 1133
|
5031, 5615
|
5665, 5812
|
4784, 5008
|
5864, 6061
|
1148, 1423
|
254, 280
|
448, 672
|
2533, 2564
|
694, 832
|
848, 1099
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,882
| 193,870
|
51646
|
Discharge summary
|
report
|
Admission Date: [**2129-2-3**] Discharge Date: [**2129-2-9**]
Service: MEDICINE
Allergies:
Penicillins / Clarithromycin / Doxycycline
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2129-2-3**] for monitoring during
milrinone initiation.
History of Present Illness:
85 yoM w/ class III CHF [**2-26**] ischemic cardiomyopathy s/p BiV ICD,
CAD s/p CABG x2 and multiple PCIs, s/p bioprosthetic MVR,
pacemaker dependent due to complete heart block [**2-26**] cardiac
surgery, PAF, CRI who presents w/ worsening DOE after a recent
admission and discharge from the hospital in [**2129-1-17**].
.
At the time of discharge, he was feeling at his best meaning
that he was able to walk 2 blocks before becoming SOB. However,
since returning home, he has become progressively more
letharigic, SOB, and DOE to the point that he can only walk
minimally. He is still able to do ADLs such as drive, shop,
wash, etc. He called his PCP today because of the lethargy and
PCP spoke to Dr. [**First Name (STitle) 437**], and patient electively admitted for
tailored milrinone therapy.
.
Upon arrival to CCU, patient walked in himself, and reports
feeling more fatigued, but breathing comfortably if he does not
move. He denies any CP, palpitations. He does have dyspnea on
exertion, paroxysmal nocturnal dyspnea every night, 3 pillow
orthopnea, and ankle edema. His weight this morning was 109.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
1. CAD s/p CABG in [**2102**] with a redo in [**4-/2121**]
- stent to LAD in [**2122-1-26**].
3. Mitral valve replacement porcine [**2121**]
4. CHF with an EF of less then 20%.
5. Pacemaker/DDD for post surgical complete heart block [**2121**]
6. Atrial fibrillation - Anticoagulation stopped secondary to
hemoptysis in [**2121-7-26**], but now resumed on coumadin
7. CRI (baseline creatinine of 2.4 to 2.9)
8. Prostate cancer.
9. L eye lens replacement
10. Dyslipidemia
11. Hypertension
12. Anemia: baseline HCT 38-40
Social History:
The patient lives lone and wife died 4 years ago. He had sons in
[**Name (NI) **] and [**Name (NI) 3844**]. Tobacco, he has a fifteen pack year
history. He quit greater then 50years ago. Occasional alcohol.
No elicits. Independent in all of his ADLS and recently moved to
a retirement community in [**Location (un) **]
Family History:
all siblings and both parents have CAD.
Physical Exam:
VS: T , BP 110/78, HR 80 , RR 21, O2 % on
Gen: thin, elderly aged male in mild resp distress. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at earlobe.
CV: Regular, II/VI holosystolic murmur, split S2
Chest: No crackles, but very coarse breath sounds throughout
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. warm
Skin: mild erythema around a small skin abrasion at left shin
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
CARDIAC CATHETERIZATION:
1. Resting hemodynamics prior to milrinone administration
revealed elevated left and right sided filling pressures with
mean PCW
of 26 mmHg and RVEDP of 14 mmHg. There was moderate-severe
pulmonary
arterial hypertension with PASP of 51 mmHg. The cardiac index
was
depressed at 1.78 L/min/m2. The SVR was calculated to be [**2077**]
dyne*sec/cm5.
2. After administration of milrinone (25 mg IV bolus followed by
0.3
mcg/kg/min IV drip), mean noninvasive aortic pressure fell from
80 to 63
mmHg, arterial sat fell from 99 to 95% and SVR fell from [**2077**] to
1195
dyne*sec/cm5. The cardiac index increased from 1.78 to 2.16
L/min/m2 and
mean PCW decreased from 26 to 21 mmHg.
FINAL DIAGNOSIS:
1. Baseline moderate-severe pulmonary arterial hypertension,
right and
left ventricular diastolic dysfunction and severe left
ventricular
systolic function.
2. Succesful milrinone trial.
Brief Hospital Course:
The patient was admitted for evaluation for home milrinone
therapy. He has a history of severe systolic heart failure,
with multiple admissions where he has required milrinone. We
performed a trial of milrinone with PA catheter in the cath lab
to see how his cardiac index, PA pressures, and SVR responded,
and all responses were favorable. A PICC line was placed, and
the patient was discharged with home milrinone.
Medications on Admission:
Amiodarone 200 mg daily
Atorvastatin 10 mg daily
Captopril ????
Carvedilol 6.25 mg [**Hospital1 **]
Isosorbide Mononitrate 90 mg daily
Digoxin 125 mcg as directed
Furosemide 80 mg [**Hospital1 **]
Allopurinol 50 mg daily
Warfarin 2.5 mg daily
Albuterol IH
Colchicine 0.3 mg daily PRN
Epogen 10,000 unit/mL every other week
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO BID (2 times a
day).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MONDAY AND
THURSDAY ().
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath.
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Saline flushes: Instill 2-10 cc flushes daily and prn
13. Heparin flushes: Please instill 3-5cc flushes of heparin
100units/mL daily and prn
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to evaluate the utility of a drug therapy
called milrinone for your heart failure. We have determined
that this medication improves your heart function, and would
like for you to get it at home. We placed a PICC line for long
term intravenous therapy, which will allow you to get the
milrinone at home. Please do the following:
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
-Adhere to 2 gm sodium diet
.
.
Please follow up with Dr. [**First Name (STitle) 437**] as indicated below
.
.
Please take all of your medications as directed.
.
.
If you develop any concerning symptoms please come to the
Emergency department.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2129-2-21**]
1:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2129-3-29**]
2:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2129-3-29**] 3:00
|
[
"584.9",
"416.8",
"414.00",
"428.0",
"427.31",
"V42.2",
"403.90",
"585.9",
"V10.46",
"285.9",
"272.4",
"V45.82",
"372.30",
"V58.61",
"414.8",
"V45.81",
"V15.82",
"V45.01",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"89.68",
"99.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6398, 6450
|
4470, 4892
|
260, 348
|
6519, 6529
|
3539, 4241
|
7245, 7692
|
2838, 2879
|
5266, 6375
|
6471, 6498
|
4918, 5243
|
4258, 4447
|
6553, 7222
|
2894, 3520
|
217, 222
|
376, 1942
|
1964, 2485
|
2501, 2822
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,042
| 135,250
|
22568+57304+57305
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2166-8-28**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2129-5-22**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Lethargy,increased LFTs, feeding tube pulled out
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 y.o. male s/p liver transplant [**6-8**] who presented for
increasing LFTs, lethargy,hyperkalemia, and dislodgement of post
pyloric feeding tube. He has had several admissions to [**Hospital1 18**]
since discharge post transplant for failure to thrive and
abdominal pain over past two months. Currently denies fever,
chills, nausea, or vomiting. Not eating and has been more
withdrawn over past 24-48 hours.
Past Medical History:
HCV cirrhosis
Hemachromatosis
BCC
Ascites, encephalopathy
Depression
DM
PSH: Liver Transplant [**2166-6-20**]
Hernia repair
Physical Exam:
Alert, lethargic, oriented x3, appears ill & frail, pale
perrla, eomi, anicteric
RRR, 2/6 SEM heard best at apex
Lungs: CTAB, no W/R/R
Abd: soft, TTP in LUQ, no masses, +BS x4, no rebound or
guarding, incision well healed
EXT without C/C/E, 2+ distal pulses
Labs at OSH: sodium 136, K+ 6.7, chloride 103, bicarb 28, bun
56, creatinine 1.0, glucose 183, calcium 10.4, ast 968, alt 712,
alk phos 1101, T.bili 2.5, T. protein 5.6, albumin 3.2
Pertinent Results:
[**2166-8-28**] 09:30PM GLUCOSE-99 UREA N-51* CREAT-0.9 SODIUM-142
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-16
[**2166-8-28**] 09:30PM CALCIUM-12.5* PHOSPHATE-5.2* MAGNESIUM-1.3*
[**2166-8-28**] 05:05PM GLUCOSE-124* UREA N-57* CREAT-1.1 SODIUM-138
POTASSIUM-7.0* CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
[**2166-8-28**] 05:05PM ALT(SGPT)-1148* AST(SGOT)-997* LD(LDH)-317*
ALK PHOS-1440* AMYLASE-15 TOT BILI-1.4
[**2166-8-28**] 05:05PM LIPASE-11
[**2166-8-28**] 05:05PM ALBUMIN-3.9 CALCIUM-11.7* PHOSPHATE-5.1*
MAGNESIUM-1.4*
[**2166-8-28**] 05:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2166-8-28**] 05:05PM WBC-2.5*# RBC-3.88* HGB-11.4* HCT-32.5*
MCV-84 MCH-29.4 MCHC-35.1* RDW-16.6*
[**2166-8-28**] 05:05PM PLT COUNT-172
[**2166-8-28**] 05:05PM PT-12.1 PTT-25.2 INR(PT)-1.0
Brief Hospital Course:
Admitted [**2166-8-28**]. Potassium was 7.0. This was treated with IV
insulin, dextrose, bicarb and calcium gluconate. EKG revealed
non-specific lateral and anterolateral ST-T wave changes. Repeat
potassium was 5.0. CT of the head revealed no intracranial
hemorrhage or mass effect.Chest and abdominal CT demonstrated
the following " 1. Diffuse bilateral segmental and subsegmental
pulmonary emboli.
2. New large splenic infarct.
3. 5 mm nodule in the right lower lobe, which appears more
prominent than on [**2166-3-25**], possibly related to slice selection.
Follow-up is recommended in 3 months." On exam, he was awake,
oriented to person & hospital only. Respiratory rate was even,
and non-labored. Breath sounds were decreased at the bases. He
was transferred to the SICU for close monitoring.
He was started on IV heparin and PTTs were monitored for goal 0f
60-80. Coumadin was initiated. INR was 1.0 on [**2166-9-1**]. A TTE was
done to evaluate for source of PEs and to assess for PFO. This
demonstrated " Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
is seen.
3. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
4. No evidence of endocarditis seen.". Bilateral lower extremity
noninvasive ultrasounds was done. A deep vein thrombosis was
identified within the right popliteal vein.
A left subclavian central venous line was inserted and a CXR
demonstrated the tip in the upper SVC. "Compared to the previous
study, the lungs are better expanded and there is near complete
resolution of multifocal parenchymal opacities. Lung volumes
still remain low with crowding of the pulmonary vessels.
Residual right basilar opacity is present." A liver duplex
demonstrated:
"1. Limited study shows heterogeneously echoic subhepatic area
which likely represents evolution of previously identified
collection in this area.
2. Normal liver Doppler ultrasound.
3. Ultrasound-guided mark over the right lobe of the liver
placed for biopsy to be performed by clinical staff."
He was transferred out of the SICU and back to the med-[**Doctor First Name **] unit
once stable on hospital day 3.
He was started on Solumedrol 250mg IV qd for three days for
presumed transplant rejection based on elevated LFTs (AST 997,
ALT 1148, Alk Phos 1440 and t.bili of 1.4). LFTs decreased to
AST 27, ALT 147, alk phos 564, and t.bili of 0.3 on [**2166-9-1**].
[**Last Name (un) **] was consulted to help manage hyperglycemia. Glucoses
ranged between 180 and 430 at which time he was started on an
insulin drip with glucoses imroving to 150. The insulin drip was
tapered off and sliding scale insulin with long acting insulin
resumed. He was continued on Prednisone 10mg qd, cellcept 500mg
qid and prograf 1.5mg [**Hospital1 **]. Prograf levels were 13.5, 9.3, 10.6
and 10.1.
A post pyloric feeding tube was replaced and tube feedings of
Nepro were started with goal rate of 60cc. The rate was advanced
without any GI discomfort. [**Hospital1 **] was consulted. Cycled tube
feedings at 60cc/hour x 14 hours were recommended.
Psychiatry was consulted for evaluation of his depression.
Initial recommendations included restarting Ritalin to help
increase energy level due to depression and to encourage
improved po intake. Remeron was recommended as well as taper of
Zoloft. Ritalin was held, zoloft was tapered off and Remeron was
initiated. A follow up psychiatry consult generated
recommendations to delay restarting Ritalin,taper Zoloft and
holding off on starting Remeron and Marinol until less confused.
An EEG was recommended as well as checking TSH and B12 level. On
admission, a urine tox screen was negative.
Blood cultures and a CMV viral load was drawn on [**2166-8-29**]. All
were negative. WBC dropped to 1.9 on hospital day 2, and
subsequently increased to 9.6 after administration of neupogen.
Vital signs were stable and he was afebrile.
Medications on Admission:
marinol 5mg [**Hospital1 **], NPH 17 units sc qam, NPH 13 units sc q6pm,
colace 100mg [**Hospital1 **], epogen 8,000units sc q Mon-Wed-Fri, tums 1
[**Hospital1 **], prevacid 30mg [**Hospital1 **], lopressor 37.5mg [**Hospital1 **], mvi 1qd,
prednisone 10mg qd, Prandin 2mg [**Hospital1 **], senokot 2tabs po qhs,
zoloft 50mg qd, bactrim DS [**1-5**] tab qd, valcyte 900mg qd, prograf
1.5mg [**Hospital1 **], Magnacal at 70cc/hr from 5p to 7am.
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Liver transplant rejection, treated with steroid pulses
h/o Hepatitis C
Pulmonary embolus, bilateral
Splenic infarct
Right popliteal DVT
DM Type II
Hyperkalemia
Depression
Malnutrition
Discharge Condition:
stable
Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, inability
to take medications, shortness of breath, chest pain, jaundice,
diarrhea, abdominal pain or any concerns.
Labs every Monday & Thursday for cbc, chem 10,ast, alt, alk
phos, t.bili, albumin, PT/INR, and trough prograf level.
Fax labs immediately to Transplant office at [**Telephone/Fax (1) 697**]
Goal INR [**2-6**] for PEs/DVT
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2166-9-3**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-9-3**] 2:40
Name: [**Known lastname 208**],[**Known firstname **] Unit No: [**Numeric Identifier 10808**]
Admission Date: [**2166-8-28**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2129-5-22**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2800**]
Addendum:
Medication adjustments:
Coumadin 4 mg po daily
Tacrolimus 2 mg po bid
Please check pt, inr and tacrolimus trough [**9-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**0-0-0**] Name: [**Known lastname 208**],[**Known firstname **] Unit No: [**Numeric Identifier 10808**]
Admission Date: [**2166-8-28**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2129-5-22**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2800**]
Addendum:
medication:
Bactrim 1 tab SS po daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**0-0-0**]
|
[
"996.82",
"250.00",
"453.41",
"415.19",
"263.9",
"276.7",
"289.59",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9896, 10132
|
2257, 6315
|
315, 322
|
7949, 7958
|
1391, 2234
|
8414, 9235
|
6809, 7618
|
7741, 7928
|
6341, 6786
|
7982, 8391
|
930, 1372
|
227, 277
|
350, 762
|
784, 915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,047
| 137,209
|
4568
|
Discharge summary
|
report
|
Admission Date: [**2126-4-3**] Discharge Date: [**2126-4-9**]
Date of Birth: [**2052-5-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Peristent nausea that is not usually associated with vomiting,
but for over six months now it has been severely debilitating
and is now refractory to traditional medications.
Major Surgical or Invasive Procedure:
1. Biliary bypass choledochoduodenostomy.
2. Primary ventral hernia repair.
3. Extended adhesiolysis.
History of Present Illness:
This 73-year-old woman has of multiple medical problems but
previously was treated for morbid obesity with a Roux-en-Y
gastric bypass. This was over
20 years ago, and she has had an excellent sustained effect from
this. Within the last 3-4 years, she has had evidence of biliary
obstruction from an ampullary stenosis. This caused nausea
originally and was dealt with over 2-1/2 years ago with
percutaneous-based stents through the liver placed by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19420**].
Once these were placed, there was an initial improvement in her
nausea problem for about 6 months, but then this recurred. It is
uncertain whether these are Silastic for expanded metal stents
that are in place. She now returns with
chronic nausea that is intractable to medications. Furthermore,
sequential imaging of her upper abdomen has indicated a growing
common bile duct in size with distal echogenic matter consistent
with stents that are migrating.
Past Medical History:
Bipolar disease
CRI 2nd to Li tox
chronic back pain
hypothyroidism
osteoporosis
Gastric banding ([**2098**])
cholecystectomy ([**2098**])
ERCP x2 ([**2121**], [**2122**])
Social History:
na
Family History:
na
Physical Exam:
AVSS
GEN - NAD. COMFORTABLE. PLEASANT.
HEENT - CLEAR OP. MMM. Non-icteric
RESP - CTAB.
CV - RRR. NML S1/S2. NO MGR. SOFT HS.
ABD - S/NT/ND. POS BS. MIDLINE OLD [**Doctor First Name 147**] SCAR. NON-TENDER EXT -
NO CCE.
NEURO - A&OX3. CNII-XII INTACT.
Pertinent Results:
[**2126-4-3**] 02:10PM BLOOD WBC-20.9*# RBC-4.19* Hgb-10.7* Hct-33.7*
MCV-81* MCH-25.7* MCHC-31.8 RDW-17.5* Plt Ct-357
[**2126-4-5**] 05:00AM BLOOD WBC-12.4* RBC-3.52* Hgb-8.8* Hct-28.5*
MCV-81* MCH-24.9* MCHC-30.8* RDW-17.7* Plt Ct-207
[**2126-4-3**] 11:15AM BLOOD PT-13.4 PTT-38.2* INR(PT)-1.1
[**2126-4-3**] 11:15AM BLOOD Plt Ct-330
[**2126-4-5**] 05:00AM BLOOD Plt Ct-207
[**2126-4-3**] 02:10PM BLOOD Glucose-169* UreaN-42* Creat-2.8* Na-142
K-4.4 Cl-113* HCO3-21* AnGap-12
[**2126-4-8**] 05:43AM BLOOD Glucose-91 UreaN-24* Creat-2.0* Na-149*
K-3.5 Cl-120* HCO3-18* AnGap-15
[**2126-4-3**] 02:10PM BLOOD CK(CPK)-69
[**2126-4-4**] 05:16AM BLOOD ALT-20 AST-31 CK(CPK)-91 AlkPhos-169*
Amylase-81 TotBili-0.3
[**2126-4-4**] 05:16AM BLOOD Lipase-75*
CXR ([**4-4**])-- 1. Improvement in aeration of left lung, with
residual left lower lobe atelectasis. 2. Elevation right
hemidiaphragm with atelectasis right lung base. 3. Successful
right central venous line placement without pneumothorax.
CXR ([**4-3**])-- 1) No evidence of pneumothorax. 2) Left pleural
effusion and apparent partial collapse of the left lower lobe
with atelectasis of the left upper region. Follow up films
requested.
Brief Hospital Course:
Pt was admitted for the purpose of undergoing the above
procedure. The procedure itself was without incident or finding
necessitating a change in diagnosis. [**Name (NI) **], pt
rousable, but somnulent with decreased ventilation and
exacerbation of her likely underlying metabolic acidosis with
CO2 retention. Poor respiratory effort and decreased lung
volumes, but no signifnicant pulm path was visualized; a swan
was placed over an existing ling. She was placed on CPAP, and
with narcotic held, her hypercarbia gradually corrected
overnight with no sequlae, and pt was discharged to floor in
stable condition with an epidural for pain control. She was
also ruled out for cardiac involvement. She was advanced to
sips on POD#2, and was transitioned to PO home meds. Pt was
noted however, to be disoriented upon awakening, but rapidly
reoriented to AOx3. The epidural was d/c'ed on POD#3 with
transition to PO pain meds. Her AM confusion resolved by POD#4,
and she was advanced to a full diet, which she tolerated well.
PT worked with pt and determined that acute rehab was not
needed. JP was removed on POD#5, and she was considered stable
for discharge to home with services. Staples were removed prior
to D/C and pain was controlled.
Discharge Medications:
1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO
1X/WEEK (TU).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
once a day.
3. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluvoxamine Maleate 50 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO
1X/WEEK (TU).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
once a day.
3. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluvoxamine Maleate 50 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Biliary obstruction due to ampullary stenosis with occluded
indwelling biliary stent.
2. Obstructed bile duct from biliary calculus.
3. Extensive adhesions, right upper quadrant.
4. Ventral incisional hernia.
Discharge Condition:
Good, stable
Discharge Instructions:
Discharge to home with instructions to follow-up with Dr.
[**Last Name (STitle) **], and observe the below instructions.
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office to schedule a follow-up
appointment.
The following have already been scheduled for you:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: KS [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) BEHAVIORAL NEUROLOGY UNIT
Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2126-4-29**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2126-4-17**] 1:00
|
[
"244.9",
"733.00",
"293.0",
"996.79",
"568.0",
"996.59",
"553.21",
"518.5",
"574.51",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.51",
"93.90",
"99.04",
"51.36",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5528, 5586
|
3307, 4555
|
453, 557
|
5842, 5856
|
2090, 3284
|
7184, 7826
|
1800, 1804
|
4578, 5505
|
5607, 5821
|
5880, 7161
|
1819, 2071
|
239, 415
|
585, 1569
|
1591, 1764
|
1780, 1784
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,983
| 116,392
|
8976
|
Discharge summary
|
report
|
Admission Date: [**2152-11-15**] Discharge Date: [**2152-11-19**]
Date of Birth: [**2093-6-2**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Alcohol
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
ORIF left ankle
History of Present Illness:
Pt suffered ankle fx, presented to [**Hospital1 18**].
Social History:
Lives with wife. 60 pack year tob hx, quit 15 years ago, no
ETOH currently, but hx of ETOH abuse and alcholism 23 years ago.
Family History:
HTN in father and brother and distant family hx of CAD
Physical Exam:
swollen ankle on admission, nvi
Brief Hospital Course:
Pt tolerated surgery well and had an uncomplicated post-op
course.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) syringe
Subcutaneous Q 24H (Every 24 Hours) for 2 weeks: 1 40mg syringe
daily.
Disp:*14 40 mg syringes* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
right ankle fracture
Discharge Condition:
Good
Discharge Instructions:
Keep your incisions clean and dry. Do not bear weight on your
right leg. Elevate your leg above your heart as much as
possible. Take all medications as prescribed. You need to take
lovenox shots for 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 1005**]
in 2 weeks for suture removal.
Please return to the emergency room if you notice:
-increased swelling or redness
-temperature > 101.4
-shortness of breathe
Call with any questions
Physical Therapy:
NWB RLE
Treatment Frequency:
Please do daily dressing changes until there is no more drainage
from wounds.
Staples out at follow-up.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] at the [**Hospital1 18**] orthopaedic
clinic in 2 weeks. Call [**Telephone/Fax (1) **] to make an appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2153-1-3**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2152-11-19**]
|
[
"401.9",
"311",
"414.00",
"E888.9",
"824.8",
"V45.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
1652, 1703
|
677, 745
|
287, 304
|
1767, 1773
|
2423, 2907
|
549, 606
|
768, 1629
|
1724, 1746
|
1797, 2248
|
621, 654
|
2266, 2274
|
235, 249
|
332, 388
|
2295, 2400
|
404, 533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,630
| 182,300
|
27736
|
Discharge summary
|
report
|
Admission Date: [**2126-4-24**] Discharge Date: [**2126-5-11**]
Date of Birth: [**2061-3-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Prochlorperazine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea and worsening fatigue
Major Surgical or Invasive Procedure:
[**2126-4-25**] Aortic Valve Replacement(19mm St. [**Male First Name (un) 923**] mechanical) and
Mitral Valve Repair utilizing a 28mm [**Doctor Last Name 405**] Band.
[**2126-4-25**] Urgent Re-exploration, Off pump single vessel coronary
artery bypass grafting utilizing saphenous vein to right
coronary artery. Esmarch Dressing for Open Chest.
[**2126-4-29**] Sternal Closure
History of Present Illness:
This is a 65 year old female with history of a heart murmur and
a diagnosis of aortic stenosis in [**2120**]. Since that time, she has
been followed by serial echocardiograms with her most recent
showing moderate to severe aortic stenosis, mild aortic
insufficiency, mild to moderate mitral regurgitation, boderline
left ventricular hypertrophy and a mildly dilated left
ventricle. Her ejection fraction was low normal at 50%. Compared
to her previous echocardiogram from [**3-/2125**], her left ventricular
size had increased, the severity of her mitral regurgitation had
increased, mild pulmonary hypertension was now noted and her
ejection fraction decreased from 60% to 50%. She has noticed
recently that she becomes more fatigued with exertion. She
denies chest pain, dyspnea, lightheadedness or orthopnea. Prior
to surgical intervention, she was admitted for further
preoperative evaluation.
Past Medical History:
-Aortic stenosis, Mitral Regurgitation
-History of Right Breast cancer s/p resection along with
chemotherapy and radiation
-Asthma
-History of Migraines
-Uterine leiomyoma
-Left thumb trigger finger
-Diabetes mellitus type 2
-Colonic adenoma
-Obesity
-Hyperlipidemia
-Thallasseia trait
-GERD
-s/p Right Breast resection
-s/p Left Knee arthroscopy
-s/p Right Carpal Tunnel Surgery
-s/p Left Lens Implant, Cataract Surgery
Social History:
Race: African American
Last Dental Exam: No recent exam
Lives with: Sister
Occupation: Retired, previously worked in human resources
Cigarettes: Quit [**2096**] Hx: Social/light use
ETOH: Rare
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease. Mother underwent
"valve replacement" surgery in her 50's....does not know
specific valve.
Physical Exam:
PREOP EXAM
BP: 152/92 Pulse: 102 Resp: 16 O2 sat: 99% room air
Height: 64 inches Weight: 241lb BSA 2.22
General: WDWN female in no acute distress. Obese.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Ronchi noted right base o/w clear
Heart: RRR [x] Irregular [] Murmur [x] grade 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: None
Varicosities: None
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Discharge Exam:
VS: T: 98.8 HR: 83 SR BP: 114/66 Sats: 98% RA WT 105 kg
(preop 109 kg)
General: 65 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: RRR normal S1,S2, soft mechanical click
Resp: clear breath sounds
GI: benign
Extr: warm trace edema
Wound: sternal incision and left lower extremity clean dry
intact. no erythema or discharge
Neuro: awake, alert moves all extremities
Pertinent Results:
STUDIES:
[**2126-4-24**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system demonstrated no angiographically
significant epicardial coronary artery disease. The LMCA, LAD,
LCx, and RCA were without angiographically apprent flow-limiting
stenosis.
.
[**2126-4-24**] Carotid Ultrasound: There is antegrade right vertebral
artery flow. There is antegrade left vertebral artery flow.
Right internal carotid artery had no stenosis. Left internal
carotid had <40% stenosis.
.
[**2126-4-25**] Cardiac Cath: 1. Supravalvular aortography demonstrated
an occluded RCA and low left coronary artery with flow
visualized into the LAD, but not into the LCx.
Date/Time: [**2126-5-3**] Echocardiographic Measurements
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - LVOT diam: 1.4 cm
TR Gradient (+ RA = PASP): *39 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients.
MITRAL VALVE: Mitral valve annuloplasty ring. Mild (1+) MR.
TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with severe hypokinesis of
the basal and mid inferior segments. The remaining segments
contract normally (LVEF = 40-45%). The right ventricular cavity
is moderately dilated with mild global free wall hypokinesis. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. A mitral valve annuloplasty
ring is present. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w RCA disease. Mild global right ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
Head CT: [**2126-5-8**]: There is no evidence of acute intracranial
hemorrhage, edema, large vessel territorial infarction, or shift
of normally midline structures. The ventricles and sulci are
normal in size and configuration. No acute fractures are
identified. The visualized mastoid air cells and paranasal
sinuses are clear.
IMPRESSION: No acute intracranial injury.
[**2126-5-11**] WBC-6.6 RBC-3.30* Hgb-9.1* Hct-29.3* MCV-89 MCH-27.7
MCHC-31.2 RDW-15.0 Plt Ct-311
[**2126-5-10**] Hct-26.7*
[**2126-4-24**] WBC-4.9 RBC-3.97* Hgb-10.5* Hct-29.7 Plt Ct-198
[**2126-5-11**] INR(PT)-3.7* 7.5 mg coumadin
[**2126-5-10**] INR(PT)-3.7* 5 mg coumadin
[**2126-5-9**] INR(PT)-1.9* 10 mg coumadin
[**2126-5-8**] INR(PT)-1.5* 10 mg coumadin
[**2126-5-7**] INR(PT)-1.6* 5 mg coumadin
[**2126-5-7**] INR(PT)-1.8* 5 mg coumadin5 mg coumadin
[**2126-5-6**] INR(PT)-1.7* 5 mg coumadin
[**2126-5-5**] INR(PT)-1.4* 5 mg couamadin
[**2126-5-11**] Glucose-116* UreaN-14 Creat-1.0 Na-140 K-4.2 Cl-100
HCO3-30
[**2126-4-24**] Glucose-134* UreaN-14 Creat-0.5 Na-139 K-3.6 Cl-89*
HCO3-25
[**2126-4-29**] ALT-37 AST-51* LD(LDH)-318* AlkPhos-59 Amylase-25
TotBili-0.5
Brief Hospital Course:
Mrs. [**Known lastname 67689**] was admitted and underwent further preoperative
evaluation. Coronary anigography demonstrated no significant
coronary artery disease and carotid ultrasound demonstrated
minimal disease of both carotid arteries. Workup was otherwise
unremarkable and she was cleared for surgery. Given Penicillin
allergy, Vancomycin was used for perioperative antibiotic
coverage.
.
On [**4-25**], Dr. [**Last Name (STitle) **] performed aortic valve replacement
and mitral valve repair. She tolerated the operation but shortly
after CVICU arrival, she was
found to have worsening right ventricular function with
deterioration in her hemodynamics. A transesophageal
echocardiogram showed that the right ventricular function was
severely depressed. She subsequently underwent cardiac
catheterization which showed no flow into the right coronary,
and was urgently brought back to the
operating room where coronary artery bypass grafting was
performed to her right coronary artery. She could not tolerate
chest closure and chest was left open with Esmarch dressing in
place. For surgical details, please see operative notes.
.
She was kept paralyzed and sedated, and remained in critical
condition for several days in the CVICU. She was aggressively
diuresed and continued to require inotropic support. Postop TEE
showed slightly improved right ventricular function with
moderate to severe tricuspid regurgitation. Hemodynamics
gradually improved and she underwent chest closure on [**2126-4-29**].
.
She weaned off pressors and inotropy. Beta-blocker,
ACE-Inhibitor, statin and aggressive diuresis was initiated.
Repeat Echo done showed mild global right ventricular systolic
dysfunction, mild mitral regurgitation, moderate tricuspid
regurgitation, moderate pulmonary hypertension. Anticoagulation
was initiated for her mechanical valve. (see results for dosing)
[**5-2**] she was successfully extubated. Speech and swallow was
consulted for prolonged extubation. Her diet was advanced per
recommendations.
Post extubation, Ms.[**Known lastname 67689**] remained confused, delerious, and
impulsive. She was placed on Olanzapine and prn Haldol. She
remained in the CVICU while her mental status cleared. A head CT
on [**2126-5-8**] showed No acute intracranial injury. Her mental
status improved.
[**2126-5-7**] she was transferred to the step down unit for further
monitoring and recovery. Physical Therapy was consulted for
evaluation of strength and mobility.
She continued to make steady progress and was discharged to
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] on [**2126-5-11**]. She will follow-up as
an outpatient.
Medications on Admission:
Albuterol MDI prn, Anastrozole 1 mg daily, Metformin 500mg three
times daily, Omeprazole 20mg daily, Simvastatin 20mg daily,
Aspirin 81mg daily, Vitamin D, Fish Oil, Multivitamin
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for wheezing/SOB.
14. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezes.
15. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
adjust dose to maintain INR 2.5-3.0.
17. insulin sliding scale and fixed dose ( attached)
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-279 mg/dL 8 Units 8 Units 8 Units 6 Units
280-319 mg/dL 10 Units 10 Units 10 Units 8 Units
320-360 mg/dL 12 Units 12 Units 12 Units 10 Units
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
-Aortic stenosis, Mitral Regurgitation - s/p AVR, MV Repair
-Postop Right Ventricular Failure/Cardiogenic Shock secondary to
occlusion of right coronary, s/p Urgent CABG
-Tricuspid Regurgitation
-Diabetes mellitus type 2
-Obesity
-Hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Doctor First Name **] [**Doctor Last Name **] [**2126-6-12**] at 1:00 in the [**Last Name (un) 2577**] Building
[**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) **] [**2126-5-17**] at 10:30 ([**Location (un) **] [**Location (un) 17879**] with [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 29819**], NP)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 67690**] [**Telephone/Fax (1) 2261**] in [**5-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Mechanical AVR
Goal INR:2.5-3.0
First draw [**2126-5-12**]
Results to phone: PCP: [**Name10 (NameIs) 67691**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 2261**] **When no
longer being followed by Rehab
Completed by:[**2126-5-11**]
|
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834
| 153,730
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50658+50659+59276+59272
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2166-6-17**] Discharge Date: [**2166-7-20**]
Date of Birth: [**2090-6-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
Russian speaking man with multiple medical problems including
type 2 diabetes mellitus and chronic renal insufficiency,
progressed to end stage renal disease, hypertension and
peripheral vascular disease, who was in his usual state of
health until [**2166-6-17**], when he presented with chronic
abdominal pain of two days. This pain was associated with
shortness of breath and diaphoresis. He was admitted to the
Medical Service [**Hospital1 69**] for
further evaluation.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Benign prostatic hypertrophy.
3. Impotence.
4. Herniated L4-L5 disc.
5. Tobacco history.
6. World War II abdominal blast wound surgery.
7. Carotid artery disease.
8. Dizziness.
9. Chronic renal insufficiency progressing to end stage
renal disease with a left hand fistula.
10. Constipation.
11. Hypertension.
12. Claudication.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 60 mg q.d.
2. Glipizide 10 mg b.i.d.
3. Lipitor 10 mg q.d.
4. Avandia 2 mg q.d.
5. Epogen 4000 units subcutaneous three times a week.
6. Aspirin 325 mg q.d.
7. Colace p.r.n.
8. Dulcolax p.r.n.
9. Lactulose p.r.n.
10. Nifedipine 120 mg q.d.
11. Pletal 50 mg b.i.d.
PHYSICAL EXAMINATION: On arrival, temperature 96.3, blood
pressure 140/60, respiratory rate 30, saturating 92%. In
general, an elderly man in no acute distress. Head, eyes,
ears, nose and throat - The pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. The neck examination revealed no
lymphadenopathy. The neck is supple. Cardiovascular regular
rate and rhythm, S1 and S2. Lung examination revealed
bilateral rales. Abdominal examination revealed midline
scar, left lower quadrant tenderness. Extremity examination
- bilaterally 2+ lower extremity edema. Neurologic
examination - awake, alert and oriented times three. Cranial
nerves II through XII are intact.
LABORATORY DATA: On discharge, white count 12.6, hematocrit
30.1, platelets 286,000. Electrolytes revealed sodium 136,
potassium 5.4, chloride 100, bicarbonate 16, blood urea
nitrogen 88, creatinine 8.3 predialysis on [**2166-7-19**].
Magnesium 2.6, phosphorus 7.6.
Video swallow on [**2166-7-1**], shows no evidence of aspiration
but mild rescue with all consistencies. This study was
obtained prior to tracheostomy placement.
Prostate ultrasound shows bilateral benign prostatic
hypertrophy with no abscess. Peripheral zone calcification
of uncertain etiology.
HIDA scan on [**2166-7-4**], shows no evidence of acute
cholecystitis. Last chest x-ray on [**2166-7-18**], shows small
bilateral effusions which are stable since [**2166-7-11**]. The
lateral decubitus bilateral films show no significant
layering.
Abdominal CT on [**2166-7-3**], shows no evidence of diverticulitis
or obstruction. Appendix is not identified. There is a
distended gallbladder with gallstone but no gallbladder
thickening. There is a left adrenal soft tissue mass with
attenuation not typical for adenoma although statistically
probably an adenoma. Bilateral pleural effusions. There is
enlarged left pectinate muscle, likely a hematoma. There is
a small hyperattenuation focus in the bladder, may be a
bladder stone or prostate gland.
Cardiac catheterization on [**2166-6-19**], shows right dominant
system with left main and three vessel coronary artery
disease. Resting hemodynamics reveal normal left and right
sided filling pressures with calculated cardiac index of 2.3
liters per minute per meter square. There is no gradient
across the aortic valve.
Microbiology data - last line culture which was positive
shows coagulase negative Staphylococcus on [**2166-7-16**], with a
groin Quinton line which was removed. Urine culture shows no
growth.
C. difficile assay is negative. Blood cultures are negative.
Cultures for gonorrhea and Chlamydia are negative.
Bronchoscopy in [**2166-7-6**], shows clean lungs and all segments
without any secretions.
HOSPITAL COURSE: The patient was admitted initially to the
Medical Service for rule out myocardial infarction protocol
after his episode of shortness of breath and diaphoresis.
His initial evaluation included renal service evaluation for
his emanate dialysis and cardiology evaluation for non Q wave
myocardial infarction. His cardiology evaluation led to a
cardiac catheterization recommendation which showed left main
disease with three vessel coronary artery disease with normal
systolic function. Given this, he was referred to the
Cardiothoracic service for coronary bypass.
The patient received a coronary bypass on [**2166-6-20**], with the
following grafts: Saphenous vein graft to left anterior
descending. Saphenous vein graft to OM1. Saphenous vein
graft to OM2. Saphenous vein graft to posterior descending
artery.
The patient's postoperative course was extensively
complicated with multiple issues. He required intubation
three times for persistent respiratory failure which
eventually required a tracheostomy tube placement. For
nutritional support, he received percutaneous endoscopic
gastrostomy tube placement. His issues are being summarized
by systems in the following section. On discharge, however,
he is on ventilator with a tracheostomy, on dialysis with a
permacath access and on tube feeds with percutaneous
endoscopic gastrostomy tube.
1. Cardiovascular - The patient was taken to the operating
room for coronary bypass on [**2166-6-20**], at which time he
received a four vessel coronary artery bypass graft. His
cardiac performance after the operation throughout
hospitalization has remained stable. His rhythm has been in
sinus in the 70s with stable blood pressure, being controlled
with Lopressor, Captopril and Norvasc. During his
respiratory distress episodes, he received rule out
myocardial infarction protocol which was negative. On
discharge, he is on Norvasc, Lopressor, Captopril and Aspirin
and is in sinus rhythm.
2. Neurological - The patient is reportedly to be alert and
oriented prior to his operation, however, there is question
of some baseline dementia. After his coronary bypass, he
received intubation three times for respiratory distress. At
third intubation, he required sedation with Ativan while he
awaited multiple procedures including tracheostomy, permacath
access placement and percutaneous endoscopic gastrostomy tube
placement. After being weaned from an Ativan drip, he is
awake and more responsive, more and more every day. On
discharge, he is moving all four extremities. He is not on
any sedation or pain medication and is communicative by
signs. He is not on any neurological medication, however,
responds well with Ativan, a small dose p.r.n. should
sedation be required.
3. Renal - The patient presented to the hospital with
chronic renal failure requiring likely dialysis. Given his
high creatinine and almost no urine output, he has been
requiring dialysis throughout his hospitalization. His left
AV fistula which he had prior to his coronary bypass was
found to be low flow and tenuous. For his access, he has
been dialyzed through temporary Quinton catheters throughout
the hospitalization, but prior to discharge has received
permanent right IJ permacath for further dialysis. On
discharge, his dialysis catheter is functioning well. He
receives dialysis every two to three days per hemodialysis
service. Specifications are with the hemodialysis team at
[**Hospital1 69**].
His renal medications include Nephrocaps, PhosLo, Epogen and
Heparin with dialysis. He has been treated with Vancomycin
renally dosed for his previous Quinton catheter line
infection. On discharge, he is afebrile.
Infectious disease - The patient was reintubated
postoperative his coronary bypass on day two for presumed
respiratory distress. Further evaluation showed a left lower
lobe infiltrate. Initial gram stain showed gram positive
cocci and PMNs for which he was treated with Quinolone and
Clindamycin for a complete course of pneumonia. Cultures
were, however, oropharyngeal flora. His pneumonia has
resolved which was evident with bronchoscopy performed in
early [**Month (only) 205**]. On discharge, he is afebrile and oxygenating and
ventilating well on a ventilator with small bilateral pleural
effusions. The patient has also had two episodes of line
catheter tips growing coagulase negative Staphylococcus,
likely Staphylococcus epidermidis. For this, he has been
treated for ten days of Vancomycin dosed renally per routine
Vancomycin levels. At discharge, he has finished his
Vancomycin course and is being discharged without any
temporary lines and without any antibiotics.
Gastrointestinal - The patient presented to the hospital with
history of constipation and on preoperative films was shown
to have stool in the colon. After the coronary bypass, he
continued to remain constipated and required a general
surgery consultation. Abdominal CT showed no intra-abdominal
process, however, showed constipation. Since then, he has
received a clean out with GoLytely and after that he receives
Colace through his gastrostomy tube. On discharge, he is
having bowel movements at least once every one or two days.
There was also a question of gallbladder infection as raised
by infection disease, however, further studies showed no
evidence of cholecystitis. This was shown with studies
including HIDA scan.
Hematology - The patient's hematocrit has been fluctuating in
the high 20s and 30s requiring approximately three units of
blood throughout his postoperative course, all given during
dialysis.
Nutrition - The patient due to his prolonged hospitalization
and intubations has had intermittent nutrition for which he
received percutaneous endoscopic gastrostomy tube placement.
He is at goal on his tube feeds which are Nephro with 60
grams of ProMod at 45 cc per hour. The Nephro tube feeds are
three quarter strength. He is being followed by nutrition
service. He is on Prevacid, Vitamin C and Zinc.
Diabetes mellitus - The patient's diabetes mellitus has been
controlled with sliding scale insulin through his
hospitalization.
Genitourinary - The patient was shown to have some urethral
discharge for which he received genital cultures which were
negative including negative for gonorrhea and Chlamydia. His
RPR test was also negative. Urology evaluation included a
prostate ultrasound which showed prostatic hypertrophy but no
abscess or any other malignant process that could be seen.
In summary, the patient presented to the hospital with
multiple comorbidities including end stage renal disease,
poor respiratory function and coronary disease. His
evaluation showed three vessel coronary disease with left
main disease and required a coronary bypass.
Postcoronary bypass course has been for respiratory failure
which shows poor respiratory compensation for acidosis likely
from his end stage renal disease. This has required
tracheostomy tube placement for difficulty weaning from a
respirator, percutaneous endoscopic gastrostomy tube
placement for poor nutrition and required nutritional support
and permanent dialysis catheter placement for nonfunctioning
left AV fistula and persistent hemodialysis needs.
On discharge, he is alert and responsive. He is in bed for
multiple days. He is on ventilator at pressure support of 10
with CPAP at 35% of FIO2 with normal arterial blood gases.
He is moving all four extremities and has clean, dry and
intact incisions. His access includes a right IJ permacath.
He is being discharged to rehabilitation for ventilator
weaning.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg per gastrostomy tube q.d.
2. Norvasc 10 mg per gastrostomy tube q.d.
3. Lopressor 25 mg per gastrostomy tube b.i.d.
4. Captopril 50 mg per gastrostomy tube t.i.d.
5. PhosLo two tablets per gastrostomy tube q.i.d.
6. Epogen 12,000 units with dialysis.
7. Heparin 5,000 units subcutaneous b.i.d.
8. Ativan 0.5 mg intravenous q6hours p.r.n.
9. Colace 100 mg per gastrostomy tube b.i.d.
10. Nephrocaps one per gastrostomy tube q.d.
11. Prevacid Elixir 15 mg per gastrostomy tube q.d.
12. Vitamin C 50 mg per gastrostomy tube q.d.
13. Zinc 220 mg per gastrostomy tube q.d.
14. Insulin sliding scale: for 150-200 give three units,
201-250 given six units, 251-300 give nine units, 301-350
give twelve units.
15. Albuterol MDI two puffs q4hours p.r.n.
16. Tube feeds three quarter strength Nephro with 60 grams
ProMod at 45 cc per hour.
ALLERGIES: No known drug allergies.
FOLLOW-UP: Dr. [**First Name (STitle) 10102**] in two to four weeks. Follow-up
with hemodialysis as required.
DISPOSITION: To acute rehabilitation.
DISCHARGE DIAGNOSES:
1. Coronary artery bypass graft times four.
2. End stage renal disease on hemodialysis.
3. Respiratory failure on ventilator with tracheostomy.
4. Percutaneous endoscopic gastrostomy tube for nutrition.
5. Noninsulin dependent diabetes mellitus.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2166-7-19**] 12:22
T: [**2166-7-19**] 14:53
JOB#: [**Job Number 105402**]
Admission Date: [**2166-6-17**] Discharge Date: [**2166-8-18**]
Date of Birth: [**2090-6-15**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This 76-year-old male with a
history of Type 2 diabetes, chronic renal insufficiency
progressed to end stage renal disease, hypertension,
peripheral vascular disease, history of chronic abdominal
pain, who presented with two days of increasing epigastric
pain, shortness of breath, diaphoresis, nausea without
vomiting. The patient's symptoms were not relieved by
nitroglycerin. The patient also complained of orthopnea and
shortness of breath with exertion. The patient had also
noticed bilateral lower extremity edema. On presentation,
the patient was found to have lateral ST depressions on
electrocardiogram and was admitted for rule out myocardial
infarction.
PAST MEDICAL HISTORY: Type 2 diabetes, benign prostatic
hypertrophy, impotence, herniated L4-L5 disc, positive
tobacco history, history of abdominal surgery secondary to a
World War II gunshot wound, peripheral vascular disease,
cerebrovascular disease, dizziness not otherwise specified,
chronic renal insufficiency progressed to end stage renal
disease, status post left fistula placement, chronic
constipation, and hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lasix 60 mg once daily, Glipizide
10 mg twice a day, Lipitor 10 mg once daily, Avandia 2 mg
once daily, Epogen 4000 units subcutaneously three times a
week, aspirin 325 mg once daily, Colace as needed, Dulcolax
10 mg suppository as needed, Lactulose as needed, nifedipine
120 mg once daily.
SOCIAL HISTORY: The patient resides with his wife. [**Name (NI) **] is
Russian-speaking. The patient denied any alcohol. The
patient admitted to smoking, 50 pack year history.
PHYSICAL EXAMINATION: On presentation, the patient had a
temperature of 96.3, pulse of 41, blood pressure 142/66,
respiratory rate 32, oxygen saturation 92% on 2 liters.
General examination: The patient was an ill-appearing,
elderly male, in no apparent distress. Head, eyes, ears,
nose and throat examination: The patient's pupils were
equally round and reactive to light. Extraocular movements
intact. Mucous membranes were pink and dry. Neck
examination: The patient had difficult to assess jugular
venous pressure. His neck was supple, without
lymphadenopathy. Cardiac examination: The patient was in
normal rate and rhythm, normal S1 and S2, and no murmurs,
rubs or gallops noted. Pulmonary examination: The patient
had bilateral rales up to one-half of the lung fields, with
increased dullness. Abdominal examination: The patient had
a midline scar, left lower quadrant tenderness. The
patient's belly was soft, nondistended, with normal bowel
sounds. There was no hepatosplenomegaly or mass palpated.
Guaiac was negative in the Emergency Department. On
extremity examination, the patient had bilateral lower
extremity edema that was 2+, trace dorsalis pedis pulses
bilaterally. On neurological examination, the patient was
alert and oriented x 3, with cranial nerves II through XII
intact. Nonfocal examination. Deep tendon reflexes were 2+
bilaterally, with downgoing toes.
LABORATORY DATA: The patient had a white blood cell count
of 11.3, hematocrit of 24.4, and a platelet count of 183.
Differential revealed 62 neutrophils, 27 lymphs, 8 monos.
Chem 7 revealed a sodium of 141, potassium of 4.9, chloride
of 109, bicarbonate of 14, BUN 99, creatinine 5.3, and
glucose of 175. The patient's initial CK was 198, with an MB
of 5 and a troponin of 1.1. Chest x-ray revealed congestive
heart failure with right lower lobe atelectasis and small
bilateral pleural effusions. A KUB revealed stool in the
colon. An electrocardiogram was performed in the Emergency
Department, which revealed normal sinus rhythm with a rate of
90, with ST depressions that were new and 1 to 2 mm, with T
wave inversions in V5 to V6. When the patient arrived on the
floor, a second electrocardiogram was done, which revealed
bigeminy with a rate of 80s, which went to normal sinus
rhythm with a rate of 70s, and [**Street Address(2) 4793**] depressions laterally.
HOSPITAL COURSE: This 76-year-old man with multiple cardiac
risk factors, originally admitted for abdominal pain,
shortness of breath and diaphoresis, was found to have an
acute myocardial infarction.
1. Cardiovascular. This 76-year-old presented with an acute
myocardial infarction. A cardiac catheterization was
performed on [**2166-6-19**], and revealed left main and three
vessel disease. The patient was referred to Cardiothoracic
Surgery for coronary artery bypass graft. On [**2166-6-20**],
the patient received a coronary artery bypass graft x 4 with
an saphenous vein graft to the left anterior descending,
saphenous vein graft to the obtuse marginal I, saphenous vein
graft to the obtuse marginal II, and saphenous vein graft to
the posterior descending artery. The patient's
cardiovascular course postoperatively has been
hemodynamically stable. The patient has continued on
Norvasc, Lopressor, Captopril and aspirin. The patient has
ruled out for acute myocardial infarction postoperatively
three times in the setting of desaturations.
2. Pulmonary. The patient had been reintubated
postoperatively three times. Initially the patient had a
left chest tube for pleural effusions. A bronchoscopy was
performed on [**2166-6-24**], for mucous plugging, and the
patient required intubation after that. The patient also had
left lower lobe infiltrates two days postoperatively. The
Gram stain revealed gram-positive cocci and neutrophils.
This was treated with quinolones and clindamycin. Culture
eventually grew oral flora. The patient was transferred to
the Medical Intensive Care Unit on [**2166-8-5**], for copious
secretions and failure to wean off the ventilator. The
patient had been off the ventilator since [**2166-8-4**], with
progressively decreased secretions. The patient required
frequent suctioning on the floor. He had been saturating
100% on 40% trach mask since [**2166-8-4**].
3. Infectious Disease. The [**Hospital 228**] hospital course was
complicated by pneumonia, as mentioned above. Bronchial
washings eventually grew out acid-fast bacteria and oral
flora. Infectious Disease was consulted and evaluated the
patient, placing him on respiratory precautions with repeat
acid fast bacilli smears. Infectious Disease felt that this
was unlikely to be tuberculosis, as chest x-rays were not
consistent with primary or reactivation tuberculosis. PPD
was placed on [**2166-8-2**], and the result was not reported. The
patient also had a urinary tract infection that grew yeast on
[**7-22**] and [**7-24**]. The patient was treated with three days
of Fluconazole. On [**8-7**], the patient was found to have
putrid urine, and cultures were sent, revealing greater than
100,000 colonies of enterococcus. Infectious Disease was
consulted, and recommended switching the patient from a ten
day course of vancomycin to linezolid 600 mg twice a day.
On [**8-16**], the patient was found to have a large increase
in his white blood cell count, and a repeat chest x-ray was
obtained. This revealed worsening consolidation at the left
base. This was suspicious for a left lower lobe pneumonia,
and the patient was started on ceftriaxone 1 gram every 24
hours.
The patient was discovered to have hepatitis serologies that
revealed exposure to hepatitis B, as he had the HBCAB found.
The patient was positive for HAVAB for hepatitis A.
Final culture on the patient's urinary tract infection
revealed vancomycin-resistant enterococcus.
4. Gastrointestinal. The patient had a history of
constipation, and an abdominal CT on [**7-3**] revealed no
diverticulitis, abscess or obstruction. It did note a
distended gallbladder, but no thickening. A left adrenal
mass was noted. Right upper quadrant ultrasound revealed a
common bile duct of 9 mm, with no stone or cholecystitis.
HIDA scan was performed, and was read as negative.
The patient presented with increased transaminases with
question of induced hepatic injury. There was also a
question of TPN vs. congestion vs. hepatic steatosis.
A negative abdominal ultrasound was done in workup for the
patient's increased liver function tests.
5. Renal. The patient did not present with anuria. The
patient had a left arteriovenous fistula which was not used
secondary to low flow. The patient was originally dialyzed
through a temporary Quinton catheter. Catheter infection x 2
in this line was discovered. The patient had a right
internal jugular Perma-Cath placed on [**2166-7-18**], which
continues to work well. The patient receives hemodialysis
Monday, Wednesday and Friday.
6. Nutrition. The patient was provided with jejunostomy
tube feedings, and was tolerating three-quarter strength
Nepro with 60 grams ProMod at a goal of 45 cc.
7. Endocrine. The patient had a history of
insulin-requiring, noninsulin-dependent diabetes. The
patient was placed on a regular insulin sliding scale.
8. Skin. The patient had required aggressive skin care
because of a right sacral decubitus ulcer. The patient had
chronic areas. The patient was provided with a Kainair
mattress, waffle boots, and right upper quadrant wound care.
9. Neurology. The patient developed what was thought to be
delirium related to the long hospital stay and urinary tract
infection. Neurology was consulted, and a head CT was
performed. The head CT was negative. An
electroencephalogram was then ordered, which revealed slow
disorganized background with bursts of generalized slowing,
suggesting a widespread encephalopathy. Thyroid studies were
performed, and the patient's TSH was 3.1, with a free T4
level of 1.1. The patient had a normal B12 level and folate
level. The patient gradually became more alert as his
hospital course continued.
DISPOSITION: The patient was evaluated by multiple
rehabilitation hospitals. He will likely be discharged to
rehabilitation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to
rehabilitation.
DISCHARGE MEDICATIONS: Prevacid 50 mg per gastrostomy tube
once daily, vitamin C 500 mg per gastrostomy tube once daily,
enteric-coated aspirin 81 mg per gastrostomy tube once daily,
Nepro tube feeds with 60 grams of ProMod at 45 cc/hour,
linezolid 600 mg per gastrostomy tube twice a day, Nystatin 5
cc swish and swallow by mouth four times a day, Norvasc 10 mg
per gastrostomy tube once daily, zinc 220 mg per gastrostomy
tube once daily, Colace 100 mg per gastrostomy tube twice a
day, Nephrocaps one tablet per gastrostomy tube once daily,
Epogen 12,000 units intravenously with hemodialysis three
times per week, Lisinopril 15 mg per gastrostomy tube once
daily, NPH insulin 15 units subcutaneously twice a day,
regular insulin sliding scale, Lopressor 25 mg per
gastrostomy tube twice a day, albuterol and Atrovent
nebulizers every four to six hours as needed for wheezing,
and Dulcolax 10 mg per gastrostomy tube/per rectum as needed
for constipation.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass graft x 4, acute myocardial infarction
2. Type 2 diabetes
3. End stage renal disease on hemodialysis
4. Hypertension
5. Peripheral vascular disease
6. Urinary tract infection
7. Pneumonia
8. Sacral decubitus ulcer
9. Right heel Stage IV ulcer
10. Widespread encephalopathy
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**MD Number(1) 5046**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2166-8-17**] 01:23
T: [**2166-8-17**] 05:51
JOB#: [**Job Number 105403**]
cc:[**Hospital1 **] Name: [**Known lastname **], [**Known firstname 17165**] Unit No: [**Numeric Identifier 17166**]
Admission Date: Discharge Date:
Date of Birth: Sex:
Service:
ADDENDUM:
DISCHARGE MEDICATIONS: Ceftriaxone 1.0 gm IV q day, Prevacid
15 mg per G-tube q day, vitamin C 500 mg per G-tube q day,
regular insulin sliding scale, enteric coated aspirin 81 mg
per G-tube q day, Nepro tube feeds with 60 gm ProMod with a
goal of 45 cc an hour, linezolid 600 mg per G-tube [**Hospital1 **] on day
six of seven, Nystatin 5.0 cc swish and swallow orally qid,
Norvasc 10 mg per G-tube q day hold for systolic blood
pressure less than 90, heparin 5,000 units subcutaneous twice
a day, zinc 220 mg per G-tube q day, Colace 100 mg per G-tube
[**Hospital1 **], Nephrocaps one per G-tube daily, Epogen 12,000 units IV
with dialysis on Monday, Wednesday, and Friday, lisinopril 15
mg per G-tube q day, hold for systolic blood pressure of less
than 90, NPH 7 units subcutaneous [**Hospital1 **], thiamine 100 mg IV q
day, Lopressor 25 mg per G-tube twice a day, Reglan 25 mg per
G-tube qid, Albuterol and Atrovent nebulizers every four to
six hours prn, Dulcolax 10 mg per G-tube/PR prn, Lactulose 30
cc per G-tube prn.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times four on [**2166-6-20**].
2. Type 2 diabetes.
3. L4-L5 herniated disk.
4. End stage renal disease.
5. Hypertension.
6. Peripheral vascular disease.
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 15196**], M.D. [**MD Number(1) 15197**]
Dictated By:[**Last Name (NamePattern1) 2134**]
MEDQUIST36
D: [**2166-8-18**] 08:59
T: [**2166-8-19**] 08:00
JOB#: [**Job Number 17174**]
cc:[**Hospital6 **] Name:[**Known lastname **],[**Known firstname 17165**] Unit No: [**Numeric Identifier 17166**]
Admission Date: Discharge Date:
Date of Birth: Sex: M
Service:
ADDENDUM: This is a continuation of a dictation from
[**8-19**] through [**2166-9-12**] (when the patient passed
away).
HOSPITAL COURSE: This is a 76-year-old male admitted for an
acute myocardial infarction, status post coronary artery
bypass graft times four on [**6-20**], who underwent a long
postoperative course with multiple complications
postoperatively. The patient experienced multiple
desaturations, and ruled out for myocardial infarction, and
required reintubation times three times. Eventually, he was
transferred to the Medical Intensive Care Unit for failure to
wean off the trach. He was then trached.
Course in the Medical ICU was complicated by pneumonia and
vancomycin-resistant enterococcus urinary tract infection
treated with linezolid. The patient with end-stage renal
disease, receiving hemodialysis on Monday, Wednesday and
Friday and has a Perm-A-Cath.
The patient was transferred to the floor on [**2166-8-8**]
and received ongoing treatment for his urinary tract
infection. He was diffusely encephalopathic. EEG revealed
and ongoing encephalopathy. He arranged to go to rehab after
acute issues resolved on [**8-19**]; however, on [**8-18**] in
the evening the patient had a systolic arrest and was down
for approximately 10 minutes. He was coded, resuscitated,
and brought to the Coronary Care Unit. He suffered anoxic
brain injury. Neurology consulted and felt the event had
left the patient with severe defects and only 1% chance of
meaningful recovery.
The patient was essentially with only plantar reflexes. He
was stabilized in the CCU. His course was complicated by
severe Klebsiella pneumoniae, and he was started on some
meropenem. Neurology reevaluated after about one week and
concluded a less than 10% chance of meaningful recovery and
maintained full code. He was then transferred to the floor
on [**8-31**] with some question of seizure activity, but
electroencephalogram was negative.
Ongoing family discussions eventually made him comfort
measures only. The patient eventually succumbed to his
illness on [**2166-9-11**] where remained afebrile.
However, was noted to not be breathing as well as no reflexes
during rounds. The patient was declared dead at 1:44 a.m.
The family was notified, and the family opted to not have an
autopsy performed.
Dictated By:[**Last Name (NamePattern1) 2917**]
MEDQUIST36
D: [**2167-4-21**] 11:20
T: [**2167-4-22**] 08:38
JOB#: [**Job Number 17167**]
|
[
"414.01",
"518.81",
"486",
"599.0",
"410.71",
"585",
"428.0",
"996.62",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"96.04",
"37.22",
"96.72",
"88.53",
"38.95",
"39.61",
"31.1",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
26484, 27331
|
25457, 26463
|
24583, 25433
|
14768, 15060
|
27349, 29672
|
15266, 17619
|
23521, 23600
|
13596, 14266
|
14290, 14740
|
15078, 15242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,845
| 134,890
|
42778
|
Discharge summary
|
report
|
Admission Date: [**2107-2-3**] Discharge Date: [**2107-2-7**]
Date of Birth: [**2042-7-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
electrode adhesive
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2107-2-3**] Coronary artery bypass grafting x4, with left internal
mammary artery to left anterior descending coronary; reverse
saphenous vein single-graft from the aorta to ramus intermedius
coronary; reverse saphenous vein single-graft from aorta to the
first obtuse marginal coronary artery; reverse saphenous vein
graft from aorta to the posterior descending coronary artery
History of Present Illness:
64 year old male with a history of CAD status post PCI of the
OM2 in [**2100**] at [**Hospital1 112**]. He has been experiencing some chest burning
with walking, especially in the cold weather. He underwent
nuclear stress testing on [**2107-1-18**] which demonstrated a new LBBB
and an abnormal ST and BP response. Nuclear imaging showed
evidence of ischemia with mild reversible defects in the mid and
apical segments of the anterior and inferior walls of the LV. He
was referred for coronary angiogram by Dr [**First Name (STitle) **]. He was found to
have left main disease and is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Coronary artery disease [**9-/2100**] s/p PCI of OM2
Diabetes mellitus type 2
Hypertension
Hyperlipidemia
History of sleep apnea, not able to tolerate, has lost 20 lbs.
Pancreatitis
Reflux
Kidney stones
Anemia, B12 deficiency with injections
Cataract onset per patient
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8509**] surgery
Social History:
Race:Caucasian
Last Dental Exam: 1 year ago
Lives with:Wife
Contact: [**Name (NI) 92428**] [**Name (NI) 3234**], wife. C: [**Telephone/Fax (1) 92429**]
[**Name2 (NI) **]ation:Program analyst at [**Hospital 789**] [**Hospital **] Hospital
Cigarettes: Smoked no [] yes [x] Hx:quit at age 25, smoked for
6-7 years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-4**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father died of CHF at age 58;
Mother with CAD s/p PCI's in her 70's; Brother s/p CABG mid 60's
Physical Exam:
Pulse:77 Resp:18 O2 sat:100/RA
B/P Right:148/61 Left:151/67
Height:5'4" Weight:155 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Carotid Bruit: no evident
Pertinent Results:
[**2107-2-3**] Echo: PRE-CPB: 1. The left atrium is normal in size. No
mass/thrombus is seen in the left atrium or left atrial
appendage. 2. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. 3. Right ventricular chamber
size and free wall motion are normal. 4. There are simple
atheroma in the descending thoracic aorta. 5. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation. Dr. [**Last Name (STitle) 914**] was notified in person of the
results.
POST-CPB: On infusion of phenylephrine. AV pacing temporarily
for CHB, then apacing. Preserved biventricular systolic function
with LVEF now = 60%. MR remains trace; AI remains 1+. Aortic
contour is normal post decannulation.
[**2107-2-6**] 05:39AM BLOOD WBC-10.2 RBC-3.44* Hgb-10.5* Hct-29.0*
MCV-84 MCH-30.5 MCHC-36.2* RDW-13.7 Plt Ct-135*
[**2107-2-5**] 06:15AM BLOOD WBC-19.5* RBC-3.72* Hgb-11.4* Hct-31.2*
MCV-84 MCH-30.6 MCHC-36.4* RDW-14.1 Plt Ct-121*
[**2107-2-6**] 05:39AM BLOOD Glucose-110* UreaN-25* Creat-1.0 Na-138
K-3.8 Cl-103 HCO3-25 AnGap-14
[**2107-2-5**] 06:15AM BLOOD Glucose-162* UreaN-13 Creat-0.9 Na-133
K-4.7 Cl-102 HCO3-25 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 3234**] was a same day admit and on [**2-3**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 4. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. On post-op day one he
was started on beta-blockers and diuretics and gently diuresed
towards his pre-op weight. Later this day he was transferred to
the step-down floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA in good condition with
appropriate follow up instructions. He is instructed to keep a
log of his blood sugars and follow-up with his PCP regarding
Diabetes management.
Medications on Admission:
AMLODIPINE 10 mg Daily
VITAMIN B-12 injections, last on in [**Month (only) 404**]
GLYBURIDE 10 mg Daily
LISINOPRIL 40 mg Daily
LOSARTAN 50 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
SIMVASTATIN 20 mg Daily
SITAGLIPTIN [JANUVIA] 100 mg Daily
ASPIRIN 81 mg Tablet - two Tablets by mouth twice a day two
tablets in am and two with dinner
Saline Nose spray in am
Discharge Medications:
1. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Januvia 100 mg Tablet Sig: One (1) Tablet PO Daily ().
Disp:*30 Tablet(s)* Refills:*2*
10. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 20 units Glargine with breakfast daily.
Disp:*qs * Refills:*2*
11. test strips Sig: Four (4) once a day: test strips for
glucometer, testing 4x/day.
Disp:*qs * Refills:*2*
12. Blood Glucose
Please keep a log of your blood sugars to present to your PCP
for further Diabetes management
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
[**9-/2100**] s/p PCI of OM2
Diabetes mellitus type 2
Hypertension
Hyperlipidemia
History of sleep apnea, not able to tolerate, has lost 20 lbs.
Pancreatitis
Reflux
Kidney stones
Anemia, B12 deficiency with injections
Cataract onset per patient
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8509**] surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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
Wound Check: [**2107-2-15**], 10:45am
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2107-2-28**], 1:30pm
Please call to schedule appointments with your
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-30**] weeks
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) 4154**] in [**3-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2107-2-7**]
|
[
"285.1",
"414.2",
"V45.82",
"530.81",
"250.00",
"272.4",
"266.2",
"414.01",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7217, 7280
|
4393, 5490
|
298, 681
|
7728, 7946
|
2978, 4370
|
8869, 9457
|
2188, 2319
|
5902, 7194
|
7301, 7362
|
5516, 5879
|
7970, 8846
|
2334, 2959
|
242, 260
|
709, 1355
|
7384, 7707
|
1740, 2172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,851
| 177,459
|
21866
|
Discharge summary
|
report
|
Admission Date: [**2193-11-1**] Discharge Date: [**2193-11-12**]
Date of Birth: [**2156-8-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Compazine / Zofran
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Intractable Nausea/Vomiting and headache
Major Surgical or Invasive Procedure:
[**2193-11-4**]: Left posterior fossa craniotomy for tumor resection
History of Present Illness:
Ms. [**Known lastname 57314**] is a 37 y/o female with metastatic colon cancer. She
was diagnosed with poorly differentiated adeno carcinoma in [**2188**]
and has been followed closely by hematology for her metastatic
disease. Since her initial diagnosis, she has had mets to the
lung, abdominal wall and pelvis. She presented today with
complaints of intractable nausea and worsening headaches. She
was sent for a CT of her head while in clinic which showed a new
large left cerebellar lesion. She was then directed to come to
the Emergency department for further neurosurgical care
Past Medical History:
ONCOLOGIC HISTORY: [**Known firstname 57315**] Bezabhe was diagnosed with T3, N2,
stage IIIC colon cancer in [**11/2188**] by colonoscopy. She
underwent
right hemicolectomy on [**2188-11-25**] with resection of a 4.5cm
poorly
differentiated adenocarcinoma with lymphovascular invasion.
Seven of thirteen nodes were involved. MRI of the abdomen at
the
time of diagnosis showed two hepatic hemangiomas; no metastasis.
She then completed six months of adjuvant chemotherapy with
5-FU/Leucovorin after having failed oxaliplatin due to severe
nausea. Cancer recurred with Krukenberg tumor resected by left
salpingoophorectomy and right salpingectomy in [**11/2189**], and
again
in right ovary status post right salpingoophorectomy in 8/[**2190**].
CEA rose and she was found to have pulmonary metastasis and then
treated with irinotecan/Erbitux, completed in 4/[**2191**].
.
CEA noted 95->276 in [**1-24**], CT TORSO on [**2191-2-13**] shows disease
progression in the thorax and pelvis. She started first cycle
of cpt-11 and erbitux on [**2-27**].
.
.
PMH:
- colon cancer as above
- bilateral oophorectomies - now on HRT
Social History:
Originally from [**Country 4812**], now living with her siblings in
[**Location (un) 3146**], MA, denies etoh, tobacco, or ivdu.
Family History:
Unaware of incidence of colorectal, gastric, uterine, ovarian Ca
in [**Country 4812**].
Physical Exam:
EXAM ON DISCHARGE:
Patient is oriented x 3. PERRL, EOMs intact. Face symmetric.
Tongue midline. No pronator drift. Strength full throughout.
Sensation intact. Nausea and vomiting have resolved. Cerebellar
incision is clean, dry, and intact.
Pertinent Results:
Labs on Admission:
[**2193-11-1**] 09:30AM BLOOD WBC-7.1 RBC-4.13* Hgb-11.9* Hct-36.9
MCV-89 MCH-28.8 MCHC-32.3 RDW-16.8* Plt Ct-231
[**2193-11-2**] 05:53AM BLOOD PT-11.9 PTT-22.1 INR(PT)-1.0
[**2193-11-1**] 09:30AM BLOOD UreaN-5* Creat-0.4 Na-138 K-3.2* Cl-103
HCO3-24 AnGap-14
[**2193-11-2**] 05:53AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
Labs on Discharge:
XXXXXXXXXXX
------------
Pertinent Imaging:
------------
MRI Head [**11-2**]: 3cm x 2.5cm mass in the posterior fossa. There
is mass effect on the fourth ventricle. There is no
hydrocephalus.
MRI Head [**11-5**](Post-op):showing gross total resection of mass.
CT Head [**11-6**]: dilitation of temporal horns, with mass effect to
the basal cisterns and 4th ventricle.
Brief Hospital Course:
Patient was admitted to the neurosurgery service after being
referred to the emergency department for a newly identifed
posterior fossa mass. She was admitted to the ICU for frequent
neuromonitoring, and surgical planning. She was additionally
started on decadron to treat surrounding mass effect. She was
then taken to the OR on [**11-4**], for posterior fossa craniotomy
and mass resection(preliminary pathology is metastatic
carcinoma). She tolerated this procedure well, and was returned
to the ICU for routine post-craniotomy care. On [**11-5**], she had
her post-resection MRI of the head which showed gross total
resection with a small amount of expected blood in the surgical
cavity. She was then transferred to the neurosurgical floor,
and decadron taper initiated.
On [**11-6**], she complained of nausea, vomiting, and subtle visual
changes. A stat head CT was performed, showing early
hydrocephalus and worsened mass effect. Fortunately, her
neurological examination remained unchanged in this setting. She
was given decadron, mannitol and lasix, and transferred to the
ICU for scrupulous neurological monitoring. On [**11-7**], head CT
was repeated showing significant improvement. Mannitol taper was
began. In the afternoon of [**11-7**], she was transferred to the
neurosurgical stepdown unit. The mannitol was tapered off and
completed on [**11-10**]. The patient continued to do well
neurologically and she was started on a decadron wean on [**11-11**].
The patient was taking in food without difficulty, and had no
nausea or vomiting. PT recommended home with services for
assistance with balance training. She was discharged to home on
[**11-12**]
Medications on Admission:
-Ondansetron 4 mg Tablet, Rapid Dissolve
-Prempro 0.625-2.5 mg Tablet Sig: One (1) Tablet PO Daily ().
-Ranitidine HCl 150 mg Tablet
-Docusate Sodium 100 mg Tablet
-Senna 8.6 mg Tablet
-Prednisone 20 mg Tablet
-Codeine-Guaifenesin 10-100 mg/5 mL Syrup
-Morphine 10 mg/5 mL Solution
Discharge Medications:
1. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left Cerebellar Mass **Prelim pathology is metastatic carcinoma
Intractable Nausea/Vomiting
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication(tapering to a
standing dose of Decadron 2mg twice daily), make sure you are
taking a medication to protect your stomach (Prilosec, Protonix,
or Pepcid), as these medications can cause stomach irritation.
Make sure to take your steroid medication with meals, or a glass
of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**7-26**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 2731**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2193-12-9**]
at 1:00 pm with Dr. [**Last Name (STitle) **]. The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **].
Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to
change your appointment, or require additional directions.
??????You will not need an MRI of the brain as this was completed
during your acute hospitalization.
Completed by:[**2193-11-12**]
|
[
"787.01",
"197.0",
"198.3",
"198.89",
"228.09",
"V10.05",
"331.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6107, 6165
|
3439, 5115
|
325, 396
|
6301, 6325
|
2686, 2691
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11363, 12236
|
2321, 2410
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6186, 6280
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3043, 3416
|
6382, 9505
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424, 1011
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2444, 2667
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2705, 3024
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1033, 2158
|
2174, 2305
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,684
| 164,389
|
45895
|
Discharge summary
|
report
|
Admission Date: [**2133-6-24**] Discharge Date: [**2133-7-14**]
Date of Birth: [**2050-9-9**] Sex: M
Service: MEDICINE
Allergies:
Lasix / Bumex
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Shortness of breath, Fatigue
Major Surgical or Invasive Procedure:
Thoracentesis on [**7-10**] with 1L of serosanguinous fluid removed.
History of Present Illness:
82 year old oxygen dependent (2L) male with diastolic CHF, CAD
s/p 5v CABG in [**2132**], A. Fib presents with chief complaint of
worsened SOB, LE edema over past 3 days. He notes that he is
normally able to ambulate throughout his one level apartment
with mild SOB, but noted SOB with shorter distances and even
while at rest. He uses 2L O2 at baseline at home which he bumped
up to 3L on his own over the last week, but SOB progressive so
presented. He has chronic LE edema for which he wears TEDS and
notes that over the past 3 days, swelling in his legs has also
worsened. He denies leg pain, redness, warmth. He denies dietary
indiscretions, no CP/palpitations. He has been urinating without
difficulty. He sleeps with 2 pillows and HOB at an angle at
baseline and reports this has not changed--however, he has been
waking up at night short of breath and moves to a recliner in
which he is somewhat more comfortable. No fevers/chills. Reports
infrequent cough which was productive of small amount of clear
sputum last night with blood specks throughout; this am clear
sputum only, no blood.
.
Of note, he was admitted in [**4-/2133**] with chief complaint of
hemoptysis. Imaging suggested pulmonary hemorrhage. He underwent
bronchoscopy at that time without HD compromise, requiring 2U
prbc transfusions throughout his stay. He underwent bronchoscopy
which did not demonstrate any active bleeding or endobronchial
lesions. Washings were sent for cytology and were negative for
malignant cells. Given negative w/u otherwise, his hemoptysis
was thought to be in the setting of decompensated CHF and
pulmonary htn. In the setting of a.fib and elevated CHADS2
score, he was continued on his coumadin upon discharge. He was
discharged home on [**Hospital1 **] 80mg PO torsemide, which has been
increased by his cardiologist to 200mg qam, and 100mg qpm since
d/c.
.
In the ED, intial vitals were T: 97.5 BP: 140/44 HR: 60 RR: 16
O2sat: 95% 3L NC. CXR was performed which showed new Left
pleural effusion and interstitial edema. He received ethacrynic
acid 50 mg IV x1 (pharmacy did not have torsemide). Hct was 23
on presentation, down from 28.5 on [**2133-4-15**] (last in our system).
Records from [**6-23**] from his [**Hospital3 **] indicate a hematocrit
of 20.4 and Cr of 3.9, and [**6-16**] HCT of 23. Physical exam
revealed guaiac positive brown stool. Repeat hct in ED was 21.6.
He reports dark colored stool in the setting of taking iron
which is unchanged and reports rare bright red blood on TP only
when constipated; none recently. He was transfused 1 u prbc in
the ED, and received a second dose of 50 gm IV ethacrynic acid.
Total recorded UOP in ED was 2 liters.
.
ROS: As above. Additionally, No LH/dizziness. +50lb weight loss
since CABG in 7/[**2132**]. Poor appetite over the past week. No
HA/changes in vision. No numbness/tingling/weakness. No
N/V/abdominal pain. No dysuria/hematuria. No joint pain. No
rashes. In general, his most bothersome complaint is fatigue.
Past Medical History:
-CAD s/p Coronary Artery Bypass Graft x 5 [**2132-8-8**] (Left internal
mammary artery > Left anterior descending, saphenous vein graft
> diagonal, saphenous vein graft > obtuse marginal 1, saphenous
vein graft > obtuse marginal 2, saphenous vein graft > posterior
descending artery)
-Diastolic CHF
-HTN
-Mitral regurg (1+), Aortic regurg (1+), Tricuspid regurg (2+)
-Dyslipidemia
-Hypothyroidism
-Gout
-Bladder CA (12 years ago)
-Pericarditis (remote)
-Stage IV CKD; largely secondary to microvascular disease of the
kidney, but possibly with a component of atheroembolic disease
in light of persistently elevated eosinophil count and mildly
low complement levels.
-Atrial fibrillation
-Hemoptysis ([**4-/2133**])
-s/p right knee replacement
Social History:
Pt. is a retired CPA, he recently moved into an [**Hospital3 **]
facility. He is able to maintain ADLs, cares for himself. Pt.
smoked but quit 45 years ago; does not drink alcohol currently
and used rarely before his CABG, and has never used recreational
drugs. He is a veteran of WWII.
Family History:
n/c
Physical Exam:
Vitals: 100.0/100.0, 140/50, 56, 18, 96%2L
Weight: 94.1kg
General appearance: Resting in bed, comfotable, pleasant.
Speaking in full sentences
Cardiac: RRR. III/VI systolic murmur heard loudest at left
sternal border. JVP not elevated, ~8cm.
Pulm: Diminshed breast sounds at left base, otherwise clear to
auscultation.
Abd: Soft, + BS, NT, ND.
Ext: Warm and well perfused. Edema not significantly changed.
Skin: No jaundice nor rashes appreciated
Pertinent Results:
CXR ([**6-23**]): 1. New moderate-to-large left pleural effusion with
left basilar opacity concerning for possible underlying
infection. Parapneumonic effusion cannot be excluded. 2.
Vascular congestion with evidence of interstitial edema.
.
CXR ([**6-25**]): Slightly improved interstitial pulmonary edema and
left pleural effusion, but residual right lower lobe airspace
opacity. Followup radiographs after appropriate diuresis
recommended to exclude underlying consolitdation.
.
Renal ultrasound ([**6-26**]): No evidence of hydronephrosis.
.
TEE ([**7-2**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 60-70%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
The tricuspid regurgitation jet is eccentric and may be
underestimated. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2133-3-31**], the findings are similar.
.
CXR ([**7-3**]): 1. Worsening left more than right pleural effusion.
2. Stable cardiomegaly and pulmonary edema.
.
CXR ([**7-6**]): 1. Worsening left more than right pleural effusion.
2. Stable cardiomegaly and pulmonary edema.
.
Chest CT ([**7-9**]): 1. New multifocal ground-glass opacities,
affecting the right lung to a much greater degree than the left.
These findings are concerning for an evolving infection in the
appropriate clinical setting. An asymmetric distribution of
pulmonary edema is less likely. Other causes such as hemorrhage
should also be considered in the appropriate clinical setting.
2. Increasing moderate left pleural effusion. 3. New 7-mm right
basilar lung nodule, most likely inflammatory or infectious
considering rapid development in three months. Followup CT in
three months is recommended to document resolution and to
exclude the less likely possibility of malignancy. 4. Improved
mediastinal lymphadenopathy.
.
CXR ([**7-10**]): Interval reduction in the large left pleural
effusions with
persistent small bilateral pleural effusions status post left
thoracentesis without development of pneumothorax.
Brief Hospital Course:
1. SOB/dCHF: CXR with pulmonary edema and new left sided pleural
effusion in conjunction with worsening LE edema, most c/w CHF
exacerbation. Denies CP and EKG without changes concerning for
active ischemia (essentially unchanged from prior). On
admission, his trop was mildly elevated to 0.13, but this is in
the setting of CKD where BL trop runs 0.10-0.15, and trending
down. Patient ruled out for MI and was diuresed with IV
ethacrynic acid and Diurel. Max 1.5 liter negative on 100 mg
eth. acid [**Hospital1 **] and 500 mg Diuril [**Hospital1 **]. Attempted transition to po
diuretics, but this yielded only a 400 cc negative fluid
balance. Patient is oxygen dependent because of chronic
pulmonary edema. Patient was transfered to the ICU and CVVH
ultrafiltration with dialysis and his weight dropped from 116kg
to 91kg. He was transfered back to the floor and resumed his
oral diuertic regimen. He continued to gain weight and
experienced electrolyte abnormailities including hyperkalemia
and hyperphosphatemia so the decision was made to initiate
dialysis on [**2133-7-11**].
.
2. Renal failure: Likely pre-renal azotemia exacerbated by CHF,
as described above. Received dialysis during ultrafiltration, on
[**7-11**], and on [**7-13**]; dispo to MACU with MWF dosing schdule.
.
3. Anemia: chronic renal insufficiency with epo resistance due
to iron deficiency. Received four units prbc on this
hospitalization and 4 infusions of IV iron with stabilization of
blood counts at 28. Has guaiac positive stool and known history
of hemorrhoids--outpatient follow up, do not think this is
playing a major role in his anemia currently. Returned to PO
iron, then epo + iron during hemodialysis.
.
4. Hemoptysis: blood tinged sputum, small volume, 1-2 times per
day. Resolved by transfer back from MICU. Had bronchoscopy and
CT at last hospitalization without clear endobronchial lesion
per notes. Pulm consulted on this hospitalization as well, and
think this is pulm hypertension with pulmonary edema. Holding
coumadin for anticoagulation for now, see below.
.
5. Paroxysmal atrial fibrillation: Given 12.5 mg [**Hospital1 **] metoprolol
which is leading to a HR near 60 on telemetry. Higher doses led
to bradycardia in 40s-50s, which possibly contributed to his
presentation (per his home meds, was on 75 mg toprol xl [**Hospital1 **]).
In normal sinus rhythm on discharge with some PVCs and missed
beats. Given the ongoing hemoptysis, plan is to continue aspirin
325 mg daily for now. Once fluid status more stable, can
re-challenge with coumadin. Would prefer coumadin for AC given
high CHADS2 score. If transitioned back to coumadin, needs
aspirin dose lowered to 81 mg daily. Please follow-up as
outpatient.
.
7. Hypertension: Began norvasc, metoprolol, hydralazine and
isordil per outpatient regimen. After ultrafiltration volume
loss resulted in hypotension, currently on ASA and metoprolol,
holding hydralazine, amlodipine, and isordil. No ace/[**Last Name (un) **] given
acute on chronic renal insufficiency, per renal recommendations.
Recommed discussion on follow-up.
.
8. Leukopenia/thrombocytopenia: Mild and not neutropenic. ?
degree of MDS or marrow suppression. No need for platelets at
this time.
.
9. Dyslipidemia: Continued statin and niacin.
.
10. Hypothyroidism: Continued outpatient dose of levoxyl. Of
note, TSH was elevated on multiple last admissions. FT4 was
normal at that time, however. Dose of levothyroxine was
increased during last admission, however TFTs have not been
repeated within our system since then. [**Month (only) 116**] be contributing to
volume status if is under repleted. Continued levothyroxine at
current dose.
.
11. Gout: Continued allopurinol renally dosed.
Medications on Admission:
Isordil 20 mg po bid
Calcitriol 0.25 mg po daily
Lipitor 20 mg daily
Toprol XL 75 mg po bid
Allopurinol 100 mg eod
Norvasc 10 mg daily
Hydralazine 50 mg tid
Torsemide 200 mg/100 mg
Synthroid 88 mcg daily
KCL 40 meq daily
Trazodone 200 mg qhs
Albuterol inh qid
Lexapro 20 mg daily
Coumadin 2 mg
Procrit [**Numeric Identifier 961**] U/mL qThursday
FeSO4 325 mg daily
Oscal 500 mg po bid
SLO Niacin 500 mg dialy
Lysine 500 mg daily
Mag Oxide 400 mg daily
Centrum silver
Vitamin C
Aspirin 81 mg daily
Citrucel
Senna [**2-4**] po bid prn
Tylenol 650 mg 2 tablets daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
CHF exacerbation
Iron deficiency anemia
Acute renal failure on chronic renal insufficiency
Secondary:
Coronary artery disease
Discharge Condition:
Stable, on 2 L O2.
Discharge Instructions:
The patient was admitted for CHF exacerbation, anemia and acute
on chronic renal failure. He was diuresed and transfused 4 units
of RBC. The patient failed transition to an oral diuretic
regimen and was admitted to the ICU for CVVH/ultrafiltration.
Over 20L of fluid was removed, and the patient was transfered
back to the medical floor. He again failed oral diuresis and was
initiated on hemodialysis.
The patient carries a diagnosis of heart failure with an
ejection fraction of 60-70% on the most recent echocardiogram.
Please weigh him before dialysis. Please maintain a low sodium
(<2g), Cardiac/Heart healthy diet. A fluid restriction is not
necessary at this time. The patient is not currently taking an
ace-inhibitor, at nephrology follow-up please discuss the
addition of an ACE-inhibitor now that the patient is on
hemodialysis.
The patient carries a diagnosis of paryoxsmal atrial
fibrilation. When admitted he was taking both aspirin and
warfarin for prophylaxis, but the warfarin was held in the
setting of hemoptysis. At follow-up, please discuss the risks vs
benefits of adding warfarin back to the patient's medication
regimen.
Please call a physician or have the patient return to the
hospital if he develops a fever > 102F, develops increasing
shortness or breath, chest pain, or any other concerning
symptoms.
Followup Instructions:
You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab after
discharge.
You have an appointment for follow-up with Dr. [**Last Name (STitle) 1366**], from
nephrology in the [**Hospital1 18**] [**Hospital Ward Name 23**] Center on Thursday, [**8-13**] at
3:30pm.
You have an appointment for follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
pulmonology at the [**Hospital1 18**] [**Hospital Ward Name 23**] Center on [**8-26**] at 1:30pm.
Please arrive at 12:30pm for a chest xray.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
Completed by:[**2133-7-14**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,077
| 186,239
|
39565
|
Discharge summary
|
report
|
Admission Date: [**2199-11-20**] Discharge Date: [**2199-11-27**]
Date of Birth: [**2121-11-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Fever, chills.
Major Surgical or Invasive Procedure:
Left pleurex catheter placement ([**2199-11-22**]).
History of Present Illness:
Mr. [**Known lastname **] is a 78M with PMH significant for gastric CA
currently on palliative chemo (last dose 3 weeks ago) and s/p
right nephrostomy tube who presented to the ED from rehab where
is was found to be febrile to 101.2 and hypoxic to 77-83% on RA
with SOB. Pt had one episode of vomitting this AM loose stools
over the past day or so. In the [**Hospital1 18**] ED, initial VS T 100.1, HR
70, BP 116/70, RR 18, sat 96% 3L. While in the [**Name (NI) **], pt was found
to be in a fib with episodes of RVR up to 140s-160s. Pt recieved
ample fuids but no rate control agents and rate ultimately came
down to 110s. UA from bladder and nephrostomy tube were both
significant for many bacteria, moderate leuk, and >50 WBCs.
Worsened L pleural effusion on CXR. He got a total of 4L IVF
while in the ED. He recievbed 2 doses of pip/tazo and 1 dose of
vanco. He also got Tylenol and a dose of 30mg Troadol for fevers
and CP. He became hypotensive into the 70s/50s. A right IJ was
placed and norepinephrine was started. At the time of transfer,
VS T 100.4, HR 112 (AF), BP 130/78, RR 20, sat 95-96% on 50%
FiO2. He was admitted to the ICU for further mangement of his
hypoxemia and likely sepsis [**1-15**] UTI as well as his pleural
effusion.
On arrival to the floor, pt has no complaints and is breathing
comfortably on 5L NC. Otherwise, ROS is unremarkable.
Past Medical History:
Basilar artery stroke [**8-/2199**], s/p embolectomy and intrarterial
tPA injection
Stage IV gastric malignancy with malignant pleural effusion
Atrial Fibrillation
Hypertension
Hyperlipidemia
BPH
Depression/Anxiety
Osteoarthritis
Obstructive Uropathy s/p right percutaneous nephrostomy
Social History:
His wife died in [**2193**] due to metastatic lung cancer. He
previously lived alone but recently moved in with his son &
daughter. [**Name (NI) **] is retired, previously working 40 years in the
airline industry as a maintenance supervisor. Has family nearby
who are involved in his care. Smoked 1ppd x 20 years tobacco,
quitting in the [**2158**]. Social alcohol. No recreational drugs. He
has been at rehab since d/c from [**Hospital1 18**] after his stroke.
Family History:
Father died of pneumonia at 64 years old; unknown other medical
issues. Mother died of pneumonia at 53 and had asthma.
Physical Exam:
VS: Temp: 95.9 BP: 129/115 HR: 104 RR: 100% O2sat on 5L
GEN: pleasant, comfortable, NAD. Oriented only to person, but
conversation is appropriate with accurate memory of recent
events.
Speech is slow with an occassional stutter.
HEENT: anicteric, MMM
RESP: decreease lung sounds in left lung base. No wheezes, no
focal crackles
CV: irregular, S1 and S2 wnl, no m/r/g
ABD: nd, soft, nt
EXT: no c/c/e
NEURO: strength symetric in UE and LE b/l. No focal deficit
noted.
exam at discharge:
teley: AF 70's-80's frequent VPB's pause 2.12
96.4 110/72 74 18 97RA.
GEN: NAD. A+0 X2-3 stable, no tachypnea
HEENT: PERRLA, EOMI, MMM, OP clear, no JVD, no cervical LAD
RESP: bil coarse basilar crackles per precussion no
reacumulation of pleural effusion after drainage today.
CV: [**Last Name (un) **], S1+2, no m/r/g
ABD: soft, NTND, BS+, no HSM, no shifting dullness. No CVA or
bladder tenderness
EXT: WWP, no c/c/e, no signs of DVT
Lines/Tubes: port accessed; foley catheter; right nephrostomy
tube; left pleurex all C/D/I.
Pertinent Results:
Labs at Admission:
[**2199-11-20**] 11:05AM BLOOD WBC-10.9# RBC-2.97* Hgb-9.1* Hct-27.8*
MCV-94 MCH-30.7 MCHC-32.8 RDW-17.6* Plt Ct-283
[**2199-11-20**] 11:05AM BLOOD Neuts-71* Bands-14* Lymphs-8* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-11-21**] 02:52AM BLOOD PT-14.8* PTT-34.2 INR(PT)-1.3*
[**2199-11-20**] 11:05AM BLOOD Glucose-91 UreaN-20 Creat-1.6* Na-142
K-4.2 Cl-104 HCO3-27 AnGap-15
[**2199-11-22**] 03:45AM BLOOD ALT-12 AST-17 LD(LDH)-236 AlkPhos-84
TotBili-0.2
[**2199-11-21**] 02:52AM BLOOD Calcium-8.1* Phos-4.9* Mg-1.5*
[**2199-11-21**] 01:50AM BLOOD Type-ART O2 Flow-3 pO2-99 pCO2-43 pH-7.36
calTCO2-25 Base XS--1 Comment-NASAL [**Last Name (un) 154**]
[**2199-11-20**] 03:37PM BLOOD Lactate-0.9
Labs at Transfer from [**Hospital Ward Name 332**] ICU:
[**2199-11-23**] 05:16AM BLOOD WBC-8.0 RBC-2.84* Hgb-9.1* Hct-26.9*
MCV-95 MCH-31.9 MCHC-33.8 RDW-17.2* Plt Ct-333
[**2199-11-23**] 05:16AM BLOOD Glucose-114* UreaN-24* Creat-1.6* Na-138
K-3.6 Cl-108 HCO3-24 AnGap-10
[**2199-11-23**] 05:16AM BLOOD ALT-10 AST-15 LD(LDH)-236 AlkPhos-69
TotBili-0.5
[**2199-11-23**] 05:16AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.1
Micro Data:
[**2199-11-20**] 3:50 pm URINE Site: CATHETER
RIGHT NEPHROSTOMY TUBE.
**FINAL REPORT [**2199-11-22**]**
URINE CULTURE (Final [**2199-11-22**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
.
Lab at discharge:
.
Imaging Studies:
Electrocardiogram ([**2199-11-20**]):
Atrial fibrillation with rapid ventricular response. Low limb
lead voltage. Delayed precordial R wave transition. Diffuse
non-specific ST-T wave flattening. Compared to the previous
tracing of [**2199-9-11**] there is variation in precordial lead
placement but the T wave abnormalities recorded in leads V4-V6
are not apparent. Otherwise, no diagnostic interim change.
Chest x-ray ([**2199-11-23**]):
As compared to the previous radiograph, there is no relevant
change. The pre-existing right lung parenchymal opacities are
stable. There is unchanged position and course of the right
central venous access line. On
the left, a segment of pleural drain is seen. There is no safe
evidence of
pneumothorax. The medial parts of the heart appear normal, the
lateral parts of the left hemithorax are not included in the
image.
Brief Hospital Course:
Mr. [**Known lastname 9147**] is a 78-year-old man with a PMH of gastric CA with
known malignant effusions, obstructive uropathy of unclear
etiology s/p right nephrostomy tube, and recent basilar stroke
who presented from rehab with hypoxia and hypotension. Workup
revealed UTI and accumulation of left pleural effusion, and
patient was admitted to [**Hospital Unit Name 153**] for need for pressors.
# UTI, hypotension: Patient had SIRS criteria given fever and
tacycardia, with either urinary or pulmonary source. Review of
prior culture data demonstrates pan-sensitive Klebsiella in
[**8-23**]. In addition, report of loose stools at rehab, so C.diff
also possible. Patient was aggressively volume resuscitated with
4L IVF prior to arrival. He was treated empirically with
vancomycin and Zosyn for urosepsis. Urine culture taken from the
nephrostomy tube later grew out Pseudomonas sensitive to Zosyn,
so the vancomycin was stopped. Stool and blood cultures were
negative. Pleural fluid cultures were negative. With treatment
of the urinary tract infection, his blood pressure improved and
the patient was quickly weaned off of Levophed. With regard to
his recent recurrent urinary tract infections, review of the
records shows that patient has had several such infections since
his right nephrostomy tube was placed in late [**Month (only) 216**]. The
nephrostomy tube has not been changed since that time. Urology
was consulted for management recommendations and recommended
that patient have the right nephrostomy tube changed in
interventional radiology. This procedure was succesffuly
performed on [**11-25**]. Patient will require 6 more days of
Zosyn for completion of total 14 day course of treatment.
Outpatient follow-up with urology was arranged. Per urology
foley catheter should be continued until this appointment.
.
# Hypoxemia: Patient saturating well on 3L NC at time of
admission. A-a gradient calculated at 61, suggesting V/Q
mismatch, diffusion, or shunt. Given CXR demonstrating large
loculated left sided pleural effusion that has previously been
sampled with results consistent with metastatic pleural
effusion, this hypoxemia is likely secondary to V/Q mismatch
from restrictive physiology of moderate to large pleural
effusion. Given hypotension, however, can not rule out
underlying consolidation. Patient underwent left pleural
catheter placement on the third hospital day. Due to
communication error, he did receive Lovenox dose on the morning
the catheter was placed. However, serial chest x-rays and
hematocrits showed stability and no evidence of bleeding
post-procedure. The effusion is a known malignant effusion, and
per interventional pulmonary, the catheter should be left in
place. As above, cultures from the pleural fluid were negative
for infection. His respiratory status improved with drainage of
the effusion and he was able to be weaned off oxygen. Patient
subsequently required drainage Q3d and drained 1L on each
occasion. Per Pulmonary consult should continue drainage every
2-3 days or per symptoms.
.
# Gastric cancer: s/p 1 cycle of EOX [**2199-8-22**] to [**2199-9-11**] and 2
cycles of irinotecan, last dose [**2199-10-30**]. Per primary
oncologist, CT scan demonstrates a mixed response to irinotecan.
A trial of capecitabine may be considered post discharge. This
was discussed at length with the patient's son, [**Name (NI) **], his proxy
by Dr. [**Last Name (STitle) **] the out patient oncologist and she will continue
to follow-up post dicharge.
.
# CVA: s/p CVA in the setting of AF: Lovenox was held after the
Pleurex was placed. Gave IV heprin in the interim per renal
functions. Pnt's CCL = 38. Lovenox was restarted at 60mg [**Hospital1 **]
(i.e. less than 1mg/kg [**Hospital1 **] as his renal functions are marginal),
anti-factor Xa measurment may be done post discharge for
optimization of dosing.
.
# AF: patient noted to have AF with a number episodes of RVR
during this admission. Good rate control was achieved by
increasing PO Metoprolol dose to 25mg QID. Anticoagulation with
Lovenox as discussed above.
.
# Anemia: Stable at baseline hct of 27. He received one unit of
packed red cells on the third hospital day, due to slight drop
in hematocrit. He had an appropriate bump in hematocrit, from 22
to 27, and he remained hemodynamically stable.
.
# HTN: well controlled with metoprolol as above.
.
# Hyperlipidemia: Statin continued.
# Depression/Anxiety: Continue home trazodone PRN at HS.
# Obstructive Uropathy s/p right percutaneous nephrostomy:
Management for his obstructive uropathy and recurrent urinary
tract infections is described above.
.
# Code Status during this admission: DNR, ok to intubate.
Medications on Admission:
- enoxaparin 80 mg/0.8 mL Syringe one injection daily.
- famotidine 20 mg Tablet one Tablet(s) by mouth daily @ 6am.
- hydrocodone-acetaminophen [Vicodin] 5 mg-500 mg every 6 hours
as needed
- imodium 2mg po at first sign of diarrhea, then every 2 hours
as needed
- ipratropium-albuterol [DuoNeb] one neb inhalation every 6
hours as needed
- metoprolol tartrate 25 mg Tablet 1.5 Tablet(s) by mouth three
times a day
- ondansetron HCl 8 mg Tablet Take 1 twice a day as needed for
nausea.
- prochlorperazine maleate 10 mg Tablet by mouth every 6 hours
as needed
- simvastatin 40 mg Tablet one Tablet(s) by mouth once a day at
bedtime
- trazodone 50 mg Tablet one Tablet(s) by mouth daily at
bedtime.
- acetaminophen [Tylenol] 325 mg 2 Tablet(s) by mouth every 4
hours as needed
- bisacodyl [Dulcolax] 10 mg one Suppository(s) rectally daily
- sodium [Colace] 100 mg Capsule
- magnesium hydroxide [Milk of Magnesia]
- multivitamin
- senna 8.6 mg Tablet one Tablet(s) by mouth twice daily
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain, fever.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
7. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 gram Intravenous Q8H (every 8 hours) for 6 days.
8. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
11. Docusil 100 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for constipation.
12. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Metastatic Gastric Cancer
Malignant pleural effusions
obstructive uropathy
Urinary Tract Infection
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in because of low blood pressure and low level of
oxygen in your blood.
.
You were found to have a urinary tract infection which was
treated with antibiotics. You will need to continue antibiotic
treatment for 6 days after your discharge.
.
You were also found to have liquid accumulation around your left
lung which was causing you trouble with oxygenation. You were
seen by our lung doctors who inserted a drain into your left
chest. The fluid will need to continue to be drained every 3
days.
.
You were also found to have irregular fast heart rate. The dose
of your home metoprolol was increased and your heart rate
subsequently improved.
.
Your nephrostomy tube was successfully replaced during this
admission. Please follow-up with urology as outlined below.
.
The following changes were made to your medications:
- CHNAGED enoxaparin to one 60 mg Subcutaneous Injection [**Hospital1 **] (2
times a day).
- INCREASED metoprolol tartrate to 25 mg Tablet, One (1) Tablet
PO QID (4 times a day).
- STARTED piperacillin-tazobactam-dextrs 4.5 gram/100 mL
Piggyback Sig: 4.5 gram Intravenous Q8H (every 8 hours) for 6
days.
.
.
Please continue the rest of your medications without change.
Followup Instructions:
Department: SURGICAL SPECIALTIES/UROLOGY
When: THURSDAY [**2199-12-19**] at 2:50 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 5727**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2199-12-18**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2199-11-29**]
|
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"785.52",
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"038.9",
"276.52",
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"600.01",
"272.0",
"V10.09",
"599.60",
"041.7",
"799.02",
"511.81",
"V12.54",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"34.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13498, 13569
|
6652, 11339
|
290, 343
|
13732, 13732
|
3712, 5733
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15109, 15760
|
2540, 2661
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12374, 13475
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13590, 13711
|
11365, 12351
|
13883, 15086
|
2676, 3148
|
5747, 5750
|
236, 252
|
371, 1736
|
13747, 13859
|
1758, 2045
|
2061, 2524
|
5768, 6629
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,135
| 153,608
|
51229
|
Discharge summary
|
report
|
Admission Date: [**2162-8-26**] Discharge Date: [**2162-9-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Palpitations and chest pressure
Major Surgical or Invasive Procedure:
Placement of tunneled HD catheter ([**2162-9-21**])
Placement of temporary internal jugular central venous line *2
Placement of tunneled IJ central venous line
Left sided thoracentesis
IR guided PICC placement
History of Present Illness:
85 year old female status post coronary artery bypass grafts x 3
and mitral valve annuloplasty on [**2162-8-16**], chronic systolic CHF
(EF 30%), HTN, and CKD presents with chest pain and
palpitations. The patient was discharged to rehab from [**Hospital1 18**] on
[**8-24**] after CABG for 3V CAD. On the day prior to admission she
experienced a fluttering sensation in her chest and "heaviness"
in her legs while walking around. She has had lower extremity
swelling bilaterally, but did not have chest pain until the
morning of admission. On the day of admission she awoke with
sub-sternal chest pain radiating to the left arm and back,
associated with palpitations but not with SOB. The pain was not
positional. She noted a stable cough with clear sputum
attributed to a new medication started post-op. She also noted
some difficulty with swallowing since leaving the hospital. She
has not had fever, chills, URI symptoms, dizziness,
light-headedness, diaphoresis, orthopnea, or PND. She did not
experience chest pain when she had her prior MI. She was taken
from rehab to [**Hospital1 **]-[**Location (un) 620**] by ambulance and subsequently
transferred to [**Hospital1 18**] for further evaluation and management.
Pre-hospital vital signs: HR 79 BP 159/78 RR 20 O2sat 100% 2L
NC. In ED, T 95.5 HR 76 BP 138/76 RR 16 O2sat 99%RA. Bedside
[**Hospital1 113**] revealed small pericardial effusion. Given ASA 324 mg PO,
morphine 2 mg IV, SL NTG x 3, lasix 40 mg IV and admitted to the
floor.
Past Medical History:
-Coronary Artery Disease with Coronary artery bypass graft x 3
on [**2162-8-16**] (LIMA-LAD, SVG-OM, SVG-PDA)
-Mitral valve annuloplasty [**2162-8-16**]
-Systolic CHF (LVEF 30% on TTE [**2162-8-16**])
-CKD (b/l Cr 3.3)
-Anemia of CKD - b/l Hct ~30
-Hyperlipidemia
-HTN
-GERD
-Gout
-Diverticulosis
-Gastroparesis
-Depression
-Status post choleycystectomy
-Status post hernia repair
-Status post hip fracture repair
Social History:
She is a retired travel [**Doctor Last Name 360**]. She quit smoking one month prior
to admission and denies alcohol use. She lives with her spouse
when he is not also a patient in [**Hospital1 18**]. She has two grown
children who are very involved in her care.
Family History:
Mother: HTN
Father: HTN and CVA
Physical Exam:
<u>On Admission:</u>
V/S - Wt 90.8 kg HR 72 BP 126/57 RR 18 O2sat 100% 2L
Gen: Elderly obese female in NAD
HEENT: normocephalic, atraumatic; sclerae anicteric, PERRL,
EOMI, conjunctiva pale; OP clear with MMM
Neck: Supple with JVP at angle of jaw with head of bed at 30
degrees
CV: Regular rate and rhythm, nl S1S2, +S3 without murmurs or
rubs; sternal incision tender to palpation but clean, dry, and
intact
PULM: crackles to mid-lung fields bilaterally, diffuse wheezes,
no rhonchi
ABD: soft, nontender, nondistended, normoactive BS
EXT: warm, dry 2+ pitting edema LE bilat; calves NT; LLE venous
graft dressing clean, dry, and intact
<u>On discharge:</u>
VS: T 97.5, BP 100/63, HR 80, RR 18, O2 Sat 98% on 3L by NC
Neck: JVP at 2cm above clavicle at 30 degrees
CV: RRR, no murmurs, rubs, or gallops, +S3, sternal incision
scabbed over in areas, staples removed, less tender
Pulm: Scattered crackles bilaterally w/o whezes or rhonchi
Abd: Obese, soft, NT, ND, BS+
Extremities: Warm, 2+ pitting edema bilaterally, venous graft
harvest sites w/o erythema or signs of infection
Pertinent Results:
<b><u>LABORATORY RESULTS</b></u>
On Admission:
WBC-7.0 RBC-3.57* Hgb-10.6* Hct-31.9* MCV-89 Plt Ct-162
-----Neuts-82.3* Bands-0 Lymphs-7.7* Monos-3.8 Eos-6.0* Baso-0.2
PT-14.2* PTT-28.7 INR(PT)-1.2*
Glucose-83 UreaN-64* Creat-3.3* Na-135 K-4.7 Cl-100 HCO3-23
AnGap-17
Calcium-8.0* Phos-4.6* Mg-2.1
Cardiac Enzymes:
CPK: 37- 39- 20
CK-MB: ND- ND- ND
TropT: 1.20- 1.17- 1.13
On Discharge:
WBC 7.5, RBC 2.70*, Hb 8.5*, Hct 26.7*, MCV 99*, Plt 148*
PT 19.3*, PTT 38.1*, INR 1.8*
Glu 77, BUN 24*, Cr 3.0*, Na 141, K 4.5, Cl 110*, HCO3 25
<b><u>RADIOLOGIC STUDIES</b></u>
Chest Radiograph from Admission ([**2162-8-26**])
IMPRESSION: Persistent left pleural effusion with associated
atelectasis. Superimposed consolidative process in the left
lower lobe cannot be ruled out. Smaller right pleural effusion.
Overall, unchanged from [**2162-8-24**].
Chest Radiograph from [**2162-9-7**] (day of PICC placement and
thoracentesis)
IMPRESSION:
1. Right PICC ends in superior vena cava.
2. Stable appearance of the chest, including degree of
mediastinal widening, pulmonary vascular congestion, left
greater than right pleural effusions and cardiomegaly as well as
dense retrocardiac opacity.
<b><u>OTHER RESULTS</b></u>
EKG: [**2162-8-26**] 17:35 - SR @ 69 bpm nl axis; IVCD; QIII,F; no ST
depr/elev., TWF III, F (new), V4-V6 (old) unchanged from exam on
[**2162-8-18**]
TTE [**2162-8-27**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *22 < 15
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.82
Mitral Valve - E Wave deceleration time: *139 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2162-8-2**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderate regional LV systolic dysfunction. No LV mass/thrombus.
No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mitral valve annuloplasty ring. Well-seated mitral annular ring
with normal gradient. No MS. [**Name13 (STitle) **] MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with inferior and apical
akinesis. 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. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. A mitral
valve annuloplasty ring is present. The mitral annular ring
appears well seated and is not obstructing flow. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
-Compared with the prior study (images reviewed) of [**2162-8-2**],
no change.
TTE [**2162-9-3**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the inferolateral wall and distal lateral wall,
apex, and distal anterior walls. The remaining segments contract
normally (LVEF = 25-30%). No masses or thrombi are seen in the
left ventricle. 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. A mitral valve annuloplasty ring is present. The
mitral annular ring appears well seated and is not obstructing
flow. An eccentric jet of mild (1+) mitral regurgitation. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be quantified. There is a very small
circumferential pericardial effusion without evidence of
hemodynamic compromise.
Compared with the prior study of [**2162-8-2**] (images reviewed),
regional left ventricular systolic function is similar.
Brief Hospital Course:
This is an 85 y.o. female with past medical history significant
for CHF, CAD s/p CABG, and CKD presenting with CHF exacerbation
complicated by [**Last Name (un) **] on CKD requiring initiation of hemodialysis.
1) Acute on chronic systolic and diastolic CHF - Initial search
for dangerous etiologies of decompensation was negative. Serial
CK's were negative, making an ischemic event an improbable
precipitant of CHF exacerbation and TTE didn't show any acute
MR, which was a concern given recent MV annuloplasty. It was
inferred that the most likely etiology of her exacerbation was
an inadequate home diuresis regimen. Therefore the patient was
placed on a 1L fluid restriction and started on aggressive
diuresis. She was treated with IV lasix boluses followed by
lasix gtt when her creatinine increased from baseline.
Eventually, when pt was nearly 7 liters negative from admission
urine output slowed despite increasing furosemide drip rate (max
at 30 mg/hr) and the patient went into anuric ATN. At this
point patient stopped making urine and further medical diuresis
impossible (see below). Patient had bilateral pleural effusions
(L>R) at this point and complaining of subjective dyspnea though
O2 requirement not dramatically worsened (saturations in upper
90's on 4L by NC). Interventional pulmonology was consulted and
decided to do therapeutic thoracentesis on left. This resulted
in some minimal improvement in subjective dyspnea. The patient
continued to appear quite fluid overloaded and had diminished
breath sounds over the ensuing days. Eventually, with
initiation of dialysis patient began to have slightly improved
lung exam. Despite this and better oxygen saturations
(consistently 99-100% on 4L) patient continued to complain of
subjective dyspnea, which was relieved somewhat by morphine.
Eventually, after longer dialysis course and consistent fluid
removal with dialysis patient began to complain of less dyspnea
and O2 requirements dropped to 3L by NC.
2)CAD s/p CABG x 3 - Although the patient presented with chest
pain, EKG was unchanged from prior and CK was WNL. Troponins
were elevated but the patient had CABG [**64**] days prior to
admission and has CKD so there was a very low index of suspicion
for acute coronary syndrome. After her first few days in the
hospital her chest pain did not recur. [**Year (2 digits) **] did not reveal any
new wall motion abnormality. She was continued on her aspirin,
clopidogrel, and statin throughout her hospitalization. Staples
from midline chest incision were removed by the CT surgery team
while the patient was in the hospital.
3) AFib - The patient had recurrence of this arrhythmia during
this hospitalization, which had initially occurred during her
post-op course following CABG. Initially, she was quite
symptomatic with this rhythm, so after being rate controlled
with metoprolol she was loaded on amiodarone and then put on
oral maintenance therapy. Later in her hospitalization she
switched back to afib with reasonable rates (80's to 90's) and
seemed to have no additional distress from this rhythm. She
always reverted back to sinus over a period of hours and then
stayed more consistently in NSR in the days preceding discharge.
Systemic anticoagulation was initially begun with coumadin and
a heparin gtt bridge, but she was later switched back to heparin
and this was then discontinued in order to facilitate necessary
procedures. She was restarted on coumadin at disposition
without a bridge as the incremental daily risk from embolic
phenomena in atrial fibrillation is quite low and she was
spending the vast majority of her time in sinus rhythm.
4) E. Coli UTI - The patient was found to have an E. coli UTI
during her hospitalization. She was treated with three days of
ceftriaxone IV based on susceptibility data. Later cultures
revealed cure of this organism but did grow yeast. As the
patient had an indwelling catheter at this point and wasn't
symptomatic the foley was removed and no further treatment was
rendered for this presumed colonization.
5) Anemia of CKD - Patient has a baseline anemia w/ Hct of
approximately 30. Hct monitored daily and trended down during
period of extreme volume overload and worse uremia in early
[**Month (only) **]. As patient was continuing to complain of subjective
shortness of breath and given generally precarious status she
was transfused three units pRBC's during this period. Hct
responded appropriately to these transfusions and no signs of
clinically apparent bleeding. Minimal symptomatic improvement
was noted with these transfusions. The patient did begin to
trend down once again as discharge approached but this was slow
and presumed due to poor nutrition. No further transfusions
given.
6) HTN ?????? On admission the patient was on metoprolol and
lisinopril. Lisinopril was stopped as the patient's renal
function began to decline and couldn't be restarted given
continued hope for renal recovery. Metoprolol had to be
stopped during period immediately preceding and immediately
following initiation of dialysis when the patient was having
multiple hypotensive episodes. Metoprolol was restarted prior
to discharge as blood pressures began to improve and hydralazine
was also started for afterload reducttion presuming that
lisinopril would not be started in the near future.
7) Hypotension: In the days immediately preceding and
immediately following initiation of dialysis the patient had
considerable problems with hypotension with [**Name (NI) 5462**] as low as the
80's. These were presumed secondary to a combination of
hypovolemia and inadequate cardiac output in the setting of
total body fluid overload and aggressive diuresis and/or fluid
removal with HD. In the days preceeding HD initiation dopamine
and dobutamine were used to maintain MAP's >60. Neo-synephrine
was needed for one night in order to maintain pressures in the
face of a need to wean dopamine secondary to tachycardia. After
dialysis was initiated the patient was hypotensive following her
first [**3-9**] treatments. Initially attempts were made to manage
this with pressors, but ultimately it was shown to respond to
fluid boluses. This stifled attempts to make patient more fluid
negative but did allow continued dialysis and improvement of
metabolic abnormalities. After the first few days of dialysis
blood pressures began to improve allowing more consistent fluid
removal without further hypotension.
8) Anuric acute kidney injury on chronic kidney disease: The
patient has CKD with baseline creatinine of approximately three.
With aggressive diuresis this eventually increased to >4 and
patient stopped making urine. This anuric [**Last Name (un) **] was presumed
secondary to dehydration and poor pump function causing prerenal
insult in setting of CKD. Diuresis was stopped prior to anuria
and the patient was started on dopamine in hopes of increasing
renal perfusion. She was not able to tolerate dopamine due to
tachycardia but was able to tolerate dobutamine and was observed
on this therapy for any signs of renal recovery. Unfortunately,
this did not occur and BUN and Cr continued to rise as patient's
volume status continued to become more progressively positive.
With increasing uremia and volume overload the patient became
increasingly symptomatic with nausea, fluctuating mental status,
mild asterixis, generalized weakness, and anorexia. BUN peaked
at 84 and Cr peaked at 5.1. Ultimately, the patient's children
(her health care proxies) elected to proceed with a temporary
course of hemodialysis. A temporary IJ line was placed and
patient received hemodialysis, which was initially complicated
by hypotension. This limited the amount of fluid removal which
was possible. BUN and Cr fell quite quickly but the patient
continued to be quite symptomatic and despondent with
fluctuating mental status and intermittent expressions of a
desire to just be left alone to die and/or stop care.
Eventually, after [**4-10**] treatments the patient's blood pressure
began to better tolerate HD and thus more aggressive fluid
removal was possible. At this the patient began to improve
symptomatically and was more interactive and had fewer
complaints of shortness of breath. Unfortunately, patient self
discontinued her first IJ line, which led to the placement of a
second after the patient was asked and expressed a desire to
continue dialysis. Prior to discharge a more permanent,
tunneled HD catheter was placed. Prior to her CABG the patient
had expressed a strong preference to not remain on permanent HD
but did express willingness to do it temporarily. There will be
continued conversations between the patient, her family, and
nephrology about the exact parameters of temporary dialysis and
duration of this therapy. Until a decision to stop is made that
patient will continue to be dialyzed as an outpatient at her
MACU.
9) Delirium: The patient had waxing and [**Doctor Last Name 688**] mental status
around the period when dialysis was initiated. She generally
remained A&O*3 but was quite unwilling or unable to participate
in discussions about her care and would vacillate between
expressing anger at having care continued versus a desire to
keep going. She also appeared quite somnolent. The patient was
also intermittently quite agitated and would scream for her
children at times. Was disoriented to time and situation on one
day in particular when she thought she was in ??????a doctors [**Name5 (PTitle) 3726**]??????
and ??????being hypnotized.?????? The patient also self-discontinued her
first IJ as described above. Patient was managed on haloperidol
at the worst of this period, which worked well. Etiology of
delirium was never fully understood as it began during worst of
uremia but continued as the uremia resolved with dialysis.
Infection was considered but she was having daily chest
radiographs at this time and urine culture revealed only yeast
(described above). EKG and daily chest radiographs showed no
acute change. Possibly metabolic encephalopathy vs ICU
psychosis vs chronic sleep disturbance vs pseudodementia were
entertained in the differential. These symptoms eventually
began to resolve with a longer period of dialysis and clearer
decisions about course and goals of care. At time of discharge
patient mentating at close to if not at baseline.
10) Depression: The patient became quite depressed and
despondent as her hospital course continued. At the peak of her
renal failure and uremia she was intermittently asking her
children to put her out of her misery and "put me to sleep like
an animal." Patient also persistently complained that she
couldn't breathe and of subjective dyspnea despite stable and
reasonable O2 saturations. The patient has a history of
depression and it was thought at least part of her despondency
and symptoms were due to depression and a degree of
somatization. Psych was consulted and initially recommended
haloperidol for agitation. Patient's mood began to improve and
she became more interactive as her situation improved. The
patient was also transitioned to an increased citalopram dose,
which she tolerated well.
11) Anorexia: The patient's appetite became very poor during
this hospitalization. This initially started during the period
of worsening fluid overload and uremia when she had considerable
nausea. This was presumed multifactorial possibly due to gut
edema and nausea. After initiation of dialysis the patient's
nausea improved but she continued to have very poor P.O. intake.
Given somewhat unclear goals of care at this point and unclear
decisions regarding desired interventions parenteral or tube
feedings were repeatedly discussed but were not initiated.
Eventually, patient's appetite began to improve though PO intake
was poor. Supplements were offered and diet was advanced with
some improvement in PO intake prior to discharge. A trial of
megesterol was initiated but eventually discontinued as the
patient objected to the taste of the medication and PO intake
was improving without it.
12) Ethics/Goals of Care: At the height of the patient's renal
failure there were multiple discussions with the patient's
family as well as nephrology, cardiothoracic surgery, and
cardiology teams about the best course to pursue. Prior to
surgery the patient had met with nephrology and agreed to
"temporary" dialysis with unclear parameters about how long this
could last. She had also expressed a strong desire to not be on
permanent dialysis. As patient's mental status was fluctuating
and expressed conflicting wishes at different times of day and
to different children it was quite difficult to ascertain her
wishes at that time. Given previous willingness to pursue
temporary dialysis and nephrology's prediction of 50% chance of
renal recovery to the point of not needing further dialysis, the
choice was made to proceed with HD. Initially, the patient was
intermittently quite despondent and expressed interest in ending
her life or not having any more therapy and/or dialysis, but
this was alternating with periods of expressing a desire for
further treatment. After the patient was dialyzed and more
consistently mentally clear she expressed a desire to proceed
with dialysis for some period of time.
13) Hyperlipidemia ?????? The patient was continued on her outpatent
atorvastatin.
The patient was initially on SC heparin for DVT prophylaxis and
this was maintained when she was not on systemic anticoagulation
for A fib. She was maintained on her home PPI. She initially
was full code but later in her hospitalization in consultation
with her family her status was changed to DNR/DNI. She will be
discharged to a MACU for further optimization of her medical
care and to continue to receive hemodialysis.
Medications on Admission:
1. Allopurinol 100 mg daily
2. Heparin (Porcine) 5,000 units SC TID
3. Epoetin Alfa 4,000 unit SC QMOWEFR (Monday
-Wednesday-Friday).
4. Pantoprazole 40 mg Tablet PO daily
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY (Every Other Day).
6. Citalopram 20 mg PO DAILY (Daily).
7. Atorvastatin 40 mg PO DAILY
8. Docusate Sodium 100 mg Capsule PO BID
9. Tramadol 50 mg PO Q 6 hrs as needed for pain.
10. Aspirin E.C. 325 mg PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet TIDAC (3 times a day (before
meals)).
12. Senna 8.6 mg Tablet PO BID
13. Metoprolol Succinate 12.5 mg PO DAILY
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
15. Lisinopril 2.5 mg PO DAILY
16. Furosemide 20 mg Tablet PO once a day
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 40 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. Acetaminophen 500 mg Capsule Sig: [**1-6**] Capsules PO Q6H (every
6 hours) as needed for pain.
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY, PRN () as
needed for pain: off for 12 hours per day.
16. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush.
18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
19. Morphine 10 mg/mL Solution Sig: 0.1cc Intravenous every
four (4) hours as needed for shortness of breath or wheezing.
20. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3
DAYS (Every 3 Days).
21. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
23. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate dose to goal INR of [**2-7**].
24. Outpatient Lab Work
Please check INR on [**2162-9-25**]. Titrate dose to goal INR of [**2-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
--------
1) Acute on chronic systolic and diastolic heart failure
2) Coronary artery disease status post coronary artery bypass
graft x 4 on [**2162-8-16**]
3) Acute Kidney Injury on Chronic kidney disease
4) Atrial fibrillation
5) S/P mitral valve annuloplasty
Secondary
----------
1) Hypertension
2) Hyperlipidemia
3) Anemia of chronic kidney disease
4) Atrial Fibrillation
5) Depression
6) Gout
Discharge Condition:
asymptomatic with stable vital signs
Discharge Instructions:
You were admitted to the hospital with worsening congestive
heart failure leading to the build up of fluid around the lungs
and in the legs.
Please weigh yourself every morning and call your physician
should your weight increase by greater than 3 lbs. Please adhere
to a 2 gram per day sodium diet and a 1 L daily fluid
restriction.
Your dose of lasix (furosemide) was increased to [ ]. Please
continue taking your other medications as prescribed.
Please call your physician or return to the Emergency Department
immediately if you experience lightheadedness, dizziness,
passing out, falls, difficulty swallowing, chest pain, shortness
of breath, palpitations, worsening cough, back pain, abdominal
pain, vomiting, diarrhea, bloody or dark stools, or leg
swelling.
.
Please continue to refrain from smoking. Information was given
to you on admission regarding smoking cessation and preventing
relapses.
Followup Instructions:
Nephrology:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Pt may see [**Hospital1 18**]
nephrologist at MACU.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**10-4**] at 1:20pm, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].
.
Primary Care:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], MD Phone: [**Telephone/Fax (1) 133**] Date/Time: Office will call
you with a time.
|
[
"311",
"414.00",
"428.0",
"585.9",
"403.90",
"584.9",
"041.4",
"599.0",
"518.81",
"427.31",
"285.21",
"V45.81",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
26396, 26462
|
9384, 23228
|
294, 505
|
26913, 26952
|
3913, 3946
|
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|
2767, 2800
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24026, 26373
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|
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|
26976, 27883
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2815, 2818
|
4302, 9361
|
4229, 4288
|
223, 256
|
533, 2030
|
3960, 4212
|
2052, 2467
|
2483, 2751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,577
| 135,411
|
18943
|
Discharge summary
|
report
|
Admission Date: [**2144-11-8**] Discharge Date: [**2144-12-4**]
Date of Birth: [**2092-8-6**] Sex: M
Service: SURGERY
Allergies:
Zestril
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
motorcycle trauma with hemodynamic instability
Major Surgical or Invasive Procedure:
[**11-8**] exploratory laparotomy, washout of BL arms, R groin and
repair R knee degloving injury
[**11-9**] washout of R groin, removal of lap band port, ORIF R elbow
[**11-10**] ORIF L elbow
[**11-11**] Trach, open placement of G-tube, removal gastric band
History of Present Illness:
52yo M on motorcycle who rearended a car and was then struck
from behind at 70mph. Initially brought to [**Hospital 189**] Hospital where
noted to have BL UE fractures, hypotensive, and thus intubated
and transferred to [**Hospital1 18**] for further eval and mgmt.
Past Medical History:
motorcycle trauma with BL open Monteggia fractures, R knee
degloving injury, hypotension, facial laceration
acute on chronic renal failure (previous baseline creatinine
2.0, now 2.7)
hypernatremia
anemia of chronic renal disease
morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now removed
DM2
CAD s/p stenting x2 ([**12-19**] at [**Hospital1 1774**])
HTN
hypercholesterolemia
CHF
OSA
Back Pain
Psoriatic Arthritis
L shoulder pain
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Former smoker, quit [**9-24**] after 80 pack year history. No current
ETOH, former heavy drinker. No illicits.
Family History:
Father - leukemia, [**Name2 (NI) 32071**] heart disease. Mother - [**Name (NI) 2320**].
Sister - [**Name (NI) 2320**].
Physical Exam:
50, 81/40, 18, 100%
Intubated. Moving legs BL, withdrawal to pain
Face swollen
BL breath sounds
L->midline abdominal laceration. FAST negative.
BL elbow lacerations with open fractures
R knee degloving injury.
Pertinent Results:
[**2144-12-4**] 01:36AM BLOOD WBC-7.4 RBC-2.62* Hgb-7.8* Hct-23.4*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 Plt Ct-174
[**2144-12-4**] 01:36AM BLOOD PT-17.6* PTT-34.0 INR(PT)-1.6*
[**2144-12-4**] 01:36AM BLOOD Glucose-46* UreaN-90* Creat-2.7* Na-139
K-5.7* Cl-106 HCO3-26 AnGap-13
[**2144-12-4**] 06:06AM BLOOD K-5.4*
[**2144-12-4**] 01:36AM BLOOD Calcium-9.1 Phos-5.8* Mg-3.0*
[**2144-11-26**] 02:33AM BLOOD calTIBC-160* Ferritn-978* TRF-123*
[**2144-11-8**] 08:22PM BLOOD ASA-NEG Ethanol-69* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
52yo M brought to [**Hospital1 18**] by ambulance as a trauma basic.
Evaluation in trauma bay demonstrated persistent hypotension
which mildly improved with IVF resuscitation and 3u PRBC
transfusion, despite a negative FAST examination. A DPL was
attempted and was not confirmatory for the absence of
hemoperitoneum. Accordingly, he was brought to the operating
room for exploratory laparotomy which did not reveal an
intraabdominal injury, as well as washout/debridement of his BL
UE injuries by orthopedics; please see each operative report for
further details. Post-operatively he was brought to the TSICU,
intubated and sedated, and hemodynamically stable. The
remainder of his hospital course will be summarized by system:
.
Neuro: Sedation and analgesia provided by drips during
intubation, weaned after tracheotomy. Currently off drips and
managed with intermittent ativan and oxycodone.
.
CV: Pressors were weaned off quickly after initial operation. He
was hemodynamically stable throughout the remainder of his
hospital stay. On lopressor, norvasc, and imdur for HTN, with
intermittent hydralazine.
.
Resp: The vent settings were progressively weaned, slowed by
volume overload from his perioperative resuscitation which was
limited due to his acute-on-chronic renal failure. He was
extubated on HD 10 but required reintubation that same day. He
was trach'd on HD 13 because of failure to wean/extubate. Vent
was progressively weaned, currently on CPAP/PS 35%, PS between 5
and 10, and PEEP 5. He tolerates trach collar intermittently.
He did have an enterobacter PNA on HD 15, resistant to
Zosyn/cephalosporins, which was treated with a 7-day course of
Cipro IV and Tobramycin inhaled.
.
GI: No intraabdominal injuries identified at laparotomy. The
port for the gastric band was exposed by the abdominal
laceration and removed on HD 2 by Dr. [**Last Name (STitle) **]. The remainder of
the gastric band was removed at the time of surgical g-tube
placement on HD 13. Tube feeds were begun the following day.
Has been on a bowel regimen with regular stools.
.
GU/Renal: Pt has chronic renal insufficiency, which flared to
acute renal failure after attempted diuresis. Initially
creatinine 2.1, peaked at 5.1, and settled at 2.7. Renal
consulted; presumably ATN. Vascular surgery consulted for
possible renal artery stenosis -- considered angiogram with
carbon dioxide contrast but deferred as renal function began to
improve. Hypernatremia of 155 treated with extensive FW
administration, resistant to improvement by both G-tube and IV,
now resolved and beginning to reduce the FW administration. One
additional attempt at diuresis on HD 25 caused sl increase in
creatinine and further attempts have been put on hold.
.
Heme: Pt was transfused in the trauma bay and OR. He remained
anemic with Hct in the low 20's over the next few days despite
continued transfusions, presumably from chronic renal failure.
Because he was hemodynamically stable, further transfusions were
not given. Ultimately he received 19 units of PRBC, 4u of Plts,
and 7u of FFP over the course of his hospitalization.
.
ID: Cellulitis of RUE surgical site treated with Kefzol for ~1
week. Enterobacter PNA on HD 15, resistant to
Zosyn/cephalosporins, which was treated with a 7-day course of
Cipro IV and Tobramycin inhaled.
.
Endo: Glycemic control managed by [**Last Name (un) **] consult, initially for
hyperglycemia and lately for hypoglycemia. Insulin gtt
initially required, now controlled with SQ by sliding scale and
long-term doses.
.
MSK: BL open Monteggia fractures washed out on HD 1, R fixed
with ORIF on HD 2, L fixed with ORIF on HD 3. Cellulitis of R
treated with Kefzol. R groin laceration washed out on HD 1 by
GenSurg, WTD dsg applied, and re-washed out on HD 2 with
placement of VAC. Currently receiving WTD to R groin. R knee
degloving injury was washed out by ortho on HD 1, wrapped, and
stitched eventually removed. Currently scabbed. C-spine and
TLS-spine were cleared radiographically. Nasal laceration at L
alar was repaired by plastics, with sutures removed prior to
discharge.
.
Proph: Hep SQ TID. GI prophylaxis ceased upon tolerance of TF.
Medications on Admission:
plavix 75', bASA', lopressor 25'', imdur 30', cozaar 100', lasix
80'', lipitor 80', zetia 10', gemfibrozil 600'', amaryl 2'',
novolin 14am/10pm, [**Last Name (un) **], celexa 20', flonase 50'', vit D
50000qwk
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-19**]
Drops Ophthalmic PRN (as needed).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q2H (every 2 hours) as needed.
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
8. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
9. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL
mL PO Q6H (every 6 hours) as needed.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q8H (every
8 hours).
18. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Insulin Glargine 100 unit/mL Solution Sig: 0.25 mL
Subcutaneous at bedtime: 25u of Glargine qday at bedtime.
21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous four times a day: Sliding Scale:
61-120 mg/dL 0 Units
121-140 mg/dL 4 Units
141-160 mg/dL 6 Units
161-180 mg/dL 8 Units
181-200 mg/dL 10 Units
201-220 mg/dL 12 Units
221-240 mg/dL 14 Units
241-260 mg/dL 16 Units
261-280 mg/dL 18 Units
281-300 mg/dL 20 Units
301-320 mg/dL 22 Units
321-340 mg/dL 24 Units
341-360 mg/dL 26 Units
361-380 mg/dL 28 Units
381-400 mg/dL 30 Units
> 400 mg/dL 32 Units
.
22. Metoclopramide 5 mg/mL Solution Sig: One (1) mL Injection
Q6H (every 6 hours).
23. Hydromorphone 2 mg/mL Solution Sig: 0.25-1 mL Injection Q3H
(every 3 hours) as needed for pain.
24. Lorazepam 2 mg/mL Syringe Sig: 0.25 mL Injection HS (at
bedtime).
25. Lorazepam 2 mg/mL Syringe Sig: 0.25 mL Injection Q8H (every
8 hours) as needed for agitation.
26. Hydralazine 20 mg/mL Solution Sig: 0.5-1 mL Injection Q6H
(every 6 hours) as needed for SBP > 160.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
motorcycle trauma with BL open Monteggia fractures, R knee
degloving injury, hypotension, facial laceration
acute on chronic renal failure (previous baseline creatinine
2.0, now 2.7)
hypernatremia
anemia of chronic renal disease
morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now removed
DM2
CAD s/p stenting x2 ([**12-19**] at [**Hospital1 1774**])
HTN
hypercholesterolemia
CHF
OSA
Back Pain
Psoriatic Arthritis
L shoulder pain
Discharge Condition:
stable, on vent via trach, tolerating tube feeds via g-tube.
Discharge Instructions:
[**Name8 (MD) **] MD for: fever or chills; nausea, vomiting, constipation,
diarrhea, or abdominal pain; redness, swelling, or drainage from
any incision.
Wean vent to trach collar as tolerated.
Tube feeds via G-tube.
Physical therapy for PROM of BL upper extremities.
Followup Instructions:
Follow-up with Trauma surgery, Dr. [**Last Name (STitle) **], in 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow-up with Orthopedic surgery, Drs. [**Last Name (STitle) 1005**] [**Name5 (PTitle) **] [**Name5 (PTitle) **],
in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow-up with Vascular surgery, Dr. [**Last Name (STitle) **], in 2 weeks.
Call [**Telephone/Fax (1) 2625**] for an appointment.
Follow-up with Bariatric surgery, Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 2723**]
for an appointment.
Follow-up with Nephrology, Dr. [**Last Name (STitle) 4090**], in 2 weeks. Call
[**Telephone/Fax (1) 3637**] for an appointment.
Follow-up with your outpatient primary care physician [**Last Name (NamePattern4) **] 2
weeks.
|
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icd9cm
|
[
[
[]
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[
"86.59",
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icd9pcs
|
[
[
[]
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9742, 9821
|
2483, 6672
|
313, 573
|
10322, 10385
|
1923, 2460
|
10704, 11492
|
1558, 1678
|
6931, 9719
|
9842, 10301
|
6698, 6908
|
10409, 10681
|
1693, 1904
|
227, 275
|
601, 868
|
890, 1348
|
1364, 1542
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,896
| 140,267
|
52066
|
Discharge summary
|
report
|
Admission Date: [**2177-3-24**] Discharge Date: [**2177-3-29**]
Date of Birth: [**2107-1-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 70-year-old man with
severe vascular disease including peripheral vascular disease
and coronary artery disease, hypertension, diabetes mellitus,
and atrial fibrillation on [**Year (4 digits) 197**] therapy, who presented to
the Emergency Room complaining of one day of abdominal pain.
The morning of admission, the patient had multiple episodes
of bright red hematemesis. In the Emergency Room, the
patient was found to be hypotensive, with a blood pressure of
90/45 and a hematocrit of 15. Nasogastric tube lavage was
done, which showed bright red blood, which did not clear
after 2 liters of nasogastric lavage. The patient was
intubated for airway protection, and had an episode of
bradycardia into the 40s. The patient had an emergent
esophagogastroduodenoscopy, which showed spurting Dieulafoy
lesion in the fundus, which was successfully cauterized using
BICAP and injected with epinephrine. Hemostasis was
achieved. The endoscopy was otherwise normal.
The patient's blood pressure then increased to 200/100 with a
heart rate of 125. He received six units of packed red blood
cells and two units of fresh frozen plasma in the Emergency
Room. He had multiple attempts to gain access during his
emergent workup in the Emergency Room, with a failed left
femoral stick, left subcutaneous stick, and left external
jugular stick. He finally had successful placement of a
right femoral line and a right external jugular line, as well
as a right hand line.
PAST MEDICAL HISTORY: Includes coronary artery disease
status post bypass surgery in [**2167**] and percutaneous
transluminal coronary angioplasty in [**2175-11-10**], one of
the obtuse marginal II, hypertension, diabetes mellitus,
hypercholesterolemia, chronic renal insufficiency with a
baseline creatinine of 1.5, peripheral vascular disease, left
femoral-popliteal bypass redone in [**2176-12-10**],
arthritis, cerebrovascular accident in [**2167**] on the right,
with subsequent right carotid endarterectomy, atrial
fibrillation, bilateral fifth toe amputation, and
perioperative myocardial infarction in [**2177-1-10**].
MEDICATIONS ON ADMISSION: Dilaudid, percocet, Lopressor,
[**Year (4 digits) 197**], aspirin, Norvasc, Colace, Lipitor,
hydrochlorothiazide, Zantac, iron, multivitamin. There is
some question of whether the patient had been taking his
[**Year (4 digits) 197**] as an outpatient. According to his primary care
provider, [**Name10 (NameIs) 197**] had been discontinued because the patient
was noncompliant with INR checks, however, the patient states
that he had been taking [**Name10 (NameIs) 197**] at home.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Occasional alcohol. He is a former tobacco
smoker.
PHYSICAL EXAMINATION: Vitals on admission: Blood pressure
200/100, heart rate in the 120s. General: He was intubated
and sedated. Skin showed no jaundice. Head, eyes, ears,
nose and throat examination showed excessive blood in the
oropharynx. His abdomen was soft, distended, and nontender.
LABORATORY DATA: On admission, white count 10.6, hematocrit
15 increased to 22.9 after two units of blood, platelets 114,
PT 14.8, INR 1.5, PTT 30.8. Lactate 5.9. Sodium 143,
potassium 3.8, chloride 112, bicarbonate 12, BUN 66,
creatinine 1.6, glucose 244. ALT 5, AST 8. CK 42, alkaline
phosphatase 28, amylase 42, total bilirubin 0.1. Calcium
6.7, albumin 2.1, phosphate 5.2. Electrocardiogram showed
possible sinus rhythm with ventricular trigeminy, left axis
deviation, right bundle branch block, ST depressions in V3
through V6. X-ray showed cardiomegaly, no infiltrates, no
pneumothorax, and adequate placement of the endotracheal
tube.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for further management of his large
gastrointestinal bleed.
1. Gastrointestinal: The patient had successful
intervention by the Gastroenterology service via endoscopy
for his Dieulafoy lesion in the Emergency Room. He was sent
to the Intensive Care Unit, and started on Protonix at 8
mg/hour continuous infusion. He had his [**Name10 (NameIs) 197**] and aspirin
held, and his hematocrit was checked every four hours. He
was given fresh frozen plasma in the Emergency Room to
maintain an INR less than 1.5. The patient had no further
episodes of hematemesis or melena, and was thought not to
have any further gastrointestinal bleeding throughout his
hospital stay. He was followed by the Gastroenterology
service throughout his course. He was gradually weaned from
Protonix continuous infusion to Protonix 40 mg intravenously
twice a day, and finally Protonix 40 mg by mouth twice a day.
This will be continued as an outpatient. He was initially
made nothing by mouth, but then gradually his diet was
advanced, which he tolerated well, with no nausea, vomiting,
or other symptoms.
2. Cardiovascular: The patient has known coronary artery
disease, and showed ischemic electrocardiogram changes in the
Emergency Room during his acute gastrointestinal bleed. At
that time, he also did complain of some chest pains. He was
therefore evaluated for possible myocardial infarction in the
context of his massive gastrointestinal bleed. His CK levels
rose to a peak of [**2174**] on [**2177-3-25**], with an MB fraction
of 320, and his troponin peaked at a level greater than 50.
The patient had one further episode of [**5-19**] chest pain the
night before discharge, with very tiny .5 mm depressions in
the ST segment of V4 and V5. These resolved after the pain
was treated successfully with two sublingual nitroglycerin
tablets. The Cardiology service followed the patient
throughout his hospital stay, and were made aware of these
changes. Therefore, their recommendations were pending at
the time of discharge.
The patient had standard post-acute myocardial infarction
medical care, including monitoring on telemetry for 72 hours
after his event. Telemetry revealed only one short episode
of supraventricular tachycardia for 12 beats. He was started
on an ACE inhibitor, which was titrated up as tolerated to
Zestril 10 mg by mouth once daily. This was tolerated very
well from a cardiovascular point of view, however, the
patient does have a cough that developed during this hospital
stay which, if it does not resolve, may require changing his
ACE inhibitor to [**First Name8 (NamePattern2) **] [**Last Name (un) **] to investigate whether the ACE
inhibitor is the underlying cause for this cough. The
patient was also continued on Lopressor 25 mg by mouth three
times a day, which was changed to Toprol XL 25 mg by mouth
once daily. He was initially on a nitrate drip, which was
then changed over to Imdur 30 mg by mouth once daily. He
will continue on aspirin 325 mg by mouth once daily, and
Lipitor 10 mg by mouth once daily.
Should the patient have recurrent chest pain, the Cardiology
service may want to consider further workup with another
cardiac catheterization.
The patient has a history of paroxysmal atrial fibrillation.
We did not anticoagulate him during his hospital stay. He
did not have any episodes of atrial fibrillation during this
hospitalization. The patient's blood pressure was well
controlled with his cardiac regimen.
The patient had an echocardiogram after his myocardial
infarction, which revealed an ejection fraction of 45 to 50%.
The left atrium was mildly dilated. There was mild symmetric
left ventricular hypertrophy. There was mild regional left
ventricular systolic dysfunction, with inferobasal and
inferoseptal severe hypokinesis and akinesis. The right
ventricle was normal. There was mild aortic regurgitation
and mild to moderate mitral regurgitation. Both of these
valvular findings were worse compared to his echocardiogram
in [**2167-4-10**].
3. Pulmonary: The patient was ventilated overnight, the
night of admission, for airway protection. He was extubated
the following morning without any complication. Chest x-ray
was done on the 15th, and again the 17th and the 19th. The
patient showed no evidence for pneumonia, but did have
bibasilar atelectasis. The patient developed a cough during
this hospital stay, which was treated symptomatically with
Tessalon Perles and Robitussin. The patient had no evidence
for pneumonia, and the cough was thought to be secondary to
his recent intubation, however, the patient was also started
on ACE inhibitor therapy during this hospitalization, and if
the cough does not resolve, it is possible that the cough may
be due to the new ACE inhibitor. This will need to be
followed up as an outpatient.
The patient, on transfer from the Intensive Care Unit, was on
5 liters of oxygen, which was gradually weaned to off, and
the patient was maintaining good oxygen saturations greater
than 96% on room air at the time of discharge. The patient's
oxygen requirement was felt to be due to volume overload
after the patient received multiple units of blood and
intravenous fluids during his resuscitation. The patient was
gradually diuresed back to his admission weight. As the
patient was diuresed, his oxygen requirement diminished.
4. Hematology: The patient was transfused to maintain a
hematocrit greater than 32%. The patient had received six
units of blood in the Emergency Room, and a further unit in
the Intensive Care Unit prior to transfer to the floor. The
patient then received an additional two units on the floor.
His hematocrit was stable upon discharge.
The patient also was noted to have thrombocytopenia of
uncertain etiology. It reached a nadir of about 90. These
were increasing at the time of discharge.
5. Infectious Disease: The patient was not thought to have
any infection during his hospital stay. He did have a
low-grade temperature, running 99 to 100. This was felt most
likely due to atelectasis. Chest x-ray did not reveal any
pneumonia, and urinalysis and urine culture were negative for
urinary tract infection.
6. Endocrine: The patient has diabetes Type 2, which is
diet controlled at home. While the patient was on the floor,
he had his blood glucose checked with finger sticks four
times a day. His blood sugars remained less than 200 the
entire stay, and only were above 150 on one occasion. He did
not require any subcutaneous insulin during his hospital
stay. The patient can continue on a diet-control regimen for
now, with addition of oral agents as needed as an outpatient.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed from a Dieulafoy lesion
2. Acute myocardial infarction
DISCHARGE CONDITION: Improving.
DISCHARGE STATUS: To [**Hospital **] Rehabilitation for short-term
rehabilitation.
DISCHARGE MEDICATIONS: Lasix 40 mg by mouth once daily,
Zestril 10 mg by mouth once daily, Imdur 30 mg by mouth once
daily, enteric-coated aspirin 325 mg by mouth once daily,
Protonix 40 mg by mouth twice a day, folate 1 mg by mouth
once daily, Robitussin AC 10 ml by mouth four times a day as
needed, Tessalon Perles 200 mg by mouth three times a day,
Ambien 5 mg by mouth daily at bedtime as needed, Cepacol
lozenge one by mouth every eight hours as needed, Lipitor 10
mg by mouth once daily, Toprol XL 25 mg by mouth once daily,
and nitroglycerin 0.4 mg sublingually every five minutes x 3
as needed for chest pain.
FOLLOW UP: With his primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1511**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2177-3-28**] 23:46
T: [**2177-3-29**] 00:00
JOB#: [**Job Number 33973**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71",
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] |
icd9pcs
|
[
[
[]
]
] |
10697, 10794
|
10818, 11415
|
10591, 10675
|
2294, 2817
|
3857, 10570
|
11427, 11804
|
2912, 2919
|
161, 1637
|
2934, 3839
|
1661, 2267
|
2835, 2888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,820
| 150,223
|
46198
|
Discharge summary
|
report
|
Admission Date: [**2203-11-20**] Discharge Date: [**2203-11-25**]
Date of Birth: [**2129-3-14**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo woman with past medical history of CHF, coronary artery
disease s/p CABG in [**2190**] who presents to the hospital with
shortness of breath that started 3-4 days ago and acutely
worsened around 5 am this morning. She increased her home 02
from 2L to 10L, took a nitro and took 40 mg Lasix without
improvement.
.
Of note, the patient was recently hospitalized in CCU for CHF
exacerbation between [**2203-10-23**] and [**2203-10-27**]. During that admission,
she was diuresed with Lasix and sent home on PO Lasix.
Amlodipine was stopped, Quinapril was decreased in dose to 5 mg
daily and she was started on aspirin. She saw her cardiologist,
Dr. [**First Name (STitle) 2031**], after admission who started Carvedilol (dose
unknown.) Three days ago when she started to feel short of
breath, Dr. [**First Name (STitle) 2031**] increased her Lasix from 20 mg daily to 40 mg
daily.
.
At baseline, the patient is quite limited by exertional dyspnea
and shortness of breath at baseline. She has 23 steps at home,
and is able to get up those stairs but only very slowly. Her
exertional dyspnea is predictable and rapidly resolves with
cessation of activities. She also had a recent admission to [**Hospital 2586**] for a CHF exacerbation in [**Month (only) 956**], at which time
she also had a cardiac catherization which per the patient
showed patency in 3 of her 4 bypass grafts. After that
admission, she was weaned off of her lasix by [**Month (only) 547**] due to drops
in blood pressure- as noted above, this was restarted on last
admission. She had a stress test in [**Month (only) 216**] which showed possible
perfusion abnormalities.
.
On review of systems, she denies recent fever. She also has a
history of DVTs x2 and had previously been on coumadin, but has
been off of coumadin for at least 2 years. She has 3 pillow
orthopnea. She denies fevers, chills or rigors. No change in
bowel habits. No symptoms of claudication. No recent weight gain
or change in eating habits.
.
On arrival to the ED, her BP was 200/100 with O2 saturations 95%
on NRB and 100% on bipap breathing in 40s with rales bilaterally
half way up the lungs on exam. In the ED, the patient was given
80 mg IV Lasix and a Nitro drip was started. Pressure dropped to
101/64 and O2 sats improved to 93% on 5L NC with RR 25.
Past Medical History:
Coronary artery disease s/p coronary artery bypass
graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr.
[**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution
consistent with old finding.)
2. Carcinoid tumor of right middle lobe s/p resection.
3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**])
4. Obesity.
5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**]
6. Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 at night at home. NO Bpap
7. obstructive sleep apnea.
8. restrictive lung disease
9. carpel tunnel syndrome b/l, [**2179**]
10. congestive heart failure (left atrium is mildly dilated.
LVEF 67%/[**2199**])
11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10.
12.HTN
13.hypercholesterolemia
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Is married, lives with husband, daughter and 1 of her sons. [**Name (NI) **]
2 other children.
She lives with her husband, adult daughter and son (38 yo) in a
[**Location (un) 1773**] apartment in [**Location (un) 538**], Mass. The indicates
that she has 31 steps to climb. Her family is very supportive.
Daughter,
[**Name (NI) 98232**], is the contact @ Cell [**Telephone/Fax (1) 98233**]/Home [**Telephone/Fax (1) 98234**].
Retired office asst. Pt is a native of [**Country 5881**], where she used to
work as a nurse. [**First Name (Titles) **] [**Last Name (Titles) **] currently or in past. No Etoh
intake.
Family History:
Mother - diabetes
Physical Exam:
Admission Exam:
GENERAL: Well appearing woman in NAD. Oriented x3. Mood, affect
appropriate. Speaking in full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: Slightly muffled S1. 3/6 systolic murmur radiating to
apex, possible [**2-2**] diastolic murmur. Normal S2. No S3/S4
LUNGS: Bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Mild bilateral edema L>R. Vein harvest scar on
left
leg. Warm and well perfused.
PULSES: 1+ radial pulses bilaterally. DP and PT Pulses not
palpable.
Pertinent Results:
STUDIES:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the mid-septum. The remaining segments contract
normally (LVEF = 55 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Mild to moderate ([**1-29**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Pulmonary artery
systolic hypertension. Moderate to severe mitral regurgitation.
Symmetric left ventricular hypertrophy with regional systolic
dysfunction suggestive of CAD. Mild-moderate aortic
regurgitation.
CLINICAL IMPLICATIONS:
The patient has severe aortic stenosis. Based on [**2199**] ACC/AHA
Valvular Heart Disease Guidelines, if the patient is a surgical
candidate, surgical intervention has been shown to improve
survival.
CT chest:
IMPRESSIONS:
1. Longstanding sternal nonunion following prior sternotomy,
with
fragmentation of multiple sternal closure wires, and
well-corticated bony
fragments in the sternotomy defect.
2. Extensive atherosclerotic disease involving both the native
and graft
coronary vessels.
3. Prior CABG with graft vessels arising from the anterior
aspect of the
ascending aorta. No atherosclerotic calcification involving the
ascending
aorta.
4. Small bilateral pleural effusions with associated
atelectasis.
5. Small hiatal hernia.
6. Cholelithiasis without cholecystitis.
Carotid US:
IMPRESSION:
1. Heterogeneous plaque at the ostium of the right internal
carotid artery as
well as slightly more significantly in the proximal left
internal and external
carotid arteries.
2. No significant stenosis noted on the right side.
3. Suspected 60-69% stenosis involving the proximal left
internal carotid
artery.
4. Prograde flow in both vertebral arteries.
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2203-11-24**] 8:06 AM
SPIROMETRY 8:06 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.23 2.10 58
FEV1 1.00 1.42 70
MMF 1.00 1.84 54
FEV1/FVC 81 68 121
LUNG VOLUMES 8:06 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 2.36 3.62 65
FRC 1.33 2.12 63
RV 1.20 1.52 79
VC 1.16 2.10 55
IC 1.03 1.51 68
ERV 0.14 0.60 23
RV/TLC 51 42 121
He Mix Time 2.13
DLCO 8:06 AM
Actual Pred %Pred
DSB 9.39 15.68 60
VA(sb) 1.98 3.62 55
HB 10.70
DSB(HB) 10.37 15.68 66
DL/VA 5.25 4.32 121
Brief Hospital Course:
74 y.o woman with history of CABG and CHF, also DVT who presents
with acute onset of dyspnea and evidence of pulmonary edema,
consistent with a severe exacerbation of congestive heart
failure.
.
# Acute on chronic diastolic Congestive Heart Failure
exacerbation: CHF exacerbation was attributed to severe Aortic
Stenosis seen on echo. Pt was initially diuresed with lasix and
had improved symptoms. Carvedilol and quinapril were initially
held and then restarted. Furosemide was continued at previous
dose of 40 mg daily. Weight at discharge was 184 pounds and pt
appeared euvolemic.
.
# Severe Aortic stenosis: Pt found to have severe Aortic
Stenosis with aortic valve area: 0.8-1.0cm2. Echo also revealed
mod-severe MR. CT surgery was consulted and reccomended surgery.
Pre-op workup was initiated. Pt had CT chest (revealing small
bilateral pleural effusions and extensive atherosclerosis).
Carotid US performed which showed 89% stenosis on left side and
no sig stenosis on right side. PFTs returned showing mixed
restrictive and obstructive disease. Cardiac surgeon Dr. [**First Name (STitle) **]
[**Name (STitle) **] will schedule surgery.
.
# Coronary Artery Disease: R/O'd. No significant chest pain
during hospital stay. Continued ASA 81 mg, Atorvastatin 40 mg
daily. Given her marginal BP, Imdur was not given during
hospital stay and not restarted at discharge. The RCA may be
bypassed during the AVR surgery. If so, vein mapping will be
needed and will be arranged by the cardiac surgeon.
.
# Hypertension: Restarted carvedilol and quinapril. Held Imdur.
SBP 98-103 on day of discharge.
.
# Diabetes Mellitus: Sugars in the 170-350 range. Family
requested [**Last Name (un) **] consult. She was started on 75/25 humalog here
in the hospital with daily [**Last Name (un) **] oversight. She will go home on
a new regimen of 70/30 Novalog (humalog with NPH) of 36 units in
the morning and 24 units at night. She will also do fingersticks
before each meal and has a new Humalog sliding scale. Metformin
was held but restarted at discharge. She will f.u with [**Last Name (un) **]
outpatient.
.
# GERD: Continued Esomeprazole
.
# Dispo: She will go home and return for surgery. She has an
appt in 4 days with her cardiologist Dr. [**First Name (STitle) 2031**].
Pt refuses VNA despite encouraging.
Pt noted to have enlarged flat tongue with MCV in low 80s. Might
have B12 def. Pts B12 levels should be checked and followed
outpatient.
Medications on Admission:
atorvastatin 40mg
Ascorbic acid 500mg [**Hospital1 **]
Vit E 400U daily
Esomeprazole Magnesium 40mg [**Hospital1 **]
Mag Oxide 400mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Nitroglycerin 0.4mg prn
Metformin 500mg- 2 tabs [**Hospital1 **]
Ferrous sulfate 325mg TID
Omeprazole 20mg, 2 tabs [**Hospital1 **]
Isosorbide Mononitrate 30mg daily
Klorcon 8 MEQ once daily
Carvedilol 3.125mg [**Hospital1 **] (Was recent started at once daily then
increased to [**Hospital1 **] as of [**2203-11-1**] appt with Dr [**First Name (STitle) 2031**]
furosemide 40 mg daily
Quinipril 5mg daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 50 U
once daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 20 U
at bedtime
XIBROM 0.09 % Drops; one drop daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
5. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Carafate 1 gram Tablet Sig: One (1) Tablet PO twice a day: do
not take with other medicines.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. XIBROM 0.09 % Drops Sig: One (1) drop Ophthalmic one drop
daily ().
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Outpatient Lab Work
please check Chem-7 at Dr.[**Name (NI) 13610**] office on [**2203-11-29**] with
results to Dr. [**First Name (STitle) 2031**] at [**Telephone/Fax (1) 77385**]
13. potassium chloride 8 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
14. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Thirty
Six (36) units Subcutaneous before breakfast.
Disp:*1 bottle* Refills:*2*
15. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Twenty
Four (24) units Subcutaneous before dinner.
16. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: check fingersticks 4 times a day
before meals and at bedtime. .
Disp:*1 bottle* Refills:*2*
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. quinapril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Critical Aortic Stenosis
Coronary Artery Disease
Diabetes Mellitus Type 2
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had an acute exacerbation of congestive heart failure that
was a result of a very tight aortic valve. You will need to have
that valve replaced in the near future. You will be [**Telephone/Fax (1) 653**] by
the cardiac surgery department at [**Hospital1 18**] to schedule and plan for
this surgery. We have done many tests here to get you ready for
the surgery including a CT scan of the chest, Pulmonary function
tests, a sleep study, and a carotid ultrasound. You will need to
have an sleep study after the surgery and should make an appt in
the sleep clinic here to have that arranged.
.
Please get blood drawn while you are seeing Dr. [**First Name (STitle) 2031**] on [**11-29**].
A prescription was given to you for that lab work.
.
Weigh yourself every morning, call Dr. [**First Name (STitle) 2031**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop taking omeprazole, Vitamin E, potassium (Kdur) and Imdur
(isosorbide mononitrate)
2. Change insulin to 70/30 Novalog at 36 units in the morning
and 24 units at night. You will also have a new sliding scale of
humalog insulin to use before each meal.
3. Decrease ferrous sulfate to once daily
4. Start aspirin 81 mg (baby aspirin)
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule an appointment
within the next week #[**Telephone/Fax (1) 917**] to discuss the upcomming
surgery. At this appointment, you will discuss: the surgery,
your questions, your concerns, the date of surgery.
[**Hospital **] Clinic
[**Last Name (un) 3911**], [**Location (un) 86**] MA
Phone: [**Telephone/Fax (1) 2378**]
Date/time: [**2203-12-6**] at 1:30pm
.
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]
Phone: [**Telephone/Fax (1) 77385**]
Date/time: Tuesday [**11-29**] at 2:30pm
[**Hospital 1263**] Hospital
.
Please make an appt in the Sleep study clinic here at [**Hospital1 18**]
after the surgery. PHONE: (66)7.LUNG (5864) ?????? Sleep [**Hospital 6920**]
Clinic
|
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"327.23",
"285.29",
"V46.2",
"428.0",
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"276.7",
"V45.81",
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"424.1",
"428.33",
"530.81",
"278.00",
"518.82",
"411.1",
"250.02",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13105, 13111
|
8074, 10517
|
332, 339
|
13294, 13294
|
5091, 6250
|
14738, 15520
|
4336, 4355
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11342, 13082
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13132, 13273
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10543, 11319
|
13445, 14715
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4370, 5072
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6273, 8051
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273, 294
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367, 2669
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13309, 13421
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2692, 3630
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3646, 4320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,780
| 157,666
|
19672
|
Discharge summary
|
report
|
Admission Date: [**2175-1-5**] Discharge Date: [**2175-1-10**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
gentleman with a past medical history of coronary artery
disease (status post myocardial infarction times three) who
presented as a transfer from [**Hospital 26200**] Hospital
secondary to respiratory distress requiring intubation and
sedation.
The patient was originally seen on [**1-1**] in the
Emergency Department for three days of shortness of breath
and a cough. At that time he was sent home on treatment with
Bactrim double strength.
The patient presented again on [**1-5**] with increased
shortness of breath and was noted to have a blood pressure
elevated to 232/96, a heart rate of 113, and a regular rate
and rhythm of 36. In addition, a chest x-ray revealed
questionable flash pulmonary edema. The patient was then
intubated and sedated and transferred to [**Hospital1 346**] for further treatment.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction times three.
2. Cardiac arrest in the setting of pneumonia.
3. Chronic renal insufficiency (with a baseline creatinine
of 1.6 to 2.1).
4. Hypercholesterolemia.
5. Questionable chronic obstructive pulmonary disease.
ALLERGIES: Questionable allergy to LIPITOR (causing back
pain and "liver pain").
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Isosorbide 60 mg by mouth once per day.
2. Lopressor 75 mg by mouth twice per day.
3. Vitamins.
4. Aspirin.
5. Bactrim double strength (since [**1-1**]).
SOCIAL HISTORY: The patient is married with five children
and eleven grandchildren. The patient quit tobacco 10 years
ago. Occasional alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination on admission revealed the patient was intubated
and sedated. Vital signs revealed his temperature was 100.8
degrees Fahrenheit, his heart rate was 90, his blood pressure
was 145/76, his respiratory rate was 21, on a ventilator AC
510/5 saturating 100%. Head, eyes, ears, nose, and throat
examination revealed the pupils were equal, round, and
reactive to light. The mucous membranes were dry. Lungs
revealed rhonchi diffusely with decreased breath sounds at
the right base. Heart was regular in rate and rhythm. There
was distant heart sounds. Barrel chested. The abdomen was
soft and nontender. There were positive bowel sounds.
Extremity examination revealed trace bilateral edema. The
hands were warm. The feet were cold.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 11.4, his hematocrit was 45, and his platelets were 300.
Differential revealed 35 neutrophils and 6 lymphocytes.
Chemistry-7 revealed the patient's sodium was 136, potassium
was 5.3, his blood urea nitrogen was 41, and his creatinine
was 2.8 (up from 1.7 on [**12-12**]). His troponin was 0.8.
Creatine kinase was 414. MB was 4.8.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed a
normal sinus rhythm at a rate of 100 with peaked T waves in
V2 through V4. There were Q waves in leads II, III, and aVF
which were old.
A chest x-ray revealed endotracheal tube and nasogastric tube
properly placed. Perihilar haziness and patchy lower lobe
densities consistent with pulmonary edema/congestive heart
failure.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Ischemia: There was
initially some concern regarding possible electrocardiogram
changes with questionable ST elevations in V2 through V3.
Upon transfer, the patient was seen by Cardiology who felt
the shape of the T waves were not consistent with infarction
and were more consistent with left ventricular hypertrophy.
The patient had been on a heparin drip, but this was
discontinued shortly thereafter. The patient's cardiac
enzymes were cycled, and they trended down. The patient was
continued on aspirin. A statin was started despite the
questionable history of an allergy. His beta blocker and ACE
inhibitor were titrated up. The patient was to have an
outpatient Cardiology followup regarding a possible
outpatient stress test or catheterization.
(b) Pump: The patient had an echocardiogram which revealed
an ejection fraction of 25% to 30% with global hypokinesis
and focal hypokinesis on the anterior free wall. The patient
was diuresed with intravenous Lasix as needed. The patient
was treated with hydralazine and nitroglycerin for afterload
reduction. ACE inhibitor was held secondary to an increased
creatinine, and Lopressor was titrated up.
The patient was extubated on hospital day two. Throughout
the remainder of his course he showed no signs or symptoms of
congestive heart failure, and no further Lasix was required.
2. ACUTE-ON-CHRONIC RENAL FAILURE ISSUES: This was felt to
be secondary to Bactrim with an acute interstitial nephritis
picture as there was positive eosinophils. Bactrim was held.
The patient's creatinine peaked at 4 and trended down. At
the time of discharge, his creatinine was 3.8. The patient
was to follow up in a few days with his primary care
physician to have his creatinine checked once again to make
sure it was going in the right direction.
3. PULMONARY ISSUES: The patient was intubated for presumed
flash pulmonary edema in the setting of likely viral
bronchitis presentation. The patient was extubated on
hospital day two. On this presentation on [**1-5**],
initially the patient was started on Levaquin for
questionable pneumonia; however, after extubation the patient
was saturating well. A chest x-ray showed no evidence of
infiltrate. Therefore, the antibiotic was discontinued as it
was felt that this was likely a viral bronchitis. At the
time of discharge, the patient was oxygenating well at rest
as well as with ambulation.
4. INFECTIOUS DISEASE ISSUES: The patient had upper
respiratory infection symptoms and a temperature at home
prior to admission. The patient was initially on Levaquin
for a question of bronchitis/pneumonia but was stopped on
[**1-6**]. The patient clinically did not appear infected.
Blood cultures, and urine cultures, and sputum cultures were
all no growth. The patient remained afebrile throughout the
rest of his admission.
DISCHARGE DISPOSITION: The patient was discharged to home in
good condition. He was saturating well on room air at rest
and with ambulation.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to weight himself every
morning and call his medical doctor if his weight increased
greater than three pounds.
2. The patient was instructed to seek medical attention if
he experienced shortness of breath, fevers, chills, or other
concerning symptoms.
3. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) **] on the Friday after his discharge
to have his blood urea nitrogen and creatinine checked.
4. The patient was instructed to follow up with his new
cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]) on [**1-24**] at 2:30
in [**Location (un) 620**].
FINAL DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Acute renal failure; likely secondary to Bactrim.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Folic acid 1 mg by mouth once per day.
3. Lopressor 75 mg by mouth twice per day.
4. Isosorbide dinitrate 20 mg by mouth three times per day.
NOTE:
1. The patient should be considered to have an allergy to
SULFA, as this was likely the cause of his acute renal
failure.
2. The patient had been treated with pravastatin in the
hospital with no adverse effects; however, reports repeated
problems with statin medications in the past and was treated
with niacin. His most recent cholesterol panel revealed his
low-density lipoprotein was 99 and a total cholesterol of
159. Therefore, the patient elected to not continue on the
pravastatin as an outpatient and would discuss this with his
new cardiologist further lipid management.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2175-1-10**] 11:51
T: [**2175-1-14**] 07:03
JOB#: [**Job Number 53254**]
cc:[**Numeric Identifier 53255**]
|
[
"428.0",
"428.23",
"491.21",
"593.9",
"414.01",
"272.0",
"412",
"584.8",
"E931.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6328, 6448
|
7297, 8377
|
1373, 1572
|
6481, 7159
|
3424, 6304
|
7186, 7271
|
110, 958
|
980, 1346
|
1589, 3390
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
163
| 138,528
|
22490
|
Discharge summary
|
report
|
Admission Date: [**2146-6-20**] Discharge Date: [**2146-6-22**]
Service: [**Hospital Unit Name 196**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
SOB at OSH, [**Location (un) **] to [**Hospital1 18**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo male w/PMH significant for CAD s/p MI in [**2131**] with 4v CABG
and redo in [**2141**], Pacemaker/ICD, DM, HTN, asbestosis on home O2
who experienced sudden SOB after his dinner. No associated CP.
He did report orthopnea and palpitations. No fever, chills, or
cough. He went to [**Hospital3 **] ED and was found to have a BP
of 204/101 and HR of 140 in sinus rhythm, RR=34, and O2 sat of
88% on RA in respiraotry distress. He was given a heparin drip,
nitroglycerin drip, 40 mg IV Lasix, ASA, nebs, 5 mg Lopressor
x3, SLNTG x3, Morphine, and 125 mg solumedrol. His BP then
dropped and he was flown to [**Hospital1 18**]. Here, his BP was 75/53, and
his nitro drip was D/Ced. He was started on dopamine ad his BP
stabilized. BNP at OSH was >6000, and initial enzymes were
negative. Given lasix and diuresed 800 cc. Currently feels
"much better", no CP, but still not at baseline. His anginal
equivalent is SOB, not CP.
Past Medical History:
1.CAD with MI and 4v CABG in [**2131**]. CABG redo in [**2141**].
2. Asbestosis with O2 requirement at home.
3.Pacer/ICD placed after syncopal episode in the airport.
4.NIDDM
5.CHF--EF~20% by report and confirmed by echo here.
6.HTN
Social History:
Libes in [**Location (un) **] with his wife. Daughter lives in FL.
Used to work in a shipyard.
No Drugs, occ EtOH, Past history of smoking, not currently.
Family History:
Non-contributory
Physical Exam:
T=96.6, HR=90, BP=94/49, RR=22, O2 sat=96% on 8LNRB, 800 cc
urine at OSH, 400 cc in ED
Gen: Pleasant, mild dyspnea, but speaking in complete sentences;
abdominal breathing; lying flat
HEENT:EOMI, PERRLA, MMM, JVD on expiration to the angle of the
jaw. CArotid bruit on R, none on L.
CV:RRR, Nl S1,S2, no S3,S4, I/VI SEM at R 2nd ICS.
Pulm:Rales 1/3 up bilaterally, bronchial sounds over Right
mid-lung zone.
Skin:Diaphoretic, No rashes
Abd: Soft, NT/ND, decreased bowel sounds, no rebound or
guarding. No organomegaly
Ext:No edema, 1+ DP pulses Bilaterally, no femoral bruits.
Neuro:A&Ox3
Pertinent Results:
[**2146-6-20**] 03:49AM BLOOD WBC-25.2* RBC-3.98* Hgb-9.3* Hct-29.9*
MCV-75* MCH-23.3* MCHC-31.2 RDW-16.8* Plt Ct-425
[**2146-6-21**] 05:00AM BLOOD WBC-19.9* RBC-3.57* Hgb-8.4* Hct-26.3*
MCV-74* MCH-23.5* MCHC-31.9 RDW-17.4* Plt Ct-381
[**2146-6-21**] 10:00PM BLOOD Hct-31.0*
[**2146-6-22**] 06:00AM BLOOD WBC-12.9* RBC-4.39* Hgb-10.8*# Hct-33.5*
MCV-76* MCH-24.7* MCHC-32.4 RDW-17.8* Plt Ct-397
[**2146-6-20**] 03:49AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3*
Monos-1.5* Eos-0.3 Baso-0.1
[**2146-6-20**] 03:49AM BLOOD PT-14.7* PTT-110.8* INR(PT)-1.4
[**2146-6-21**] 05:00AM BLOOD PT-13.9* PTT-57.8* INR(PT)-1.3
[**2146-6-22**] 06:00AM BLOOD PT-12.6 PTT-27.4 INR(PT)-1.1
[**2146-6-22**] 06:00AM BLOOD Plt Ct-397
[**2146-6-20**] 03:49AM BLOOD Glucose-247* UreaN-42* Creat-2.2* Na-140
K-5.3* Cl-104 HCO3-20* AnGap-21*
[**2146-6-21**] 05:00AM BLOOD Glucose-98 UreaN-49* Creat-2.0* Na-141
K-5.0 Cl-106 HCO3-21* AnGap-19
[**2146-6-22**] 06:00AM BLOOD Glucose-47* UreaN-45* Creat-1.7* Na-142
K-4.5 Cl-105 HCO3-23 AnGap-19
[**2146-6-20**] 03:49AM BLOOD ALT-6 AST-27 CK(CPK)-195* AlkPhos-90
[**2146-6-20**] 01:23PM BLOOD CK(CPK)-244*
[**2146-6-20**] 08:06PM BLOOD CK(CPK)-190*
[**2146-6-21**] 05:00AM BLOOD CK(CPK)-120
[**2146-6-20**] 03:49AM BLOOD CK-MB-25* MB Indx-12.8*
[**2146-6-20**] 03:49AM BLOOD cTropnT-0.52*
[**2146-6-20**] 01:23PM BLOOD CK-MB-27* MB Indx-11.1*
[**2146-6-20**] 08:06PM BLOOD CK-MB-16* MB Indx-8.4*
[**2146-6-21**] 05:00AM BLOOD CK-MB-10 MB Indx-8.3* cTropnT-0.44*
[**2146-6-20**] 03:49AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.4* Iron-36*
[**2146-6-22**] 06:00AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6
[**2146-6-20**] 03:49AM BLOOD calTIBC-309 Ferritn-631* TRF-238
[**2146-6-20**] 03:49AM BLOOD Triglyc-58 HDL-41 CHOL/HD-3.0 LDLcalc-68
[**2146-6-20**] 04:58AM BLOOD Lactate-2.2* K-4.8
[**2146-6-20**] 07:03AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-6-20**] 07:03AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2146-6-20**] 07:03AM URINE RBC-[**1-28**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2146-6-20**] 01:26PM URINE Hours-RANDOM UreaN-448 Creat-48
Echo:
Conclusions:
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The
left ventricular cavity is dilated. Overall left ventricular
systolic function
is severely depressed (ejection fraction approximately 20
percent). Right
ventricular chamber size is normal. Right ventricular systolic
function
appears depressed. The aortic root is mildly dilated. The aortic
valve
leaflets (3) are mildly thickened but not stenotic. Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is no mitral valve prolapse. Moderate (2+) mitral regurgitation
is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but
cannot be quantified.
Chest CT:
IMPRESSION: 1) Extensive calcified pleural plaques consistent
with prior history of asbestos exposure. Right pleural effusion
with equivocal smooth enhancement of the right posterior lateral
pleural surface but without nodularity or other findings to
suggest mesothelioma. Correlation with pleural aspirate should
be considered.
2) Cardiomegaly and extensive coronary artery calcifications.
3) Borderline enlargement of the main pulmonary arteries suggest
a possible pulmonary artery hypertension.
4) Atelectasis at the left lung base and bronchiectasiss.
5) Extensive calcifications throughout the pancreas consistent
with chronic pancreatitis.
6) Small nodule in the left adrenal gland which possibly
represents an adenoma. However, this cannot be fully
characterized due to the lack of non- contrast series.
CXR:
IMPRESSION:
1) CHF
2) Calcified pleural plaques with a large right effusion or
pleural thickening. Further evaluation with CT scan is
reccommended to exclude malignant mesothelioma.
Brief Hospital Course:
This 80 y/o male with h/o CAD, DM, HTN, asbestosis was admitted
in fairly stable condition after a modest diuresis at the OSH
and the ED. He was managed for an NSTEMI and acute CHF
exacerbation. We spoke with his PCP and pulmonologist while he
was here, and obtained records from his cardiologist.
1.CHF: This exacerbation was likely due to a combination of
ischemia(NSTEMI), severe HTN, and chronic systolic/diastolic
dysfunction. We started him on Natrecor due to his underlying
CRI and he diuresed well with daily goals of 1L negative fluid
balance. Also got an echo which confirmed an EF of approx 20%,
and 2+MR. His SOB rapidly improved, but he was still using
minimal O2 upon D/C. He is on 2LNC at home chronically. He was
able to walk without O2 in the hospital though without dropping
his O2 sats. Patient was instructed to not eat salty foods and
wife confirmed they have seen nutritionist before and have
handouts at home of appropriate and inappropriate foods. He was
transitioned to Lasix on D/C at 20 mg/day, with instructions to
weigh himself and take extra Lasix iof his weight increases by 2
lbs in 1 day. Hopefully this will keep him from slowly entering
CHF again. He was on Lasix in the past, then Bumex, but for
now, we will try Lasix with the above instructions. His
cardiologist or PCP may elect to alter this regimen depending on
his stability as an outpatient.
2.CAD:Known h/o coronary issues. His EKG showed a new
incomplete LBBB and his cardiac enzymes were positive for MI.
No ST elevations seen. His anginal equivalent is also SOB,
which was his primary complaint. Initially started on ASA,
heparin, statin. His Coreg was held due to initially tenuous
BP. He was briefly on dopamine, but was quickly weaned from
this. His CKs peaked in 200s and began trending down. There
was question of whether this was result of demand ischemia or
not. It was decided that he did not need a cath due to quick
improvement and no further symptoms. The heparin was stopped
and his Coreg was restarted when his BP could tolerate it. He
was sent home on coreg, but his diovan was not restarted as his
BP was in normal range without it. Will need this monitored.
3.EP:He has a pacemaker that was placed after syncopal episode.
There were no issues with abnormal rhythms as an inpt. Repeat
EKGs showed QRS narrowing to more normal value.
4.Renal: Initial creatinine was elevated and was reported that
he had CRI since a hospital admission last year. Records
obtained showed a Cr baseline close to 3 after that admission,
but latest labs in records showed Cr of 2.0 on [**2146-6-6**]. He was
in this range throughout admission, with last value being 2.0.
He had good urine output on Natrecor here and no other issues
with his kidneys.
5.Asbestosis: CXR done which showed pleural plaque and effusion.
CT of chest again showed plaques and effusion. His
pulmonologist reported that he has had this effusion 3 times in
the past and fluid analysis was negative for malig mesothelioma.
It was not retapped here due to this information. We scheduled
a f/u appointment for him with Dr [**Last Name (STitle) **]. Also instructed him to
continue using his oxygen at home as before.
6. Initially had elevated WBC ct. Possibly due to solumedrol,
but believed to be elevated before this as well. No evidence of
infection was found. COunt was followed, and gradually returned
to nL.
7.He was discharged stable and at his baseline respiratory
status, with close follow-up stressed to him and his family with
cardiologist, PCP, [**Name10 (NameIs) **] pulmonologist. Plan for daily weights
and Lasix adjustment as appropriate will hopefully help keep him
from redeveloping volume overload.
Medications on Admission:
1.Coreg 6.125 mg [**Hospital1 **]
2.Diovan 40 mg qd
3.Lipitor 10 mg qd
4.Amaryl 1 mg qd
5.[**Doctor First Name **]
6.Nexium 40 qd
7.Celebrex 200 qd
8.Bumex?
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*40 Tablet(s)* Refills:*2*
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1.CHF
2.CAD
3.CRI (baseline Cr~2.0)
4.asbestosis
5.NIDDM
Discharge Condition:
Pt was stable. He was eating well.Shortness of breath was
resolved and he is at his baseline. [**Month (only) 116**] still require O2 at
night as before.No chest pain.
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience chest pain or increasing shortness of breath.
Please weigh yourself every day. If your weight increases by 2
lbs or more in one day, take an extra 20 mg of Lasix (in
addition to your daily dose of 20 mg Lasix that we started you
on). If your weight remains up the next day, then call your
doctor to report this.
Please STOP your Diovan.
Your Lipitor dose was INCREASED from 10 mg/day to 40 mg/day.
We STARTED you on aspirin, Plavix, and Lasix (furosemide).
Please take each of these daily.
All of your other medications have stayed the same.
Followup Instructions:
Pulmonology appointment with Dr [**First Name (STitle) **]: [**2146-7-19**] at 5:20
pm
Please call your PCP to arrange an appointment in 1 week.
Cardiology appointment with Dr [**Last Name (STitle) 174**] on [**7-25**] at 2:15 pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"V45.02",
"428.40",
"494.0",
"410.71",
"428.0",
"577.1",
"501",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
10947, 10953
|
6333, 10053
|
290, 297
|
11054, 11225
|
2349, 6310
|
11890, 12255
|
1707, 1725
|
10261, 10924
|
10974, 11033
|
10079, 10238
|
11249, 11867
|
1740, 2330
|
196, 252
|
325, 1261
|
1283, 1518
|
1534, 1691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,917
| 176,935
|
5969
|
Discharge summary
|
report
|
Admission Date: [**2102-7-13**] Discharge Date: [**2102-7-21**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Alchohol Withdrawl
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 yo man with a history of etoh abuse/withdrawl (last admit
[**Date range (1) 23527**]), HCV, and anxiety who was admitted yesterday for etoh
withdrawl requesting detox. This was prompted reportedly by an
altercation with his landlord and he was brought in by his
girlfriend. EtOH level on admit (0810 [**7-13**]) 328. On the medical
floor he was noted to have increasing benzodiazepine
requiriements with increased anxiety and tremulousness. Prior to
transfer he received:
[**7-13**]: diazepam 5mg iv: 1700, 1800, [**2015**], [**2125**], 2120, 2220, 2230
(35mg)
[**7-14**]: diazepam 5mg iv 0000, 0100
diazepam 20mg iv 0130, 0615, 0815, 1000 (90mg)
lorazepam 4mg iv 0200
He notes on interview that he has had etoh withdrawl in the past
with report of seizure. He is asking for '40mg valium every hour
so he can sleep through it'. He notes chest pressure (chronic,
baseline), productive cough (yellow sputum, no blood) also
baseline; denies fevers, chills, SOB, abdominal pain, nausea,
vomitting, constipation, diarrhea, melena, BRBPR, dysuria, leg
pain. During the interview however he experienced 'an anxiety
attack' associated with abdominal pain. He notes last cocaine 4
days prior to admission, 1 line. He notes last drink [**7-12**],
drinks 1L vodka/day, h/o iv cocaine (not recent), tried heroin
age 18, last marijauna 1 week ago. He is currently requesting
inpatient etoh detox. VS prior to transfer: T 99.2 BP 125/103
(125-170/107-131) HR 98 (98-104) RR 20 Sat 98% RA. CIWA
currently 11 ([**9-18**]).
With his last admission he required 20mg po q1-2 hours until
lethargic for the first 36 hours, then was able to be managed
with CIWA. Additionally he was seen by psychiatry on his last
admit and started on zyprexa 5mg qam/7.5mg qpm and buspar 5mg
tid for anxiety. He discontinued these medications on discharge.
He was recommended for psychiatric f/u on d/c which he did not
pursue.
.
Past Medical History:
- EtOH abuse with multiple admissions for w/d
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (last [**Hospital1 18**] records indicated
an EF of 40-45% with mild global HK)
- cocaine abuse
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated
Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]. TB negative. Pt did not comply with course of
anti-fungals, but has no evidence of active infection.
- h/o C. diff colitis, no current diarrhea
- h/o IVDA per OSH records (pt denies)
- HCV (no serologies in OMR)
Social History:
Recently cut down to 5-6 cigs/day, prior to that he smoked 1 ppd
x30 years. Heavy EtOH use; drinks 1 shot of Vodka every 3 hours
(~1 pint per day). Sober x10 years, started drinking again 1.5
yrs ago. +Cocaine abuse. He denies IVDA although history
questionable. Sexually active with his girlfriend. Reports
negative HIV test 2 yrs ago.
Family History:
Mother - CAD. Sister - h/o CVA.
Reports his father was the "[**Location (un) 86**] Strangler," and that he and
his mother changed their names after his arrest, etc.
Physical Exam:
Vitals: Tm 97.6, Tc 96.1, BP 120/80, HR 88, RR 20, sat 98% on
room air
Gen -- calm, interactive, nad, very thin
HEENT -- evidence of well healed remote left radical neck
dissection, op clear, sclera anicteric, no evidence of
lymphadenopathy
Heart -- regular
Lungs -- clear
Abd -- soft, nontender, well healed gastrostomy scar superior to
umbilicus, appropriate bowel sounds
Ext -- no edema, rash or lesion
Pertinent Results:
[**2102-7-18**] 07:45AM BLOOD WBC-6.3 RBC-3.42* Hgb-11.6* Hct-34.9*
MCV-102* MCH-34.0* MCHC-33.4 RDW-15.0 Plt Ct-157#
[**2102-7-14**] 07:15AM BLOOD Plt Smr-LOW Plt Ct-81*
[**2102-7-15**] 05:24AM BLOOD Plt Ct-75*
[**2102-7-16**] 08:20AM BLOOD Plt Ct-83*
[**2102-7-18**] 07:45AM BLOOD Plt Ct-157#
[**2102-7-20**] 06:50AM BLOOD Glucose-100 UreaN-23* Creat-0.9 Na-140
K-4.2 Cl-101 HCO3-29 AnGap-14
[**2102-7-13**] 08:10AM BLOOD cTropnT-<0.01
[**2102-7-13**] 08:30PM BLOOD CK-MB-7 cTropnT-<0.01
[**2102-7-14**] 09:05AM BLOOD CK-MB-5 cTropnT-<0.01
[**2102-7-16**] 08:20AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.6
[**2102-7-17**] 07:25AM BLOOD Calcium-10.5*
[**2102-7-18**] 07:45AM BLOOD Calcium-11.0* Phos-5.3*# Mg-1.6
[**2102-7-20**] 06:50AM BLOOD Calcium-10.2
[**2102-7-14**] 09:05AM BLOOD VitB12-415 Folate-GREATER TH
[**2102-7-19**] 08:10AM BLOOD PTH-12*
[**2102-7-13**] 08:10AM BLOOD ASA-NEG Ethanol-328* Acetmnp-UNABLE TO
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-7-19**] 04:30PM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
[**2102-7-19**] 04:30PM BLOOD VITAMIN D 25 HYDROXY-PND
[**2102-7-19**] 04:30PM BLOOD VITAMIN D [**1-26**] DIHYDROXY-PND
[**2102-7-19**] 08:20AM BLOOD freeCa-1.30
Brief Hospital Course:
1. alcohol withdrawal -- Mr. [**Known lastname 4223**] required large amounts of
Valium (greater than 100 mg q24 hours) to control his withdrawal
symptoms. He was briefly transferred to the [**Hospital Unit Name 153**] for concerns
about the quantity of his benzodiazepines and possibility of
sedation. However, he did well and 5 days after admission a
taper was initiated 10% per day, discharging to inpatient
psychiatry on 10 mg po Valium q6hours with 5 mg po q3 hours prn,
to continue tapering as tolerated.
2. anxiety -- Mr. [**Known lastname 4223**] complained of severe anxiety
throughout his stay, initially attributed to his withdrawal, but
persisting after withdrawal symptoms resolved. Psychiatry had
been contact[**Name (NI) **] in previous stays, and kindly offered their
advice again. We initiated Buspar 5 mg po qday and 10 mg po
qhs, and increased his olanzipine dose to 7.5 mg po bid with prn
2.5 mg doses q8h.
3. delusional psychosis/impaired judgement -- Psychiatry
consulted regarding Mr. [**Known lastname **] anxiety as well as bizarre
behavior, attempts to leave AMA, and agitation. His behavior
was felt to be potential for harm to self, and he had a Section
12 placed so he could not leave AMA. He will be transferred to
an inpatient psychiatry facility on discharge for further
evaluation and management.
4. hypercalcemia -- Mr. [**Known lastname 4223**] was noted to have Calcium
levels as high as 11.0 during his stay. A PTH was low, and PTH
related peptide and calcitriol/calcidiol levels were pending on
discharge. Given his history of head/neck carcinoma, this is
concerning for hypercalcemia of malignancy. This was explained
to the patient and he will need close follow up for malignancy
workup if his PTH-RP returns elevated, likely starting with a
neck CT scan. Clinically, he has no physical exam evidence of
recurrence.
5. Hypertension -- remained stable on metoprolol and HCTZ.
6. alcoholic dilated cardiomyopathy -- stable, on metoprolol
[**Hospital1 **]. It should be considered to initiate an ace inhibitor in
his case, but the patient refused during this hospitalization
because of previous episodes of hypotension.
Medications on Admission:
- Aspirin 81 mg PO DAILY
- Folic Acid 1 mg DAILY
- Hexavitamin PO DAILY
- Thiamine HCl 100 mg PO DAILY
- Lisinopril 5 mg PO DAILY
- Levothyroxine 75 mcg PO DAILY
- Nicotine 21-14-7 mg/24 hr Patch Daily once a day.
- Digoxin 125 mcg PO once a day
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for agitation.
13. Buspirone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
14. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
15. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): taper by 20% per day.
16. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for CIWA>10.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
1. alcohol dependence and withdrawal
2. anxiety
3. acute psychosis
4. hypertension
5. history of probable aspergillosis, stable
6. mild hypercalcemia of unknown cause
Discharge Condition:
medically stable, on Valium taper, with continued acute
psychosis
Discharge Instructions:
You were hospitalized for alcohol withdrawal. You have been
doing well with a benzodiazepine taper. Because of your
symptoms of anxiety and psychosis, we are sending you to an
inpatient psychiatric facility for further evaluation and
treatment.
Followup Instructions:
You should follow up with your primary care physician at [**Name9 (PRE) **]
COMMUNITY HEALTH CENTER [**Telephone/Fax (1) 23520**] for further evaluation and
care after discharge from the psychiatry facility, particularly
for your hypercalcemia. This may be related to several possible
reasons, including a recurrence of your malignancy.
|
[
"428.0",
"401.9",
"298.9",
"292.0",
"428.20",
"425.5",
"112.0",
"300.00",
"291.81",
"287.5",
"304.21",
"686.9",
"244.9",
"303.01",
"275.42",
"V15.81",
"117.3",
"V10.89",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.68"
] |
icd9pcs
|
[
[
[]
]
] |
8867, 8912
|
5120, 7295
|
334, 341
|
9123, 9191
|
3912, 5097
|
9486, 9827
|
3303, 3469
|
7592, 8844
|
8933, 9102
|
7321, 7569
|
9215, 9463
|
3484, 3893
|
276, 296
|
369, 2266
|
2288, 2930
|
2946, 3287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,280
| 199,369
|
5331
|
Discharge summary
|
report
|
Admission Date: [**2164-2-13**] Discharge Date: [**2164-2-16**]
Date of Birth: [**2114-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
IABP placement
History of Present Illness:
49 year old male with h/o severe MR s/p MVR [**7-/2163**], s/p AVR due
to endocarditis in [**2156**], redo bioprosthetic AVR [**2157**] for
endocarditis recurrence, CAD s/p CABG [**2157**] with SVG to RCA and
SVG to LAD, HTN who presented to the ED at [**2185**] with chest pain
and dyspnea, N/V, loose stools. Pt initially received SL NTG and
ASA in ambulance on way to ER and was on CPAP. BP 170/100 on
presentation, HR 80 in SR. ECG showed STE anterior leads with
lateral depressions. TTE done in ED and seen by cardiology. CXR
with pulmonary edema and given 80 IV lasix, became hypotensive
to 80. He was given 2L IVF, SBP improved to 100. Blood and urine
cx's sent, given vanco and gentamicin. He subseqently developed
rapid AFib to 110, became more dyspneic and was intubated.
Became hypotensive to 60s in setting of intubation. A-line was
placed with SBP 107, transferred to CCU.
On arrival pt was hypotensive to 70's, started on levophed, L
femoral central line placed. Pt was transferred to cath lab for
emergent IABP, in addition R sided cath revealed severe MR.
During this time, increasing difficulty with ventilation and
hypercarbic acidosis, despite attempts at various types of
ventilation, limited by resp pressure in high 40's. Pt was
paralyzed with vecoronium to aid with ventilation. After IABP
added, SBP improved to 90's, however continued difficulty
oxygenating, ABG pH 7.06/79/83. PCW 41, Fick CI 2.78.
On evaluation, pt is intubated and sedated.
Past Medical History:
#CAD s/p CABG [**10-30**] (SVG->LAD, SVG->RCA)
#MVR s/p MV repair and mechanical MVR [**7-5**]
#hx aortic endocarditis s/p AVR '[**56**], redo bioprosthetic AVR in
'[**57**] for recurrent endocarditis
#h/o embolic stroke with episodes of endocarditis.
#h/o paroxysmal atrial fibrillation in the setting of
endocarditis.
# DM II
# Chronic Pseudomonal respiratory colonization, UTIs.
# hx hypercalcemia on pamidronate
# Seizure disorder since age of 12. The patient has been
seizure free on Keppra.
# Chronic malnutrition.
# Depression.
# Recurrent aspiration.
# Bowel dysmotility, previously on Reglan and erythromycin.
# h/o fungemia.
# tracheal-cutaneous fistula: s/p closure [**10-2**]
# h/o right hemicolectomy.
# h/o type 1 renal tubular acidosis.
# h/o gastric outlet obstruction by GJ tube abutting pylorus.
# h/o anoxic encephalopathy.
# Chronic intermittent chemical pancreatitis.
# h/o severe esophagitis
# s/p choclear implant ([**3-5**]) for deafness.
# Left eye blindness.
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Cath [**2164-2-14**]:
4+ MR, 60% LVEF
LAD mid-segment competitive flow from patent SVG which is
patent, RCA occluded at origin, SVG patent.
CI 2.78, PCW 41
.
CARDIAC CATH performed on [**2163-1-25**] demonstrated:
1. Two vessel native coronary artery disease.
2. Patent SVG to LAD.
3. Moderate origin stenosis of SVG to RCA.
4. Moderate pulmonary systolic arterial hypertension.
5. Giant V waves consistent with mitral regurgitation.
6. Preserved cardiac index (CI 2.9, PCWP 16).
Social History:
No reported history of IV drug use, had edentulation after
initially presented with endocarditis in '[**57**]. No smoking hx.
Lives alone
Family History:
NC. No history of stroke.
Physical Exam:
VS: T 97.1, BP 98/73, HR 118 sinus tach , RR , on PCV
100%/434/40/PEEP 12 on PIP 48 at 1:1.5 ratio, Plateau 25.
Gen: intubated, sedated
HEENT: puplis symmetrical, consitricted, minimally reactive
Neck: Supple with elevated JVP while flat
CV: regular, tachy, difficult to ascultate given baloon pump
active.
Chest: No chest wall deformities, scoliosis or kyphosis. BS
bilateral, + crackles b/l when auscultated anteriorly
Abd: soft, ND, No HSM or tenderness.
Ext: R groin with baloon pump, L groin with TLC
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: palpable DP and PT b/l
Pertinent Results:
[**2164-2-13**] 08:30PM PT-36.8* PTT-38.9* INR(PT)-3.9*
[**2164-2-13**] 08:30PM PLT COUNT-226
Brief Hospital Course:
49 year old male with h/o severe MR s/p MVR [**7-/2163**], s/p AVR due
to endocarditis in [**2156**], redo bioprosthetic AVR [**2157**] for
endocarditis recurrence, CAD s/p CABG [**2157**] with SVG to RCA and
SVG to LAD, HTN found to be in cardiogenic shock due to acute
severe MR in setting of volume overload with extreme difficulty
mantaining oxygenation and adequate MAP.
.
# Cardiogenic shock/Multiorgan failure due to acute MR
Due to severe MR, on triple pressors (dopa 5, NE 0.3 to 0.4,
vaso 2.4), lasix gtt (15), IABP. Multiorgan failure, kidney
(creat 3.1 to 4.2), liver (INR 6 to 13, bili 4.6 to 7.6),
cardiac, and pulmonary function is all trending down. Patient
was currently not a surgical candidate per CT surgery. Decision
made my HCP [**Name (NI) 21709**] [**Name (NI) 1968**] (brother) and family to withdraw care.
Patient expired with family present on [**2164-2-16**] at 2100. Autopsy
to be performed, consent given by son [**Name (NI) 4035**] [**Name (NI) 1968**].
Medications on Admission:
ASA 81mg daily
Atorvastatin 10mg daily
Metoprolol 50mg [**Hospital1 **]
Warfarin 5mg daily
Amiodarone 200mg daily- postop atrial fib, stopped [**2164-1-16**]
Lisinopril 10mg daily- primarily for afterload reduction in the
context of severe MR, stopped [**10-5**]
Keppra 500mg [**Hospital1 **]
Pantoprazole 40mg daily
Reglan 10mg QID
Docusate
Senna
Bisacodyl PRN
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"V58.61",
"389.9",
"424.0",
"584.9",
"518.81",
"785.51",
"427.31",
"272.0",
"250.00",
"276.2",
"414.01",
"428.0",
"E879.9",
"514",
"780.39",
"401.9",
"996.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"88.53",
"37.61",
"42.92",
"33.23",
"38.91",
"88.56",
"37.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5786, 5795
|
4352, 5341
|
335, 351
|
5846, 5855
|
4230, 4329
|
5911, 5921
|
3572, 3600
|
5754, 5763
|
5816, 5825
|
5367, 5731
|
5879, 5888
|
3615, 4211
|
276, 297
|
379, 1850
|
1872, 3401
|
3417, 3556
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,930
| 144,435
|
24833
|
Discharge summary
|
report
|
Admission Date: [**2162-8-4**] Discharge Date: [**2162-10-29**]
Date of Birth: [**2095-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
Transthoracic esophagectomy with cervical
anastomosis ([**Last Name (un) 62523**] Procedure).
Esophagogastroduodenoscopy.
multiple paracenteses
Abdominal washout.
2. Placement of left chest tube.
3. Esophagogastroduodenoscopy.
4. Bronchoscopy.
Abdominal wash out.
2. Placement of Bovine pericardial mesh (
Tracheostomy (#7 Portex cuffed).
2. Therapeutic bronchoscopy.
3. VAC dressing change.
History of Present Illness:
The patient is a 67-year old male who was
recently diagnosed with stage T3N1 distal esophageal
adenocarcinoma by EUS and biopsy who underwent preoperative
chemo/radiation treatment. The patient also had a feeding
jejunostomy placed in [**2162-4-8**] and was able to tolerated
p.o. intake. He was admitted electively for a three hole
esophagectomy.
Past Medical History:
- duodenal ulcer '[**21**]; '[**43**], tx for H pylori '[**52**]
- hiatal hernia, gastritis, duodenitis '[**49**]
- asthma, exercise induced (well controlled w/ pulmicort,
albuterol prn, no O2)
- ADHD
- s/p MVA w/ depressed skull fx '[**23**]
- SBO '70s, managed conservatively
- colonic polyps, s/p colonoscopy & excision (adenoma), last
colonoscopy '[**58**] - no polyps, hemorrhoids
PSH:
- s/p appy
- s/p ing hernia repair [**5-9**]
Social History:
former smoker (1ppd x 10yrs, quit 35yrs), ETOH one wine or
beer/day; denies drugs; married w/ 3 children, realtor
Family History:
mother w/ gastric or uterine CA '[**00**], s/p surgery, MI - deceased
father w/ resp disease, attributed to occupational exposure to
dust or mold
Brief Hospital Course:
OPERATIONS DURING ADMISSION:
[**8-4**] Transthoracic esophagectomy with cervical anastomosis
([**Last Name (un) 62523**] Procedure).
Esophagogastroduodenoscopy (3-hole esophagectomy)
[**9-8**] ex-lap, abdominal wash-out
[**9-13**] abdominal wash-out
[**9-22**] abdominal wash-out, bovine pericardium abdominal closure,
VAC dressing placement
[**9-24**] trach placement
[**9-26**] colocutaneous fistula w/leaking feces [**9-26**] s/p vac,
skin, and pericardium takedown with bedside placement of red
rubber tube in fistula
[**10-8**] portacath out, PICC out
[**10-8**] bronch neg
CONSULTATIONS DURING ADMISSION:
Interventional Pulmonology
Acute Pain Service
Nephrology Service x2
Surgical ICU
Trauma-Surgical ICU
General Surgery
Infectious Disease
cardiology
HOSPITAL COURSE:
The patient was admitted to the hospital for known esophageal
cancer (T3N1MO) s/p portacath placement and J-tube placement in
[**2162-4-8**], followed by neoadjuvant chemo (F5U/cisplatin) and
radiation for an esophagectomy with cervical anastomosis
([**Last Name (un) 62523**] procedure).
Postoperatively he went into acute renal failure and was seen by
the nephrology service. He was also seen to develop loculated
pleural effusions, and so he had a pigtail placed on [**8-25**]; CXR
post placement revealed a right lung fluid in new loculated
effusion/ hydropneumothorax towards apex with the left effusion
unchanged. THe patient then had a chest tube placed on the left
for drainage of that effusion. When drainage had decreased
significantly and there were no signs of pneumothorax, the
patient's left and then right pigtails were removed, which he
tolerated well.
He remained on the ventilator and had a tracheostomy placed on
[**9-24**], which he tolerated well.
On [**9-7**] the patient went into septic shock and was transferred
to the CVICU. He triggered 6x on the floor for dyspnea and
hypotension. Pressures noted to be in the 70s. Pt given albumin
for volume expansion transiently resulting in an increase in BP
into the 90s. Pt was noted to have a burst of SVT with HR in
160s which improved with carotid massage. [**1-9**] overwhelming
nursing concern, transient hypotension, concern for worsening
hypercarbia, decrease in mental status, pt transferred to ICU
for further management. Placed US guided L AC 18 gauge. Pt
intubated for hypercarbia and for fluid management concern as
latest cxr revealed volume overload versus underlying pna(no
fevers)
[**9-8**] - Pt self-extubated in AM, reintubated in CVICU, was
hypotensive, femoral a-line and RIJ triple lumen placed. Pt
taken back to OR for ~5hr exploration as to acute
decompensation, bronchoscopy unrevealing, on ex-lap multiple
loculated abscesses found and drained, JPs left in place,
anastomosis no leak. Pt hypotensive during abdominal closure -->
asystolic arrest, CPR initiated, epi/atropine given --> Vtach,
defib into sinus rhythm. Abd left open. Then had episode of SVT
during transfer from OR table to bed -Afib w/ RVR w/
hypotension, cardioverted back to sinus. Overnight in CVICU had
a slight dropoff of UOP and mild hypotension, responded to fluid
bolus. Remains sedated on fent/midaz, with slow weaning of
levophed. postop hct 33 --> Midnight Hct 30, INR 1.5, lytes wnl,
ABGs improving - last 7.54/34/110/30/+7.
[**9-9**]-off pressors, excellent urine output, transfused 1UPRBC,
continues on TPN, started on lasix gtt to augment diuresis for
possible closure, vanc trough appropriate
[**2162-9-10**]-Transfused 1 unit of PRBC's with goal of keeping patient
above goal of 30. Diuresed to goal of 100cc/hour of urinary
output with a CVP greater than 10 and an SBP > 100.
[**9-11**] - likely washout on Sunday or Monday with closure;
autodiuresis >2L, off lasix. 4am RN noticed slightly uneven
pupils and less reliable response to voice/command on neuro
check. Communicated with primary service which will decide on
course in AM as per Dr. [**First Name (STitle) **].
[**9-12**] washout Monday with closure; diuresis augmented with lasix
gtt and diamox, rate increased to blow off more co2, TPN
concentrated, non contrast head and chest shot, negative 3+L
over 24h
[**9-13**]-Pt to OR for attempted closure. Failed. Had Left chest tube
placed for pleural collection. 300cc's of yellow serous fluid
drained from site. Pt still not on pressors making 50-80cc's
hour.
[**9-14**] - albumin added in attempt to decrease edema, lasix bolus
to [**Male First Name (un) **] albumin as neg balance reaching even. diamox d/c'ed.
[**9-15**] lasix boluses d/c'ed in favor of lasix gtt, [**State **] patch
tightened, IR/CT guided drainage deferred to tomorrow AM,
vivonex 20cc/hr to be held at midnight started.
[**9-16**] - stool for guaiac, search for source of anemia. For IP
drainage of right apical effusion today, if drainage successful
chest tube to be d/c'ed by thoracic.
[**9-17**]- maintained negative, R chest tube removed by thoracic
surgery
[**9-18**] - Continue to make 1/2L negative, follow BUN/Cr, daily CXR
[**9-19**]-started vanc--goals remain similar as yesteday.
[**9-20**] - TPN reordered, lasix gtt to continue per thoracic,
titrate to goal 0-1L negative. CVL displaced in PM, new RIJ CVL
placed. Also noted to be jaundiced - LFTs elevated, TB 4.7,
AST/ALT in 80s, primary team requests to repeat LFTs in AM.
Post-line CXR - small line near left heart border, rads resident
read as possible pneumomediastinum, again line on repeat CXR.
Possible pneumomediastinum unlikely related to line placement,
pt w/ esophagectomy, ?air tracking from open abdomen or surgical
site, pt remain hemodynamically stable overnight. Discussed with
primary team, agree to plan to monitor and manage conservatively
until repeat CXR in AM or further plan by Dr [**Last Name (STitle) **]. Plan for OR
[**9-21**] for possible abdominal closure.
[**9-21**]: Unable to take back to OR, will go back [**9-22**] for closure
of negative pressure therapy, d/c'ed versed gtt in favor of
intermittent ativan with minimal requirement of usage, TF off
after MN/NPO p MN for OR [**9-22**].
[**9-22**] Went back to OR today, DC left chest tubes, dc both JP
drains, DC ng tube, placed bovine pericarial matrix on superior
portion of wound, and closed the infraumbilical portion.
Attached vac dressing to superior portion. For vac change on the
18th. Consideration of add on for trach on Friday. Want to
continue vanc, zosyn, fluconazole for a few more days. Goal for
euvolemia. Per nursing, pt was tried on CPAP which was not
tolerated. Fentanyl was weaned from 200 to 150.
[**9-23**] TF advanced w/ TPN x 1 more day. PICC attempted on R arm
at bedside but unable, IR order placed, will need bicarb to be
written at time of procedure. No OR cultures to follow. No
change in vent setting (kept on CMV) as NPO for trach in AM.
[**9-24**] trach'ed, picc line in place, vac changed in OR, sedation
weaned, resp weaning as much as possible
[**9-25**] - On [**9-25**] the patient was noted to be febrile to 103 -
though with a stable blood pressure, and he was pancultured for
concern with sepsis. On [**9-26**] the patient was noted to have
copious amount of frank green thick feces emanating from his vac
dressing. He underwent takedown of the vac dressing and the
pericardial mesh with opening of the skin closure on [**9-26**] at
the bedside. He was found to have a colocutaneous fistula, from
which was emanating the stool. That day he underwent a CT
abd/chest with contrast that revealed leakage of contrast to
anterior abdomen from transverse colon; no biliary dilatation
or gallbladder distension.
[**9-26**] - Kept on amp/zosyn/fluconazle per thoracic (vanco denied
by ID). CT C/A/P w/ small perf transverse colon to anterior
abdomen, kept NPO, TPN restarted. HIDA scan ordered per
thoracic. Left radial a-line placed.
[**9-27**] - no HIDA scan, ostomy nurse creates large vacuum sump for
EC fistula, 2UPRBC xfused, TPN continues, no tube study
necessary for EC fistula as prior contrast passes distal to the
fistula, currently on only Zosyn - added Vanco due to new
culture data from cath tip
[**9-28**] - Pt taken by IR for placement of cholecystostomy tube. Pt
off pressors, making good urine with no other O/N issues.
[**9-29**] - Bactrim started for stenotrophomonas. Lasix gtt started
for diuresis.
[**9-30**] - ID consulted, [**Last Name (un) 2830**] caspo bactrim started,
hemodynamically stable so far, weaned of versed gtt with
intermittent ativan used for sedation, daily cultures to be
obtained with sputum per ID
[**10-2**] - tolerating PS (PS18/PEEP5/50%) x 12 hours overnight.
[**10-3**] - became intolerant of CPAP+PS placed back on the vent,
spiked to 102 pan cultured, lasix gtt restarted with goal
-500/-1L negative, CXR in am to be obtained, nutrition labs
obtained, OT consulted, abx continue
[**10-4**]: DC vanco, DC [**Last Name (un) 2830**], started vivonex tube feeds for
nutrition; Dr. [**First Name (STitle) **] wants daily plan update emailed to him from
team. SP family meeting yesterday. O/N patient had BUN/Creat
ration of 35/1. He was producing 20cc's hour of urine. Given
albumin with hope of mobilizing extravascular fluid(albumin
2.0). Started patient on methadone 20 Q 8 and PO valium 10 Q 6.
DC fentanyl and versed drip. Wrote for PRN fentanyl/versed.
[**10-5**]: vent regimen to PS20 (from PS25) 2-3x/day for diaphragm
exercise. Cr to 1.2 today - hold lasix gtt; good uop. Bowel
regimen started (MoM, colace, dulcolax), enema next; received 2
units PRBC; restarted lasix gtt at low dose in PM for net pos 3
L --> aim for euvolemia.
[**10-6**] : Continued to tolerate PS20 throughout the day and night;
lasix gtt held [**1-9**] to reduced effect and rising BUN/Cr over the
course of the day; speciation of sputum culture from [**10-1**] shows
bactrim resistance -> tobramycin added
[**10-7**] - tobra d/c'ed, increasing cr, lasix gtt d/c'ed. o/n high
peak pressures (PIP 40s, plateau 30s), severe resp acidosis +
metab acidosis, anuria/oliguria, back to pressure controlled
ventilation
10/31 - hypothermic x 2 (both axillary temps), bedside echo
adequate intravascular filling with nl contractility; bronch for
elevated airway pressures, no plugs, minimal thin secretions,
BAL sent; left IJ placed w/ SvO2 monitoring, SvO2 80s. Remains
oliguric. Bicarb 2 amps x 2. Renal consulted - ATN w/ granular
non-muddy cast, monitor, CVVH/HD if needed. Concern for ARDS,
ARF.
[**10-9**] - [**10-11**] - off caspo, tobramycin d'c'd. Reamined on pressure
support ventilation, poor tidal volumes. Unable to wean off
vent - increasing acidemia with HCO3 to low of 15.
[**10-12**] The patient's creatinine increased to 3.6 and he failed to
respond to 200 IV lasix. He required increasing sedation to
fentanyl 400/hr. The patient also underwent a gastrograffin
study that revealed free flow of contrast from the rectum to the
distal transverse colon with drainage into the anterior
abdominal wound via colocutaneous fistula without evidence for
an obstructing lesion in the left colon.
[**10-13**] The patient's acute renal failure worsened to a creatinine
of 3.9 with clonus on exam and concern for uremic encephalopathy
as per the renal fellow. He was started on CVVH. The output
from his NGT was concerning for possible stool. His antibiotics
were continued. He remained on PCV ventilation but became
hypocapnic but also with a low bicarb.
[**10-14**]- [**10-15**] Bilirubin up to 14.7, becoming more jaundiced; had
RUQ U/S and evaluation of perc choly tube that was negative for
cholecystitis or infection or abnormality of the biliary tract.
On half dose tube feeds with fat free TPN. Feces out of
abdominal fistula. Creatinine decreasing to 2.7 on CVVH.
Changed from PCV to AC. Pt suffering from ARDS, ARF, hepatic
failure.
[**10-16**] - CVVH continued with 1.5L of fluid removed. Open abdomen
developed small but persistent area of bleeding lateral and
slightly superior to the fistula. Hemostasis was achieved
through application of Surgicell.
[**10-17**] - patient remained on CVVH with goal net negative 2L.
Dressing changes continued. Sedation decreased slightly from
300 fentanyl to 200 fentanyl.
[**10-20**] - VAC dressing applied to abdominal wound by general
surgery service
[**10-21**] - atrial flutter, low blood pressure. failed attempted
cardioversion at 50, 100 and 200J. started on neo gtt,
continuing sedation. placed on amio gtt per cardiology rec. TF
stopped prior, now progressing to full TPN.
[**10-22**]: CT torso - no changes/new acute issues very hypotensive,
tachycardic overnight, was in A flutter, cardioversion x 2.
CVVHDF running
[**10-25**]: AFlutter cardioverted, started on amio again, changed
pressors from neo to levophed and vasopressin. Remains in NSR.
Family meeting on [**10-25**], no escalation of care, but full code
currently. LFTs continuing to rise.
Patient continued on pressors, tpn, amiodarone for afib, stable
ventilartory setting but continued to have rising liver finction
tests and required increased doses of pressors so that he also
had a very positive fluid balance for a few days in a row. There
were continued daily family discussions during this time. ON
[**10-29**] the family
decided that it was time to make the patient CMO. care was
withdrawn with multiple family memebers present and he expired
just before 6pm on [**2162-10-29**]. Dr [**Last Name (STitle) **] was present during the
family meetings and was notified of his passage. The family
declined an autopsy.
Discharge Disposition:
Expired
Discharge Diagnosis:
esophageal cancer
Discharge Condition:
death
Completed by:[**2162-11-3**]
|
[
"276.7",
"584.5",
"486",
"263.9",
"493.90",
"997.4",
"575.0",
"518.81",
"348.39",
"038.8",
"150.5",
"997.39",
"995.92",
"511.9",
"998.59",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.57",
"96.04",
"45.13",
"99.15",
"42.69",
"96.72",
"42.42",
"54.62",
"34.91",
"31.1",
"96.59",
"33.21",
"33.22",
"34.04",
"51.01",
"51.03"
] |
icd9pcs
|
[
[
[]
]
] |
15341, 15350
|
1890, 2657
|
338, 733
|
15411, 15447
|
1719, 1867
|
15371, 15390
|
2675, 15318
|
281, 300
|
761, 1111
|
1133, 1571
|
1587, 1703
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,714
| 133,181
|
7378
|
Discharge summary
|
report
|
Admission Date: [**2167-4-15**] Discharge Date: [**2167-4-20**]
Date of Birth: [**2108-4-19**] Sex: M
Service: [**Hospital1 **] MEDICINE
CHIEF COMPLAINT: Lethargy and altered mental status
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
a history of human immunodeficiency virus x21 years, history
of cerebrovascular accident, acute renal failure who
presented to the Emergency Room with lethargy and feeling
like he had a seizure. The patient said this lasted for
about three weeks. He has been passing out. This entails
him waking up early hours in the morning in his wheelchair
after five to six hours of not knowing what happened. He
wakes up with some confusion. He denies any feeling in his
arms or legs. No loss of bowel or bladder function. No
tongue biting. The patient has had intermittent episodes of
nausea and vomiting for the last two weeks, but more over the
last three days. He also reports increased output from his
stoma.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus with his last CD4 count of
492
2. History of thrush
3. Cerebrovascular accident in [**2161**] with residual left sided
weakness
4. Osteoarthritis
5. Depression
6. Chronic renal insufficiency
7. Hypertension
8. Status post colectomy with colostomy for Clostridium
difficile colitis in [**2163**]
9. Neuropathy
10. Gastroesophageal reflux disease
ALLERGIES: FOOD DYES, PERFUMES, PENICILLIN WHICH CAUSES
SWELLING, VERAPAMIL, FENTANYL, VASOTEC, HYDROCHLOROTHIAZIDE,
TRILAFON, ELAVIL, SULFONAMIDE
ADMISSION MEDICATIONS:
1. Indinivir 800 mg po tid
2. Epivir 100 mg [**Hospital1 **]
3. Retrovir 100 mg [**Hospital1 **]
4. Prilosec 20 mg q day
5. Neurontin 300 mg tid
6. MS Contin 30 mg [**Hospital1 **]
7. Zoloft 200 mg qd
8. Trazodone 100 mg q hs
SOCIAL HISTORY: No tobacco history. He has a history of
ETOH use; he quit four years ago. The patient is wheelchair
bound. He lives at a program at JRI. [**Name2 (NI) **] illicitable drug
use.
FAMILY HISTORY: The patient's mother had a history of
stones.
PHYSICAL EXAM:
ADMISSION VITAL SIGNS: Temperature 99.4??????, heart rate 76,
blood pressure 88/50, respiratory rate 16, 96% on room air.
GENERAL: The patient was alert, awake and oriented x3 and
was arousable.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular movements intact. Oral
cavity, oropharynx showed minimal thrush, no lymphadenopathy.
NECK: Supple.
HEART: Regular rate and rhythm, no murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, positive bowel sounds. Ostomy
with clean liquid output, 1+ trach edema bilaterally.
EXTREMITIES: On the left lateral malleolus, there is a stage
2 ulcer. On the right heel there is a stage 1 ulcer.
Strength 4/5 on the left side, [**5-17**] on the right. Babinski's
equivocal bilaterally. Cranial nerves II through XII intact.
LABS: White count 8.2, hematocrit 37.0, platelets 329.
Chem-7 139, 4.0, 109, 18, 19, 2.1 and 100.
IMAGING: Head CT done in the Emergency Department showed an
old infarct in the right basal ganglia and possibly the right
caudate lobe. Electrocardiogram had normal sinus rhythm at
69, left atrial dilatation, normal intervals. T-wave
flattening in V1, no other ST or T-wave inversions. No
change compared to the [**2167-2-4**] electrocardiogram.
ASSESSMENT: This is a 58-year-old male with history of human
immunodeficiency virus, chronic renal insufficiency,
cerebrovascular accident with deficits who presented with
altered mental status, lethargy and hypotension.
HOSPITAL COURSE:
1. CARDIOVASCULAR: HYPOTENSION: The patient received
multiple boluses of normal saline in the Emergency Room with
minimal improvement. Blood pressure was subsequently started
on a dopamine drip and transferred to the Medical Intensive
Care Unit. In the Medical Intensive Care Unit, the patient
was weaned off the dopamine with a stable blood pressure.
The patient's cardiac enzymes were cycled and he was ruled
out for myocardial infarction. The patient had no [**Doctor Last Name 1356**]
events. The patient had no evidence of congestive heart
failure. Over the course of the hospitalization, the
patient's blood pressure was stable. It was believed that
his increased stoma output contributed to hypovolemia which
lead to hypertension .
2. NEUROLOGIC: The patient presented with lethargy and
altered mental status. Head CT in the Emergency Room showed
old deficits. The patient subsequently had a head MRI
without contrast which showed no significant change in the
appearance of his right basal ganglia and caudate nucleus
infarction. He has high grade stenosis in his right internal
carotid artery and probable stenosis of the right external
carotid artery. He subsequently had a MR of his head with
contrast to further clarify these findings. The head MRI
with contrast revealed the same chronic infarcts as the
previous studies. No new infarcts were noted. The patient
also had a lumbar puncture on this admission which was
negative. The patient's history was concerning for seizure
activity. Per the patient's primary care physician, [**Name10 (NameIs) **] has
no prior history of seizure activity. The patient had an EEG
done and the preliminary [**Location (un) 1131**] showed no focal
abnormalities, no epileptiform activity and the EEG was read
as normal. Neurology will provide input as to whether or not
to start antiepileptic. The patient's mental status did
improve throughout the course of his hospitalization and he
was back to his baseline upon discharge. A second
contributing factor to his altered mental status was believed
to be excessive narcotics. In the Neonatal Intensive Care
Unit, the patient received a trial of Narcan with improvement
in his mental status. Subsequently, the patient's OxyContin
dose was decreased from 30 mg [**Hospital1 **] to 10 mg [**Hospital1 **] and his pain
was well controlled on this dose.
3. INFECTIOUS DISEASE: The patient has a history of human
immunodeficiency virus for 21 years. He was continued on his
heart regimen and did well over the course of his
hospitalization.
4. RENAL: The patient has a history of chronic renal
insufficiency. Creatinine was stable over the course of his
hospitalization.
5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient's phos
was low and the patient was given Neutra-Phos. He will be
discharged on a three day course of Neutra-Phos 1 packet po
tid for three days.
6. DERM: The patient developed a rash after starting broad
spectrum antibiotics in the Emergency Room. These were
subsequently discontinued secondary the patient was taken to
the operating room no fever, no white count. It was believed
that the rash was due to the cephalosporin. This rash
improved over the course of his hospitalization.
7. GASTROINTESTINAL: It is believed that the patient had a
viral gastroenteritis with increased stoma output. The
patient had multiple stool studies sent including Clostridium
difficile which was negative, O&P which was negative to date,
cultures which were negative. Stool was also negative for
Cyclospora, Microspora and Isospora. Over the course of the
hospitalization, the patient's stoma output decreased to the
normal range which was 500 to 1000 cc per day.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Good
DISCHARGE DIAGNOSIS:
1. Gastroenteritis
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2167-4-20**] 10:37
T: [**2167-4-20**] 10:41
JOB#: [**Job Number 27154**]
|
[
"707.14",
"693.0",
"584.9",
"E935.8",
"042",
"585",
"276.5",
"292.81",
"008.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7341, 7374
|
2018, 2065
|
7395, 7662
|
3608, 7319
|
1567, 1802
|
2080, 3591
|
176, 212
|
241, 986
|
1008, 1544
|
1819, 2001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,161
| 138,960
|
40753
|
Discharge summary
|
report
|
Admission Date: [**2168-9-19**] Discharge Date: [**2168-9-24**]
Date of Birth: [**2099-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE, fatigue
Major Surgical or Invasive Procedure:
[**2168-9-19**] AVR ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Epic porcine)/ CABG x2 (LIMA to LAD,
SVG to PDA)
History of Present Illness:
69M with a bicuspid Aortic Valve who has been followed by echo
for aortic stenosis. Over the previous 2-3 months he has noted
an increase in fatigue and dyspnea on exertion. He is quite
active as he owns a landscaping business. Cardiac cath revealed
two vessel disease. He is admitted for AVR, CABG.
Past Medical History:
Coronary Artery Disease
Aortic Stenosis
PMH:
Hypertension
Aortic Stenosis
Aortic Insufficiency
Hyperlipidemia
Colon Cancer [**2160**]
PSVT
Proteinuria
Scarlet Fever
Benign Prostatic Hypertrophy
Past Surgical History:
Right clavicle wired to sternum s/p MVA [**2138**]
Partial colectomy [**2160**]
herniorrhaphy remotely
Social History:
Lives with: married, 3 children
Occupation: retired professor, works in landscaping now
Tobacco: 1PPD, quit [**2138**]
ETOH: rare
Family History:
father died at [**Age over 90 **]yo with h/o prostate and colon cancer
mother died at [**Age over 90 **]yo
son with hypercoagulation d/o
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 97%
B/P Right: 124/73 Left:
Height: 5'[**67**]" Weight: 200lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
radiation of cardiac murmur
Pertinent Results:
[**2168-9-24**] 06:40AM BLOOD WBC-8.1 RBC-3.25* Hgb-10.0* Hct-29.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.7 Plt Ct-257#
[**2168-9-22**] 06:05AM BLOOD WBC-11.8* RBC-3.14* Hgb-9.9* Hct-28.7*
MCV-92 MCH-31.4 MCHC-34.4 RDW-13.6 Plt Ct-162
[**2168-9-24**] 06:40AM BLOOD Glucose-114* UreaN-19 Creat-1.2 Na-143
K-3.9 Cl-103 HCO3-29 AnGap-15
[**2168-9-22**] 06:05AM BLOOD Glucose-122* UreaN-29* Creat-1.1 Na-138
K-4.4 Cl-104 HCO3-24 AnGap-14
[**2168-9-24**] 06:40AM BLOOD PT-18.6* INR(PT)-1.7*
[**2168-9-23**] 06:00AM BLOOD PT-16.3* INR(PT)-1.4*
[**2168-9-22**] 06:05AM BLOOD PT-13.3 INR(PT)-1.1
[**2168-9-20**] 02:08AM BLOOD PT-14.1* PTT-30.0 INR(PT)-1.2*
[**2168-9-19**] 04:07PM BLOOD PT-14.4* PTT-39.4* INR(PT)-1.2*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 89100**] (Complete)
Done [**2168-9-19**] at 8:45:54 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-3-14**]
Age (years): 69 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Chest pain.
Coronary artery disease. Hypertension. Mitral valve prolapse.
Pulmonary hypertension. Shortness of breath.
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0
Test Information
Date/Time: [**2168-9-19**] at 08:45 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW6-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *61 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No thrombus
in the RAA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Mildly dilated aortic arch. Mildly dilated
descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is
seen in the left atrial appendage. No thrombus is seen in the
right atrial appendage
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
6. The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The aortic annulus measures 23 mm.
7. Mild (1+) mitral regurgitation is seen.
8. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. Atrial pacing.
1. There is a well-seated, well-functioning bioprosthetic valve
in the aortic position. No aortic regurgitation is seen. There
is a peak gradient of 27 mmHg across the aortic valve.
2. Biventricular function is unchanged.
3. There is mild (1+) mitral regurgitation.
4. There is trace tricuspid regurgitation.
5. The ascending aorta, aortic arch, and descending aorta are
intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
?????? [**2160**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr.[**Known lastname **] was brought to the operating room on [**2168-9-19**] where the
patient underwent Aortic valve replacement(#23-mm Biocor tissue
valve)/Coronary artery bypass grafting x2,(left internal mammary
artery graft to left anterior descending,reverse saphenous vein
graft of the posterior descending artery)with Dr. [**Last Name (STitle) **].
Please refer to operative report for further surgical details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU intubated and
sedated in stable but critical condition. He awoke
neurologically intact and was extubated without incident. He
weaned from vasopressor support. Beta blocker, Statin, Aspirin
and diuresis were initiated. He was gently diuresed toward the
preoperative weight. All lines and drains were discontinued per
protocol. POD#1 his rhythm went into rate controlled atrial
fibrillation. He was bolused with IV Amio and placed on oral
amio. AFib persisted and he was started on coumadin. His pain
was difficult to control and he required a Dilauded PCA. He was
transferred to the telemetry floor for further monitoring. The
patient was evaluated by the physical therapy service for
evaluation of strength and mobility. By the time of discharge
on POD 5, the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA services in good condition
with appropriate follow up instructions.
Medications on Admission:
Lisinopril 10mg daily
simvastatin 40mg daily
Aspirin 81mg daily
ascorbic acid 1000mg daily
fish oil
MVI
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR, Coumadin for A-fib
Goal INR 2-2.5
First draw [**2168-9-25**], Then please do INR checks Monday, Wednesday,
and Friday for 2 weeks then decrease as directed. Results to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 170**]
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
Disp:*60 Tablet(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. lorazepam 0.5 mg Tablet Sig: .5 Tablet PO Q6H (every 6 hours)
as needed for anxiety .
Disp:*20 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
may change daily for goal INR 2-2.5.
Disp:*30 Tablet(s)* Refills:*2*
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis
PMH:
Hypertension
Aortic Stenosis
Aortic Insufficiency
Hyperlipidemia
Colon Cancer [**2160**]
PSVT
Proteinuria
Scarlet Fever
Benign Prostatic Hypertrophy
Past Surgical History:
Right clavicle wired to sternum s/p MVA [**2138**]
Partial colectomy [**2160**]
herniorrhaphy remotely
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
LLE incision- healing well, no erythema or drainage
Edema- trace, auto-diuresing
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check [**2168-9-29**] 10:00 at [**Hospital Unit Name 4081**],
[**Location (un) 86**]
[**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**10-26**] at 1:00pm at [**Hospital Unit Name 89101**], [**Location (un) 86**]
Cardiologist: Dr. [**Last Name (STitle) 5874**] on [**10-13**] at 4pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**Doctor Last Name **] M. [**Telephone/Fax (1) 3658**] in [**5-17**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR, Coumadin for A-fib
Goal INR 2-2.5
First draw [**2168-9-25**], Then please do INR checks Monday, Wednesday,
and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 170**]
Completed by:[**2168-9-24**]
|
[
"427.31",
"600.00",
"285.9",
"997.1",
"401.9",
"424.1",
"414.01",
"272.4",
"V10.05",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.21",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10750, 10809
|
7615, 9111
|
324, 459
|
11173, 11410
|
2166, 5761
|
12198, 13173
|
1300, 1439
|
9266, 10727
|
10830, 11024
|
9137, 9243
|
11434, 12175
|
11047, 11152
|
5810, 7592
|
1454, 2147
|
271, 286
|
487, 792
|
814, 1008
|
1152, 1284
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,692
| 161,480
|
31486+57749
|
Discharge summary
|
report+addendum
|
Admission Date: [**2131-7-29**] Discharge Date: [**2131-8-7**]
Date of Birth: [**2051-2-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2131-8-6**] Thyroid fine needle aspiration - ultraosund guided
History of Present Illness:
80 yo female s/p fall down ~13 stairs sustaining multiple
bilateral rib fractures and lumbar fracture. She was brought to
[**Hospital1 18**] for further care.
Past Medical History:
HTN
COPD
Rheumatoid arthritis
Osteoporosis
Family History:
Noncontributory
Pertinent Results:
[**2131-7-29**] 10:15PM GLUCOSE-178* UREA N-19 CREAT-0.8 SODIUM-140
POTASSIUM-5.3* CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
[**2131-7-29**] 10:15PM CK(CPK)-1584*
[**2131-7-29**] 10:15PM cTropnT-<0.01
[**2131-7-29**] 10:15PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.5
[**2131-7-29**] 10:15PM WBC-15.6* RBC-4.80 HGB-13.3 HCT-39.8 MCV-83
MCH-27.7 MCHC-33.4 RDW-14.5
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: r/o intrabdominal injury
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p fall down 13 stairs with multipl eR sided
rib fx, pulmonary contusion, L1 endplate fx per osh
REASON FOR THIS EXAMINATION:
r/o intrabdominal injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fall down 13 stairs.
COMPARISON: None.
TECHNIQUE: Non-contrast axial images of the chest, abdomen and
pelvis were obtained with multiplanar reformatted images, as
patient recently received contrast for an outside hospital
trauma study she was not administered IV contrast.
NON-CONTRAST CT CHEST: Non-contrast evaluation of the heart and
great vessels demonstrates scattered mural atherosclerotic
calcification and mild coronary artery calcification. The right
main pulmonary artery appears prominent but poorly evaluated
without contrast. There is no evidence of pericardial effusions.
Trace pleural effusions are noted bilaterally. There is no
evidence of pathologically enlarged axillary, mediastinal or
hilar lymphadenopathy. A 25 x 24 cm right thyroid lobe hypodense
lesion is incompletely evaluated.
Lung windows reveal diffuse emphysema. Scattered calcified
pleural plaques are noted at the right base. Subsegmental
atelectasis is noted at the bases and right middle lobe but
there is no evidence of contusion or pneumothorax. A 4-mm
pulmonary nodule is noted at the left base (2:47).
Non-contrast evaluation of intra-abdominal organs is limited but
there is no evidence of abnormality involving the liver, spleen,
pancreas, or adrenal glands. Gallstones are noted within the
gallbladder. A hypodense lesion of the upper pole of the left
kidney measures 7 mm and is too small to characterize. Contrast
within the renal collecting system is noted bilaterally. Intra-
abdominal loops of small bowel are unremarkable. There is no
free air or free fluid or pathologically enlarged lymph nodes.
CT PELVIS WITHOUT CONTRAST: The rectum and bladder are
unremarkable. There is sigmoid diverticulosis without
diverticulitis. No free fluid or pathologically enlarged pelvic
lymph nodes are seen.
Bone windows reveal compression deformity of L1 with mild height
loss which likely involve the anterior and middle columns. Rib
fractures involve the right fifth, sixth and seventh ribs. The
left shoulder is incompletely evaluated, however the humeral
head appears slightly posterior with respect to the glenoid with
joint space narrowing. No worrisome lytic or sclerotic lesions
are identified.
IMPRESSION:
1. L1 compression fracture with mild loss of vertebral body
height. Evaluation of intrathecal detail is limited on CT.
2. Multiple right-sided rib fractures without evidence of
pneumothorax or pulmonary contusion. Small bilateral pleural
effusions noted.
3. Left-sided pulmonary nodule at base. If there are priors for
comparison, this would be helpful. If no priors are available
could be followed up at one year unless there is history of
malignancy or significant risk factors, in which case a 3-month
followup is recommended.
4. Left humeral head appears positioned slightly posterior with
respect to the glenoid on axial images with joint space
narrowing, though the shoulder is not entirely imaged. Recommend
correlation with exam and plain radiographs as clinically
indicated. D/w Dr. [**Last Name (STitle) 11753**].
5. Cholelithiasis without cholecystitis.
6. Diverticulosis without diverticulitis.
Cardiology
Sinus rhythm. Probable left atrial abnormality. RSR' pattern in
lead VI,
probably a normal variant. Mildly prolonged QTc interval. No
previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 174 82 384/435.71 65 -14 46
Brief Hospital Course:
She was admitted to the Trauma Service. Her injuries were
nonoperative. She initially required intensive care unit stay
because of her rib fractures and concern for respiratory
compromise. She was started in PCA for pain control and required
supplemental oxygen. She was then transferred to the floor and
in less than 24 hours became hypoxic and was transferred back to
the ICU for better pain control; she was maintained on high
FiO2, but did not require intubation. Early discussions took
place regarding epidural analgesia for managing her rib fracture
pain; she declined this on several occasions. She was eventually
started on an oral pain regimen which included scheduled Tylenol
and Ultram; Oxycodone prn. This combination appeared to be very
effective.
There was a thyroid nodule found on CT imaging; a General
surgery consult was obtained. She underwent fine needle
aspiration on [**8-6**] by Dr. [**Last Name (STitle) 30330**]. She will need to follow up
with him in the next 1-2 weeks. A lung nodule was also noted on
chest imaging; this information, along with the thyroid nodule
was relayed to her primary care doctor (Dr. [**Last Name (STitle) **]. She will
require a follow chest CT in the next 3 months per
recommendations by radiology.
She was also treated with Bactrim DS for a UTI; she has one more
day until course complete.
Physical and Occupational therapy were consulted and have
recommended that she go to rehab post hospital stay.
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
6. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for Hr <60, SBP <110.
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
s/p Fall
Mutltiple bilateral rib fractures
L1 fracture
Urinary tract infection
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your lumbar support brace while out of
bed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Trauma Clinic in [**2-6**] weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery, in [**5-11**]
weeks. call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up with your primary care doctor, Dr. [**Last Name (STitle) **] regarding the
thyroid and lung nodule. You will need to call for an
appointment.
Completed by:[**2131-8-7**] Name: [**Known lastname 8235**],[**Known firstname 4497**] D. Unit No: [**Numeric Identifier 12264**]
Admission Date: [**2131-7-29**] Discharge Date: [**2131-8-7**]
Date of Birth: [**2051-2-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9036**]
Addendum:
She had an episode of chest discomfort during the night shift;
this was reproducible to touch and with movement. An EKG was
done and compared to her admission EKG; no acute changes were
noted. Her troponin was <0.01; her CK's were cycled and remained
flat. She was given an ASA x1; these symptoms did not recur. It
was felt likely the pain was related to musculoskeltal due to
her multiple rib fractures.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] [**Hospital **] Hospital
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2131-8-7**]
|
[
"401.9",
"599.0",
"807.03",
"799.02",
"707.05",
"733.00",
"562.10",
"241.0",
"714.0",
"805.4",
"E880.9",
"574.20",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.11"
] |
icd9pcs
|
[
[
[]
]
] |
8896, 9127
|
4834, 6294
|
322, 390
|
7482, 7491
|
696, 1165
|
7609, 8873
|
660, 677
|
6317, 7265
|
1202, 1318
|
7380, 7461
|
7515, 7586
|
274, 284
|
1347, 4811
|
418, 578
|
600, 644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,303
| 140,526
|
6849
|
Discharge summary
|
report
|
Admission Date: [**2122-1-11**] Discharge Date: [**2122-1-18**]
Date of Birth: [**2047-6-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Weakness.
Major Surgical or Invasive Procedure:
Central line placement (femoral).
R radial artery line placement.
Lumbar puncture.
History of Present Illness:
Per chart as pt intubated/sedated. Pt is a 74 y/o F s/p renal
txp [**2116**] [**2-20**] DM, who was brought to ED by EMS for weakness and
hadn't been eating as much as usual per husband.
.
In the ED, she was initially awake, but then at 5:45 pm was
noted to be unresponsive without corneal reflexes. She then had
generalized tonic clonic activity. She was intubated for airway
protection in the setting of a seizure. She received ativan 2 mg
IV x2. She was found to have a UTI and was given vancomycin,
ceftriaxone, and zosyn. She became hypotensive and was started
on dopamine. She was noted to have a right mainstem intubation
with complete collapse of her left lung, which resolved with
pulling back the ETT. She was loaded with dilantin and was seen
by Neurology who recommended LP, MRI, and MICU admission. LP was
not done as coags had not been drawn.
Past Medical History:
1. s/p CRT [**1-19**] [**2-20**] DM, baseline creat mid-high 1's
2. DM
3. CVA with persistent left sided hemiparesis
4. HTN
5. Hyperlipidemia
6. GI bleed [**2115**] s/p hemicolectomy
7. Anemia
8. Osteoporosis
Social History:
Lives at home with husband. [**Name (NI) **] [**Name2 (NI) 269**]. Denies tobacco, alcohol,
illicits.
Family History:
Father had a CVA.
Mother and brother w/CHF
Physical Exam:
T: 103.4 BP: 107/42 (on levophed at 0.142) P: 69
Vent: AC 450x14, peep 5, fio2 0.5, 100%
Gen: intubated, not on sedation, initially did not respond to
pain but later responded to pain during LP, A-line. initially no
corneals but + cough w/suctioning
HEENT: NC, AT, pupils 2 mm and nonreactive, sclerae anicteric
Neck: supple, no LAD, JVD diff to assess
Lungs: CTA anteriorly, no w/r/c
CV: RRR, II/VI SEM at LSB
Abd: soft, large ventral hernia without tenderness or distention
Ext: no edema, 1+ dp bilaterally
Neuro: moves all extremities, tone is increased esp in RUE, no
corneals but + gag, babinski mute bilaterally
Skin: warm/dry
Pertinent Results:
Significant for elevated lactate (even prior to sz), creat 1.9
(at baseline), glucose 298, anion gap 15
.
EKG: NSR at 109, normal axis, normal intervals, early RWP, TWI
in I and aVL (new in I), 0.5-[**Street Address(2) 4793**] dep in V3-6 (new)
.
CXR #1 [**1-11**]: The lungs are clear. There is minimal subsegmental
bibasilar atelectasis. The cardiomediastinal contours are
stable. There is tortuosity of the aorta. The pulmonary
vasculature is
within normal limits. No pleural effusions or pneumothorax are
seen. Soft tissue and osseous structures are stable. Again seen
is dense material for vertebroplasty in the lower thoracic/upper
lumbar spine.
IMPRESSION: No evidence of pneumonia.
.
CXR #2 [**1-11**]: There has been interval intubation, and the ET
tube is positioned within the right main stem bronchus. There is
associated complete opacification of the left hemithorax, shift
of the heart to the right, and hyperinflation of the right lung.
No pneumothorax or pleural effusion is seen. NG tube is seen
with the tip positioned in the proximal duodenum. Soft tissue
structures are stable in appearance. Again seen is dense
material within a lower thoracic vertebral body from
vertebroplasty.
IMPRESSION: Interval placement of an ET tube, with the tip in
the right main stem bronchus, and likely collapse of the left
lung with complete opacification of the left hemithorax.
.
CXR #3 [**1-11**]: There has been interval withdrawal of the ET tube,
with the tip now in the mid trachea, approximately 5 cm above
the carina. There has been resolution of the complete left lung
collapse seen in
the prior chest radiographs, with normal aeration bilaterally.
minimal scattered subsegmental atelectasis may be noted at the
left lung base. The remainder of the study is unchanged in
comparison to the prior exam.
IMPRESSION: Satisfactory position of the ET tube.
.
Head CT [**1-11**]: Comparison with [**2121-6-7**]. Again seen is
prominence of ventricles and sulci, similar to the previous
examination. Extensive hypodensity is seen in the corona radiata
and centra semiovale of both cerebral hemispheres. A cystic
low-density lesion in the left parietal lobe (series 2, image
20) is unchanged since previous exam. No hydrocephalus, shift of
normally midline structures, intra- or extra-axial hemorrhage,
or acute major vascular territorial infarct is identified. No
fractures are seen. The imaged sinuses are notable for scattered
opacification of ethmoid
air cells, otherwise, sinuses are clear. Mastoid air cells are
clear. Also, the right external auditory canal contains some
soft tissue density material, which may be cerumen. There is
moderate calcification of both cavernous internal carotid
arteries.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Cerumen in right external auditory canal.
Urine culture:
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
This is a 74 year old woman with CKD secondary to DM,
hypertension, and s/p CRT on chronic immunosuppression, who
presented with weakness, found to have a UTI, then began seizing
in ED, complicated by hypotension requiring pressors. She was
intubated for airway protection in the setting of her seizure
and received 2 doses of ativan. Started on broad spectrum,
meningitic antibioitics (ceftriaxone, vancomycin, along with
acyclovir and then transferred to unit. Urine culture grew
pansensitive proteus. LP revealed no sign of infection. Weaned
off pressors by HD 2, self extubated that day as well. She was
oxygenating well and hemodynamically stable since that time.
Antibiotic coverage narrowed to ciprofloxacin only. Also
received bicarbonate therapy for acidosis, likely related to her
chronic kidney disease, per renal consult. Pt restarted on
antihypertensive regimen on HD 3 and transferred to general
medical floor.
.
1. Sepsis: Met criteria for sepsis protocol with fever,
tachycardia, and hypotension unresponsive to fluids requiring
pressors. Likely UTI related sepsis, urine culture revealed pan
sensitive proteus species. She was treated with a 14 day course
of ciprofloxacin (start date: [**1-11**]) which was renally dosed
when appropriate, which should be continued until [**2122-1-25**]. Given
fevers and seizure, meningitis was a concern; LP was, however,
negative. Initial CXR did not show evidence of pneumonia, no abd
symptoms to suggest that as a source. Blood cultures remained
negative. LP did not reveal any infection. She was continued
on home prednisone regimen. C.diff was negative.
.
2. Seizure: Neuro has evaluated, felt likely to be due to
toxic-metabolic derangements in the setting of sepsis. No focal
abnormality on head CT. LP unrevealing. EEG showed diffuse
encephalopathy with no focal findings. She was started on
dilantin per neurology given that she had a ? of eye deviation.
Her levels remained therapeutic and she tolerated the medication
well. She should follow up in neurology residents clinic.
.
3. Respiratory failure: Was intubated for airway protection in
ED in setting of seizure. For the remainder of her hospital
stay, she was oxygenating and ventilating well
.
4. CKD, s/p CRT: [**2-20**] DM. Creatinine was at baseline at
discharge. Renal following for the duration of hospital stay.
She was continued on Prograf, Imuran and prednisone (which was
decreased to 5mg from 8mg/d).
.
5. Acute renal failure: Creatinine peaked at 2.2, now 2.1, above
baseline of around 1.7. Likely prerenal from sepsis, as
patient's creatinine recovered well with hydration.
.
6. Anemia: Likely [**2-20**] renal disease. No current indication for
transfusion. Started on Epo 6000 units M, W, F.
.
7. Hypertension: Metoprolol was changed to 50mg [**Hospital1 **] given
continued bradycardia to 40s. Lisinopril was increased to 20mg
daily. Normotensive.
.
8. Hyperlipidemia: Continued atorvastatin.
.
9. FEN: Repleted lytes prn.
.
10. Communication: with husband and sons.
.
11. Code: Full.
.
12. Dispo: In good condition, to rehabilitation facility.
Medications on Admission:
aspirin 325 mg daily
azathioprine 50 mg daily
lipitor 20
lisinopril 10
prograf 3 mg [**Hospital1 **]
toprol 150 mg qam
nph 20 units qam
prednisone 8 mg daily
caltrate
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) Units Subcutaneous qam.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO HS (at bedtime).
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
Urosepsis
Seizures
.
Secondary diagnosis:
Diabetic nephropathy, status post cadaveric renal transplant in
[**1-/2116**]
Type 2 diabetes
Cerebrovascular accident with persistent left sided hemiparesis
Hypertension
Hyperlipidemia
GI bleed [**2115**], status post-hemicolectomy
Anemia of chronic disease
Osteoporosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a urinary tract infection. You are being
treated for this with an antibiotic called ciprofloxacin. You
should continue to take this until [**2122-1-25**].
.
You also developed seizures during your hospital stay and were
started on a new medication called phenytoin. You should
continue to take this until you follow up with neurology.
.
You were also started on epogen shots to help with your anemia.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2528**] to make an appointment to see a
neurologist in the neurology residents clinic within the next
1-2 months to follow up with your seizures.
.
Please call [**Telephone/Fax (1) 250**] to make an appointment to see your
primary care doctor (Dr. [**Last Name (STitle) **] within the next 2 weeks.
.
You have the following appointments already made:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-2-6**] 11:00
|
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10,006
| 142,345
|
46977
|
Discharge summary
|
report
|
Admission Date: [**2164-10-23**] Discharge Date: [**2164-11-1**]
Date of Birth: [**2094-3-5**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine / Heparin Sodium
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
HD tunnel catheter replacement
History of Present Illness:
Ms. [**Known lastname **] is a 70 year old female with ESRD on HD through
tunneled catheter (hx of peritoneal dialysis until VRE
peritonitis and PD catheter removal in [**2164-10-13**]), HTN, DMII,
CAD, Afib, CHF (EF 50%), who presents from [**Location (un) 4265**] Dialsis with
fever, chills for one hour during HD. Dialysis was completed
and the patient was transferred to [**Hospital1 18**] where she was found to
have a temperature of 103 and HR of 120 with lactate of 4.4.
Ms. [**Known lastname **] received Ceftriaxone 1g IV, Flagyl 500mg IV, and
tylenol (unasyn 3g x1 written for but never signed) in the ED.
She denied any SOB, cough, sputum, n/v/d, dysuria, burning or
difficulty with urination. As per patient and her family, the
patient has been in her USOH up until this point. Ms. [**Known lastname **]
was admitted to [**Hospital Unit Name 153**] for sepsis protocol.
Past Medical History:
Atrial fibrillation
Significant for recurrent GI bleeding from AVMs-colonoscopy
gastro and small bowel enteroscopy all showing AVM.
Four endoscopies which showed bleeding ulcers in the colon and
small intestine, and were
treated with cauterization.
Non-insulin-dependent diabetes - diagnosed at the age of 50-
HgbA1C = 6.2 in [**7-18**]
hypertension
congestive heart failure,
gout
ESRD secondary to hypertensive nephrosclerosis on peritoneal
dialysis x 3 years without complications
chronic anemia
aortic insufficiency.
Recent admission to NEBH in [**7-18**] for diverticulitis
[**3-18**]- C. dificile, pancolitis associated with hypokalemia,
profound weight loss, dehydration, and hypomagnesemia.
H/o parotitis
H/o gout
H/o Clostridium [**Doctor Last Name **] sepsis
PAST SURGICAL HISTORY:
Laminectomy, C-section x4, and cholecystectomy.
Past Cardiac history:
[**7-/2161**]- MIBI- 1) Moderate, fixed perfusion defects in the
lateral wall, involving especially the inferior portion. 2)
Multi-vessel disease cannot be excluded given left ventricular
enlargement, global hypokinesis, and depressed EF of 43%.
Cath: [**2161-10-15**]- R dominant system with nml coronary
arteries
[**7-18**]:Echo: LVK, global HK, LVEF is 50%.
Social History:
Retired RN. Pt has been living at [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] rehab since her last
discharge from [**Hospital1 18**] and communtes to [**Location (un) 4265**] for dialysis three
times a week. Pt admits to 100 pack year history of smoking
(2ppd x 49 years). However, the patient denies any history of
alcohol use or illicit drug use.
Family History:
One son has hypertension and one son recently had a cerebro
vascular accident. Her mother died of a ruptured cerebral
aneurysm and father died when he was 80.
Physical Exam:
Physical Exam:
VS: Tc: 98.6 HR: 93 BP: 120s/50s RR: 15 SaO2: 100%
Gen: patient lying in bed in NAD, appearing younger than her
stated age. She is alert and oriented x3 and conversing
appropriately
HEENT: PERRL, EOMI, anicteric, mmm
Neck: Left IJ bandage has dried blood but otherwise, no obvious
signs of bleeding, hematoma, tenderness at site.
CV: RRR S1, S2, ?SEM at LSB
Chest: CTA bilaterally, R tunneled IJ with dressing c/d/i. No
signs of acute bleeding, hematoma, pus drainage, tenderness to
palpation
Abd: soft, NT, ND, well healed scar at PD site
Ext: warm, well perfused, no c/c/e
Pertinent Results:
[**2164-10-23**] 05:33PM LACTATE-4.4*
[**2164-10-23**] 05:38PM PT-21.2* PTT-32.7 INR(PT)-2.8
[**2164-10-23**] 05:38PM NEUTS-86.6* LYMPHS-7.9* MONOS-5.0 EOS-0.4
BASOS-0.2
[**2164-10-23**] 05:38PM WBC-7.8 RBC-4.46 HGB-13.7 HCT-42.4 MCV-95
MCH-30.8 MCHC-32.4 RDW-20.0*
[**2164-10-23**] 05:38PM CRP-8.92*
[**2164-10-23**] 05:38PM CORTISOL-49.3*
[**2164-10-23**] 05:38PM ALT(SGPT)-9 AST(SGOT)-40 ALK PHOS-167* TOT
BILI-1.0
[**2164-10-23**] 05:38PM GLUCOSE-217* UREA N-9 CREAT-3.0*# SODIUM-139
POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-29 ANION GAP-20
CLOSTRIDIUM DIFFICILE(Final [**2164-10-31**]): FECES NEGATIVE FOR C.
DIFFICILE TOXIN BY EIA.
AEROBIC BOTTLE (Final [**2164-10-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) **]. ABULO (PAGER [**Numeric Identifier **]).
FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2466**])
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---------- 4 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC BOTTLE (Final [**2164-10-26**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) 99628**] ON [**2164-10-24**] @
2118.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
CT abdomen:
1) Thickened wall in long segment of sigmoid colon, consistent
with diverticulitis, unchanged. There is a small amount of
interlooped free fluid in the pelvis, not amenable to drainage.
2) Pelvic fluid collection, of uncertain origin, that was
aspirated from [**10-17**] and shown to be not contaminated, and
unchanged.
TTE: Moderate aortic regurgitation and minimal aortic stenosis
but no discrete vegetation seen (does not exclude). Regional
left ventricular systolic dysfunction c/w CAD. Mild mitral
regurgitation.
Compared with the prior study (tape reviewed) of [**2161-7-23**], left
ventricular systolic function is now depressed (40%). The
severity of aortic regurgitation is similar.
CXR: Right jugular dialysis catheter is in right atrium. PICC
line is in SVC, partly obscured by the dialysis catheter. Linear
atelectases are present in both lower zones. No pleural
effusion. Degenerative changes are present in the thoracic spine
and in the glenohumeral joints bilaterally. Surgical clips are
present in the right upper quadrant status post cholecystectomy.
Brief Hospital Course:
A/P: Ms. [**Known lastname **] is a 70 year old women with ESRD on HD who
presents with fever to 103, chills, and tachycardia to 103 with
possible line infection.
.
1. Sepsis: The patient was initially sent to the intensive
care unit under the sepsis protocol. She was started on
vancomycin for skin flora and unasyn for Group D enterococcus
(VRE) sensitive to amp (previous infections over last year). Her
blood cultures drawn at [**Location (un) 4265**] grew out oxacillin resistant coag
negative staph. Her urine cultures were without grown. A CXR
was obtained and was without signs of pneumonia. Once she was
stabilized, Ms. [**Known lastname **] was sent to the floor where her
tunneled catheter was removed. The tip was sent for culture but
did not grow any organisms.
Access was an issue as 3 attempts in ED failed, including one
with US. Instead a PICC was placed and eventually, after she was
free of bacteria for > 48 hours, a new tunnel line was placed.
Despite placement of a new line and clean surveillance cultures,
Ms. [**Known lastname **] continued to spike fevers. She spiked through her
vancomycin which was always re-dosed when her daily levels fell
below 15. An [**Known lastname 1676**] CT was obtained, revealing a 7 cm mass,
consistent with an abscess, above the bladder. Considering that
she had been recently hospitalized with a diverticulitis and
peritonitis, it seemed urgent to intervene on this "abscess". It
was evacuated under IR guidance but no organisms appeared on
gram stain and nothing grew on culture. It became apparent that
this was most likely a fluid collection from the patient's
peritoneal dialysis. The patient continued to spike fevers so a
work up was commenced that included a chest x ray, a TTE (since
she has a murmur, although old) and more blood and urine
cultures. All these studies were negative. As the patient
continued to spike fevers and had one bout of emesis, another
[**Known lastname 1676**] CT was obtained. It showed diverticulitis and so a 14
day course of flagyl and levofloxacin was started. It was
decided that a general surgery consult would be obtained once
she was an outpatient in order to faciliate resection of the
affected length of bowel. At discharge, Ms. [**Known lastname **] was
instructed to continue her levo, flagyl, and vanco to complete a
14 day course of each one. Her vanco levels were to be followed
and redosed at HD.
.
2. ESRD: Ms. [**Known lastname **] usually dialyzes on Tues, Thurs, Sat but
here she was switched to Monday, Wednesday and Saturday under
the guidance of the renal team. Her electrolytes were followed
and repleted very consevatively as needed. It was noted that her
phosphate calcium product was quite high, so her sevelamer was
titrate up. She was also placed on a renal diet. The patient
reports making urine, however not an adequate measure of
perfusion due to ESRD. She hopes to continue her peritoneal
dialysis and felt were upset at having to start HD. The method
of dialysis was to be further addressed as an outpatient with
her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **], after her diverticular disease was resolved.
.
3. DMII: Ms. [**Known lastname **] is usually on oral hypoglycemics. These
oral agents were held due to their long half life and instead
she was covered with RISS with QID finger sticks. Her home
regimen of glipizide was restarted at discharge. While in house,
she was on a controlled carbohydrate diet.
.
4. HTN: Ms.[**Known lastname 14301**] home regimen includes metoprolol,
moexipril and diltiazem. Initially the metoprolol was continued
and the diltiazem and moexipril were held since the patient is
currently not hypertensive. Before discharge, she was restarted
on moexepril but not diltiazem. She was also started on an
aspirin and atorvastatin before discharge.
.
5. Afib: The patient is on coumadin as outpatient for
anticoagulation. This was hold anticoagulation in case she
required urgent line placement. Her rate was easily controlled
with beta blocker. Before discharge, her coumadin was restarted,
but very cautiously as it interacts with her 2 antibiotics for
her diverticulitis, flagyl and levofloxacin. She was advised to
have her INR followed carefully and her warfarin titrated as
needed for an INR [**1-17**].
.
6. CAD by hx (fixed perfusion defect) but clean coronaries by
cath: The patient was continued on metoprolol but given her
current anticoagulation status and possible need for urgent line
placement the aspirin was held. Her ACE inhibitor and statin
were initially held and re-started later in her course.
Medications on Admission:
1. Metoprolol 150mg TID
2. Diltiazem 360mg once daily
3. Glipizide 10mg [**Hospital1 **]
4. Coumadin 2mg once daily
5. Sevelamer 800mg TID
6. Moexipril 7.5mg once daily
7. Flagyl (completed course on [**2164-10-20**])
Discharge Medications:
1. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Moexipril HCl 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous QHD (each hemodialysis).
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 14 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. comode Sig: One (1) as needed.
14. hospital bed
1 bed for patient with CHF
15. commode
1 commode for patient with CHF
16. shower chair
1 shower chair for patient with CHF
17. wheelchair
1 wheelchair for patient with CHF
18. Vancocin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
QHD prn level < 15 for 7 days.
19. pulse oximetry
please use for overnight oximetry on room air and record each
morning.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
diverticulitis
chronic renal insufficiency with HD line sepsis
anemia
CHF
diabetes
CAD
atrial fibrillation
recurrent GIB
colonic ulcers
gout
c.diff pancolitis
cholecystectomy
laminectomy
parotitis
c section x 4
Discharge Condition:
good
Discharge Instructions:
Please restart your medications except for your diltiazem. You
will also be taking 2 new antibiotics for your diverticulitis.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc per day
Please note, you should have your INR and vancomycin level
checked at HD on Saturday. Your medications need to be adjusted
accordingly. You will need to get vancomycin at HD for the next
7 days each time your level is < 15 each time it is measured. It
should be measured each time you go to HD.
Since you will not be dialyzing until Saturday, please be
especially careful with your diet and avoid excess fluid and
potassium.
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 1676**] pain, fevers, chills,
diarrhea, or constipation.
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2164-11-19**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-12-5**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Where:
TRANSPLANT SOCIAL WORK Date/Time:[**2165-1-7**] 1:00
Please call your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 18145**] for an
appointment right after [**Holiday 1451**].
Please note, you should have your INR and vancomycin level
checked at HD. Your medications need to be adjusted accordingly,
eg. you should receive 1000 mg of vancomycin for a level less
than 15 and you should increase your warfarin if the INR is less
than 2 and decrease it if the level is greater than 3. Your
warfarin level will need to be checked 2-3 times per week while
you are on the metronidazole and levofloxacin because these
antibiotics will increase your INR.
* you were vaccinated with the pneumococcal vaccine but not the
infuenza vaccine
|
[
"274.9",
"038.19",
"E934.2",
"428.0",
"562.11",
"E879.1",
"414.01",
"424.1",
"285.29",
"995.91",
"287.4",
"V58.67",
"567.2",
"403.91",
"V09.0",
"305.1",
"785.0",
"996.62",
"427.31",
"424.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"99.07",
"38.95",
"54.91",
"00.14",
"97.49"
] |
icd9pcs
|
[
[
[]
]
] |
13314, 13363
|
6945, 11559
|
305, 337
|
13617, 13623
|
3695, 6922
|
14491, 15762
|
2899, 3060
|
11835, 13291
|
13384, 13596
|
11585, 11812
|
13647, 14468
|
2063, 2499
|
3090, 3676
|
249, 267
|
365, 1249
|
1271, 2040
|
2515, 2883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,559
| 153,087
|
15282+15312+56631+56632
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2140-8-12**] Discharge Date: [**2140-10-13**]
Date of Birth: Sex:
Service: NEUROSURGERY
DISCHARGE DATE: Undetermined.
DISCHARGE PLAN: The patient is to be transferred back to his
home country of [**Country 4194**] at some time in the near future. The
dictation of this discharge summary is done in preparation
HISTORY OF THE PRESENT ILLNESS: This is a 34-year-old
Brazilian male, who was transferred from the [**Hospital **]
Hospital in [**Location (un) 47**], MA on the day of admission having
experienced nausea and vomiting over several hours during the
middle of the day. He then went to the emergency room at
[**Hospital6 1109**], where he complained of headache and
revealed subarachnoid hemorrhage with interparenchymal and
intraventricular blood and he underwent placement of two
ventricular drains immediately at that time at the outside
hospital prior to being transferred to the [**Hospital1 346**].
Repeat head CT scan, upon arrival, at the [**Hospital1 346**], showed findings consistent with
massive interparenchymal hemorrhage, as well as
intraventricular hemorrhage and massive subarachnoid
hemorrhage. In the patient's physical examination, he was
grade 5, unresponsive, pupils nonreactive and entirely
unresponsive. Previous medical history was reportedly
unremarkable although questionable due to absence of family
members for thorough questioning and obtaining of history.
Due to the clinical findings, the patient was taken urgently
to the Neuroangiography Suite for coiling of aneurysm after
angiogram. The angiogram showed aneurysm in the anterior
communicating artery and nine coils were placed at that time.
The patient tolerated the procedure well. The patient
remained neurologically unchanged and, therefore, admitted to
the Intensive Care Unit for further treatment. The in situ
ventricular drains were removed at the time of the angiogram
due to clot formation in the drain tube and new drains were
placed urgently at that time. The patient was brought to the
ICU with three intraventricular drains, all of the drains,
draining small amounts of thick, bloody fluid at the time of
admission to the ICU. The patient had positive corneal
reflexes bilaterally and a weak intermittent cough, but,
otherwise, entirely unresponsive.
HOSPITAL COURSE: On post-op day 1 the patient underwent
instillation of intraventricular tPA for dissolution of
intraventricular clot and this helped improve drainage from
the drains and resulted in a lower intracranial pressure. The
patient remained in the Intensive Care Unit for several days.
On
the 11th, he was noted to show pupils 2.5 mm bilaterally and
minimally to nonreactive, neurologically unchanged. The vent
drains were showing high intraventricular correction and
intracerebral pressures of 8 to 31 cm water. The patient was
maintained on sedation at that time. Later on the 12th, the
patient was taken to the operating room for treatment of [**Last Name (un) **]
ve
brain edema, at which time a left frontotemporal parietal
craniectomy was performed by Dr. [**Last Name (STitle) 1132**] with the bone flap plac
ed
into the abdominal subcutaneous adipose tissue for preservatio
n.
The patient tolerated the procedure well. The patient went to
the recovery room stable. The above procedure was done due to
persistent elevated intracranial pressures. During the
postoperative course, the intracranial pressure came down
slightly and the patient remained in the Intensive Care Unit
for an additional several days at which time on the [**9-17**] the sputum culture showed positive growth and
Staphylococcus aureus. The patient was placed on Oxicillin.
He remained in the Intensive Care Unit again for several
days. On the 17th, he spiked a fever to 103.5 and he was
resulted. All cultures came back negative with the exception
of the sputum. Pupils remained 2.0 mm and nonreactive on the
right and 2 to 1.5 sluggishly reactive on the left. He had
positive doll's eyes. He began to open his eyes on occasion
inconsistently to sternal rub. However, he remained,
otherwise, decerebrate in the left upper extremity. He did
not localize. He showed mild withdrawal of the right upper
extremity. He triple flexed the bilateral lower extremities.
He was considered to be neurologically without change and in
grave condition, status post the grade 5 subarachnoid
hemorrhage. However, the family felt they wanted to continue
aggressive therapy and this was continued. The patient
remained in the ICU until the [**2140-9-2**], at which
time bronchoscopy and placement of trach was done.
Subsequently to this, in early [**Month (only) **] a PEG tube was
placed for feeding. The patient tolerated these procedure
quite well. The patient was maintained in the Intensive Care
Unit and remained essentially neurologically without change.
The patient was periodically cultured. He was also seen in
consultation by the Stroke Service for further evaluation.
However, due to the clinical findings and the presence of
ventricular drains, no further interventions were felt to be
appropriate. Decision was made for the patient to undergo
removal of the drains and placement of a ventricular
peritoneal shunt. He was, therefore, taken back to the
operating room on the afternoon of the [**2140-9-9**], where he underwent removal of the ventricular drains
and placement of a right frontal ventriculoperitoneal shunt
and also had replacement of the bone flap with a small
incision made in the left abdominal wall for removal of the
bone flap and replacement of the bone flap onto the left
frontotemporoparietal area. The patient tolerated all
procedures well. The patient returned to the Intensive Care
Unit and remained essentially unchanged neurologically with
occasions when the patient's eyes were opened and he would
appear to be awake or minimally response if at all to light
sternal rub and deep painful stimulation. However, he never
attended the examiner. He does not blink to threat. He
minimally withdraws to painful stimulation and he remained,
otherwise, neurologically unchanged. Therefore, toward the
end of the first week of [**Month (only) **], discussion was made with
the family, who indicated the desire to maintain current
aggressive therapy with plans for the patient to be
transferred to [**Country 4194**] to his home country when arrangements
could be made.
CONDITION ON DISCHARGE: Neurologically minimally responsive
male who remains severely comatose with grade 5 subarachnoid
hemorrhage status post multiple procedures.
MEDICATIONS ON DISCHARGE: Medications will be dictated in an
addendum note.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 22907**]
MEDQUIST36
D: [**2140-9-12**] 18:29
T: [**2140-9-14**] 15:49
JOB#: [**Job Number **]
Admission Date: [**2140-8-12**] Discharge Date: [**2140-10-13**]
Date of Birth: [**2106-6-11**] Sex: M
Service:
Discharge summary was originally done on [**2140-9-20**].
MEDICATIONS ON DISCHARGE: Ciprofloxacin 500 mg PO q.12h.
Ciprofloxacin should be continued for a total of 10 days. It
was started on [**2140-10-13**]. It may be discontinued on
[**2140-10-14**].
Other medications include the following: Diltiazem 30 mg PO
q.i.d.; Hydrochlorothiazide 12.5 mg PO q.d.; Nystatin oral
suspension 5 cc PO q.i.d. p.r.n.; free water 250 cc per PEG
q.6h. for sodium of 147 or greater; Metoprolol 150 mg PO
t.i.d.; Clonidine patch, one patch to the skin, change
q.Thursday; Epogen alfa 40,000 units subcutaneously q.week;
Colace 100 mg PO b.i.d.; Ibuprofen 400 mg NG q.6h.p.r.n.;
Lacrilube one application OU p.r.n.; Artificial Tears one to
two drops OU p.r.n.; heparin 5000 units subcutaneously q.12h.
The patient did spike a temperature on [**2140-10-3**]. The
patient was fully cultured and grew out pseudomonas in the
urine and the lungs. Therefore, the patient is now being
treated with Ciprofloxacin, which will finish on [**2140-10-14**].
He has, otherwise, been in stable condition. Neurologically,
he opens his eyes. He does not blink to threat. He moves
all extremities. Withdraws to pain. He does not follow
commands. He has a PEG tube in place. The site is clean,
dry, and intact. He is on a tracheostomy collar for missed
oxygen. Vital signs have been stable and he is ready for
transfer.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-133
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2140-10-13**] 09:39
T: [**2140-10-13**] 09:58
JOB#: [**Job Number 44514**]
Name: [**Known lastname 8136**],[**Known firstname 7661**] Unit No: [**Unit Number 8137**]
Admission Date: [**2140-8-12**] Discharge Date: [**2140-10-13**]
Date of Birth: [**2106-6-11**] Sex: M
Service:
The patient's medications at the time of discharge are 250 cc
of free water via his PEG q6 hours, metoprolol 150 mg/PEG
tid, clonidine patch one patch q day to the skin q Thursday,
Epoetin alpha 40,000 units subQ q week, ibuprofen 400 mg
nasogastric q6 hours prn, Colace 100 mg per PEG [**Hospital1 **],
Artificial Tears 1-2 drops OU prn, acetaminophen 650 PR q6
hours prn, Heparin 5,000 units subQ q12 hours, lansoprazole
oral solution 30 mg per nasogastric q day.
Patient's prognosis is unknown at this point, though patient
is going to need six months to a year of [**Hospital 2754**]
rehabilitation in order to improve his condition. He is a
young gentleman without any medical history aside from this
subarachnoid hemorrhage and will require at least six months
to a year of therapy to determine his final outcome.
His condition right now is stable. He neurologically opens
his eyes. He withdraws his extremities to pain. He blinks
to threat. He does not tend to the examiner nor does he
follow commands. His vital signs have been stable. He is in
stable condition and ready for transfer to [**Country 8138**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2140-9-20**] 09:16
T: [**2140-9-20**] 09:26
JOB#: [**Job Number 8139**]
Name: [**Known lastname 8136**],[**Known firstname 7661**] Unit No: [**Numeric Identifier 8137**]
Admission Date: [**2140-8-12**] Discharge Date: [**2140-9-20**]
Date of Birth: [**2106-6-11**] Sex: M
Service:
The patient's medications at the time of discharge are 250 cc
of free water via his PEG q6 hours, metoprolol 150 mg/PEG
tid, clonidine patch one patch q day to the skin q Thursday,
Epoetin alpha 40,000 units subQ q week, ibuprofen 400 mg
nasogastric q6 hours prn, Colace 100 mg per PEG [**Hospital1 **],
Artificial Tears 1-2 drops OU prn, acetaminophen 650 PR q6
hours prn, Heparin 5,000 units subQ q12 hours, lansoprazole
oral solution 30 mg per nasogastric q day.
Patient's prognosis is unknown at this point, though patient
is going to need six months to a year of [**Hospital 2754**]
rehabilitation in order to improve his condition. He is a
young gentleman without any medical history aside from this
subarachnoid hemorrhage and will require at least six months
to a year of therapy to determine his final outcome.
His condition right now is stable. He neurologically opens
his eyes. He withdraws his extremities to pain. He blinks
to threat. He does not tend to the examiner nor does he
follow commands. His vital signs have been stable. He is in
stable condition and ready for transfer to [**Country 8138**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2140-9-20**] 09:16
T: [**2140-9-20**] 09:26
JOB#: [**Job Number 8139**]
|
[
"780.01",
"599.0",
"482.1",
"518.81",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.25",
"02.2",
"96.6",
"38.93",
"31.1",
"99.10",
"02.34",
"39.72",
"43.11",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
7121, 11900
|
2334, 6419
|
181, 2316
|
6444, 6586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,007
| 143,152
|
28308
|
Discharge summary
|
report
|
Admission Date: [**2196-2-1**] Discharge Date: [**2196-2-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
RLE ischemia and 2 week h/o cold R foot
Major Surgical or Invasive Procedure:
1. Diagnostic abdominal aortogram and pelvic arteriogram and
right lower extremity runoff, contralateral third order
catheterization. CPT codes [**Numeric Identifier 4237**], [**Numeric Identifier 4238**] and [**Numeric Identifier 8881**].
2. Right superficial femoral to peroneal artery bypass with
nonreversed saphenous vein, angioscopy and ligation of popliteal
artery aneurysm
History of Present Illness:
The patient is an 84-year-old male who presented with a 2-week
history of progressive acute onset of right foot ischemia
secondary to a thrombosed large right popliteal aneurysm. The
patient was scheduled for diagnostic
arteriogram of the right lower extremity
Past Medical History:
PMH: AAA, PVD w/ L iliac aneurysm, R [**Doctor Last Name **] aneurysm approx 5cm, L
[**Doctor Last Name **] aneurysm approx 3 cm, chronic Afib, HTN, benign prostatic
hyperplasia (no surgical history)
Social History:
pos smoker
pos drinker
Family History:
n/c
Physical Exam:
Expired
Pertinent Results:
[**2196-2-14**] 03:56AM BLOOD
WBC-15.6* RBC-2.87* Hgb-9.6* Hct-29.2* MCV-102* MCH-33.5*
MCHC-33.0 RDW-17.8* Plt Ct-186
[**2196-2-14**] 03:56AM BLOOD
PT-24.6* PTT-31.0 INR(PT)-2.5*
[**2196-2-14**] 08:40AM BLOOD
Glucose-155* UreaN-30* Creat-1.0 Na-142 K-3.7 Cl-102 HCO3-32
AnGap-12
[**2196-2-12**] 07:50AM BLOOD
ALT-18 AST-21 CK(CPK)-42 Amylase-11 TotBili-0.4
[**2196-2-11**] 08:48AM BLOOD
proBNP-4534*
[**2196-2-14**] 08:40AM BLOOD
Calcium-8.1* Phos-3.4 Mg-2.0
[**2196-2-14**] 08:47AM BLOOD
Type-ART pO2-170* pCO2-46* pH-7.46* calTCO2-34* Base XS-8
[**2196-2-12**] 07:51AM
URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-8.0 Leuks-TR
URINE RBC-21-50* WBC-[**2-15**] Bacteri-FEW Yeast-NONE Epi-[**2-15**]
[**2196-2-12**] 5:07 pm CATHETER TIP-IV Source: right IJ.
WOUND CULTURE (Final [**2196-2-14**]):
STAPH AUREUS COAG +. >15 colonies.
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- S
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2196-2-13**] 4:39 AM
CHEST AP:
The tip of the left IJ line lies in the left innominate vein.
There is no pneumothorax. Bilateral pleural effusions are again
seen, not significantly changed since the prior chest x-ray of
[**2-12**].
IMPRESSION: No change since prior chest x-ray. Failure persists.
Cardiology Report ECHO Study Date of [**2196-2-3**]
PATIENT/TEST INFORMATION:
Indication: Atrial fibrillation/flutter. Hypertension. Left
ventricular function.
Height: (in) 69
Weight (lb): 170
BSA (m2): 1.93 m2
BP (mm Hg): 146/69
HR (bpm): 112
Status: Inpatient
Date/Time: [**2196-2-3**] at 14:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W008-0:44
Test Location: West Inpatient Floor
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *3.9 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 72 mm Hg
Aortic Valve - Mean Gradient: 46 mm Hg
Aortic Valve - LVOT Peak Vel: 0.70 m/sec
Aortic Valve - LVOT Diam: 2.2 cm
Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave Deceleration Time: 125 msec
TR Gradient (+ RA = PASP): *53 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: *1.1 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Small
secundum ASD. The IVC is normal in diameter with <50% decrease
during respiration (estimated RAP 11-15mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately
depressed LVEF. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Moderate mitral annular calcification. Mild thickening of
mitral valve chordae. No MS. LV inflow pattern c/w restrictive
filling abnormality, with elevated LA pressure.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions:
A small secundum atrial septal defect is present. The estimated
right atrial pressure is 11-15mmHg. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is mildly
to moderately depressed with global hypokinesis (the inferior
and infero-lateral walls appear slightly more hypokinetic in
some views). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Cardiology Report ECG Study Date of [**2196-2-8**] 4:33:34 PM
Atrial fibrillation with a mean ventricular response rate, 97
with ventricular premature depolarizations. Left ventricular
hypertrophy with non-diagnostic repolarization abnormalities
consistent with left ventricular strain pattern. Compared to the
previous tracing of [**2196-2-3**] multiple abnormalities persist
without major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 0 90 [**Telephone/Fax (2) 68729**] -134
Brief Hospital Course:
Pt admitted
Had angiogram / no complications. Sheah pulled in the usual
fashion.
Pt pre-op'd for surgery
Cardiology consulted / recommended echo
ECHO:
A small secundum atrial septal defect is present. The estimated
right atrial
pressure is 11-15mmHg. There is mild symmetric left ventricular
hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is mildly to moderately depressed with global
hypokinesis (the
inferior and infero-lateral walls appear slightly more
hypokinetic in some
views). There is no ventricular septal defect. The right
ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral
valve leaflets are moderately thickened. There is no mitral
valve prolapse.
The left ventricular inflow pattern suggests a restrictive
filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic
hypertension. There is no pericardial effusion.
Pt underwent a Right superficial femoral to peroneal artery
bypass with nonreversed saphenous vein, angioscopy and ligation
of popliteal artery aneurysm.
When foley placed, Traumatic placement, noticed pt had blood in
urine post foley placement.
Urology consulted:
--Upper tracts have been assessed for mass lesions or other
causes of hematuria with US which is negative; no need for
further imaging studies.
--Minimize anticoagulation as medically possible.
--Hand irrigate PRN clots, decreased output, or increased urine
redness. If urine worsens, will need 3 way placed and CBI
initiated.
--Patient should have foley catheter in place per primary
medical
team.
Pt tolerated the procedure well. No complications. because of
the severe aortic stenosis. Pt was transfered directly to the
TICU post operatively. Once extubated. he was brought up to the
VICU.
while in the VICU it was noticed that the pt had a hard time
swallowing, pt made NPO.
A speech and swallow exam was done:
[**2-5**] The pt had signs of aspiration after the ice chips, thin
liquids and nectar thick liquids with overt coughing and drop in
O2 SATs. This is likely [**1-15**] his recent extubation and is
expected to improve over time. He is safe at this time to take
his pills with purees, recommend he remain NPO.
Pt had difficulty breathing, requiring lasix. A chest x-ray was
done:
[**2-7**] - [**2-11**]
1. Right IJ central line tip in region of SVC/RA junction. Left
lower lobe collapse and/or consolidation and small left
effusion, slightly worse compared with [**2196-2-5**].
2. CHF findings, worse compared with [**2196-2-9**], with new right
effusion vs atelectasis.
Pt diuresed / On AB to cover presumed PNA.
Pt monitered in VICU status all lines remained.
Follow-up speech:
[**2-8**] Had signs of aspiration with thin liquids, but was advanced
to nectar thick liquids and ground consistency solids.
Follow-up speech:
[**2-10**] The pt continues to have intermittent coughing during meals
per
the pt's family and RN, but the aspiration has been reduced
significantly with the nectar thick liquids.
[**2-12**]
Fevers / pan cx'd
Pt had severe respiratory failure. Transfered to the SICU. Here
he was intubated / NG tube placed.
CXR: Mild improvement in diffuse pulmonary edema with persistent
bilateral pleural effusions.
Lasix / propofol drip
Resp cx'd via Bronchcoscopy:
[**2196-2-12**] BRONCHIAL WASHINGS LEFT LUNG.
GRAM STAIN (Final [**2196-2-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2196-2-16**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
[**2196-2-12**] CULTURE Source: Venipuncture.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
[**2-13**]
Pt respiratorry status worsened. Another x-ray was obtained.
CXR: Comparison is made with the prior chest x-ray of six hours
previous. The right lung appears clearer than on the prior
occasion with a marked reduction in the size of the right
pleural effusion. There is no evidence of pneumothorax.
The left pleural effusion persists and may indeed be somewhat
larger. The degree of pulmonary edema appears less.
[**2-14**]
Discussion was made with the family.
Pt made CMO
Pt [**Month/Day (4) **] shortly afterwards.
-septecemia
-aspiration pna
-severe aortic valve stenosis
Medications on Admission:
[**Last Name (un) 1724**]: Ultram 100mg qd, Coumadin 2mg qT/Th/Sat/Sun and 3mg qM/W,
Digoxin 0.25mg qd, Catapres 0.2mg/Friday, Fosamax 70mg/Sat,
lasix 20mg qd
Discharge Medications:
n/a - pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
PT [**Name (NI) 17581**]
-septecemia
-aspiration pna
-severe aortic valve stenosis
Discharge Condition:
n/a - pt expired
Discharge Instructions:
n/a - pt expired
Followup Instructions:
n/a - pt expired
Completed by:[**2196-2-25**]
|
[
"496",
"442.3",
"038.11",
"998.59",
"995.92",
"401.9",
"440.23",
"444.22",
"707.14",
"518.81",
"599.7",
"424.1",
"428.0",
"441.4",
"427.31",
"286.9",
"996.62",
"518.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"99.05",
"38.93",
"96.04",
"99.07",
"88.42",
"99.04",
"96.71",
"33.24",
"39.29",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
12489, 12498
|
6986, 12239
|
300, 683
|
12625, 12643
|
1302, 3025
|
12708, 12755
|
1254, 1259
|
12448, 12466
|
12519, 12604
|
12265, 12425
|
12667, 12685
|
3051, 6963
|
1274, 1283
|
221, 262
|
711, 973
|
996, 1198
|
1214, 1238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,501
| 117,726
|
36083
|
Discharge summary
|
report
|
Admission Date: [**2130-10-16**] Discharge Date: [**2130-10-19**]
Date of Birth: [**2069-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Neck and arm pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and stent placement
History of Present Illness:
Mr. [**Known lastname 81858**] is a 61M with DM who presented to an OSH with right
neck and L forearm pain. He describes the pain as a dull ache
that started while walking and did not resolve until he was
treated at the OSH. He denies any history of similar neck and
arm pain. He reports mild shortness of breath with pain but
denies any other associated symptoms such as diaphoresis,
nausea, palpitations, or dizziness. In the OSH his EKG
reportedly showed inferolateral ST depression and initial
troponin I was 0.35. He was given nitroglycerin SL, fentanyl,
and then started on nitroglycerin and heparin drips. He also
received plavix 300mg. Pt was then transferred to [**Hospital1 18**] for
further management and cardiac catheterization.
Pt initially went to the [**Hospital1 1516**] service where his EKG changes
resolved and he was chest pain free and was planned for cath in
AM. Pt does report retroactively that he had some chest pain
overnight that he did not report and AM cardiac enzymes
continued to trend up: CK 1579->1550, Trop 1.4->3.3.
In the cath lab, pt had venous and arterial sheath placed,
received 381ml dye, had SBPs in the 70s requiring 1200ml IVF,
dopamine drip and 1mg atropine. He also received heparin,
integrillin. Pt reported pain with placement of stents (3BMS to
OM2 and 2BMS to midLAD).
On presentation to [**Name (NI) 42137**], pt was off pressors and chest pain
free.
Past Medical History:
DM Type II (diet controlled)
Social History:
Pt is a security guard at [**University/College 4700**]. He lives with his
wife.
[**Name (NI) **] smokes 1 ppd x 40 years.
Drink at social events but denies drinking on daily or weekly
basis. He denies any past or present drug use.
Family History:
Noncontributory
Physical Exam:
Post cath:
VS: T 98.7 BP 100/53 HR 61 SpO2 98% 2L WT 208 lbs
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
MMM.
Neck: Supple, JVP to mandible
CV: RRR, no M/R/G
Chest: No resp distress. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND, No HSM, positive BS
Ext: No c/c/e. Strong distal pulses
Skin: No rashes or lesions
Groin: No bruits, no tenderness, small hematoma (1x2cm)
Pertinent Results:
[**2130-10-19**] 06:05AM BLOOD WBC-9.4 RBC-4.20* Hgb-13.1* Hct-35.9*
MCV-85 MCH-31.3 MCHC-36.7* RDW-13.6 Plt Ct-156
[**2130-10-16**] 09:30PM BLOOD Neuts-61.9 Lymphs-30.7 Monos-6.6 Eos-0.5
Baso-0.3
[**2130-10-17**] 06:05AM BLOOD PT-13.0 PTT-47.0* INR(PT)-1.1
[**2130-10-19**] 06:05AM BLOOD Glucose-104 UreaN-14 Creat-1.0 Na-138
K-3.8 Cl-106 HCO3-24 AnGap-12
[**2130-10-16**] 09:30PM BLOOD ALT-23 AST-97* CK(CPK)-1579*
[**2130-10-17**] 06:05AM BLOOD ALT-33 AST-180* LD(LDH)-560*
CK(CPK)-2550* AlkPhos-71 TotBili-0.5
[**2130-10-17**] 08:05PM BLOOD ALT-42* AST-202* LD(LDH)-755*
CK(CPK)-2209* AlkPhos-67 TotBili-0.7
[**2130-10-16**] 09:30PM BLOOD CK-MB-148* MB Indx-9.4* cTropnT-1.40*
[**2130-10-17**] 06:05AM BLOOD CK-MB-212* MB Indx-8.3* cTropnT-3.33*
[**2130-10-17**] 08:05PM BLOOD CK-MB-103* MB Indx-4.7
[**2130-10-19**] 06:05AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
[**2130-10-17**] 06:05AM BLOOD Albumin-4.1 Cholest-246*
[**2130-10-17**] 06:05AM BLOOD %HbA1c-6.9*
[**2130-10-17**] 06:05AM BLOOD Triglyc-303* HDL-40 CHOL/HD-6.2
LDLcalc-145*
[**10-18**] ECHO: Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the basal half of the
inferolateral wall. The remaining segments contract normally
(LVEF = 55 %). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. 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 no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with focal
regional dysfunction c/w CAD. Mild pulmonary artery systolic
hypertension. Dilated ascending aorta.
CATH [**10-17**]: No formal results
Brief Hospital Course:
61 year old smoker without recent medical following, presented
to OSH with arm pain and found to have NSTEMI. Pt transferred to
[**Hospital1 18**] and is now s/p cath where he was found to have a total
occlusion requiring 2 BMS to OM2 and 2BMS to mid LAD.
# NSEMI - On transfer to [**Hospital1 18**] pt was pain free with minimal STD
on EKG. His cardiac enzymes continued to [**Last Name (un) **] up and peaked at
CK of 2550 and Trop 3.3 on [**10-17**]. That morning pt underwent
catheterization and found to have total occlusion of the OM2 and
mid LAB with multiple bare metal stents placed in both. Pt was
medically managed with aspirin, plavix, statin, heparin gtt,
integrillin gtt. Beta blocker was initially held for hypotension
and started prior to discharge. Pt will also need addition of
ace inhibitor.
- Continue Toprol XL 25mg daily
- Continue Simvastatin 80mg daily
- Continue ASA daily
# DMt2: Pt not medically managed as outpt. His HbA1c was
measured for risk stratification and found to be 6.9. His blood
sugars were monitored and treated with insulin sliding scale. At
discharge pt was asked to follow up with [**Last Name (un) **] diabetes clinic.
# Tobacco abuse: Pt was given nicotine patch for symptomatic
control and counseled re importance of smoking cessation for
both himself and family.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Non ST elevation MI
Secondary Diagnosis: Type II Diabetes mellitus (diet-controlled)
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. You had two bare metal stents placed into your heart
vessel to open up the blockage. You were started on new
medications for your heart. It is very important for you to
continue this medication (clopidogrel) as it keeps the stent
open. You should not stop taking this medication unless your
cardiologist tells you to.
.
New medications:
Toprol XL 25 daily
Aspirin 325mg daily
Plavix 75mg daily (keeps stent open)
Atorvastatin 80mg daily
Please stop smoking. Information was given to you on admission
regarding smoking cessation and discussed with you by the
doctors [**Name5 (PTitle) **].
Followup Instructions:
Please call Dr [**Last Name (STitle) 8098**], your new cardiologist, at [**Telephone/Fax (1) **]
to schedule follow up in the next 1-2 weeks.
You should also set up a primary care doctor. You can choose a
PCP or use the [**Hospital 18**] clinic. The [**Hospital 18**] [**Hospital6 **]
phone number is [**Telephone/Fax (1) 250**].
Completed by:[**2130-10-20**]
|
[
"E879.0",
"305.1",
"416.8",
"410.71",
"E849.7",
"414.01",
"250.00",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.06",
"37.23",
"00.48",
"00.66",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
6481, 6487
|
4613, 5930
|
336, 381
|
6635, 6644
|
2660, 4590
|
7348, 7711
|
2135, 2152
|
5985, 6458
|
6508, 6508
|
5956, 5962
|
6668, 7325
|
2167, 2641
|
279, 298
|
409, 1817
|
6568, 6614
|
6527, 6547
|
1839, 1869
|
1885, 2119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,054
| 168,691
|
18802
|
Discharge summary
|
report
|
Admission Date: [**2153-9-19**] Discharge Date: [**2153-11-1**]
Date of Birth: Sex: M
Service: [**Hospital Ward Name 332**] MICU
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old
gentleman with a history of hypercholesterolemia and
hyperlipidemia who was transferred from an outside hospital
with acute pancreatitis.
The patient reported on admission that four weeks prior to
admission, and again two weeks prior to admission, he hurt
his back when lifting up a heavy object for his job. After
two weeks he noticed that the pain was not getting better,
and he went to see his primary care physician. [**Name10 (NameIs) **] pain was
also present in his abdomen where it was a diffuse and dull
but unrelenting.
At his primary care physician's office he was noted to have a
calcium of 16, an elevated amylase, lipase, and low platelets
before he was admitted to a local hospital where he was
diagnosed with hypercalcemia and pancreatitis. At the local
hospital he was treated with intravenous fluids, Lasix,
calcitonin, and pamidronate with improvement in his calcium
level but with marked worsening of his creatinine to 6.2. In
addition, during his short stay at the outside hospital, he
had worsening abdominal pain, distention, and developed
shortness of breath with hypoxemia.
He was then transferred to [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY: Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Lopid as an outpatient.
ALLERGIES: BACTRIM.
SOCIAL HISTORY: The patient is married with two children.
He use to drink one drink of alcohol per month. A
12-pack-year history of tobacco; but he quit four years ago.
He is a Jehovah Witness and is not accepting of any human blood
products. He is a heating-airconditioning technician.
FAMILY HISTORY: His father had bilateral kidney stones.
Mother has hypothyroidism. Grandfather had [**Name2 (NI) 499**] cancer.
Another grandfather had liver cancer, but this was secondary
to alcohol abuse.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
presentation revealed his temperature was 97 degrees
Fahrenheit, his blood pressure was 114/61, his heart rate was
122, his respiratory rate was 23, and his oxygen saturation
was 92% on 3 liters nasal cannula. His weight was 110
kilograms. General appearance revealed he was sitting up in
bed and looked comfortable. Head, eyes, ears, nose, and
throat examination revealed sclerae were anicteric. The
mucous membranes were moist. Pupils were constricted
bilaterally. Extraocular movements were intact. The neck
was supple. No jugular venous distention. No palpable
lymphadenopathy but tenderness to palpation in the
submandibular space and supraclavicular space.
Cardiovascular examination revealed tachycardia with a
regular rhythm. The lungs revealed decreased breath sounds
one half of the way bilaterally. No wheezes, crackles, or
rhonchi. The abdomen was distended and soft. Tender in the
right upper quadrant and left lower quadrant and also left
upper quadrant. There were active bowel sounds; mostly in
the left lower quadrant and left upper quadrant. There was
marked hepatosplenomegaly on palpation. No ascites.
Extremity examination revealed no edema. Dorsalis pedis
pulses were palpable bilaterally. Neurologic examination
revealed alert and oriented times three. Cranial nerves II
through XII were intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on presentation revealed complete blood count with a white
blood cell count of 26, his hematocrit was 53, and his
platelets were 72. Chemistry-7 revealed his sodium was 138,
potassium was 4.9, chloride was 102, bicarbonate was 22,
blood urea nitrogen was 69, creatinine was 6.2, and his blood
glucose was 127. Calcium was 15.3, magnesium was 1.3, and
phosphate was 5.7. Total triglycerides were 206 and
cholesterol was 180.
PERTINENT RADIOLOGY/IMAGING: A computerized axial tomography
of the abdomen revealed hepatosplenomegaly with moderate
pancreatitis and a right lobe atelectasis.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: Briefly,
Mr. [**Known lastname 51479**] is a 25-year-old gentleman with a past medical
history only significant for hyperlipidemia and
hypercholesterolemia who presented to his primary care
physician complaining of back pain and abdominal pain and was
found to have acute necrotic pancreatitis complicated by
renal failure and hypercalcemia and thrombocytopenia.
1. ACUTE SEVERE NECROTIZING PANCREATITIS ISSUES: The patient
was initially treated with aggressive fluid resuscitation
and required intubation for respiratory compromise due to
abdominal distention and abdominal pain . His pain
control was addressed after intubation with Fentanyl. He was
started on meropenem for infection prevention. His
fingerstick blood glucose levels were monitored and adjusted
with an insulin sliding-scale.
Several computerized axial tomography scans of his abdomen
with intravenous contrast, but not by mouth contrast, were
obtained which revealed necrotic liquefaction of the tail and
body of the pancreas and a interval increase in the size of a
loculated collection along the anterior pancreas with the
lesser sac. Minimal pancreatic bed enhancement was evident on
most recent CT scan.
Meropenem was stopped as he developed a rash. He continued
to receive supportive care (as above). He was also started
on trophic tube feeds at 10 cc per hour which had to be
stopped intermittently during his 6-week course because of
increased abdominal distention and the suggestion of ileus.
2. ACUTE RENAL FAILURE ISSUES: The patient initially
presented with acute renal failure that resolved with
aggressive hydration, with his creatinine dropping to 2.8.
However, five days prior to discharge he was started on Zosyn
and vancomycin which resulted in a second event of acute
renal failure. At that time, there were no eosinophils in
his urine, and the acute renal failure resolved once again
with aggressive hydration.
3. ANEMIA ISSUES: The patient's entire hospital course was
marked by progressive anemia. On the day of his arrival,
after aggressive fluid resuscitation, his hematocrit dropped
over 10 points from 52 to 40. The patient continued to have
a drop in his hematocrit slowly but consistently.
On the last week of his stay at [**Hospital1 188**], he started to ooze from his endotracheal tube and
nasojejunal tube. He underwent a bronchoscopy on [**2153-10-31**] which revealed some granulation tissue around the
cuff and some oozing in the trachea around the cuff. Epogen had
been started since admission, and at the time of discharge, was
10,000 units three times per day. He received two courses of
ferrous gluconate eight days each to replete his iron stores.
Blood draws were limited to strictly as necessary in order to
avoid unnecessary blood waste.
4. FEVER OF UNKNOWN ORIGIN ISSUES: Mr. [**Known lastname 51480**]
hospital course was also marked by recurrent fevers up to
102.6 degrees Fahrenheit almost every day or every 48 hours.
He was extensively cultured with consistently negative blood
cultures and urine cultures except for one bottle which grew
Lactobacillus which was considered to be a contaminant.
During his hospital course, he developed two
ventilator-associated pneumonias which were not felt to be
the main cause of his recurrent fevers. As his blood
cultures, urine cultures remained negative, and his continued
to have high fevers, also when he did not have pneumonia, it
was felt that the main cause of his recurrent high
temperatures was the inflammation and possibly infection
occurring in his abdomen; specifically, around his pancreas.
5. VENTILATOR-ASSOCIATED PNEUMONIA ISSUES: The patient
developed one pneumonia earlier; approximately three weeks
after his admission. At that time, the pneumonia was in the
right lower lobe. He was treated with meropenem and
vancomycin; at which point, he developed a maculopapular rash
all over his body. It was felt that this was most likely an
allergy to meropenem or vancomycin, and both of them were
stopped. Zosyn was started instead. While he was taking
Zosyn, his skin rash resolved, and his pneumonia also
resolved.
One week prior to his discharge, he developed a second
ventilator-associated pneumonia in the retrocardiac space;
mostly localized to the left lobe. He was initially started
on vancomycin and Zosyn, and 24 hours after the initiation of
this therapy he once again developed a rash. His antibiotics
were immediately stopped, and he was switched to levofloxacin
and clindamycin. A sputum culture revealed gram-negative
rods, not a fermenter, not pseudomonal; sensitive only to
Bactrim and levofloxacin. Therefore, he was continued on the
two medications levofloxacin and clindamycin with a good
improvement in the pneumonia (as per subsequent chest
x-rays). His respiratory status did not require changes in
his ventilatory settings.
Current ventilatory settings at the time of discharge were
assist control with a FIO2 of 50%, tidal volume of 500 to
520, a respiratory rate of 28, a positive end-expiratory
pressure of 15, and a proximal interphalangeal positive
inspiratory pressure of 42 (which has been his baseline given
the massive abdominal distention).
6. SKIN RASH ISSUES: Given the fact that the patient
developed a skin rash twice and that he was on different
antibiotics when this happened (particularly vancomycin,
Zosyn, meropenem, and had incidentally received a dose of
Lasix when he developed the first rash) the Allergy Service
was consulted. They performed some skin testing which
reported that the patient was not sensitive to penicillin;
however, it was unclear if it was also not sensitive to
histamine.
7. THROMBOCYTOPENIA ISSUES: The patient remained
thrombocytopenic throughout most of his hospital stay with
platelets above 50s only for a few days; scattered throughout
the hospital stay. This hampered the attempts to perform a
tracheostomy for which the Surgery Service and the
Interventional Pulmonology Service required platelets above
50. No clear etiology was found for this thrombocytopenia.
Disseminated intravascular coagulation and hemolysis were
ruled out by laboratories.
A bone marrow biopsy was attempted to clarify the etiology of
the patient's thrombocytopenia and anemia but failed and was
not attempted given the risk of bleeding in a patient who
would not be able to be transfused.
8. NUTRITION ISSUES: The patient has been on total
parenteral nutrition which he tolerated well.
9. PROPHYLAXIS ISSUES: The patient had been heparin and
his total parenteral nutrition for many days; which was
recently stopped given his worsening anemia and
thrombocytopenia with some active bleeding. The patient was
wearing pneumatic boots, and he was on pantoprazole 40 mg by
mouth and intravenously.
10. CODE STATUS ISSUES: His code status is full with
directives requiring no transfusions of any blood or blood
products.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 19227**]
MEDQUIST36
D: [**2153-11-1**] 15:53
T: [**2153-11-1**] 16:02
JOB#: [**Job Number 51481**]
|
[
"276.5",
"518.81",
"284.8",
"276.0",
"486",
"276.2",
"584.9",
"577.0",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.6",
"38.93",
"96.72",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1822, 4078
|
1467, 1514
|
4112, 11309
|
186, 1393
|
1417, 1440
|
1531, 1804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,187
| 138,921
|
27750
|
Discharge summary
|
report
|
Admission Date: [**2141-7-30**] Discharge Date: [**2141-9-15**]
Date of Birth: [**2101-12-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Pedestrian Struck by Car
Major Surgical or Invasive Procedure:
[**7-30**]-Exploratory Laparotomy with packing of Liver
[**8-1**]-Hepatic Debridement and G/J-tube placement and closure of
abdominal wound
[**8-2**]-Bifrontal Craniotomies
[**8-4**]-Open Reduction Internal Fixation of Bilateral Tibias and
Fibulas
[**8-9**]-Bilateral Lower Extremity Flap Placement
[**8-23**]- Debridement and Flap Coverage of Bilateral Lower
Extremities
[**9-6**]- split-thickness skin graft
History of Present Illness:
39 yo male trauma transfer from [**Hospital 1474**] Hospital s/p being
struck by car. + FAST and hypotensive at referring hospital as
well as pneumothorax with right chest tube in place and
bilateral open tib/fib fractures and pulseless lower
extremities.
Past Medical History:
Seizures
Hepatitis C
Social History:
Recently released from prison, Married, ETOH and Drug history
unknown.
Family History:
NC
Physical Exam:
Vitals: Temp-96, HR-104, BP-70/48, 95%
HEENT: Pupils 4mm bilaterally and nonreactive
Chest: Bilateral Coarse BS, + crepitus, Left Clavicle Lac, right
CT in place
Abd: Abrasions over lower abdomen
Pelvis: Abrasions over R hip, stable
Rectal: + tone
MSK: Obcious bilateral open tib/fib fx, cool mottled feet
without pulses
Pertinent Results:
[**2141-7-30**] 01:17PM GLUCOSE-109* UREA N-21* CREAT-1.6* SODIUM-143
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-22 ANION GAP-14
[**2141-7-30**] 01:26PM HGB-7.9* calcHCT-24 O2 SAT-98
[**2141-7-30**] 01:26PM TYPE-ART PO2-143* PCO2-39 PH-7.37 TOTAL
CO2-23 BASE XS--2
[**2141-7-30**] 02:16AM WBC-9.7 RBC-4.24* HGB-13.1* HCT-37.2* MCV-88
MCH-30.9 MCHC-35.1* RDW-13.6
[**2141-7-30**] 02:16AM PLT COUNT-183
[**2141-9-9**] 07:00AM BLOOD WBC-7.4 RBC-3.29* Hgb-9.0* Hct-28.5*
MCV-86 MCH-27.4 MCHC-31.7 RDW-15.2 Plt Ct-645*
[**2141-9-9**] 07:00AM BLOOD Plt Ct-645*
[**2141-9-5**] 08:49PM BLOOD PT-14.4* PTT-30.8 INR(PT)-1.3*
[**2141-7-30**] 02:22AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
[**2141-7-31**] 08:25PM URINE Osmolal-398
[**2141-7-30**] 02:22AM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2141-9-5**] 08:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
WOUND CULTURE (Final [**2141-8-15**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
[**2141-8-14**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP.}
[**2141-8-16**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {[**Female First Name (un) **]
ALBICANS, PRESUMPTIVE IDENTIFICATION}
[**2141-8-18**] IMMUNOLOGY HCV VIRAL LOAD-FINAL
CXR [**7-30**]: Multiple displaced right-sided rib fractures,
Right-sided pulmonary contusion
CT head ([**7-31**]) Bifrontal acute epidural hemorrhages. Massively
comminuted facial fractures as noted above.
CT abd/pelvis/LE ([**7-31**]) 1. Hepatic laceration involving the
right posterior segment of the liver with adjacent packing
material identified.
2. Right superior pole renal laceration with small adjacent
subcapsular hematoma and perinephric stranding. The renal
vessels are intact.
3. Small right pneumothorax and small bilateral pulmonary
contusions.
4. Extensive fractures involving the right-sided ribs, left
scapula, both tibiae and fibulae.
5. Non-opacification of the left posterior tibial artery. Please
note that the entire lower extremities were not covered during
this examination, and that 3D reconstructions were not available
of the lower extremities at the time of this report. Dedicated
CT angiogram of the left lower extremity can be performed for
further evaluation.
6. Moderate amount of fluid within the peritoneum and
retroperitoneum. No areas of active contrast extravasation
identified
UENIs ([**8-11**]): Evidence of superficial thrombophlebitis involving
the left cephalic vein without extension into the deep venous
system.
x-ray R elbow: 1) Large joint effusion. If there is a history of
trauma, then intra-articular fracture cannot be excluded.
2) If the patient has point tenderness over the olecranon
process, the possibility of small avulsed bony fragments at the
site of triceps insertion would be considered. However, in the
absence of focal tenderness in this area, this likely represents
small enthesiophytes
Brief Hospital Course:
Pt. arrived in the ED intubated and unresponsive with obvious
open tib/fib fx, blown pupils and a + FAST exam. He was taken
immediately to the OR for ex lap and liver packing for Grade 4
laceration and washout ex/fix of lower extremity fractures. He
received multiple doses of blood products during his
resuscitation. Pt also had a bolt placed at admission.
Post-operatively the patient was admitted to the TSICU and was
placed on Gent/Ancef/Clindamycin and also received Vancomycin
and Zosyn during ICU stay. Pt initially required pressors to
maintain BP in the TSICU, but was gradually weaned off. He
received a tracheostomy on HD#10. See above for surgical
proceudres and dates. By HD#18 patient had weaned off of the
ventilator and no longer required pressors. He was extubated
and passed a swallowing evaluation. He was transferred to the
step-down unit on HD #18. Pt was afebrile and thus remained off
of ABX. On [**2141-8-30**] tracheostomy was removed; trach site
healed well and patient breathing well with good oxygen
saturation. He complained of diarrhea on the floor and was
tested for Cdiff which was negative. Tube feeds were maintained
throughout his ICU stay and continued on the floor. He remained
NWB on the floor. Pt required management of
hyponatremia/hyperkalemia on the floor. He tolerated Tube feeds
well and also received PO; when his PO intake increased his tube
feeds and his G and J tube were discontinued. Pt abdominal
wound required [**Hospital1 **] WTD dressing changes throughout floor stay.
Pt. wound healing and neurological status progressively improved
over hospital course. Pt is discharged NWB bilat LE
Medications on Admission:
unknown
Discharge Medications:
1. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily).
4. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold if having loose stools.
7. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Hydromorphone 4 mg Tablet Sig: one to one and a half Tablet
PO q3-4 hours as needed for breakthrough pain: 4-6 mg PO Q3-4H
prn breakthrough pain.
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain: Not to exceed 4 grams
daily.
15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Bilateral Frontal Epidural Hemorrhage
Multiple Facial and Sinus Fractures
Liver Laceration
Bilateral Pulmonary Contusions
Right Scapula Fracture
Right Renal Contusion
Bilateral Tibia and Fibula Fractures
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized at [**Hospital1 18**] for an extended period of time
after you were struck by a motor vehicle. You had numerous
injuries, including many fractures (broken bones) and some
injury to abdominal injuries. You underwent numerous surgeries
to fix your injuries. Because you have had so many injuries,
you will need close follow-up with the physicians caring for
you, as well as rehabilitation to help you regain your strength.
Currently, you are not allowed to bear weight on your legs
because you have new skin grafts; you may dangle your legs for
approximately 20 minutes, but most of the time your legs should
be elevated. You will be followed up by plastic surgery in 1
week time.
Return to the Emergency Room for:
Fever > 101.5
Dizziness
Shortness in Breath, difficulty breathing
Blurry Vision
Extreme Pain
Nausea and Vomiting
Loss of Consciousness
Followup Instructions:
Follow-up in Trauma Clinic in [**4-8**] weeks. Please call ([**Telephone/Fax (1) 9946**] to schedule an appointment.
Follow up in Plastic Surgery clinic in 1 week, call [**Telephone/Fax (1) 4652**]
for an appointment.
Follow-up with Orthopedics in 4 weeks. Please call [**Telephone/Fax (1) 1228**]
for an appointment.
Completed by:[**2141-9-15**]
|
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icd9cm
|
[
[
[]
]
] |
[
"76.74",
"83.82",
"51.22",
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icd9pcs
|
[
[
[]
]
] |
7715, 7788
|
4629, 6285
|
340, 752
|
8036, 8045
|
1549, 4606
|
8970, 9323
|
1186, 1190
|
6343, 7692
|
7809, 8015
|
6311, 6320
|
8069, 8947
|
1205, 1530
|
276, 302
|
780, 1038
|
1060, 1082
|
1098, 1170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,016
| 148,115
|
18090
|
Discharge summary
|
report
|
Admission Date: [**2176-9-22**] Discharge Date: [**2176-10-9**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Myocardial infarction (NSTEMI)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87M w/CAD s/p CABG ~10 yrs ago, HTN, increased lipids, admitted
([**9-17**]) to [**Last Name (un) 50061**] Hosp s/p falling and found to have R hip
fracture. CK initially WNL then inc to 500 range w/tropI inc to
4.4 (although MB 7.45, index 3.2). S/p R-hip repair [**9-19**] and
afterwards noted to be tachycardic and hypertensive (SBP 200s)
despite previously adequate regimin. Ck peaked to 936 ([**9-21**] @
11pm) and MB peak at 102, tropI peak of 92. ECG w/sinus
tach/atrial tach. Meds titrated up including lopressor 100 qid,
captopril 75 qid, started on nitro drip & dilt drip, both maxed.
Pt's NSTEMI tx with BP meds as well as ASA 325, Plavix 75,
statin, and pt already antcoagulated with INR @ 3.9 (had been on
coumadin post-hip surgery). Transferred to [**Hospital1 18**] for expectant
cath and HTN control.
Past Medical History:
CAD,
LBBB,
Prostate CA;
Depression;
Dementia;
R hip surgery [**9-19**];
L hip surgery in [**2-10**];
CABG [**82**] years ago;
HTN;
Hypercholesteremia
Social History:
no tobacco hx
etoh socially
drug use none
Family History:
non-contributory
Physical Exam:
afebrile HR 81 BP 170/100 O2 95% 4L NC
Gen: elderly male
Heent: PEERLA, mucous membranes moist, +JVD 3-4cm above
clavicles
Lungs: CTA B/L
Cardio: RRR S1/S2 holosystolic murmur at apex
Abd: Distended, soft, tympanic, NT NABS
Ext: +scrotal edema, no peripheral edema
Pertinent Results:
[**2176-9-22**] 08:39PM TYPE-ART PO2-78* PCO2-32* PH-7.49* TOTAL
CO2-25 BASE XS-1
[**2176-9-22**] 08:18PM GLUCOSE-112* UREA N-25* CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13
[**2176-9-22**] 08:18PM CK(CPK)-423*
[**2176-9-22**] 08:18PM CK-MB-38* MB INDX-9.0* cTropnT-5.08*
[**2176-9-22**] 08:18PM CALCIUM-8.2* PHOSPHATE-2.5* MAGNESIUM-2.1
CHOLEST-125
[**2176-9-22**] 08:18PM TRIGLYCER-96 HDL CHOL-33 CHOL/HDL-3.8
LDL(CALC)-73
[**2176-9-22**] 08:18PM WBC-11.2*# HCT-33.1*
[**2176-9-22**] 08:18PM PLT COUNT-211
[**2176-9-22**] 08:18PM PT-21.5* PTT-54.2* INR(PT)-2.9
Echo @ [**Location (un) 620**] ([**2176-9-17**]): mild LVH; EF 55-60%; inf HK; mild 1+
AK; mild MR ([**2-9**]+)
Echo @ [**Hospital1 18**] ([**2176-9-23**]): 3+ MR; 2+ TR; LVEF 33-40%
TTE ordered ([**9-30**]) to r/o endocarditis which showed EF 30-40%,
3+MR, 1+AR, distal inf septum and apex severly HK, HK of inf
wall, no mass or vegetations
[**Month/Year (2) **] Cx: positive for MRSA
[**2176-9-23**] 03:53AM BLOOD WBC-10.4 Hct-30.5* Plt Ct-177
[**2176-9-24**] 03:23AM BLOOD WBC-9.3 Hct-32.5* Plt Ct-229
[**2176-9-25**] 04:30AM BLOOD WBC-14.8*# RBC-3.85* Hgb-11.5* Hct-33.0*
MCV-86 MCH-29.8 MCHC-34.8 RDW-13.9 Plt Ct-269
[**2176-9-25**] 07:47PM BLOOD WBC-10.4 RBC-3.45* Hgb-10.2* Hct-29.8*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.1 Plt Ct-229
[**2176-9-26**] 06:11AM BLOOD WBC-9.9 Hct-29.7* Plt Ct-257
[**2176-9-26**] 05:14PM BLOOD Hct-29.6* Plt Ct-255
[**2176-9-27**] 05:33AM BLOOD WBC-11.3* RBC-3.25* Hgb-9.5* Hct-27.7*
MCV-85 MCH-29.3 MCHC-34.3 RDW-13.7 Plt Ct-238
[**2176-9-27**] 10:43PM BLOOD Hct-29.9*
[**2176-9-28**] 06:08AM BLOOD WBC-10.5 RBC-3.48* Hgb-10.2* Hct-29.6*
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.0 Plt Ct-231
[**2176-9-29**] 06:00AM BLOOD WBC-12.3* RBC-3.43* Hgb-10.2* Hct-29.2*
MCV-85 MCH-29.8 MCHC-35.0 RDW-14.1 Plt Ct-268
[**2176-9-30**] 06:04AM BLOOD WBC-13.3* RBC-3.57* Hgb-10.7* Hct-31.3*
MCV-88 MCH-29.8 MCHC-34.0 RDW-14.1 Plt Ct-350
[**2176-10-1**] 05:14AM BLOOD WBC-13.2* RBC-3.67* Hgb-10.6* Hct-31.3*
MCV-85 MCH-28.8 MCHC-33.8 RDW-14.1 Plt Ct-350
[**2176-10-2**] 04:14AM BLOOD WBC-19.0* RBC-3.38* Hgb-9.9* Hct-30.2*
MCV-89 MCH-29.3 MCHC-32.8 RDW-14.2 Plt Ct-433
[**2176-10-2**] 10:50PM BLOOD WBC-18.3*
[**2176-10-3**] 06:43AM BLOOD WBC-17.0* RBC-2.73* Hgb-8.3* Hct-23.2*
MCV-85 MCH-30.4 MCHC-35.7* RDW-14.2 Plt Ct-358
[**2176-10-3**] 10:54AM BLOOD WBC-18.6* RBC-2.86* Hgb-8.4* Hct-24.6*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.4 Plt Ct-395
[**2176-10-3**] 06:04PM BLOOD Hct-30.8*#
[**2176-10-3**] 07:53PM BLOOD Hct-26.2*
[**2176-10-4**] 02:58AM BLOOD WBC-16.3* RBC-3.49* Hgb-10.3* Hct-29.7*
MCV-85 MCH-29.5 MCHC-34.7 RDW-15.1 Plt Ct-343
[**2176-10-4**] 09:50AM BLOOD WBC-14.9* RBC-3.73* Hgb-11.2* Hct-33.6*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.8 Plt Ct-448*
[**2176-10-4**] 03:59PM BLOOD WBC-31.3*# RBC-3.73* Hgb-11.2* Hct-32.6*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.9 Plt Ct-428
[**2176-10-4**] 11:53PM BLOOD WBC-18.8* Hct-30.3* Plt Ct-365
[**2176-10-5**] 06:11AM BLOOD WBC-20.2* RBC-3.33* Hgb-9.9* Hct-28.2*
MCV-85 MCH-29.7 MCHC-35.0 RDW-14.7 Plt Ct-300
[**2176-10-5**] 05:52PM BLOOD Hct-32.9*
[**2176-10-6**] 06:12AM BLOOD WBC-19.3* RBC-3.48* Hgb-10.3* Hct-30.1*
MCV-87 MCH-29.6 MCHC-34.2 RDW-14.8 Plt Ct-294
[**2176-10-7**] 03:53AM BLOOD WBC-12.3* RBC-3.32* Hgb-9.8* Hct-29.0*
MCV-87 MCH-29.5 MCHC-33.8 RDW-14.7 Plt Ct-315
[**2176-10-8**] 05:55AM BLOOD WBC-9.8 RBC-3.10* Hgb-9.2* Hct-27.3*
MCV-88 MCH-29.6 MCHC-33.7 RDW-14.7
[**2176-10-8**] 08:57PM BLOOD Hct-32.7*
[**2176-10-9**] 06:19AM BLOOD WBC-9.7 RBC-3.98*# Hgb-11.9*# Hct-35.7*
MCV-90 MCH-29.9 MCHC-33.4 RDW-14.8 Plt Ct-266
[**2176-9-26**] 05:14PM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2176-10-2**] 04:14AM BLOOD Neuts-88* Bands-4 Lymphs-2* Monos-4 Eos-0
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2176-9-26**] 05:14PM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Target-OCCASIONAL Bite-OCCASIONAL Fragmen-OCCASIONAL
[**2176-10-2**] 04:14AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-1+
[**2176-9-22**] 08:18PM BLOOD PT-21.5* PTT-54.2* INR(PT)-2.9
[**2176-9-22**] 08:18PM BLOOD Plt Ct-211
[**2176-9-23**] 03:53AM BLOOD PT-21.9* PTT-46.1* INR(PT)-3.0
[**2176-9-23**] 03:53AM BLOOD Plt Ct-177
[**2176-9-24**] 03:23AM BLOOD PT-21.9* PTT-47.1* INR(PT)-3.0
[**2176-9-24**] 03:23AM BLOOD Plt Ct-229
[**2176-9-24**] 04:10PM BLOOD PT-21.6* PTT-43.8* INR(PT)-3.0
[**2176-9-24**] 10:50PM BLOOD PT-20.4* PTT-37.7* INR(PT)-2.6
[**2176-9-25**] 04:30AM BLOOD PT-18.1* PTT-77.1* INR(PT)-2.1
[**2176-9-25**] 04:30AM BLOOD Plt Ct-269
[**2176-9-25**] 08:57AM BLOOD PT-16.5* PTT-137.9* INR(PT)-1.7
[**2176-9-25**] 07:47PM BLOOD PT-14.8* PTT-65.9* INR(PT)-1.4
[**2176-9-25**] 07:47PM BLOOD Plt Ct-229
[**2176-9-26**] 06:11AM BLOOD PT-14.9* PTT-76.0* INR(PT)-1.4
[**2176-9-26**] 06:11AM BLOOD Plt Ct-257
[**2176-9-26**] 05:14PM BLOOD PT-15.2* PTT-87.6* INR(PT)-1.5
[**2176-9-26**] 05:14PM BLOOD Plt Smr-RARE Plt Ct-255
[**2176-9-27**] 05:33AM BLOOD PT-14.7* PTT-66.9* INR(PT)-1.4
[**2176-9-27**] 10:43PM BLOOD PT-14.2* PTT-41.4* INR(PT)-1.3
[**2176-9-28**] 06:08AM BLOOD PT-14.6* PTT-55.4* INR(PT)-1.4
[**2176-9-28**] 06:08AM BLOOD Plt Ct-231
[**2176-9-28**] 04:13PM BLOOD PTT-70.0*
[**2176-9-29**] 06:00AM BLOOD PT-14.8* PTT-73.8* INR(PT)-1.4
[**2176-9-29**] 06:00AM BLOOD Plt Ct-268
[**2176-9-30**] 06:04AM BLOOD PT-14.5* PTT-65.0* INR(PT)-1.3
[**2176-9-30**] 06:04AM BLOOD Plt Ct-350
[**2176-10-1**] 05:14AM BLOOD PT-14.4* PTT-59.2* INR(PT)-1.3
[**2176-10-1**] 05:14AM BLOOD Plt Ct-350
[**2176-10-2**] 04:14AM BLOOD Plt Smr-HIGH Plt Ct-433
[**2176-10-3**] 06:43AM BLOOD Plt Ct-358
[**2176-10-3**] 06:43AM BLOOD PT-15.0* PTT-93.2* INR(PT)-1.4
[**2176-10-3**] 10:54AM BLOOD Plt Ct-395
[**2176-10-4**] 02:58AM BLOOD Plt Ct-343
[**2176-10-4**] 09:50AM BLOOD PT-14.1* PTT-28.8 INR(PT)-1.3
[**2176-10-4**] 09:50AM BLOOD Plt Ct-448*
[**2176-10-4**] 03:59PM BLOOD PT-15.4* PTT-108.5* INR(PT)-1.5
[**2176-10-4**] 03:59PM BLOOD Plt Ct-428
[**2176-10-4**] 11:53PM BLOOD PT-15.0* PTT-81.5* INR(PT)-1.4
[**2176-10-4**] 11:53PM BLOOD Plt Ct-365
[**2176-10-5**] 06:11AM BLOOD Plt Ct-300
[**2176-10-5**] 11:38AM BLOOD PT-14.6* PTT-39.8* INR(PT)-1.3
[**2176-10-5**] 05:52PM BLOOD PT-14.1* PTT-30.6 INR(PT)-1.3
[**2176-10-6**] 06:12AM BLOOD PT-14.4* PTT-29.7 INR(PT)-1.3
[**2176-10-6**] 06:12AM BLOOD Plt Ct-294
[**2176-10-7**] 03:53AM BLOOD Plt Ct-315
[**2176-10-8**] 05:55AM BLOOD PT-14.7* PTT-30.9 INR(PT)-1.4
[**2176-10-8**] 05:55AM BLOOD Plt Smr-UNABLE TO
[**2176-10-9**] 06:19AM BLOOD Plt Ct-266
[**2176-10-3**] 06:43AM BLOOD ESR-24*
[**2176-9-30**] 04:50PM BLOOD ESR-67*
[**2176-10-3**] 10:54AM BLOOD Ret Aut-3.0
[**2176-10-3**] 10:54AM BLOOD Ret Aut-3.0
[**2176-9-22**] 08:18PM BLOOD Glucose-112* UreaN-25* Creat-0.8 Na-138
K-4.0 Cl-105 HCO3-24 AnGap-13
[**2176-9-23**] 03:53AM BLOOD Glucose-116* UreaN-27* Creat-0.9 Na-136
K-4.0 Cl-103 HCO3-23 AnGap-14
[**2176-9-24**] 03:23AM BLOOD Glucose-104 UreaN-28* Creat-1.1 Na-135
K-3.6 Cl-101 HCO3-24 AnGap-14
[**2176-9-24**] 09:44PM BLOOD Glucose-284* UreaN-29* Creat-1.3* Na-132*
K-4.8 Cl-97 HCO3-19* AnGap-21*
[**2176-9-25**] 04:30AM BLOOD Glucose-131* UreaN-38* Creat-1.5* Na-134
K-4.3 Cl-99 HCO3-23 AnGap-16
[**2176-9-25**] 07:47PM BLOOD Glucose-131* UreaN-41* Creat-1.5* Na-133
K-3.5 Cl-100 HCO3-21* AnGap-16
[**2176-9-26**] 06:11AM BLOOD Glucose-120* UreaN-40* Creat-1.5* Na-134
K-4.5 Cl-100 HCO3-20* AnGap-19
[**2176-9-26**] 05:14PM BLOOD K-4.3
[**2176-9-27**] 05:33AM BLOOD Glucose-114* UreaN-46* Creat-1.6* Na-134
K-3.5 Cl-99 HCO3-23 AnGap-16
[**2176-9-27**] 10:43PM BLOOD Glucose-140* UreaN-47* Creat-1.6* Na-136
K-3.5 Cl-100 HCO3-25 AnGap-15
[**2176-9-28**] 06:08AM BLOOD Glucose-106* UreaN-45* Creat-1.6* Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
[**2176-9-28**] 04:13PM BLOOD Creat-1.5* K-3.9
[**2176-9-29**] 06:00AM BLOOD Glucose-108* UreaN-40* Creat-1.5* Na-137
K-3.7 Cl-99 HCO3-25 AnGap-17
[**2176-9-30**] 12:11AM BLOOD Glucose-103 UreaN-37* Creat-1.5* Na-135
K-3.7 Cl-99 HCO3-25 AnGap-15
[**2176-9-30**] 06:04AM BLOOD Glucose-109* UreaN-35* Creat-1.5* Na-136
K-3.7 Cl-99 HCO3-27 AnGap-14
[**2176-9-30**] 04:50PM BLOOD K-4.0
[**2176-10-1**] 05:14AM BLOOD Glucose-105 UreaN-29* Creat-1.3* Na-134
K-4.3 Cl-99 HCO3-27 AnGap-12
[**2176-10-2**] 04:14AM BLOOD Glucose-107* UreaN-30* Creat-1.6* Na-131*
K-3.9 Cl-93* HCO3-27 AnGap-15
[**2176-10-2**] 10:50PM BLOOD UreaN-29* Creat-1.6* K-3.8
[**2176-10-3**] 06:43AM BLOOD Glucose-98 UreaN-26* Creat-1.5* Na-133
K-3.8 Cl-96 HCO3-27 AnGap-14
[**2176-10-3**] 10:54AM BLOOD Glucose-110* UreaN-28* Creat-1.7* Na-133
K-4.6 Cl-96 HCO3-29 AnGap-13
[**2176-10-3**] 06:04PM BLOOD Creat-1.4* K-7.7*
[**2176-10-3**] 07:53PM BLOOD K-3.8
[**2176-10-4**] 02:58AM BLOOD Glucose-103 UreaN-28* Creat-1.6* Na-135
K-3.9 Cl-97 HCO3-26 AnGap-16
[**2176-10-4**] 09:50AM BLOOD Glucose-269* UreaN-29* Creat-1.9* Na-134
K-4.9 Cl-96 HCO3-22 AnGap-21*
[**2176-10-4**] 03:59PM BLOOD Glucose-144* UreaN-35* Creat-2.1* Na-136
K-3.8 Cl-98 HCO3-24 AnGap-18
[**2176-10-4**] 11:53PM BLOOD Glucose-93 UreaN-36* Creat-2.1* Na-138
K-3.4 Cl-98 HCO3-25 AnGap-18
[**2176-10-5**] 06:11AM BLOOD Glucose-88 UreaN-36* Creat-2.1* Na-139
K-4.2 Cl-99 HCO3-26 AnGap-18
[**2176-10-5**] 05:52PM BLOOD UreaN-33* Creat-2.1* K-3.9
[**2176-10-6**] 06:12AM BLOOD Glucose-123* UreaN-39* Creat-2.2* Na-141
K-3.9 Cl-102 HCO3-28 AnGap-15
[**2176-10-7**] 03:53AM BLOOD Glucose-84 UreaN-35* Creat-1.9* Na-142
K-3.3 Cl-102 HCO3-26 AnGap-17
[**2176-10-8**] 01:55AM BLOOD K-3.0*
[**2176-10-8**] 05:55AM BLOOD Glucose-107* UreaN-24* Creat-1.4* Na-141
K-3.4 Cl-108 HCO3-22 AnGap-14
[**2176-10-8**] 08:57PM BLOOD K-4.1
[**2176-10-9**] 06:19AM BLOOD Glucose-108* UreaN-24* Creat-1.6* Na-139
K-3.9 Cl-102 HCO3-26 AnGap-15
[**2176-9-22**] 08:18PM BLOOD CK(CPK)-423*
[**2176-9-23**] 03:53AM BLOOD CK(CPK)-313*
[**2176-9-23**] 12:13PM BLOOD CK(CPK)-234*
[**2176-9-24**] 09:44PM BLOOD CK(CPK)-146
[**2176-9-25**] 04:30AM BLOOD CK(CPK)-102
[**2176-9-27**] 05:33AM BLOOD LD(LDH)-378* TotBili-0.4
[**2176-10-3**] 06:43AM BLOOD LD(LDH)-289* TotBili-0.7
[**2176-10-4**] 09:50AM BLOOD CK(CPK)-476*
[**2176-10-4**] 03:59PM BLOOD CK(CPK)-357*
[**2176-10-4**] 11:53PM BLOOD CK(CPK)-248*
[**2176-10-5**] 06:11AM BLOOD CK(CPK)-184*
[**2176-10-6**] 06:12AM BLOOD CK(CPK)-98
[**2176-10-8**] 05:55AM BLOOD ALT-13 AST-19 LD(LDH)-228 AlkPhos-46
TotBili-0.9
[**2176-9-22**] 08:18PM BLOOD CK-MB-38* MB Indx-9.0* cTropnT-5.08*
[**2176-9-23**] 03:53AM BLOOD CK-MB-22* MB Indx-7.0* cTropnT-6.49*
[**2176-9-23**] 12:13PM BLOOD CK-MB-16* MB Indx-6.8* cTropnT-6.38*
[**2176-9-24**] 09:44PM BLOOD CK-MB-7 cTropnT-11.33*
[**2176-9-25**] 04:30AM BLOOD CK-MB-5 cTropnT-13.66*
[**2176-10-4**] 09:50AM BLOOD CK-MB-12* MB Indx-2.5 cTropnT-0.87*
[**2176-10-4**] 03:59PM BLOOD CK-MB-9
[**2176-10-4**] 11:53PM BLOOD CK-MB-6 cTropnT-0.98*
[**2176-10-5**] 06:11AM BLOOD CK-MB-5 cTropnT-0.85*
[**2176-10-6**] 06:12AM BLOOD CK-MB-NotDone
[**2176-9-22**] 08:18PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1 Cholest-125
[**2176-9-23**] 03:53AM BLOOD Albumin-2.6* Calcium-7.9* Phos-2.6*
Mg-1.9
[**2176-9-24**] 03:23AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.8
[**2176-9-24**] 09:44PM BLOOD Calcium-8.6 Phos-4.4 Mg-2.3
[**2176-9-25**] 04:30AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.0
[**2176-9-25**] 07:47PM BLOOD Calcium-7.8* Phos-3.8 Mg-1.8
[**2176-9-26**] 06:11AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.7 Mg-1.9
[**2176-9-26**] 05:14PM BLOOD Mg-1.9
[**2176-9-27**] 05:33AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9
[**2176-9-27**] 10:43PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.9
[**2176-9-28**] 06:08AM BLOOD Albumin-2.7* Calcium-8.2* Phos-3.5 Mg-2.0
[**2176-9-28**] 04:13PM BLOOD Mg-2.0
[**2176-9-29**] 06:00AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
[**2176-9-30**] 12:11AM BLOOD Mg-2.2
[**2176-9-30**] 06:04AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
[**2176-9-30**] 04:50PM BLOOD Mg-2.0
[**2176-10-1**] 05:14AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.4
[**2176-10-2**] 04:14AM BLOOD Mg-2.0
[**2176-10-2**] 10:50PM BLOOD Mg-2.1
[**2176-10-3**] 06:43AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
[**2176-10-3**] 10:54AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
[**2176-10-3**] 06:04PM BLOOD Mg-1.9
[**2176-10-3**] 07:53PM BLOOD Mg-2.1
[**2176-10-4**] 02:58AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1
[**2176-10-4**] 09:50AM BLOOD Calcium-8.6 Phos-6.2*# Mg-2.5
[**2176-10-4**] 03:59PM BLOOD Calcium-8.3* Phos-4.3# Mg-2.2
[**2176-10-4**] 11:53PM BLOOD Albumin-2.9* Calcium-8.0* Mg-2.0
[**2176-10-5**] 06:11AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.1
[**2176-10-5**] 05:52PM BLOOD Mg-2.0
[**2176-10-6**] 06:12AM BLOOD Calcium-8.2* Phos-4.8* Mg-2.1
[**2176-10-7**] 03:53AM BLOOD Calcium-8.1* Phos-3.0# Mg-1.9
[**2176-10-8**] 01:55AM BLOOD Mg-1.8
[**2176-10-8**] 05:55AM BLOOD Albumin-2.3* Calcium-7.6* Phos-2.5*
Mg-18.6*
[**2176-10-8**] 09:02AM BLOOD Mg-3.2*
[**2176-10-8**] 08:57PM BLOOD Mg-2.2
[**2176-10-9**] 06:19AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1
[**2176-10-4**] 09:29AM BLOOD freeCa-1.20
[**2176-10-4**] 03:20PM BLOOD freeCa-1.13
[**2176-9-25**] 04:57AM BLOOD O2 Sat-97
[**2176-9-26**] 12:34PM BLOOD O2 Sat-98
[**2176-9-27**] 06:04AM BLOOD O2 Sat-98
[**2176-10-5**] 11:52PM BLOOD O2 Sat-95
[**2176-9-25**] 12:51AM BLOOD Lactate-1.5
[**2176-10-4**] 09:29AM BLOOD Lactate-6.5*
[**2176-10-4**] 03:20PM BLOOD Lactate-1.1
[**2176-10-5**] 11:52PM BLOOD Lactate-2.8*
[**2176-9-22**] 08:39PM BLOOD Type-ART pO2-78* pCO2-32* pH-7.49*
calHCO3-25 Base XS-1
[**2176-9-25**] 12:51AM BLOOD Type-ART Temp-37.1 Rates-/25 Tidal V-650
PEEP-5 pO2-139* pCO2-35 pH-7.46* calHCO3-26 Base XS-2
Intubat-NOT INTUBA Vent-IMV
[**2176-9-25**] 04:57AM BLOOD Type-ART pO2-83* pCO2-35 pH-7.44
calHCO3-25 Base XS-0
[**2176-9-26**] 12:34PM BLOOD Type-ART pO2-88 pCO2-33* pH-7.46*
calHCO3-24 Base XS-0
[**2176-9-26**] 05:34PM BLOOD Type-ART Temp-39.6 O2-40 pO2-148* pCO2-36
pH-7.41 calHCO3-24 Base XS-0
[**2176-9-27**] 06:04AM BLOOD Type-ART pO2-129* pCO2-39 pH-7.44
calHCO3-27 Base XS-2
[**2176-10-4**] 09:29AM BLOOD Type-ART O2 Flow-5 pO2-71* pCO2-69*
pH-7.14* calHCO3-25 Base XS--6 Comment-SFM
[**2176-10-4**] 01:07PM BLOOD Type-ART O2-60 pO2-360* pCO2-33* pH-7.47*
calHCO3-25 Base XS-1 Comment-MASK VENT
[**2176-10-4**] 03:20PM BLOOD Type-ART pO2-66* pCO2-34* pH-7.48*
calHCO3-26 Base XS-2
[**2176-10-5**] 11:52PM BLOOD Type-ART O2-100 pO2-80* pCO2-45 pH-7.32*
calHCO3-24 Base XS--3 AADO2-602 REQ O2-97 Intubat-NOT INTUBA
[**2176-9-28**] 11:07AM BLOOD Vanco-10.6*
[**2176-9-29**] 01:59PM BLOOD Vanco-12.7*
[**2176-10-1**] 03:59PM BLOOD Vanco-24.9*
[**2176-10-3**] 03:46PM BLOOD Vanco-2.7*
[**2176-10-4**] 09:50AM BLOOD Vanco-19.9*
[**2176-10-7**] 03:53AM BLOOD Vanco-27.0*
[**2176-10-8**] 04:00AM BLOOD Vanco-22.7*
[**2176-9-24**] 03:23AM BLOOD Cortsol-20.8*
[**2176-9-25**] 04:30AM BLOOD Cortsol-33.8*
[**2176-9-22**] 08:18PM BLOOD Triglyc-96 HDL-33 CHOL/HD-3.8 LDLcalc-73
[**2176-9-27**] 05:33AM BLOOD Hapto-342*
[**2176-10-3**] 06:43AM BLOOD Hapto-265*
Brief Hospital Course:
## ID: On [**9-26**] pt spiked temp and [**Month/Year (2) **] cx sent. Pt central line
was changed and pt abx was started on ceftriaxone/vanco/flagyl.
Pt [**Name (NI) **] Cx eventually came back positive for MRSA on [**9-27**] and pt
was switched to vancomycin and zosyn. Zosyn was continued for
full 10 day course to because of thought that pt may have PNA.
Surviellance [**Month/Year (2) **] Cx remained negative. Pt had TTE which showed
no vegetations and TEE was deferred since treatment course with
vanco would remain 6weeks since pt had recent hip surgery. On
[**10-3**] had increased WBC, with CXR which was consistent with
aspiration PNA. Pt was continued on Zosyn with extended course
of 13 days. Pt WBC continued to increase while on Zosyn and
vanco, so pt stool was sent for C. diff and pt started on flagyl
empirically. Pt was sent to get R hip aspirated to r/o seeding
but no fluid could be aspirated by IR. Pt never showed clinical
signs of hip infection. Vanco to be cont for 6 weeks, Day 14 of
42 on d/c. Flagyl d/c'd per ID reccs. Pt completed 13d course of
Zosyn prior to d/c. Pulmonary status improved, no further
evidence of aspiration.
## CAD: Pt had NSTEMI and his cardiac enzymes peaked at OSH. Pt
cath was intitially deferred because pt had high INR, but then
was deferred due to pt CHF exacerbation and infection. Obtained
records about CABG in [**2159**]; LIMA-LAD; RIMA-RCA; SVG-LCx. Pt was
continued on ASA, Plavix, BB, and ACEI. Metoprolol was titrated
to 100 PO TID by d/c. Was on NTG drip that was titrated off
prior to d/c.
## HTN: Pt initially presented with tachycardia and HTN. Pt was
transferred on max dose BB, max dose ACEI, and nitro and
diltiazem gtt. Eventually hydralazine was added because of poor
BP control. On [**9-24**] pt SBP rose > 200s with CVP to 32. Pt
desated to 88% and was put on bipap. It was thought that pt
went into flash pulmonary edema due to increased afterload. Pt
PO HTN meds were stopped and pt put on nipride and labetolol
drip. Pt was initially not diuresed since Cre bumped to 1.6.
It was then thought that pt was volume overloaded and pt was
transitioned from nipride and labetolol drip to aggresive
diuresis with natrecor drip and lasix. Pt was then restarted on
PO HTN meds with amlodipine, hydralazine, ACEI (max dose), Beta
blocker. Natrecor was d/c as pt continued to be diuresed and PO
HTN titrated up. Workup for HTN was done; U/S of kidney was
suboptimal but no evid of renal art stenosis; atrophic R kidney.
Urine pheo studies & serum [**Male First Name (un) 2083**] were sent and were pending.
Pt's HTN was difficult to control, but was eventually maintained
with Metoprolol 100 TID, Captopril 75 TID, Amlodipine 5 qd.
## Aspiration Risk: On [**10-4**] pt aspirated while taking medicines
and became agitated, pt SBP rose to 190s and pt desated to 80s.
Pt put on Bipap and was given lasix (with poor response).
Eventually pt did well on Bipap and afternoon of [**10-4**] pt was
taken off bipap. NGT was placed due to aspiration risk and pt
getting meds and feeds through NGT. Pt was initially put on
nitro drip to reduce HTN which was turned off shortly after. Pt
was slowly started on PO ACEI and IV labetolol, which was
transitioned to PO metoprolol. Pt had both bedside S+S test as
well as video S+S test, both of which he passed. Swallow reccs:
dry swallow after each bite, thick liquids, soft solids.
## Rhythm: Pt initially presented with atrial/sinus tach. After
pt was put on labetolol drip his rate was well controlled even
when drip was stopped and metoprolol started. Pt was
tachycardic after his Hct dropped due to psoas hematoma, but
returned to [**Location 213**] after given blood. Pt continued on BBlocker.
Pt then in and out of A tach, eventually maintained mostly in
NSR on Amiodarone 400 po tid, with metoprolol 100 tid for rate
control on top.
## Drop in Hct: Pt Hct dropped 6 on [**10-3**] so pt was workedup for
source of bleed. Pt remianed giuac negative and no obvious
source of bleeding could be found so pt had CT scan abd/pelvis
which showed left psoas hematoma 6x6cm. Pt was kept on heparin
for hip anticoagulation but at lower goal PTT. Pt Hct was
monitored and pt recieved 3 units of blood. Pt received one more
unit after his hct dropped to 27 on [**10-8**] for a total of 4units,
to keep his Hct above 30 given his CAD. His hct on d/c was up to
36 one day after transfusion.
## M.S.: h/o baseline dementia; stable; cont Effexor
## Hip: Ortho consulted, pt was closely monitored for signs of
hip being seeded. There was no evidence that pt hip was seeded
while inpatient. Pt was continued on heparin for
anticoagulation. Received PT while in house.
Medications on Admission:
Lipitor 10mg; Nitro gtt@200mcg/min; Dilt gtt@15mg/hr; captopril
75 qid; lopressor 100 qid; Norvasc 10 qd; ASA 325; Plavix 75;
Effexor 75qam/ 37.5
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed. nebulizer
treatment
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
4. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
Q24H (every 24 hours) for 4 weeks: last dose on [**2176-11-8**].
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours). Tablet(s)
7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Imdur 30 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*
9. Captopril 25 mg Tablet Sig: Three (3) Tablet PO three times a
day.
10. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Outpatient Lab Work
please follow Chem-7 and Mg qod
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Myocardial infarction (NSTEMI)
Congestive Heart Failure
Central Line MRSA bacteremia
Aspiration pneumonia
Discharge Condition:
Fair
Discharge Instructions:
Please contact your primary care provider to set up an
appointment within the next two weeks to be re-evaluated for
your medical issues. Also, your primary care provider should
set up a pulmonary function test for you, to obtain baseline
measurements of your lung function now that you are starting on
Amiodarone (which can affect lung function).
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17753**] in the next two weeks to readdress your
medical issues.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7179**] within [**4-11**]
weeks of leaving the hospital.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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|
313, 319
|
22829, 22835
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1731, 16564
|
23232, 23768
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1413, 1431
|
21484, 22584
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22701, 22808
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21314, 21461
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1446, 1712
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243, 275
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347, 1165
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1187, 1338
|
1354, 1397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,022
| 174,571
|
44527+44528+58724
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2154-12-29**] Discharge Date: [**2155-1-2**]
Date of Birth: [**2101-4-11**] Sex: F
Service: MICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
woman, with past medical history most notable for advanced
unresectable pancreatic cancer, who underwent cystic duct
stenting in [**2154-11-25**], and received Xeloda chemotherapy
and radiotherapy. She states that after completing the
course of chemotherapy and radiation, she has appreciated
several episodes of hematochezia, the last being 3 days prior
to presentation, and approximately 3 tbsp in volume/episode,
and there are 3-5 episodes/day.
On review, the patient also states that she has no appetite,
limited PO intake, decreased energy, lightheadedness and
dizziness, without chest pain. She also states she has
occasional abdominal pain.
She also reports significant weight gain attributed entirely
to edema in her legs and ascites collection in her abdomen.
She also states she has limited ambulation owing to
discomfort in her legs. She also reports nausea and bilious
vomiting that was not bloody.
In the Emergency Department, the patient declined nasogastric
lavage. She received 3 liters of normal saline volume
resuscitation, as well as 1 unit of packed red blood cells.
PAST MEDICAL HISTORY:
1. Pancreatic cancer, as described above. Please see Dr.[**Name (NI) 95388**] notes in the OMR for details of the diagnosis and
treatment course.
2. Portal venous thrombosis.
3. Cholecystitis.
MEDICATIONS ON ADMISSION:
1. Morphine SR 50 mg q 12 h.
2. Morphine sulfate SA 10 mg q 4-6 h prn.
3. Pantoprazole 40 mg qd.
4. Metronidazole--recently completed a course of 500 mg po
tid for 7 days and Levofloxacin 500 mg for 7 days.
5. Furosemide 20 mg qod.
6. Ondansetron 2-4 mg prn.
ALLERGIES:
1. Prozac causes hives.
2. Azithromycin causes abdominal pain.
3. Gemcitabine causes bleeding and hives.
FAMILY HISTORY: Significant for [**Name (NI) 499**] cancer.
SOCIAL HISTORY: There is no history of alcohol, or tobacco
exposure, or injection drug use. She is married and has 2
children.
PHYSICAL EXAMINATION: Temperature 99.4, heart rate initially
120, blood pressure 123/70, respiratory rate 18, oxygen
saturation 97% on room air.
HEENT: She had a clear oropharynx with dry mucous membranes.
She had anicteric sclerae with normal conjunctivae. The
pupils equal, round and reactive to light and accommodation.
NECK: Supple. She had prominent carotid pulsations at the
base of the neck.
HEART: Sinus rhythm. Normal S1 and S2. There were no S3 or
S4 murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Distended with a fluid wave and percussion splash
present. It was not tender. No organs palpable.
EXTREMITIES: Warm, no rash, no clubbing, no cyanosis. There
was +2 edema from the toes to the midcalves.
VASCULAR: The radial, carotid and dorsalis pedis pulses were
brisk and equal.
INITIAL LABORATORY EVALUATION: Hemoglobin 6.5, hematocrit
24.4, platelets 277. Chemistry panel - sodium 135, potassium
3.4, chloride 95, bicarbonate 32, blood urea nitrogen 10,
creatinine 0.7, glucose 137, AST 58, ALT 27, alkaline
phosphatase 734, amylase 27, total bilirubin 1.3, magnesium
1.8, albumin 2.7, calcium 8.8, phosphate 2.7, INR 1.1.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit and received transfusion with
packed red blood cells, a total of 3 in the first 24 hours.
She then underwent esophagogastroduodenoscopy which revealed
an actively bleeding gastric ulcer that underwent epinephrine
injection on [**2154-12-31**] with good hemostasis.
Hematocrit following the procedure remained stable for 2
days. However, repeat endoscopic evaluation on [**2155-1-2**] showed persistent bleeding from said site. Attempts at
electrocautery and epinephrine injection did not limit the
bleeding significantly, and at the time of this dictation
serial hematocrit checks were continuing.
Owing to the patient's poor nutrition, a percutaneously
inserted central catheter was placed, and total parenteral
nutrition was administered without complications. Once the
patient's hemodynamic status was stabilized, furosemide and
spironolactone were added to her medications to relieve the
peripheral edema, specifically to decrease the swelling in
her legs and the ascites.
MEDICATIONS AT TIME OF DICTATION:
1. Furosemide 40 mg po q am.
2. Spironolactone 25 mg po q hs.
3. Beclomethasone diproprionate nasal spray 2 sprays in both
nares [**Hospital1 **].
4. Morphine sulfate SA 15 mg q 12 h.
5. Pantoprazole 40 mg intravenously q 12 h.
6. Ondansetron 2 mg q 6 h prn nausea.
7. Morphine sulfate intravenously q 2 h prn pain.
8. Senna 1 tablet [**Hospital1 **].
9. Docusate 100 mg [**Hospital1 **].
DISPOSITION: Pending serial evaluation of hematocrit.
Should her hematocrit fail to stabilize, angiography shall be
ordered.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2155-1-2**] 10:56
T: [**2155-1-2**] 12:34
JOB#: [**Job Number 95389**]
Admission Date: [**2154-12-29**] Discharge Date:
Date of Birth: [**2101-4-11**] Sex: F
Service: MICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
woman with a past medical history significant for advanced
unresectable pancreatic cancer who presented complaining of
bright red blood since [**2154-9-25**] that has intensified
over the three days prior to evaluation in the Emergency
Department. She describes it as several tablespoons per
bowel movement for approximately three to five bowel
movements per day.
In general, she states that she feels "crummy". She has no
appetite and has not been eating. She states that she is
lightheaded and dizzy without chest pain. She does not have
chest pain, abdominal pain.
She also reports an appreciable increase in lower extremity
edema approximately 25 pounds, which has responded initially
to diuresis on her last admission but has since
reaccumulation and this has limited her ability to ambulate
and has caused significant discomfort in her legs. She also
has had decreased energy level.
In the Emergency Department, the patient had a witnessed
episode of bilious vomiting. She refused nasogastric lavage.
She received a total of three liters of normal saline and one
unit of packed red blood cells there.
PAST MEDICAL HISTORY:
1. Pancreatic cancer as described above, diagnosed in
[**2154-8-26**]; status post cystic duct stenting in
[**2154-11-25**]. She underwent radiotherapy and received
Xeloda. She did not tolerate Gemcitabine. Her radiation
therapy was complicated by proctitis.
2. Interval evaluation of her biliary draining system
reveals portal venous thrombosis and a recent admission for
cholecystitis.
MEDICATIONS:
1. Sustained acting morphine sulfate 50 mg every 12 hours.
2. Short acting morphine sulfate 10 mg every four to six
hours as needed.
3. Pantoprazole 40 mg daily.
4. Furosemide 20 mg every other day.
5. Ondansetron 2 to 4 mg as needed every six hours.
6. She completed a course of metronidazole 500 mg p.o. every
eight hours times seven days and Levofloxacin 500 mg every 24
hours for seven days.
ALLERGIES:
1. Fluoxetine causes hives.
2. Azithromycin causes abdominal pain.
3. Gemcitabine causes hives and bleeding.
FAMILY HISTORY: Significant for [**Year (4 digits) 499**] cancer.
SOCIAL HISTORY: There is no alcohol use, tobacco exposure
or injection drug use. She is married with one daughter.
PHYSICAL EXAMINATION: Temperature is 99.9 F.; heart rate
was 87 to 102; blood pressure 94/41; respiratory rate 16.
Generally, she was pale, lying in bed. HEENT: Oropharynx
was clear with moist mucous membranes. She had anicteric
sclerae. Normal conjunctivae. Neck supple. There was brisk
carotid pulses without bruits. Lungs: She has faint
bibasilar crackles without egophony or fremitus. Abdomen
distended with a small reducible peri-umbilical hernia. She
had hypoactive bowel sounds. It is nontender and there is a
fluid wave and percussion splash. Organs are not palpable.
Extremities are warm. She has plus two pitting edema from
her ankles extending to her mid-calves. Her left hand has
one plus pitting edema.
LABORATORY: White blood cell count 6.5, hematocrit 24.4,
platelets 277, INR 1.1.
Chemistry panel was sodium 135, potassium 3.4, chloride 95,
bicarbonate 31, blood urea nitrogen 10, creatinine 0.7,
glucose 137. Her AST was 58, ALT 26, amylase 27, alkaline
phosphatase 734, albumin 2.7, calcium 8.8, phosphate 2.7,
magnesium 1.8.
Two sets of blood cultures were drawn which were ultimately
sterile.
Chest x-ray showed a decrease in the right sided pleural
effusion which was unchanged and small left pleural effusion
as well as atelectasis of the left base.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for her acute gastrointestinal bleeding.
Over the course of her stay she required a transfusion of
packed red blood cells. At the time of this dictation she
was averaging one per day, however, initially she required
two to three units per day for which she had a PICC placed.
She underwent an esophagogastroduodenoscopy and an antral
gastric and antral ulcer was identified and injected with
epinephrine with good hemostasis.
Interval assessment of her hemoglobin and hematocrit however
showed continuing decline.
A repeat esophagogastroduodenoscopy showed diffuse bleeding
from a very friable gastric mucosa.
Based on this finding, no further intervention was performed
by the Gastroenterology Service. The Interventional
Radiology and General Surgery Services were contact[**Name (NI) **] and
both stated that the patient is not a surgical candidate
given her terminal diagnosis. Likewise, expected management
using angiographic techniques will be entertained.
At the time of this dictation, the patient is hemodynamically
stable, but however should she require an increased amount of
transfusion, angiography will be entertained with the
understanding that it is very unlikely that adequate
hemostasis through embolization will be achieved.
For pancreatic cancer, the patient had persistent abdominal
pain. Initial increase in her pain medications resulted in
excessive sedation, however, by hospital day four, she was
able to tolerate the doses of morphine as described above and
she required additional intravenous administration. She also
received lorazepam for nausea with good effect.
On [**2154-1-4**], the patient was found to be febrile.
Blood cultures were obtained and at the time of this
dictation, one set (it is unclear if it was drawn from her
PICC line or peripherally), had grown Gram positive cocci in
pairs and clusters.
A urinary culture was performed and enterococcal species were
isolated. The sensitivities to antibiotics were pending at
the time of this dictation.
She also had a paracentesis performed which showed no
evidence of peritonitis and the cultures remained sterile at
the time of this dictation.
She was started empirically on Vancomycin for an enterococcal
urinary tract infection as well as the morphologic findings
of her blood culture. Antibiotic selection should be guided
based on sensitivities of the isolates.
To treat her discomfort owing to the presence of peripheral
edema, furosemide and spironolactone were initiated with
modest effect in that she was receiving large volume of total
parenteral nutrition.
Her electrolytes remained in good order with sporadic
repletion of potassium and magnesium being required.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2155-1-4**] 19:45
T: [**2155-1-4**] 20:17
JOB#: [**Job Number 95390**]
Name: [**Known lastname 4583**], [**Known firstname 9188**] Unit No: [**Numeric Identifier 15096**]
Admission Date: [**2154-12-29**] Discharge Date: [**2155-1-10**]
Date of Birth: [**2101-4-11**] Sex: F
Service:
ADDENDUM: The patient was transferred from the Intensive
Care Unit on [**2155-1-7**] where she remained
hemodynamically stable without evidence of further
hematemesis, melena, or bright red blood per rectum. Her
hematocrit remained stable without transfusion requirements
(baseline between 28% and 30%). The patient finished seven
days of intravenous vancomycin for an enterococcal urinary
tract infection without further evaluation of infection. She
remained afebrile.
She continued to be aggressively diuresed with Bumex with a
reduction of anasarca. Currently, Bumex dose titrated down
to 0.5 mg by mouth every day. Voiding around two liters per
day. Dry weight goal is 150 pounds. CA19 was pending at the
time of this dictation. Total parenteral nutrition orders as
per page 1. Transition off total parenteral nutrition once
meeting full by mouth caloric needs.
MEDICATIONS ON DISCHARGE:
1. Ondansetron 2 mg intravenously q.6h. as needed (for
nausea).
2. Promethazine 12.5 mg to 25 mg intravenously q.6h. as
needed.
3. Morphine extended release 30 mg by mouth q.12h.
4. Morphine sulfate immediate release 15 mg by mouth q.6h.
as needed.
5. Colace 100 mg by mouth twice per day.
6. Senna one tablet by mouth twice per day.
7. Bisacodyl 10 mg by mouth twice per day as needed (for
constipation).
8. Beclomethasone nasal spray two sprays per nostril twice
per day.
9. Sucralfate 1 gram by mouth four times per day.
10. Protonix 40 mg by mouth q.12h.
11. Simethicone 40 mg to 80 mg by mouth four times per day
as needed.
12. Ativan 0.5 mg to 1 mg by mouth or intravenously q.4-6h.
as needed.
13. Bumex 0.5 mg by mouth every day.
14. Spironolactone 25 mg by mouth once per day.
15. Lactulose 30 mL by mouth q.8h. as needed (for
constipation).
16. Ambien 5 mg by mouth at hour of sleep as needed (for
insomnia).
17. Milk of Magnesia 30 mg by mouth q.6h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with her oncologist one week after discharge
from rehabilitation facility. The patient was given Dr.[**Name (NI) 15100**] clinic number.
CONDITION AT DISCHARGE: The patient was discharged to
rehabilitation in fair condition with a stable hematocrit.
No evidence of further gastrointestinal bleeding. Followup
as indicated above.
[**Name6 (MD) 3354**] [**Last Name (NamePattern4) 5357**], M.D. [**MD Number(1) 6820**]
Dictated By:[**Last Name (NamePattern1) 3036**]
MEDQUIST36
D: [**2155-1-10**] 15:37
T: [**2155-1-11**] 06:02
JOB#: [**Job Number 15101**]
|
[
"263.9",
"789.5",
"531.40",
"599.0",
"452",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.43",
"99.15",
"54.91",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7521, 7572
|
13152, 14149
|
1581, 1958
|
9004, 13125
|
14183, 14372
|
7715, 8986
|
14387, 14821
|
5341, 5371
|
5401, 6547
|
6569, 7503
|
7590, 7691
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,540
| 117,416
|
47617
|
Discharge summary
|
report
|
Admission Date: [**2156-8-3**] Discharge Date: [**2156-8-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
Transfusion 4 Units blood
History of Present Illness:
[**Age over 90 **]yo male w/h/o L-sided diverticulosis ('[**43**]) presents with 1
episode of BRBPR during a bowel movement this evening. Pt denies
abdominal pain, nausea, straining, dizziness, rectal pain,
melena, coffee ground emesis or hemoptysis. He reports feeling
well and denies recent epiosodes of bleeding. His vitals in ED
were T 96.9, HR 56, BP 186/66, RR 16, and 96% RA. Hct = 30
(baseline 32-38). No recent changes in stool consistency; last
colonoscopy in '[**43**].
.
While in the ED the patient had a stool containing a significant
amount of red blood. Hct taken 3 hours after episode was 29.
Past Medical History:
1. Hypertension.
2. ?Congestive failure.
3. Gout.
4. Rectal bleeding from diverticulosis
5. anemia not consistent with iron deficiency on w/u outpatient,
more likely ACD
6. L inguinal hernia repair ([**2146**])
Social History:
Widower ~7 yr. No children. Lives alone at [**Hospital3 **] at
[**Location (un) **] Place??????provides meals and cleaning although the patient
works out regularly and ambulates at baseline without any
assistance. Retired lawyer and worked for costumer service of
the Postal Service. Minimal smoking hx (sniffed but never
smoked). ~1 glass of wine a day. Works out and lifts weights
regularly.
Family History:
noncontributory
Physical Exam:
PE: T 96.9 P 56 BP 186/66 RR 16 O2 96 on RA
Gen - A+Ox3 NAD
HEENT - EOMI, pale conjuntivae, no JVD
Cor - RRR sys murmur
Chest - CTA B
Abd - s/nt/nd +BS
Rectal (per ED) blood in rectal vault, no hemorrhoids
Ext - w/wp, no c/c/e, 2+ DP
Pertinent Results:
EKG - Sinus brady flat T in V2, LAD, nl intervals
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with delirium, doing infectious work-up.
REASON FOR THIS EXAMINATION:
r/o infiltrate.
AP CHEST, [**2156-8-7**], 08:27 HOURS
HISTORY: [**Age over 90 **]-year-old man with delirium. Rule out sepsis.
IMPRESSION: AP chest compared to [**2156-5-29**]:
Heart is mildly enlarged and the pulmonary vasculature engorged.
There is no pneumonia or pleural effusion. Thoracic aorta is
generally tortuous and calcified, but not focally dilated.
HISTORY: Acute GI bleed.
REPORT: Following intravenous injection of autologous red blood
cells labelled
Tc-[**Age over 90 **]m, blood flow and delayed images of the abdomen for 60
minutes were
obtained.
Blood flow images show normal, expected uptake of tracer. No
areas of
extravasation are seen.
Delayed blood pool images again show no evidence of
extravasation of tracer to
indicate a location of gastrointestinal hemorrhage.
IMPRESSION: No extravasation of tracer identified to indicate
location of
gastrointestinal hemorrhage.
/nkg
Reason: eval for bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with HTN, admitted with gi bleed, now suddenly
confused with blown right pupil
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Hypertension, now confused with dilated right pupil.
TECHNIQUE: Noncontrast head CT. This study is limited by motion.
FINDINGS: Comparison with [**2156-5-29**]. No hydrocephalus, shift
of normally midline structures, intra- or extra-axial
hemorrhage, or acute major vascular territorial infarct is
identified. There is prominence of the sulci and ventricles;
however, this is not significantly changed since the last
examination. Minor mucosal maxillary thickening is again noted
in the right maxillary sinus. No fractures are identified.
IMPRESSION: Study limited by motion, however, no acute
intracranial pathology identified. No significant interval
change since [**2156-5-29**].
Brief Hospital Course:
A/p: [**Age over 90 **] yo M
1. GI Bleed: patient with mult episodes of BRBPR. Likely from
lower source given that Hct slowly going down. Has remained
hemodynamically stable in ED. No reoccurrence of GI bleed in
past 3 days. Location of bleed is yet to be determined. Bleeding
test was negative. Continue to monitor for any changes.
Colonoscopy is necessary to determine location, as per GI. HCT
has been running in 27-29 for the past days. It has been stable
but it low. Lab results today show that crit has decreased to
27.6. A unit of blood is necessary as the crit has dropped.
Discussed patient with GI. GI is following patient. Feel that he
is stable at the moment. [**Name2 (NI) **] plan from them. ON [**8-9**], crit had
increased to over 30. Still awaiting decision if f/u colonoscopy
is warranted given pt HX with the prep. Pt was given senna and
had 200 cc melena over night on [**8-12**]. Pt had not had bowel
movement since GI prep; this could just be residual blood from
initial GIB/. Repeat colonoscopy was decided against due to pts
present state
.
2. Delirium: Pt has remained in a confused state for the past 4
days. He has been placed in restraints due to threatening
behavior and trying to pull at tubes. MS change has been
improving. He remains confused. He is responsive to voice and
tactile stimulation. Pt is mumbling but beginning to make more
sense. Concern remains what MS change is due to. Infectious work
up is in process. Began pt on olanzapine as per geriatric
consult. Pt had a run of SVT over the night on [**8-7**] but was
easily arousable. NO concern felt. ON [**8-8**], pt was conversing.
He appeared to be returning to his original state. Foley was d/c
and ucx and BCX taken. ucx was negative. UA obtained showed some
bacteria and WBC. That evening, Foley replaced due to lack of
output. Pt became combative and was given olanzapine. On rounds
on [**8-9**], pt unarousable. Tried to arouse him with multiple
stimuli with little response. Suction was used to remove sputum
and fluid accumulating in his throat and mouth. Pt was
responsive to this measure. His eyes would bunch up and he tried
to block the suction. His blood pressure decreased to 90/60.
But then returned between 118-120 and then increased to 130/85.
CXR showed Left retrocardiac opacity. Pt afternoon, pt
responsive and more alert. D/c haldol and olanzapine. If
combative, pt will be placed in restraints. Trying to have
patient come off the past medications. On [**8-9**], began Levaquin
due to CXR showing possible aspiration pneumonia and a possible
UTI as shown by UA. These are both possible causes for patients
current state. Marked improvement noted on [**8-10**]. Pt became more
responsive and was able to tell the story of how he ended up in
the hospital. SPS consulted again for evaluation. Vanco was d/c
as blood CX on [**8-3**] showed that bacteria was susceptible to
oxacillin.
-Bacteremia seems to be the cause of the delirium
Pt given trazodone and lodaxaprine on the night of [**8-10**]. The
following morning, pt arousable but became agitated. Mitt
restraints initiated to stop patient from pulling foley. Pt
continues to wax and wane in his knowledge of place and time.
The AM of [**8-12**], pt was conversive and alert to his location. He
then proceeded to begin pulling on his IV and trying to removed
bandages. Pt continues to have bouts of waxing and [**Doctor Last Name 688**]. He
alert to people but confused over who people are and various
events that are occurring.
.
3. HTN: Hydralazine
- if pt becomes re-oriented, possibly return to Univasc 15mg PO
daily. On [**8-13**], began Univasc as replacement for hydralazine.
4.PPX: pneumonic boots have been placed on patient since initial
changes. Request for patient to be repositioned q2h to avoid
pressure ulcers.
5. FEN: Pt begun on D5W upon admission. When MS change,
continued on D5W. On [**8-9**], begun on D5 [**12-28**] N. SPS consulted and
found pt should remain NPO. Decision made to check the next day
for alertness. If pt remains alert and partially oriented, SPS
will be re consulted. if not, NG tube and nutrition consult will
be obtained. SPS reevaluated patient on [**8-11**] and determined that
soft foods are acceptable. Recommended a video swallow which
showed that ground food was acceptable. Switched all meds to PO
form to see how patient fairs.
Medications on Admission:
lasix 20mg qd
univasc 15mg qd
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: [**12-28**] Ophthalmic QID (4
times a day).
Disp:*1 5* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnosis:
GI bleed
Mental status change
.
Secondary Diagnosis:
L-sided diverticulosis hx
anemia - likely ACD
HTN
CHF
gout
Discharge Condition:
good
Discharge Instructions:
continue antibiotics as directed.
Continue to monitor any abnormal bleeding
Return for bleeding, bowel changes, pain , any changes in mental
status
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] Where: [**Name12 (NameIs) **] Date/Time:[**2156-9-27**] 2:00
Completed by:[**2156-8-13**]
|
[
"285.1",
"599.0",
"790.7",
"562.12",
"274.9",
"285.29",
"507.0",
"293.0",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9360, 9450
|
3989, 8352
|
269, 309
|
9625, 9631
|
1911, 1962
|
9828, 9999
|
1619, 1636
|
8433, 9337
|
3069, 3180
|
9471, 9471
|
8378, 8410
|
9655, 9805
|
1651, 1892
|
221, 231
|
3209, 3966
|
337, 949
|
9543, 9604
|
9490, 9522
|
971, 1185
|
1201, 1603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,093
| 107,231
|
2801
|
Discharge summary
|
report
|
Admission Date: [**2129-8-18**] Discharge Date: [**2129-8-24**]
Date of Birth: [**2081-2-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Bactrim
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
shortness of breath, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48-year-old female with PMH significant for IDDM, chronic
idiopathic pancreatitis, HTN and prior splenic vein thrombosis (
> 10 yrs. ago) who presented to the ED after 3 days of worsening
cough and shortness of breath. She reports having developed
fatigue and sore throat about 5 days ago and then she developed
a cough about 2 days ago with a "brownish" productive sputum.
She also reports having alternating chills and sweats over past
2-3 days as well but she did not take her temperature at home.
She denies recent travels but states several of her
grandchildren had bad colds at a recent family gathering last
week. She denies any known history of CHF, PEs, or MIs in the
past. She denies LE edema but has noticed some mild orthopnea
over past day but never before in the past.
In the ED, initial vital signs were : Temp 98.2F, Tmax 100.4F,
BP 136/70, RR 20, O2 sats were 99% on NRB. She was given IV
750mg Levaquin and IV 1g Vancomycin. Also received IV Zofran x 1
for some nausea complaints. In ED, AP CXR showed bilateral
opacities concerning for ARDS initially but repeat PA & lateral
views notable for diffuse pulmonary edema with underlying patchy
infiltrates concerning for PNA.
Upon arrival to the [**Hospital Unit Name 153**] the patient appeared to be in no acute
distress, she was able to speak in full sentences and did not
appear to be using any accessory muscles to breath. She had temp
98.5F axillary, BP 105/62, HR 89, RR 16-18, and O2 saturation
level of 99% on NRB ( 12L).
REVIEW OF SYSTEMS:
(+) Per HPI, also has intermittent headaches, diffuse muscle
aches, nausea. Chronic right sided and epigastric abdominal pain
is at baseline per patient.
(-) Denies recent weight loss or gain. Denies chest pain or
tightness, palpitations. Denies vomiting, diarrhea, constipation
and last BM yesturday. Denies recent change in bowel or bladder
habits. Denies dysuria. Denies arthralgias.
Past Medical History:
-Chronic pancreatitis biopsy proven, followed by Dr. [**Last Name (STitle) 3315**]
here at [**Hospital1 18**]. On chronic narcotics and enzymes.
-IDDM, secondary to chronic pancreatitis, followed by Dr. [**First Name (STitle) 3636**]
at [**Last Name (un) **]
-Hypertension
-history of splenic vein thrombosis
-Depression
-Mitral regurgitation
-h/o MRSA bacteremia
-Genital herpes
-I & D of LLE abscess [**12/2128**]
-tobacco use
Social History:
Ms. [**Known lastname **] lives in [**Location 686**]. She has 3 children, 5
grandchildren. Former nursing assistant. Long-standing smoker,
smoked 2PPD x 30 years and then 1PPD x last 3 years. No EtOH. No
illicit drug use. She is currently separated from her spouse who
was recently incarcerated.
Family History:
Her father died of pancreatic cancer at age 56. Her mother died
from anesthesia reaction. + h/o breast cancer in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals -Temp 98.5F axillary, BP 105/62, HR 89, RR 16-18, and O2
saturation level of 99% on FM( 12L / FiO2 100%).
.
GEN: - Resting comfortably in bed, no acute distress
HEENT: -PERRL, sclera anicteric, MMM, erythematous posterior
oropharynx noted, no exudates noted
NECK: - supple, JVP at 9cm, mildly tender cervical lymph nodes
but no appreciable enlargement
PULM: Bilateral crackles at bases, no wheezes or rhonchi
CVS - RRR, normal S1/S2; loud S2 and otherwise no murmurs, rubs,
or gallops appreciated
ABD: normoactive bowel sounds; soft, mild TTP over right side of
abdomen and epigastric region, non-distended, no rebound or
guarding
EXT- Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
SKIN - no rashes, warm to the touch
Neuro -CNs [**3-17**] in tact, appropriate 5/5 strength with
upper/lower extremities, no focal sensory deficit, gait
assessment deferred
Pertinent Results:
[**2129-8-24**] 05:30AM BLOOD WBC-8.7 RBC-3.52* Hgb-9.5* Hct-29.3*
MCV-83 MCH-27.0 MCHC-32.3 RDW-16.7* Plt Ct-450*
[**2129-8-20**] 05:09AM BLOOD WBC-9.2 RBC-3.44* Hgb-9.4* Hct-28.9*
MCV-84 MCH-27.2 MCHC-32.4 RDW-16.9* Plt Ct-266
[**2129-8-19**] 01:31PM BLOOD WBC-12.0* RBC-3.71* Hgb-10.1* Hct-30.4*
MCV-82 MCH-27.3 MCHC-33.3 RDW-16.8* Plt Ct-301
[**2129-8-18**] 04:20AM BLOOD WBC-14.6* RBC-3.72* Hgb-10.2* Hct-31.0*
MCV-83 MCH-27.4 MCHC-32.9 RDW-17.4* Plt Ct-244
[**2129-8-17**] 10:20PM BLOOD WBC-14.3* RBC-4.04* Hgb-11.2* Hct-33.9*
MCV-84 MCH-27.7 MCHC-33.0 RDW-16.9* Plt Ct-263
[**2129-8-17**] 10:20PM BLOOD Neuts-85.2* Lymphs-12.4* Monos-2.1
Eos-0.1 Baso-0.1
[**2129-8-19**] 01:31PM BLOOD PT-13.5* PTT-34.0 INR(PT)-1.2*
[**2129-8-19**] 01:31PM BLOOD Fibrino-910*
[**2129-8-19**] 01:31PM BLOOD ESR-105*
[**2129-8-19**] 01:31PM BLOOD Ret Aut-1.5
[**2129-8-24**] 05:30AM BLOOD Glucose-189* UreaN-13 Creat-0.8 Na-138
K-5.0 Cl-102 HCO3-29 AnGap-12
[**2129-8-23**] 05:15AM BLOOD Glucose-60* UreaN-10 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-28 AnGap-11
[**2129-8-18**] 04:20AM BLOOD Glucose-64* UreaN-22* Creat-1.3* Na-141
K-3.6 Cl-108 HCO3-19* AnGap-18
[**2129-8-17**] 10:20PM BLOOD Glucose-67* UreaN-20 Creat-1.3* Na-140
K-3.3 Cl-108 HCO3-20* AnGap-15
[**2129-8-19**] 05:01AM BLOOD LD(LDH)-784* AlkPhos-83 TotBili-0.2
[**2129-8-18**] 06:52PM BLOOD CK(CPK)-103
[**2129-8-18**] 04:20AM BLOOD ALT-9 AST-42* LD(LDH)-895* CK(CPK)-119
AlkPhos-81 TotBili-0.1
[**2129-8-17**] 10:20PM BLOOD ALT-6 AST-47* LD(LDH)-959* CK(CPK)-85
AlkPhos-87 TotBili-0.1
[**2129-8-18**] 06:52PM BLOOD CK-MB-3 cTropnT-<0.01
[**2129-8-18**] 04:20AM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-8-17**] 10:20PM BLOOD cTropnT-<0.01
[**2129-8-17**] 10:20PM BLOOD CK-MB-NotDone proBNP-4677*
[**2129-8-24**] 05:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
[**2129-8-19**] 05:01AM BLOOD Calcium-7.1* Phos-1.8* Mg-1.7 Iron-14*
[**2129-8-18**] 04:20AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.4 Mg-2.0
[**2129-8-19**] 01:31PM BLOOD Hapto-407*
[**2129-8-19**] 05:01AM BLOOD calTIBC-187* Hapto-341* Ferritn-87
TRF-144*
[**2129-8-19**] 01:31PM BLOOD ANCA-NEGATIVE B
[**2129-8-19**] 01:31PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **]
[**2129-8-18**] 09:24AM BLOOD HIV Ab-NEGATIVE
[**2129-8-22**] 12:37PM BLOOD Type-ART Temp-36.5 O2 Flow-4 pO2-107*
pCO2-45 pH-7.39 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2129-8-21**] 01:49PM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-68*
pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2129-8-19**] 01:52PM BLOOD Type-ART Temp-37.2 Rates-/22 FiO2-95
pO2-64* pCO2-37 pH-7.39 calTCO2-23 Base XS--1 AADO2-576 REQ
O2-95 Intubat-NOT INTUBA
[**2129-8-19**] 07:31AM BLOOD Type-ART pO2-74* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2129-8-18**] 04:07PM BLOOD Type-ART pO2-61* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
[**2129-8-18**] 03:24AM BLOOD Type-ART Temp-37.8 FiO2-99 pO2-98
pCO2-31* pH-7.38 calTCO2-19* Base XS--5 AADO2-594 REQ O2-95
Intubat-NOT INTUBA
[**2129-8-19**] 01:52PM BLOOD Lactate-1.0
[**2129-8-17**] 11:02PM BLOOD Lactate-2.0
[**2129-8-19**] 01:52PM BLOOD freeCa-1.15
[**2129-8-20**] 01:00PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-PND
[**2129-8-20**] 01:00PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-PND
[**2129-8-20**] 12:54PM BLOOD CHLAMYDOPHILA PNEUMONIAE ANTIBODIES
(IGG,IGA,IGM)-PND
[**2129-8-17**] 11:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2129-8-17**] 11:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2129-8-17**] 11:25PM URINE RBC-0 WBC-[**4-7**] Bacteri-MOD Yeast-NONE
Epi-21-50
[**2129-8-17**] 02:28PM URINE Hours-RANDOM Creat-129 Na-LESS THAN
[**2129-8-17**] 02:28PM URINE Osmolal-459
**FINAL REPORT [**2129-8-19**]**
Legionella Urinary Antigen (Final [**2129-8-19**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2129-8-18**] 9:24 am SPUTUM Site: INDUCED Source: Induced.
**FINAL REPORT [**2129-8-18**]**
GRAM STAIN (Final [**2129-8-18**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2129-8-18**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2129-8-18**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
[**2129-8-18**] 8:02 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2129-8-20**]**
Respiratory Viral Culture (Final [**2129-8-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Rapid Respiratory Viral Antigen Test (Final [**2129-8-18**]):
Respiratory viral antigens not detected
[**2129-8-20**] 3:49 pm SPUTUM Site: INDUCED Source: Induced.
**FINAL REPORT [**2129-8-21**]**
GRAM STAIN (Final [**2129-8-20**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2129-8-21**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
ECG Study Date of [**2129-8-17**] 10:09:50 PM
Sinus rhythm. Left ventricular hypertrophy. Diffuse non-specific
ST-T wave
changes. Compared to the previous tracing of [**2128-12-4**] the rate
has increased. Non-specific ST-T wave changes are more
prominent. There are new T wave inversions in leads I, aVL with
ST segment flattening in lead V6. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 152 84 344/401 24 50 171
CHEST (PA & LAT) Study Date of [**2129-8-17**] 11:51 PM
IMPRESSION: Findings are consistent with pulmonary edema with
overlying
airspace disease such as infection (likely hemorrhage). Consider
diuresis and repeating radiograph.
Portable TTE (Complete) Done [**2129-8-18**] at 12:27:46 PM
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is high
(>4.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2127-7-21**], the
findings are similar
CT CHEST W/O CONTRAST Study Date of [**2129-8-18**] 3:03 PM
IMPRESSION:
1. Extensive parenchymal abnormalities seen as areas of ground
glass, some
degree of septal thickening and more solid areas of
consolidation.
Differential diagnosis would include widespread infection,
severe
hypersensitivity reaction, ARDS and unlikely pulmonary edema.
Correlation
with bronchoscopy may be suggested. Sparing of lingula in full
part of right middle lobe is noted.
2. Thyroid enlargement, correlation with thyroid ultrasound is
recommended.
3. Left intramuscular fat-containing lesion most likely within
the left
deltoid muscle that giving its septation may represent either
septated lipoma or liposarcoma( much less likely) and should be
further followed.
BILAT LOWER EXT VEINS PORT Study Date of [**2129-8-18**] 3:58 PM
IMPRESSION:
1. No DVT in either the right or left lower extremity.
2. Borderline enlarge right inguinal lymph node, minimally
enlarged since
exam from one year prior. Recommend clinical correlation.
CT CHEST W/O CONTRAST Study Date of [**2129-8-23**] 9:22 AM
IMPRESSION: Marked interval improvement in overall lung aeration
compared to CT from five days prior. Persistent diffuse
pulmonary abnormality, now
primarily upper lobe in distribution, right greater than left.
The
differential diagnosis remains nonspecific and clinical
correlation is
recommended. Improving mediastinal adenopathy.
UNILAT UP EXT VEINS US RIGHT Study Date of [**2129-8-23**] 1:58 PM
IMPRESSION: Occlusive thrombus around the distal portion of the
basilic vein surrounding the PICC line. No other thrombosis
identified in right upper extremity including no deep venous
thrombosis.
Brief Hospital Course:
1. Hypoxia, Probable Pneumonia vs. Probable Interstitial Lung
Disease:
Patient admitted to the [**Hospital Unit Name 153**], on [**8-17**], w/ productive sputum,
fevers , leukocytosis, cough and marked shortness of breath with
desaturations to the 70s range on room air are all concerning
for PNA. CXR showed bilateral edema and cephalization. [**8-18**] CT
Chest showed extensive parenchymal abnormalities seen as areas
of ground glass, some degree of septal thickening and more solid
areas of consolidation. She was started on Vancomycin,
Levofloxacin and Aztreonam on [**8-18**]. Sputum Cx were
non-diagnostic as they were contaminated by oral flora, PCP (-),
respiratory virus serologies (-), urine legionella antigen (-).
Serologies for atypicals (mycoplasma, chlamydia) are pending, as
are autoimmune labs (Anti-neutrophil Cytoplasmic Antibody;
Anti-GBM; Anti-Nuclear Antibody Screen). Her O2 sats continued
to improve and she transitioned from NRB to 4L NC on [**8-21**]. She
has been afebrile throughout admission. Repeat Chest CT after
arriving on the floor showed interval improvement. Pulmonary
consultation was obtained, and the patient will follow up in
pulmonary clinic. She was changed to levofloxacin on discharge.
Smoking Cessation was advised, although the patient was not
interested.
2. Leukocytosis
- Patient presented w/ elevated WBC to 14.3 with left shift.
Likely secondary to PNA in setting of aforementioned symptoms of
cough, fevers, productive sputum and dyspnea. Cx results as
above. WBC trended down to normal by time of discharge.
3. Acute Diastolic CHF
EKG with prominent LVH. Longstanding HTN makes diastolic
dysfunction quite likely. Last TTE in [**2127**] showed LVEF >55% but
may have worsened systolic function and/or additional diastolic
CHF since that time. She had an elevated BNP in 4k range which
supports CHF exacerbation which was likely triggered by new PNA.
TTE done on [**8-18**] results are pending.
4. Type 2 Diabetes Uncontrolled:
Her ICU course has been complicated by both hypoglcemia and
hyperglycemia. She has a home insulin regimen of humalog and
Lantus. On ICU discharge, she was at 32 units of Lantus.
5. Chronic pancreatitis
Per multiple OMR GI notes she is noted to have idiopathic
chronic pancreatitis of unclear etiology after mutiple studies.
She is seen by Dr. [**Last Name (STitle) 3315**]. At current time her chronic
abdominal pain is near usual baseline and she has normal lipase
level. Enzyme replacement was as her home regimen.
6. Benign Hypertension
Patient initially had BPs in the 100s/50s w/o BP medication.
Once she was started on treatment for her PNA, her BP went up to
the 110s-120s/60s-70s. Her BP continue to trend up to SBP
180-190s, lisinopril was re-started on [**8-21**] and amlodipine on
[**8-22**].
7. Anemia of Chronic Disease
Chronic in nature. Her normal Hct range is 30-33. Hct was 29 on
[**8-22**].
8. Depression
Slightly flattened affect on exam. She denied any current
suicidal ideation/homicidal ideation. Per OMR notes, long
history of depressive symptoms. Stable at current time.
Medications on Admission:
Amlodipine 10 mg PO daily
Amylase-Lipase-Protease ( VIOKASE 16) - 935 mg (60,000
unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit) Tablet - 2 Tablet PO with meals
Atenolol-50 mg PO qdaily
Fentanyl-75 mcg/hour Patch 72 hr, apply 2 patchs q3days
Insulin [**Unit Number 7452**] - 40 units QHS
Insulin Lispro (Humalog)/ SSI PRN four times a day
Lisinopril - 40 mg PO qdaily
Omeprazole - 20 mg qdaily
Oxycodone-Acetominophen- 5 mg/325 mg Tablet - [**Hospital1 **] PRN
Prochlorperazine- 10 mg tablet - Q-6 hrs PRN for nausea
Colace -100 mg Capsule - [**Hospital1 **]
Discharge Medications:
1. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Insulin [**Hospital1 7452**] 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. Insulin Lispro 100 unit/mL Insulin Pen Sig: ASDIR Sliding
Scale Subcutaneous ASDIR.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain.
12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia
Probable Pneumonia
Probable Interstitial Lung Disease
Acute Diastolic CHF
Chronic Pancreatitis
Upper Extremity Line Thrombus
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with difficulty breathing,
nausea/vomitting, fever/chills, coughing up blood or chest pain.
You are being discharged on antibiotics, levofloxacin, which can
make your tendons weak while taking it. Do not engage in heavy
phsyical activity such as sports. Continue taking this even if
you feel better.
Followup Instructions:
Follow up in pulmonary clinic Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] [**2129-10-5**] at
4:00pm. Prior to this appointment go to Spirometry at [**Location (un) 8661**] 7
on [**2129-10-5**] at 3:30
|
[
"285.29",
"401.9",
"428.31",
"518.81",
"250.81",
"577.1",
"E879.8",
"486",
"530.81",
"428.0",
"311",
"996.74",
"E849.7",
"305.1",
"366.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"97.49"
] |
icd9pcs
|
[
[
[]
]
] |
18160, 18166
|
13279, 16368
|
324, 330
|
18342, 18348
|
4124, 13256
|
18721, 18959
|
3047, 3170
|
16992, 18137
|
18187, 18321
|
16394, 16969
|
18372, 18698
|
3210, 4105
|
1876, 2264
|
257, 286
|
358, 1857
|
2286, 2717
|
2733, 3031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,689
| 171,165
|
32149
|
Discharge summary
|
report
|
Admission Date: [**2140-11-5**] Discharge Date: [**2140-11-15**]
Date of Birth: [**2092-9-13**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 48 year old woman with ovarian cancer s/p hysterectomy
and now lower abdominal mass who was last seen well at 5 pm
today. She started having an occipital headache yesterday that
was a [**8-16**]. Today between 5.30 pm and 5.45 pm she noticed
sudden dizziness and left sided weakness. She was initially
taken to an outside hospital and then transferred here as a code
stroke. She reached here at 8.51 pm and code stroke was called
at the same time. Initial stroke scale was 6 (1 for LOC, 1
Partial gaze, 1 minor facial palsy, 1 drift of left arm, 2 some
antigravity effort of left leg, 1 mild to moderate dysarthria).
Give the concern that this could be a metastatic lesion with her
cancer history vs stroke, she was taken to MRI, and bilateral
cerebellar and left medulla stroke was found. On MRA, she had
occlusion of her left vertebral artery. For evaluation of
possible dissection, a CTA was performed, which did
not show any evidence of that.
With her chemotherapy, she has been feeling nauseated and unwell
with decreased appetite and fluid intake. She has otherwise not
had any fevers, cough, shortness of breath, chest pain, has
abdominal pain that is treated with narcotics, no dysuria.
Past Medical History:
Diagnosed with stage 3 ovarian cancer in [**2135**] with mass in the
lower abdomen that is being treated with chemotherapy. Her last
treatment was 3 days ago. She had a total hysterectomy at the
time of diagnosis with complications of hernia and wound
infection.
Social History:
Smokes several cigarettes per day and up to 1ppd for the past 30
years, no alcohol. Used to work for a customer service
department.
Family History:
Negative for stroke, seizures, DM, CAD, cancer.
Physical Exam:
Vitals: T AF BP 160/65 HR:85 RR 18 on RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Arousable by verbal stimulation but somnolent,
cooperative with exam.
Orientation: Oriented to person, place, and date.
Attention: Able to recite DOW backwards.
Language: Speech fluent with good comprehension and repetition.
Able to describe the cookie jar picture accurately. Moderate
dysarthria (more with gutteral sounds). No paraphasic errors. No
apraxia, no neglect. [**Location (un) **] intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.
III, IV, VI: Leftward gaze deviation but able to cross midline
and fully look over to the right, decreased upward gaze, intact
down gaze. At midline, the left eye is down and abducted.
V, VII: Left lower facial droop.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Difficult to fully assess strength. Left arm is at
least [**5-12**] and left leg at least [**4-11**]. Right arm and leg appears
to be full in strength.
Sensation: Could not test due to somnolence.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Left toe up, right toe down.
Coordination and gait deferred.
Brief Hospital Course:
Ms. [**Known lastname 805**] was admitted to the CCU for closer monitoring. Her
hospital course by problem is as follows:
Bilateral Cerebellar infarcts + L vert occlusion:
It was unclear if she had had a vertebral artery disection by
imaging. Initially she was treated with a heparin drip (goal
50-70) however her platelets continued to drop. The issue of her
thrombocytopenia was discussed with Hematology and the decision
was made to stop the heparin if the platelets dropped below
50,000. At that point she would also be transfused a 6 pack of
platelets. From hospital day 2 to 3, her platelets fell and the
above plan was enacted. She was then started on Aspirin EC 81mg
for secondary stroke prevention as well as 10 mg of
Atorvastatin.
Throughout her initial course, her BP was allowed to
autoregulate to 185 and DBP 90-105. She was also closely
monitored with neuro checks as she was at risk for edema and
obstructive hydrocephalus from blocking the 4th ventricle. TTE
on [**11-8**] was unremarkable, revealing EF of 55% and no evidence of
ASD or PFO by doppler or saline contrast. HbA1c was 6.1 with
total cholesterol of 161, HDL 28. Atorvastatin 10 mg po qhs was
continued due to potential antiatherothrombotic properties. Asa
81 mg po qd was started for secondary prevention.
HEME/ONC: Metastaic ovarian cancer to the liver. Pancytopenia
secondary to gemcitabine which she reportedly received around
[**11-3**]. Pt was neutropenic, which recovered on [**11-11**]. Pt to f/u
with outside oncologist, Dr. [**Last Name (STitle) 699**], when rehabilitation
completed. Dr. [**Last Name (STitle) 699**] was made aware, and will resume
chemotherapy after rehabilitation hospitalization completed.
PT) Pt evaluated pt and recommended discharge to rehab.
Proph) Pneumoboots=for DVT prophylaxis were used, and should be
continued until pt. is ambulatory.
FULL CODE
Medications on Admission:
Oxycodone and Oxycontin.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
CVA-Bilateral cerebellar infarcts and left vertebral artery
occlusion
Pancytopenia secondary to Gemcitibine
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to hospital for any acute loss of strength and change in
motor function, loss of sensation, vision change or other
suggestive signs of a stroke.
Followup Instructions:
Pt to f/u with outpt gyn oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**], at [**Hospital1 75214**], [**Doctor Last Name 410**] Center [**Telephone/Fax (1) 72212**]. Pt. will
need to schedule appointment for within one week of leaving the
[**Hospital **] Hospital.
|
[
"284.1",
"433.21",
"729.89",
"518.0",
"V58.69",
"V10.3",
"V58.66",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6152, 6222
|
3778, 5655
|
294, 300
|
6374, 6395
|
6595, 6900
|
2001, 2050
|
5730, 6129
|
6243, 6353
|
5681, 5707
|
6419, 6572
|
2065, 2423
|
234, 256
|
328, 1544
|
2857, 3755
|
2438, 2841
|
1567, 1834
|
1850, 1985
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,753
| 178,391
|
44576
|
Discharge summary
|
report
|
Admission Date: [**2129-4-5**] Discharge Date: [**2129-4-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p MVC right frontal SAH, left occipital SAH, RLE pain, abd
pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 95459**] is an 86 year old male who presented to [**Hospital1 18**] ED
s/p MVC in which he was the restrained passenger, his wife, Ms.
[**Known lastname 95459**] was the driver. On presentation he reported abdominal
pain. In addition he reported right sided headache and mild
nausea. He denied change in vision, dizziness, neck pain, and
upper extremity symptoms. He reported recent history of LBP and
RLE radiation to lateral thigh that was improving with PT. He
reported worsening of this thigh pain with new medial thigh
pain. He denied LE numbness/paresthesias. CT head revealed
small foci of subarachnoid hemorrhage in the right fronal
anterior. CT spine revealed no subluxation or fracture. No
acute intraabdominal pathology or injury was noted.
Past Medical History:
Aortic stenosis, DM, gout, LBP, hypercholesterolemia, colon
CA s/p colostomy
Social History:
Lives with wife [**Name (NI) **] [**Name (NI) 95459**]. No EtOH.
Family History:
Non-contributory
Physical Exam:
VS: 99.1 98.8 79 100/60 18 98RA
GA: alert and oriented x 3
HEENT: hematoma over right forhead, extraocular movements
intact, PERL
CVS: normal S1, S2, no murmurs
Resp: CTAB
[**Last Name (un) **]: soft, NT, ND
Ext: moves all 4 limbs spontaneously, right leg swelling, duplex
negative for DVT.
Pertinent Results:
[**2129-4-5**] 04:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-4-5**] 01:58PM LIPASE-41
[**2129-4-5**] 01:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2129-4-5**] 01:58PM WBC-5.3 RBC-4.13* HGB-13.1* HCT-37.8* MCV-91
MCH-31.7 MCHC-34.7 RDW-16.8*
[**2129-4-5**] 01:58PM PT-12.9 PTT-30.5 INR(PT)-1.1
[**2129-4-5**] 01:58PM PLT COUNT-120*
[**2129-4-5**] 01:55PM GLUCOSE-174* LACTATE-1.9 NA+-145 K+-4.0
CL--104 TCO2-29
Brief Hospital Course:
Mr. [**Known lastname 95459**] was admitted to the trauma service in the tSICU
for Q1hr neurological monitoring. His neurological exam remained
unchanged. Neurosurgery was consulted and recommended repeat
head CT. On HD#2 Mr.[**Known lastname 95459**] [**Last Name (Titles) 1834**] repeat CT head which
was unchanged from his previous CT head on HD#1 which showed two
small subarachnoid hemorrhages: right occipital and right
frontal. On HD#2 he was transferred to the floor. Serial neuro
exams and CT head imaging remained stable. He was assessed by
physical therapy who determined he would require continued
physical therapy. He was screened for rehabilitation center
placement. On HD#3 right leg swelling was note but duplex US
was negative for DVT. This swelling was attributed to trauma
acquired during his car accident. At discharge he was tolerating
a regular diet and ambulating with assistance. He will
follow-up with Dr. [**Last Name (STitle) 739**] in clinic with a repeat Head CT
prior to his appointment.
Medications on Admission:
Colchicine, metoprolol 5O', allopurinol 300', glypizide 10",
Januria 100', colace 100', tylenol prn, ASA 81', lorazepam
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone 5 mg Tablet Sig: One (1) 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. Januvia 100 mg Tablet Sig: One (1) Tablet PO daily ().
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
right frontal/right occipital hematoma, RLE trauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 17816**] [**Telephone/Fax (1) 88**] for f/u in 4weeks.
Follow-up CT head on [**2129-5-3**]. Please present to [**Hospital1 18**] [**Hospital Ward Name **] radiology for follow-up CT head.
Please call Trauma clinic @ [**Telephone/Fax (1) 2359**] for follow-up.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"424.1",
"V44.3",
"E849.5",
"401.9",
"851.86",
"E816.1",
"V10.05",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4136, 4230
|
2241, 3268
|
325, 332
|
4324, 4324
|
1680, 2218
|
6091, 6499
|
1336, 1354
|
3438, 4113
|
4251, 4303
|
3294, 3415
|
4475, 5456
|
1369, 1661
|
5488, 6068
|
219, 287
|
360, 1138
|
4339, 4451
|
1160, 1238
|
1254, 1320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,849
| 161,593
|
49485+59182
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-4-13**] Discharge Date: [**2112-3-21**]
Date of Birth: [**2090-7-7**] Sex: M
Service: MICU-[**Location (un) **] TEAM
CHIEF COMPLAINT: Shortness of breath and hypotension.
The patient initially was admitted to the [**Hospital6 7482**] on [**4-13**] for a history of worsening dyspnea and
was transferred to the Medical Intensive Care Unit on [**4-14**].
HISTORY OF PRESENT ILLNESS: This is a 49 year old male with
a history of severe pulmonary hypertension on Flolan,
scleroderma with CREST variety, transferred to the Medical
Intensive Care Unit for hypotension, blood pressure 68/5 and
worsening hypoxia. The patient states that for the last week
he has had increasing shortness of breath and cough with
yellow sputum and rare blood streaks. The patient improved
with three days of azithromycin and reportedly was compliant
with medications and diet. The patient went from walking
around the apartment to being only able to ambulate for a few
feet.
The patient was admitted [**4-13**] to the Medicine Floor. In the
Emergency Room, the patient had a saturation of 100% on four
liters and received empiric Levaquin, Lasix 40 to 80, Bumex,
Spironolactone, Diltiazem. The patient continued on Levaquin
in-house. A pulmonary and hypertension doctor [**First Name (Titles) **] [**Last Name (Titles) 4221**]
and recommended intravenous antibiotics, gentle diuresis and
decreasing the Flolan rate to 23. The Congestive heart
failure Service was also [**Last Name (Titles) 4221**] who agreed with the plan.
Earlier on the day prior to transfer, the patient had an
episode of increasing respiratory rate to the 40s and
tachypnea, shortness of breath, and decrease in his systolic
blood pressure to the 90s on 100% non-rebreather, which
improved his respiratory rate to 30. Ativan and Lasix were
given. The patient now had an increasing oxygen requirement
and desaturating to 71 to 80 on six liters and blood pressure
of 78/48 with respiratory rate in the 30s. On nonrebreather,
the patient had a saturation to 90%. The patient originally
slightly lightheaded but resolved after 250 cc normal bolus
with a gas of 7.47, 37, and 118 on 100% non-rebreather.
The patient currently reports intermittent shortness of
breath worse with exertion, nausea and left axillary pain.
The patient denies recent fevers, chills, night sweats, head
trauma, head congestion, sick contacts, sore throat, chest
pain, left arm pain, abdominal pain, bloody stool. The
patient has baseline three pillow orthopnea and now feels
that he could not lay back more than head around 60 degrees
due to his dyspnea. The patient also says baseline systolic
blood pressure is 110.
PAST MEDICAL HISTORY:
1. Scleroderma of the CREST variety.
2. Severe pulmonary hypertension on Flolan and home O2 of
approximately four liters. As noted, Flolan was increased
from 23 to 25 as an outpatient two days prior to admission
and he has been on it for one year.
3. Bilateral pleural effusions status post thoracentesis in
[**2139-12-21**] that was non-malignant.
4. Congestive heart failure with diastolic dysfunction.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. History of Staphylococcus aureus bacteremia.
8. History of low potassium and low calcium.
9. History of chest wall cellulitis.
ALLERGIES: Morphine, percocet, codeine, causing itchiness
and rash and Viagra causing headaches.
MEDICATIONS ON ADMISSION:
1. Diltiazem 120 XR q. p.m.
2. Lisinopril 2.5 q. day, discontinued on [**4-14**].
3. Fluoxetine 20 mg p.o. q. day.
4. Coumadin 1 mg p.o. q. day.
5. Flolan 25 nanograms per kg per minute to 23 nanograms per
kg per minute.
6. Protonix.
7. Digoxin 0.125 p.o. q. day.
8. Spironolactone 25 p.o. q. day.
9. Potassium chloride.
10. Metolazone 2.5 mg q. Monday.
11. Bumetanide 4 mg p.o. twice a day.
12. Levaquin 500 mg q. 24.
13. Ativan p.r.n.
14. Tylenol p.r.n.
15. Imodium p.r.n.
16. Ambien p.r.n.
17. Albuterol p.r.n.
18. Zofran p.r.n.
SOCIAL HISTORY: Lives alone in an apartment where his sister
lives above. The patient denies tobacco history or alcohol
history.
PHYSICAL EXAMINATION: Temperature 98.1 F.; blood pressure
72/53 with a MAP of 57; heart rate of 105; oxygen saturation
98% on seven liters nasal cannula. In general, the patient
appropriately answered questions but is in very mild
respiratory distress. HEENT: Pupils equally round and
reactive to light. Extraocular muscles are intact. Mucous
membranes were moist. Neck with jugular venous pressure
approximately 11 cm; no lymphadenopathy. Cardiovascular:
regular rate and rhythm, tachycardia, no murmurs, rubs or
gallops. Possible S4. Lungs: Right greater than left
crackles approximately half way on the right base. Left
axilla tender to palpation with reproducible pain. Abdomen:
Hickman line on the right chest dry with dressings; clean,
dry and intact. Positive abdominal bowel sounds. Mild
tenderness in the epigastrium; otherwise soft without masses.
Extremities are warm; no lower extremity edema. Tight skin
of skin and fingers, and question toes. Pink nodules on the
shin.
LABORATORY: Data is CK of 37, troponin less than 0.1, white
blood cell count of 9.0, hematocrit 30.0, platelets 194, zero
bands. INR is 1.2, potassium 3.5, creatinine 1.7. Lactate
1.2 with a gas of 7.47, 37, 118, on 100% non-rebreather.
EKG is sinus tachycardia to 102, low voltage, poor R wave
progression.
Chest x-ray with small right effusion, right interstitial
opacity greater than left.
Right heart catheterization on [**2140-2-4**], revealed an
RA-pressure of 86, RV of 67/8, PA of 67/22; a wedge pressure
of 11, cardiac output of 5.7 and 3.1 for the index and a PVR
421.
An echocardiogram is ejection fraction of greater than 60%,
left atrium mildly dilated, left ventricular cavity wall,
right ventricle moderately dilated, moderate global RV free
wall hypokinesis. Abnormal septal motion consistent with RV
volume overload. Trace aortic regurgitation, trace mitral
regurgitation, one plus tricuspid regurgitation, moderate
pericardial effusion, no signs of tamponade. Brief right
atrium collapse.
Pulmonary function tests on [**2139-2-19**], FVC of 51% of
predicted, 2.32; FEV1 2.06, 61% of predicted; FEV1 to FVC
ratio is 89 or 119% of predicted.
Cytology from a tap in [**2139-11-21**], cytology is negative
for malignant cells.
HOSPITAL COURSE:
1. HYPOTENSION: The patient was likely hypotensive after
significant diuresis prior to the day of admission and
worsening volume status. Initially concern for septic shock,
however, the patient was afebrile and did not have any blood
cultures.
The patient's systolic blood pressure and symptoms of
dizziness responded to a small bolus, making hypovolemia the
more likely etiology. Other etiologies included cardiac and
distributive shock, however, the patient subsequently
underwent placement of a Swan-Ganz catheter placement for
evaluation of his cardiac function, which was placed on [**2140-4-20**], which subsequently revealed elevated PA pressures
with a systolic in the 90s and a wedge pressure of 14. It
was unlikely thought that this patient was in congestive
heart failure but was likely thought to have progressing of
his pulmonary hypertension.
2. HYPOXIA: The patient also presented with worsening
hypoxia. Differential included worsening progressive disease
of severe pulmonary hypertension as well as pneumonia from a
chest x-ray which showed right opacity for which the patient
was treated with a course of Levaquin. Other etiologies
included a pulmonary embolism; LENIs were performed which
were negative and concern for an in situ pulmonary embolism
was high given the patient's current medical condition. The
patient was subsequently treated with a heparin drip;
however, this was complicated by a decrease in his platelets
and thrombocytopenia. Heparin was stopped in favor of
Argrotaban and a HIT antibody was sent which is pending at
this time.
The patient's course was subsequently complicated by episode
of worsening hemoptysis, at which point anti-coagulation was
discontinued given the patient's risk for bleeding and an INR
of 1.8.
Other etiologies for his hypoxia included possible congestive
heart failure and volume overload given his volume
resuscitation, however, his Swan numbers did not reveal any
evidence of this. The Congestive heart failure Team was
involved in the care of this patient and recommended no
diuresis at this time.
Other etiologies included interstitial lung disease due to
scleroderma. The patient's rheumatologist, Dr. [**Last Name (STitle) **],
was [**Last Name (STitle) 4221**] regarding management of this patient and
recommended a course of Solu-Medrol times three days for
interstitial disease and the patient received those doses
which transitioned to p.o. Prednisone after the course.
However, despite these aggressive measures, the patient
continued to be hypoxic. Dr. [**Last Name (STitle) **], the patient's primary
pulmonologist was involved in the care of this patient. The
patient's Flolan was subsequently increased while measuring
his cardiac output index and subsequently he was found to
have a tolerable dose at 31, limited by symptoms. The
patient's Viagra was also started at around the clock dosing
of q. four hours with subsequently improvement of his
pulmonary pressures, however, the patient continued to have
worsening hypoxia to the point where on [**4-23**], the patient
was subsequently intubated after worsening respiratory status
despite maximal noninvasive or positive pressure ventilation
with CPAP. The patient was intubated using etomidate and had
significant complications with hypotension upon intubation
given the hypotensive effects of sedatives.
The patient was subsequently transitioned to propofol as a
sedative and vented on A/C. This was also complicated by
rising PA pressures and decreased systemic hypotension likely
due to septal deviation of the right ventricular free wall
into the left ventricle, decreasing the left ventricular
outflow. The patient subsequently required the addition of
Levophed as a pressor to improve systemic cardiac output as
well as maintaining renal perfusion and preventing shock.
At the time of the dictation, the patient was still currently
intubated and ventilated on A/C.
3. ACUTE RENAL FAILURE: The patient presented with an
elevated creatinine on the day of admission which was likely
thought to be due to hyperperfusion and prerenal azotemia
with improvement of his cardiac output. The patient's
creatinine improved to 1.3 at the time of this dictation.
The goal was to maintain a MAP of greater than 65% while on
Levophed to improve renal perfusion.
4. ANEMIA: The patient had a stable hematocrit, however,
had an episode of acute bleed and hemoptysis which dropped
his hematocrit to 26. The patient was transfused two units
of packed red blood cells initially with improvement of his
hematocrit. When the patient was initially admitted, the
patient was thought to subsequently benefit from the pressure
of blood and this was initially given, however, the patient
subsequently had some worsening shortness of breath with the
second transfusion and was likely discontinued.
5. HEMATOLOGIC: The patient had an episode of
thrombocytopenia thought to be due to and related to heparin
infusion. HIT antibodies were sent and are still pending at
this time.
6. PROPHYLAXIS: The patient was maintained on Pneumoboots
and Protonix for GI prophylaxis. No anti-coagulation was
given due to his thrombocytopenia.
7. PSYCHIATRIC: The patient has a significant anxiety
component which worsened his shortness of breath. The
patient was initially sedated using ativan which improved
some of his tachypnea. Once intubated, the patient was
subsequently sedated using Propofol and versed.
8. ACCESS: The patient had a left Swan placed for the
management of his hypotension and pulmonary artery
hypertension.
9. CODE STATUS: Full. The patient is to be maintained as a
full code.
The remainder of the hospital course and discharge
information will be dictated by the next team covering for
this patient.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2140-4-24**] 15:56
T: [**2140-4-24**] 16:19
JOB#: [**Job Number 103543**]
Name: [**Known lastname 16777**], [**Known firstname **]
Unit No: [**Numeric Identifier 16778**]
Admission Date: [**2140-4-13**] Discharge Date: [**2140-4-26**]
Date of Birth: Sex:
Service:
ADDENDUM: The patient was a 49-year-old male on the MICU
[**Location (un) 289**] team. I took over the care of this patient on [**2140-4-25**].
Briefly, this was a 49-year-old male with a history of severe
pulmonary hypertension and scleroderma of the Crest type
admitted with increasing dyspnea attributed to progressive
pulmonary hypertension. As stated prior, this patient had
experienced worsening dyspnea requiring intubation on AC
ventilation with ongoing hypotension.
On the night prior to transfer of care, he had been diuresed
800 cc and had spiked a fever to 101.8. His Swan line had
been removed and the tip sent for culture. A femoral access
line was placed, and blood cultures were drawn. In addition,
the patient was started on ceftazidime and vancomycin.
A CT of the chest was obtained and revealed improving
pulmonary edema with a persistent bilateral infiltrate with a
differential diagnosis including pulmonary hemorrhage,
atypical infection, pulmonary venal occlusive
disease/pulmonary capillary hemangiomatosis. In addition,
note was made of small peripheral wedge opacifications in the
right lower lobe consistent with a possible small PE versus
vasculitis. In addition, the patient had bilateral pleural
effusions and a pericardial effusion.
Unfortunately, the patient's hypotension limited our ability
for continued diuresis. In addition, the patient was
exhibiting ongoing pulmonary deterioration requiring
increasing positive end-expiratory pressures which
exacerbated his hypotension. He developed worsening renal
failure with subsequent acidosis.
A Swan line was re-placed on [**2140-4-25**]. PA pressure was
84/49 with a mean of 59. Pulmonary capillary wedge pressure
was noted to be 34. The patient underwent a bronchoscopy for
BAL. Gram stain was consistent with 1 plus PML's, yeast; but
otherwise oropharyngeal flora. Viral and bacterial cultures
were negative.
A KUB was obtained and revealed a gaseous abdomen with no
dilated loops. The patient was continued on supportive care.
However, on the morning of [**2140-4-26**] the patient was
noted to be hypotensive and bradycardic, followed by a PEA
arrest run by the Pulmonary Critical Care fellow. The
patient was administered 0.5 mg of epinephrine followed by 1
mg of epinephrine and converted into asystolic arrest. An
additional 1 mg of epinephrine was administered followed by
chest compressions; however, no heart rate or blood pressure
was obtained. The patient was declared dead at the time of
12:16 p.m. on [**2140-4-26**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 781**], [**MD Number(1) 782**]
Dictated By:[**Last Name (NamePattern1) 5234**]
MEDQUIST36
D: [**2140-8-28**] 13:30:44
T: [**2140-8-28**] 13:54:51
Job#: [**Job Number 16779**]
|
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"486",
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icd9cm
|
[
[
[]
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[
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"93.90",
"00.13",
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"33.23",
"38.93",
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icd9pcs
|
[
[
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3448, 3990
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6394, 15451
|
4145, 6377
|
180, 401
|
430, 2702
|
2724, 3422
|
4007, 4122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,316
| 135,378
|
34258
|
Discharge summary
|
report
|
Admission Date: [**2141-5-31**] Discharge Date: [**2141-6-23**]
Date of Birth: [**2085-2-5**] Sex: F
Service: NEUROLOGY
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
weakness, diplopia, SOB and swallow
difficulties.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname 78877**] is a 56 year-old right handed woman with significant
hx of MuSK Ab positive MG here with progressive weakness,
respiratory trouble as well as swallow difficulties concerning
for MG exacerbation. Patient has been in the prednisone wean
process for the past few month in order to prepare for her
planned surgery to correct the cystocele and plastic correction
of the scars in the neck. She reported that 2 weeks ago her
chronic prednisone regimen was adjust from 12.5mg to 10mg daily.
Since then she developed progressive weakness, mostly in the
proximal upper extremities. Difficulties on breathing with
heaviness sensation on her chest. The shortness of the breath
were noticed with minimun effort. In addition she also has
experienced swallow difficulties for the past 3 days. She called
Dr[**Name (NI) 78878**] office on [**5-26**] and [**5-29**] and the dose was
increased slowly up to 20mg daily, from the 10mg dose. She
continue to have the symptoms and they seemed to progress. Today
patient also reported diplopia with lateral gaze to the right
side.
Of note, last IVIG treatment was in [**Month (only) 958**]/[**2140**], and according to
the patien, it hasn't helped in controlling her disease.
ROS:
The pt reported a right sided hemicrania headache this morning
which has resolved with analgesics. Patient denied loss of
vision, blurred vision, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denied difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention. The pt denied recent fever or chills. Denied chest
pain or palpitations. Denied nausea, vomiting, constipation or
abdominal pain. She tends to have loose stools. No recent change
in bowel or bladder habits. No dysuria.
Past Medical History:
1. Myasthenia [**Last Name (un) 2902**] - MuSK Ab+, initial symptoms (dyspnea,
diplopia, neck weakness) in [**2139-1-23**]. Transferred to
[**Hospital1 18**] ICU in [**2139-4-23**] in myasthenic crisis. Underwent IVIg
(at [**Hospital6 2561**] prior to transfer) then plasmapheresis
at
that time, also started on prednisone and CellCept. Due to
difficulty to wean, she also underwent tracheostomy and
placement
of a PEG
tube at that time.
2. Tracheobronchomalacia status post tracheal stent in [**2139-4-23**] - since replaced then removed.
3. GERD and hiatal hernia.
4. History of nephrolithiasis.
5. Anxiety.
6. Status post partial hysterectomy.
7. Status post bladder suspension at age 29.
8. Cystocele.
9. DM - prednisone induced, treating with insulin.
Social History:
Lives with son with whom she has had problems- does not work but
was a former case manager.
No tobacco, EtOH or illicit drug use.
Family History:
No FH of MG - multiple members with DM.
Physical Exam:
Vitals: T: 97F P: 95 R: 16 BP: 115/77mmHg SaO2: 98%
VC 600 NIF -32. Deep breath following by counting, she reached
21.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,VI: EOMI, fatigue ptosis L>R. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength decreased/symmetrically,
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-26**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus. No
pronator drift. Dreased strength in neck extension and preserved
in neck flexion
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 4- 5 5 5 5 5 5
R 4- 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 3 3 3 4 4 Flexor
R 3 3 3 4 4 Flexor
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: not tested.
Pertinent Results:
[**2141-6-2**] 12:02AM BLOOD WBC-3.9*# RBC-3.88* Hgb-11.7* Hct-37.1
MCV-96 MCH-30.2 MCHC-31.6 RDW-18.8* Plt Ct-273
[**2141-6-1**] 01:47AM BLOOD WBC-8.7 RBC-3.91* Hgb-11.8* Hct-37.5
MCV-96 MCH-30.2 MCHC-31.4 RDW-18.8* Plt Ct-307
[**2141-5-31**] 02:30PM BLOOD WBC-5.8 RBC-4.13* Hgb-12.4 Hct-39.0
MCV-94 MCH-29.9 MCHC-31.7 RDW-18.5* Plt Ct-356
[**2141-5-31**] 02:30PM BLOOD Neuts-83.2* Lymphs-13.2* Monos-2.8
Eos-0.7 Baso-0.1
[**2141-6-1**] 01:47AM BLOOD Glucose-181* UreaN-15 Creat-0.6 Na-137
K-3.4 Cl-95* HCO3-37* AnGap-8
[**2141-6-1**] 01:47AM BLOOD ALT-49* AST-52* AlkPhos-76 TotBili-1.3
[**2141-5-31**] 02:30PM BLOOD ALT-48* AST-57* LD(LDH)-261* AlkPhos-78
TotBili-0.9
[**2141-6-1**] 01:47AM BLOOD GGT-30
[**2141-5-31**] 02:30PM BLOOD Lipase-43 GGT-30
[**2141-6-2**] 12:02AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2141-6-1**] 01:47AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.5 Mg-1.7
[**2141-5-31**] 02:30PM BLOOD Albumin-4.4
[**2141-6-2**] 02:24PM BLOOD Type-ART Temp-36.4 pO2-130* pCO2-67*
pH-7.37 calTCO2-40* Base XS-10 Intubat-NOT INTUBA
[**2141-6-2**] 06:16AM BLOOD Type-ART pO2-82* pCO2-69* pH-7.36
calTCO2-41* Base XS-9 Intubat-NOT INTUBA
[**2141-6-1**] 10:16PM BLOOD Type-ART Temp-36.7 pO2-86 pCO2-65*
pH-7.34* calTCO2-37* Base XS-6 Intubat-NOT INTUBA
[**2141-6-1**] 04:23PM BLOOD Type-ART pO2-69* pCO2-62* pH-7.37
calTCO2-37* Base XS-7 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2141-6-1**] 02:33PM BLOOD Type-ART pO2-110* pCO2-81* pH-7.32*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2141-6-1**] 01:55AM BLOOD Type-ART pO2-79* pCO2-68* pH-7.35
calTCO2-39* Base XS-8
[**2141-6-2**] 06:16AM BLOOD O2 Sat-95
[**2141-6-1**] 10:16PM BLOOD O2 Sat-96
[**2141-5-31**] 02:30PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.024
[**2141-5-31**] 02:30PM URINE Blood-SM Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
CXR [**2141-5-31**]
IMPRESSION:
1. Minimal increase in the right lung base opacity which most
likely
represents atelectasis; however, infectious process such as
pneumonia cannot
be completely excluded in the correct clinical setting.
2. Unchanged bilateral trace pleural effusions.
3. Stable appearance of right Port-A-Cath.
Video swallow eval [**2141-6-6**]
IMPRESSION: Mild oropharyngeal dysphagia, without evidence for
penetration or aspiration.
TTE [**2141-6-8**]
The left atrium is normal in size. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses and cavity size
are normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve 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.
Compared with the prior study (images reviewed) of [**2140-2-3**],
the findings are similar.
CT abdomen/pelvis [**2141-6-14**]
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Resolution of obstructing left distal ureteric stone since
[**2141-2-20**].
3. Non-obstructing bilateral sub-2-mm renal calculi.
[**6-20**]; HCT 27.3, platelets 257
Brief Hospital Course:
Ms. [**Known lastname 7518**] was admitted with shortness of breath, proximal
muscle weakness, and dysphagia, thought to be consistent with
myasthenia [**Last Name (un) 2902**] exacerbation, likely secondary to her recent
wean of prednisone as an outpatient. Due to concerns for
respiratory status, she was admitted to the neurological ICU for
close observation.
.
Neuro
She underwent frequent neuro checks for keeping an eye on
progression of symptoms of myasthenia. She did not have any
cholinergic symptoms , thus excluding cholenergic crisis as
possible cause. She was continued on outpatient doses of
prednisone and azothioprine. She was started on IVIG in dose of
2 gm/kg, divided over 4 days. She showed mild subjective as well
as objective improvement in strength after initiation of IVIG,
but her respiratory status remained tenuous. After this, she
completed a three day course of high-dose steroids
(methylprednisolone 1000 mg daily) without significant change in
examination. After this, her daily prednisone dose was
increased to 60 mg and she underwent five courses of
plasmapheresis. During this time she had a slow but steady
improvement in her respiratory function and strength. Her
diplopia resolved, neck flexors and extensors as well as
proximal muscles improved to 4+/5. Her NIF and VC improved
significantly (-80 and 1.2 L at time of discharge).
.
Resp
She underwent initially Q2H, monitering of mechanics including
NIF and VC. After staring IVIg she steadily showed improvement
from values as low as -30 /650 to -80 / 1.4 L. The apparently
low values disproportionate to clinical status were though to be
result of tracheomalacia. She underwent A line for checking
ABGs. She transiently required BiPAP during sleep due to
tachypnea and rising pCO2. She did not require intubation
during the hospital course and had been doing well on room air
at the time of discharge, and able to count to 40 in one breath.
.
Cards
She was constantly monitered on telemetry. She was noted to have
atrial fibrilation during the hospital stay on [**6-6**] night. This
was preceded by placement of a central line which was thought to
have possibly provoked the incident. She was evaluated by
cardiology, was started on IV amiodarone and IV heparin was
started. She converted back to sinus within 24 hrs. Amiodarone
was switched to PO in dose of 400 mg [**Hospital1 **] and was advised to
switch to 200 mg daiy after a period of 2 weeks. She underwent
TTE which showed EF of 30-35 percent. In view of DM, and CHF,
she was continued on heparin with goal PTT 50-70. She was
started on coumadin once plasmapheresis was completed with goal
INR [**1-25**]. As she had been chemically cardioverted,
anticoagulation for at least one month was recommended by
cardiology. She was monitored on telemetry throughout the
hospitalization and was in normal sinus rhythm from [**6-8**] through
time of discharge ([**6-20**]). On [**2141-6-23**] INR was 1.3. Patient will
have outpatient follow up in [**Hospital 197**] clinic on [**2141-6-27**].
Hematology
The patient developed a slow drift in all cell lines (WBC,
hematocrit, and platelets) during the hospital course. As her
platelets dropped to a nadir of 130 while on heparin, HIT
antibody was checked and was negative. Her hematocrit dropped
to a nadir of 22.5 and the patient had multiple ecchymoses
throughout her body. Hemolysis labs were unremarkable and stool
guaiacs were negative. CT abdomen and pelvis showed no evidence
of retroperitoneal hematoma. It was thought the pancytopenia
may have been a late result of her IVIG infusions earlier in the
hospital course. She received a total of 2 units pRBCs due to
presumed symptomatic anemia (lightheadedness on standing), and
hematocrit remained stable after transfusion (27-30) at the time
of discharge.
.
Vascular
The patient was found to have a left thigh ecchymosis on [**6-20**] PM
as well as bilateral foot edema, L>R. Concern was highest for
hematoma due to recent removal of left femoral central line the
day prior, although DVT was also considered. A LLE ultrasound
is currently pending. The patient's hematocrit has been stable
and is continuing to be monitored.
.
ID
The patient remained afebrile throughout her hospital course.
At time of admission, routine infectious workup was negative.
During the hospital course the patient was found to have a
urinary tract infection, with urine Cx [**6-15**] growing klebsiella
pneumonia. She completed a seven-day course of ciprofloxacin.
On [**6-17**], she was found to have small sores in her mouth, similar
to prior HSV infections. She was started on a 5-day course of
acyclovir.
.
Endocrine
The patient was noted to have elevated fingersticks, ranging
from low 100s to low 300s. This was thought to be secondary to
her increased steroid doses. Her lantus was gradually increased
up to 35 units daily and regular insulin sliding scale was used
for coverage during the day.
Medications on Admission:
1. Azathioprine 100mg [**Hospital1 **]
2. Alendronate 70 mg PO QSUN (every Sunday).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual four times a day as needed for
with mestinon.
5. Pyridostigmine Bromide 60 mg PO Q6H (every 6 hours).
6. Ranitidine HCl 150 mg PO HS (at bedtime).
7. Paroxetine HCl 20 mg PO HS (at bedtime).
8. Prednisone currently 20 mg PO DAILY
9. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day) as needed for to
manage secretions.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
12. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous qAM.
13. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO QHS (once a day (at bedtime)).
7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q6H (every 6 hours).
8. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust as needed for goal INR [**1-25**].
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Please check INR two times weekly for goal INR [**1-25**].
16. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
units Subcutaneous at bedtime.
17. Insulin Lispro 100 unit/mL Cartridge Sig: 2-10 units
Subcutaneous three times a day: Sliding scale with meals as
directed.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Myasthenia [**Last Name (un) **]
Atrial Fibrillation
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and weakness,
consistent with exacerbation of myasthenia [**Last Name (un) 2902**]. You
underwent treatment with IVIG, high-dose steroids, and
plasmapheresis, with good clinical response. You were continued
on your home dose of mestinon and azathioprine. Your prednisone
was increased to 60 mg daily and you should remain on this dose
until you follow up with Dr. [**Last Name (STitle) 557**] in four weeks. You also
developed atrial fibrillation and were treated with heparin and
amiodarone for this. You will need to continue anticoagulation
until you follow up with your cardiologist as an outpatient, and
further management can be discussed at that time. You were also
treated with acyclovir for lesions in your mouth and with an
antibiotic for a urinary tract infection. Also, your lantus
dose was increased as your finger sticks have been running high.
This is likely due to your higher dose of steroids.
Followup Instructions:
An appointment has been made for you with Dr. [**Last Name (STitle) 557**] on
Wednesday, [**7-12**] at 2 PM. His office can be reached at ([**Telephone/Fax (1) 36648**] with any questions or concerns.
Also, please continue coumadin as prescribed due to the
irregular heart rhythm (atrial fibrillation) which you had
during the hospitalization. An appointment has been scheduled
for you with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-28**] at 1:20 PM at [**Hospital1 18**]
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) 436**]. You may discuss with
him if you should continue on anticoagulation after this
appointment.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 9466**] [**Name (STitle) **] within one week of
discharge. Her office can be reached at ([**Telephone/Fax (1) 1300**]. Please
have your INR checked at that time.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2141-6-27**] 9:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-7-11**] 8:15
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2141-7-11**] 9:00
Completed by:[**2141-6-23**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.71"
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icd9pcs
|
[
[
[]
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|
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335, 341
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16251, 16251
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,271
| 170,516
|
19080
|
Discharge summary
|
report
|
Admission Date: [**2132-7-23**] Discharge Date: [**2132-8-8**]
Date of Birth: [**2073-2-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
Increasing abdominal distension and hyponatremia
Major Surgical or Invasive Procedure:
Paracentesis x3
History of Present Illness:
Mr. [**Known lastname **] is a 59 year old man with a history of alcoholic
cirrhosis who presents one week following hospital discharge
with increasing abdominal distension and hyponatremia in the
setting of medication noncompliance and active alcohol abuse.
Of note, he was admitted to [**Hospital1 18**] from [**Date range (1) 52084**] on the liver
service for increasing ascites and underwent a 10 L therapeutic
paracentesis on that admission; he was discharged with
prescriptions for new diuretic doses but never filled these; his
sodium was 129 on discharge. Also of note, on a prior admission
earlier in [**6-/2132**]/[**2131**] his sodium was as low as 110 which
responded to fluid restriction.
He reports that he hasn??????t been taking any of his medications for
the past few days and his abdomen has been growing in girth. He
reports compliance with sodium and fluid restriction, and
reports that he did drink 2-3 beers with his brother about 24
hours prior to admission. By report, he wouldn??????t let VNA into
his house on the day of admission and so she alerted EMS.
In the ED, he was afebrile, BP 100/69, HR 96, Sat 99% on room
air. He was given 1000 cc of normal saline and admitted to the
MICU for hyponatremia.
Past Medical History:
ETOH cirrhosis, h/o SBP, recurrent ascites
Anemia
H/O hepatitis A
Social History:
Actively drinking; drank 2-3 beers on day prior to admission.
Denies IVDU or smoking. From rehab ([**Hospital1 **]), no family,
originally from [**Country 7192**]
Family History:
Non-contributory
Physical Exam:
Admission PE:
General Appearance: cachectic, chronically-ill-appearing
Eyes / Conjunctiva: scleral icterus
Neck: no lymphadenopathy, supple, JVP 7 cm
Chest: poor lung expansion; no wheezes, rales, or ronchi
CV: regular rate/rhythm, nl S1S2, II/VI systolic murmur
Abdomen: tensely distended with ascites; (+) caput; nontender;
normal bowel sounds; no HSM
Extremities: 3+ edema, 1+ PT pulses
Skin: no rash; marked jaundice
Neurologic: Alert, oriented x3, CN 2-12 intact, no asterixis
Pertinent Results:
[**2132-7-23**] 03:05PM PT-14.8* PTT-25.9 INR(PT)-1.3*
[**2132-7-23**] 03:05PM WBC-7.0 RBC-3.97* HGB-13.3* HCT-38.4* MCV-97
MCH-33.5* MCHC-34.6 RDW-16.9*
[**2132-7-23**] 03:05PM ASA-NEG ETHANOL-139* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-7-23**] 03:05PM TOT PROT-7.6 ALBUMIN-3.9 GLOBULIN-3.7
CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.4
[**2132-7-23**] 03:05PM LIPASE-99*
[**2132-7-23**] 03:05PM ALT(SGPT)-82* AST(SGOT)-143* LD(LDH)-670* ALK
PHOS-677* TOT BILI-16.1*
[**2132-7-23**] 03:05PM GLUCOSE-96 UREA N-28* CREAT-1.0 SODIUM-116*
POTASSIUM-6.9* CHLORIDE-82* TOTAL CO2-19* ANION GAP-22*
[**2132-7-23**] 06:00PM AMMONIA-97*
[**2132-7-23**] 06:09PM NA+-121* K+-5.1
[**2132-7-23**] 09:37PM PT-14.7* PTT-25.2 INR(PT)-1.3*
[**2132-7-23**] 09:37PM PLT COUNT-144*
[**2132-7-23**] 09:37PM WBC-6.8 RBC-4.09* HGB-14.1 HCT-40.4 MCV-99*
MCH-34.4* MCHC-34.8 RDW-17.0*
[**2132-7-23**] 09:37PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2132-7-23**] 09:37PM ALT(SGPT)-71* AST(SGOT)-88* LD(LDH)-296* ALK
PHOS-653* TOT BILI-17.5* DIR BILI-11.7* INDIR BIL-5.8
[**2132-7-23**] 09:37PM GLUCOSE-83 UREA N-26* CREAT-0.8 SODIUM-119*
POTASSIUM-5.7* CHLORIDE-86* TOTAL CO2-18* ANION GAP-21*
[**2132-7-30**] 06:35AM BLOOD HIV Ab-NEGATIVE
[**2132-8-8**] 06:30AM BLOOD WBC-6.6 RBC-2.35* Hgb-8.4* Hct-24.9*
MCV-106* MCH-35.7* MCHC-33.6 RDW-20.9* Plt Ct-46*
[**2132-8-8**] 06:30AM BLOOD PT-19.9* INR(PT)-1.9*
[**2132-8-8**] 06:30AM BLOOD Glucose-116* UreaN-108* Creat-5.2* Na-138
K-5.7* Cl-107 HCO3-12* AnGap-25*
[**2132-8-4**] 06:55AM BLOOD ALT-29 AST-33 LD(LDH)-177 AlkPhos-215*
TotBili-11.0*
[**2132-8-6**] 05:40AM BLOOD Mg-2.6
[**2132-7-24**] 02:54PM ASCITES WBC-2133* RBC-533* Polys-90* Lymphs-3*
Monos-7*
[**2132-7-28**] 03:36PM ASCITES WBC-3445* RBC-3375* Polys-96* Lymphs-3*
Monos-0 Basos-1*
[**2132-8-1**] 07:06PM ASCITES WBC-115* RBC-507* Polys-33* Lymphs-36*
Monos-20* Mesothe-3* Macroph-8*
[**2132-7-24**] 2:54 pm Ascites culture
Fluid Culture in Bottles (Final [**2132-8-5**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2132-7-28**] Ascites cx:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].
PRESUMPTIVE IDENTIFICATION PREFORMED ON CULTURE #
256-9817C
[**2132-7-24**].
[**2132-8-1**] Ascites cx:
Fluid Culture in Bottles (Final [**2132-8-7**]): NO GROWTH.
[**2132-7-29**] URINE CULTURE:
ENTEROCOCCUS FAECIUM. >100,000 ORGANISMS/ML..
Sensitivity testing performed by Sensititre.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>16 R =>32 R
LINEZOLID------------- 1 S 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- S =>16 R
VANCOMYCIN------------ =>128 R =>32 R
Blood cx ([**7-26**] x2, [**7-29**] x2): negative
Abdominal U/S ([**7-23**]):
IMPRESSION:
1. Cirrhotic liver, splenomegaly, and large amount of ascites.
2. While color Doppler flow was demonstrated within the main
portal vein,
wall-to-wall color flow is not seen, suggestive of partial
occlusion of the
main portal vein.
3. Sludge-filled gallbladder.
CXR ([**7-23**]):
There are marked low lung volumes unchanged from prior study.
Multifocal
subsegmental atelectasis in the left lung are also unchanged.
There is no
pneumothorax or pleural effusion. Cardiomediastinal contours are
normal.
There is no evidence of CHF.
CT abd/pelvis ([**7-25**]):
IMPRESSION: Small amount of layering hemoperitoneum within the
abdomen and
pelvis, left greater than right.
Renal U/S ([**7-31**]):
IMPRESSION:
1. No hydronephrosis on limited views of the kidneys.
2. Ascites.
TTE ([**8-1**]):
IMPRESSION: No vegetation or abscess seen. The study was limited
by patient deciding to prematurely end the study.
Brief Hospital Course:
1) SBP: Patient presented with medication noncompliance, active
alcohol abuse, and increasing abdominal girth. Large volume
(10L) paracentesis was performed on [**7-23**] with albumin given,
and showed E coli and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 10577**]. He was clinically stable,
with chronically low BP, so diuretics and nadolol were held. He
was given a 13d course of ceftriaxone and 11d course of
caspofungin (see ARF). Subsequent abdominal CT with small amount
of blood, but hematocrit stable. Repeat paracentesis on [**7-28**]
showed increased polys, no bacteria, yeast still present. His
blood pressure dropped to 64/42, but improved with fluid bolus,
albumin, midodrine, and octreotide. Paracentesis [**8-1**] with 4
liters removed showed improved cell count and negative culture.
All blood cultures were negative. Urine showed VRE, but was not
treated as he was asymptomatic and UA was unremarkable.
2) ARF: His creatinine has gradually increased from 1.2 to 5.2,
with low urine Na, no hydronephrosis. Due to this, his
caspofungin for SBP was stopped at day 11. He was given IVF and
albumin on multiple occasions and titrated up on midodrine and
octreotide with no improvement in renal function. This clinical
course is consistent with hepatorenal syndrome. As he will be
unable to receive octreotide at hospice, and his medications are
not improving his kidneys, his octreotide and midodrine were
held at discharge, as were his lasix and spironolactone.
3) Cirrhosis: Seceondary to alcohol abuse. He is not a
transplant candidate given his continued drinking. His cirrhosis
has been complicated by refractory ascites, coagulopathy, and
hyperbilirubinemia. He was continued on lactulose, and his other
medications were managed as discusssed above.
4) Hyponatremia: Most likely hypervolemic hyponatremia due to
fluid retention from his cirrhosis and diuretic noncompliance.
He was 116 on admission, and as been as low as 110 on prior
admissions. He was fluid restricted to 1.5L/day and his sodium
gradually returned to [**Location 213**] without complications.
5) Dispo: His other medical conditions were managed per his
outpatient regimen. Due to his poor prognosis and inability to
be considered for transplant, he will be discharged to hospice
for further care. The patient understands this plan and is
agreeable.
Medications on Admission:
(not taking any prescribed meds)
prescribed meds:
nadolol 20 mg daily
ciprofloxacin 250 mg daily
furosemide 40 mg daily
spironolactone 75 mg tid
lactulose 30 cc [**Hospital1 **]
omeprazole 20 mg daily
multivitamin
zinc sulfate 220 mg daily
ascorbic acid 500 mg [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 BMs daily.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stool.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for dry itchy skin.
7. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
9. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Lights
Discharge Diagnosis:
Primary: spontaneous bacterial peritonitis, hyponatremia
Secondary: end-stage liver disease, refractory ascites, anemia
Discharge Condition:
Alert and mentating well, hemodynamically stable.
Discharge Instructions:
You presented to [**Hospital1 18**] with increased size of your belly and low
blood sodium levels. We found an infection in the fluid in your
belly and started you on antibiotics. Your sodium and infection
seem to have improved, but your kidney function has been
worsening even with medical treatment, and is unlikely to
improve.
As we have discussed, you are being discharged to a hospice
facility that will handle your care and medications. Please take
your medications as prescribed. We have stopped your nadolol,
furosemide, and spironolactone since your blood pressures have
been too low.
If you experience any fevers, chills, abdominal pain, confusion,
or any other concerning symptoms, please seek medical attention
or come to the ER immediately.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name (STitle) 679**], at ([**Telephone/Fax (1) 52085**] for any concerns.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
Completed by:[**2132-8-9**]
|
[
"276.1",
"567.23",
"303.91",
"571.2",
"285.9",
"789.59",
"584.9",
"799.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10774, 10824
|
7262, 9625
|
363, 381
|
10988, 11040
|
2467, 7239
|
11844, 12136
|
1932, 1950
|
9954, 10751
|
10845, 10967
|
9651, 9931
|
11064, 11821
|
1965, 2448
|
275, 325
|
409, 1646
|
1668, 1735
|
1751, 1916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,961
| 105,397
|
10223
|
Discharge summary
|
report
|
Admission Date: [**2118-2-28**] Discharge Date: [**2118-3-3**]
Date of Birth: [**2037-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo man with CAD and carotid disease s/p stents, sCHF EF 45%
in [**1-17**], hypothyroidism presents for evaluation after having his
metoprolol dose increased. He was in his usual state of health
until 3 days PTA when he had an episode of full body shaking and
rapid breathing. The next day he went to his PCP who increased
his metoprolol dose and told him that it would be fine to take
the increased dose until his appointment with Dr. [**First Name (STitle) 437**] on [**3-2**].
However, because pt was anxious about increased dose of
metoprolol, he came to ED.
.
In triage, BP was in systolic 90s, which was attributed to the
recent BBKer increase. He then dropped his BP to systolic 60s,
no symptoms except darkening in his vision, unclear etiology,
and was given 1 liter IVF. He responded appropriately with
repeat BP 90/46 and HR in 70s. ECG was V-paced and without
changes. CXR in ER showed mild interval increase in bibasilar
effusions with persistent findings of mild congestive heart
failure. Patient was discussed with Dr. [**First Name (STitle) 437**] and who
recommended reducing metoprolol tartrate to 12.5 mg [**Hospital1 **]. The
patient was about to be admitted to the general medicine floor,
when his BP dropped again to systolic 80s. He was instead
admitted to the MICU for further investigation and management.
.
On arrival to the unit, the patient appeared comfortable. He had
no complaints. While in the unit, he received more fluid and his
bp remained stable (85-150)/(51-81). He was asymptomatic.
Infectious w/u was neg and he was transfered to the floor.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope
[**Last Name (NamePattern4) **]dical History:
CAD: s/p RCA and LAD intervention by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
[**9-/2112**], s/p proximal LAD Cypher stent placed by Dr. [**First Name (STitle) **] on
[**4-/2115**]
sCHF with EF 45% in [**2118-1-9**]
Complete heart block s/p PPM
s/p AV replacement with bioprosthetic valve and MV repair in
[**2111**] (Aortic valve replacement using #21 [**Last Name (un) 3843**]-[**Doctor Last Name **]
tissue
valve and mitral valve ring annuloplasty using #26 [**Last Name (un) 3843**]
ring by Dr. [**Last Name (Prefixes) **])
PVD- s/p R ICA stent by Dr. [**First Name (STitle) **] in [**9-/2112**]
Hypertension
Hyperlipidemia
Afib
Sick sinus syndrome s/p pacemaker in [**2111**]
Hypothyroidism
GERD
Non-Hodgkins Lymphoma [**2091**] s/p CHOP and radiation
BPH
COPD
Depression
Microscopic hematuria
Social History:
Lives by himself in [**Location (un) **]. Wife passed away 2 years ago.
Very lonely. Has one son, but not very close. No tobacco,
alcohol, or any Illicit drugs. Walk [**3-13**] miles daily, and tried
to live a healthy life. Moved here from Sicily in [**2068**]. Worked
in construction, food industry, tailoring.
Family History:
No family hx CAD, HTN, or DM
Physical Exam:
ICU Admission Exam:
Vitals: T: 97.6 BP:151/80 P:74 R:16 O2:100%
General: Alert, oriented, emotional
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP to the angle of mandible. No LAD
Chest: Linear mid-sternal scar; Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: RRR, II/VI SEM. Anterolaterally displaced PMI.
Abdomen: soft, NDNT, +BS
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
.
Floor Transfer Exam:
97.9 107/58 (85-150)/(50-80) 83 (50-83) 97% RA I/O: 1110/625
Gen: WDWN middle aged man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP of 14-16 cm.
CV: RRR, 3/6 systolic murmur. No m/r/g. No thrills, lifts. No S3
or S4.
Chest: Mild kyphosis. Resp were unlabored, no accessory muscle
use. Decreased breath sound at the bases, no crackles, wheezes
or rhonchi.
Abd: Soft, NTND.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, or xanthomas.
Pulses: Right: Carotid 2+ DP 1+ PT 1+; Left: Carotid 2+ DP 1+
PT 1+
Pertinent Results:
[**2118-2-28**] 05:03PM WBC-7.5 RBC-4.43* HGB-13.0* HCT-37.7* MCV-85
MCH-29.3 MCHC-34.4 RDW-15.0
[**2118-2-28**] 05:03PM NEUTS-81.4* LYMPHS-10.5* MONOS-6.4 EOS-1.4
BASOS-0.4
[**2118-2-28**] 05:03PM PLT COUNT-255
[**2118-2-28**] 05:03PM proBNP-2638*
[**2118-2-28**] 05:03PM GLUCOSE-104 UREA N-28* CREAT-1.3* SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2118-2-28**] 08:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2118-2-28**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
Blood cx ([**2118-2-28**], [**2118-3-1**]): neg
.
Imaging:
[**2-28**] Chest XRay: Mild interval increase in bibasalar effusions
with persistent findings of mild congestive heart failure.
[**2118-3-3**] 06:20AM BLOOD WBC-7.8 RBC-4.55* Hgb-12.9* Hct-38.7*
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.9 Plt Ct-236
[**2118-3-1**] 03:09AM BLOOD PT-15.1* PTT-33.4 INR(PT)-1.3*
[**2118-3-3**] 06:20AM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
[**2118-3-1**] 03:09AM BLOOD ALT-22 AST-26 LD(LDH)-198 CK(CPK)-44
AlkPhos-71 TotBili-0.8
[**2118-2-28**] 05:03PM BLOOD proBNP-2638*
[**2118-3-1**] 03:09AM BLOOD CK-MB-4 cTropnT-0.02*
[**2118-3-1**] 03:09AM BLOOD TSH-3.1
[**2118-3-2**] 06:30AM BLOOD Cortsol-11.2
Brief Hospital Course:
ICU Course:
Mr. [**Known lastname 34083**] is a 80 yo male with HTN, HL, SSS, hypothyroidism,
CAD s/p MI, here s/p rigors two days ago and transient
hypotension that responded to IVFs in the ED.
.
#.Hypotension: The patient presented with hypotension in setting
of recently doubling metoprolol dose, so this is likely
secondary to medication effect. His blood pressure was fluid
responsive. He reported subjective rigors 2 days prior to
presentation, but has no documented fevers, and no leukocytosis
or localizing symptoms to suggest infectious etiology. His
urinalysis was clear. CXR showed no focal consolidations
suggestive of PNA. Given the patient's level of anxiety, there
may be a strong psychiatric component to this hypertension that
led to an increase in his metoprolol dosage two days ago. All
antihypertensives and diuretics were held during ICU stay and
patient's BP stabilized. The patient had received 1 L normal
saline in the ED, and further boluses were held given his
history of CHF. His metoprolol was re-started at 12.5 mg po bid
w/ normalization of blood pressured prior to discharge.
.
#.CAD/CHF: The patient has an EF of 45% from an ECHO in [**1-/2118**],
secondary to ischemic cardiomyopathy. CXR on [**2-28**] showed
evidence of chronic mild CHF, and BNP was mildly elevated. ASA
and statin were continued, beta blocker and lasix were held
initially due to hypotension. Lasix was decreased from 20 mg po
qam and 10 mg po qafternoon to just the am dose.
.
#.Hypothyroidism: Levothyroxine was continued at home dose. TSH
was checked to rule out hypothyroidism as cause of hypotension,
and was normal at 3.1.
.
#.Chronic renal insufficiency. Cr ranged 1.2-1.6 during his last
admission in [**2118-1-9**], and was stable at 1.2. Medications were
renally dosed.
.
#. PAF: The pt has a h/o PAF but was in sinus rhythm during this
admission. No anticoagulation given his fall risk. Metoprolol
12.5 mg po bid re-started prior to discharge.
.
#. Dispo: We recommended that he have a VNA for blood pressure
monitoring and medication help but he refused this service. He
was evaluated by physical therapy and they deemed him to be
stable on his feet. As noted in the HPI, he walks [**3-13**] miles
daily.
Medications on Admission:
1. Aspirin 81 mg PO Qday
2. Atorvastatin 10 mg PO Qday
3. Clopidogrel 75 mg PO Qday
4. Levothyroxine 50 mcg PO Qday
5. Metoprolol Tartrate 25 mg PO BID
6. Lasix 20 mg QAM and 10 mg QHS
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension
Secondary:
Valvular heart disesae (s/p AVR, MV repair)
Complete heart block s/p pacemaker placement
Systolic heart failure (EF 45)
Coronary artery disease
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You came in with low blood pressure. You were given fluids and
your blood pressure medicine was stopped. Your blood pressure
improved and you had no symptoms.
We made the following changes to your medications:
- Metoprolol: we changed the dose of this medication for your
blood pressure.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please seek immediate medical attention if you have chest pain,
shortness of breath, light-headedness, palpitations, fever or
any other concerning symptoms.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. You can call
his office at [**Telephone/Fax (1) 18099**] to schedule an appointment.
Please follow-up with your cardiologist, Dr. [**First Name (STitle) 437**] (tel
[**Telephone/Fax (1) 62**]). You have an appointment to have your pacemaker
checked on [**3-16**] at 9AM and an appointment with Dr. [**First Name (STitle) 437**] on
[**3-16**] at 10:20AM in [**Hospital Ward Name 23**] [**Location (un) 436**].
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
] |
9089, 9095
|
6178, 8406
|
326, 333
|
9316, 9354
|
4829, 6155
|
9950, 10499
|
3688, 3718
|
8641, 9066
|
9116, 9295
|
8432, 8618
|
9378, 9560
|
3733, 4810
|
9589, 9927
|
275, 288
|
361, 3338
|
3354, 3672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,014
| 163,168
|
43830
|
Discharge summary
|
report
|
Admission Date: [**2174-8-11**] Discharge Date: [**2174-8-24**]
Date of Birth: [**2135-11-15**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Heparin Agents
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
Ms. [**Known firstname **] [**First Name4 (NamePattern1) 2431**] [**Known lastname **] is a 38yo F ALL s/p double cord blood
SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease, well-known to the [**Year (4 digits) 3242**]
service who was just discharged yesterday ([**2174-8-10**]) after a
prolonged hospital course for acute on chronic CHF thought be be
due to cardiac GVHD and acute on chronic renal failure. She was
discharged home with daily infusions of IV torsamide and
methylprednisolone. She came to clinic today fopr follow-up
where she was found to be febrile to 102 and up 0.5lbs from her
discharge weight. CXR was done and cardiac silloette was
increased, concerning for pleural effusion. Blood (PICC and
peripheral) and urine cultures were sent, and she was started on
empiric meropenem.
.
On arrival to the floor, pt has no complaints. She spent an hour
outside yesterday and was otherwise at home resting. She does
nto recal any bug bites. She did not feel subjectively febrile.
She has some cough, but no different or worse than prior to
discharge. She has some pedal [**Last Name (un) **],a put attributes this to
being up and walking around today. No calf pain. Otherwise, ROS
is negative. Per her sister, the pt got her torsemide and
methyprednisolone in clinic today. [**Name6 (MD) **] outpatient NP, pt's
weight was 137# today, up slightly from 136.5# on the day of
discharge.
Past Medical History:
ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV. UGI and SBFT [**4-/2174**] was mostly unremarkable. She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction. RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.
Social History:
She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis. Lifelong nonsmoker, but not currently. Denies
illicits or EtOH.
Family History:
Mother with history of gastric cancer, died at age 40. Father
with hypertension.
Physical Exam:
Physical Exam on Admission:
VS: T97.9/Tm 102, BP 110/67, HR 86, RR 18, 94% on 2L
GEN: AOx3, NAD
HEENT: Pupil equal and round. Sclera and conjunctiva clear. MMM.
No oral lesions or exudates.
Cards: S1/S1, S3. RRR.
Pulm: Bibasilar crackles
Abd: soft, NT, ND
Extremities: wwp, edema of the feet and distal ankles B/L
Skin: no rashes or bruising
Neuro: nonfocal
Pulsus paradoxus 2mmHg
.
Physical Exam on Discharge:
Patient expired.
Pertinent Results:
[**2174-8-11**] 02:07PM UREA N-82* CREAT-2.7* SODIUM-129*
POTASSIUM-4.4 CHLORIDE-90* TOTAL CO2-27 ANION GAP-16
[**2174-8-11**] 02:07PM ALT(SGPT)-23 AST(SGOT)-75* LD(LDH)-1186* ALK
PHOS-540* TOT BILI-1.9* DIR BILI-1.4* INDIR BIL-0.5
[**2174-8-11**] 02:07PM ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2174-8-11**] 02:07PM WBC-4.1 RBC-2.62* HGB-8.8* HCT-24.4* MCV-93
MCH-33.7* MCHC-36.3* RDW-23.7*
[**2174-8-11**] 02:07PM NEUTS-86* BANDS-0 LYMPHS-6* MONOS-7 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-5*
[**2174-8-11**] 02:07PM PLT SMR-VERY LOW PLT COUNT-24*
[**2174-8-11**] 02:07PM GRAN CT-3543
.
IMAGING:
CXR ([**2174-8-11**]):
AP single view of the chest has been obtained with patient in
upright position. Comparison is made with the next preceding PA
and lateral
chest examination of [**2174-8-3**]. The heart size has increased
further in
size. There is no typical configurational abnormality. The
rather general
increase of the heart shadow is suggestive of pericardial
effusion. Previously described right-sided PICC line remains in
unchanged position.
Pulmonary vascular congestive pattern has not changed
significantly; however, the previously described patchy and
partially confluenting parenchymal densities persist and
apparently have progressed further. They are most marked in the
mid lung field on the right side and the lateral upper lobe area
on the left. Lateral pleural sinuses are partially concealed by
the described parenchymal densities. Conclusive evidence of
pleural effusion is not present, and major pleural effusion is
unlikely as it did not exist on the lateral view on the
preceding chest examination.
.
Progression of bilateral pulmonary infiltrates in this patient
on stem cell
transplant therapy.
.
Echo ([**2174-8-12**]): Moderate ?partially loculated pericardial
effusion without definite evidence for tamponade physiology.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2174-8-4**],
the pericardial effusion is larger. Serial evaluation is
suggested.
.
Echo ([**2174-8-18**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 65%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
small to moderate sized pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade.
.
Echo ([**2174-8-23**]):
The left atrium appears extrinsically compressed (mildly)
posteriorly, possibly by a consolidated posterior pericardial
effusion. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is unusually small. Overall left
ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. with depressed
free wall contractility. The epicardial surface of the right
ventricle as well as atria appears to be encased in a layer of
echodense material (epicardial fat vs consolidated effusive
material). No evidence of cardiac tamponade seen.
.
RUQ ([**2174-8-23**]):
1. No evidence of acute cholecystitis, as clinically queried.
2. Reversed flow in the main portal vein, could be secondary to
cardiac
tamponade or tricuspid regurgitation.
3. Redemonstration of FNH in the right hepatic lobe.
4. Moderate-sized bilateral pleural effusions and a small amount
of ascites
Brief Hospital Course:
38 year old female with ALL s/p cord blood transplant
complicated by multi-organ GVHD admitted directly to the ICU for
recurrent fever and increased pulmonary infiltrates on CXR.
#Sepsis:
Patient presented to the clinic with fevers to 102; CXR showed
increased pulmonary infiltrates and heart size. She received a
dose of meropenem, blood and urine cultures were sent, and she
was admitted directly to the ICU. After transfer to the ICU she
was given IV fluids and continued on broad-spectrum antibiotics
(vancomycin, cefepime), antifungal (voriconazole) and antiviral
(gancyclovir). Bronchoscopy lavage fluid was sent for
pan-culture, pneumocystis smear, and CMV screen. CMV pneumonitis
was suspected given previous BAL CMV+. Hypoxia and work of
breathing worsening and she required intubation for ventilation
(see below). Microbiology revealed parainfluenza 3, but no other
pathogens: sputum bacterial and fungal cultures + BAL
cultures/stains/labs were all negative, including negative PCRs
for PCP and CMV. She received vancomycin, cefepime, ganciclovir,
voriconazole, and amphotericin B for broad anti-bacterial,
anti-fungal, and anti-viral coverage. She also received four
doses of IVIG.
.
# Hypoxia:
Serial CXRs showed diffuse bilateral infiltrates. Microbiology
as above. Patient arrived in the ICU unintubated but was
intubated on the day after transfer for increasing respiratory
effort and somnolence. She was sedated on fentanyl and versed
due to agitation and discomfort on the vent. She was difficult
to wean from 80% Fi02 and 14 PEEP. She required mechanical
ventilation at an Fi02 of 100% O2 until the time of expiration.
In addition to infection, there was concern for ARDS. The
patient expired on the ventilator.
.
#Pericardial Effusion: Admission CXR showed increased heart
size, and the echo done on [**2174-8-12**] showed increase in pericardial
effusion without evidence of tamponade. Patient's primary
cardiologist, Dr. [**First Name (STitle) 437**] was alerted and recommended follow up
with echo on [**2174-8-15**]. Follow-up echo showed worsening
moderate-to-large pericardial effusion, which was drained by
bedside pericardiocentesis. Pericardial fluid included 30%
lymphocytes and 60% macrocytes, cultures negative. Although she
does not carry a diagnosis of cardiac GVHD, this was suspected.
A third follow-up echo showed normal LVEF.
.
#Congestive heart failure with systolic dysfunction:
Patient has known CHF with systolic dysfunction from chemo, XRT
and suspected cardiac GVHD. Considered whether patient's recent
CHF lability might contribute to current respiratory acuity. She
was euvolemic to slightly volume up on exam with lower extremity
pitting edema. Daily weights showed her to be under her recent
discharge weight of 136.5 lb. She was on torsemide on arrival,
but this was held in the context of hypovolemia (see below).
NiCOM maneuvers were performed and a transesophageal Balloon was
placed for pleural pressure monitoring. Following
pericardiocentesis her cardiac output improved, repeat Echo was
performed, and congestive heart failure was thought not to be
the cause of her declining clinical picture. A repeat ECHO did
show worsening right ventricular function. Despite being on
three pressors, the patient's clinical picture declined and she
developed hypotension.
#Chronic Kidney Disease: Patient baseline creatinine 2.5 - 3.0
with admission Cr of 2.7. Creatinine continued to rise from 3.0
to 3.7 despite IVF. Renal service followed. Pt was hypocalcemic
to 5.9 (requiring standing supplementation) and
hyperphosphatemic, both likely secondary to renal failure. She
became anuric and was started on CVVHD. CVVHD was discontinued
as the patient developed hypotension despite being on three
pressors.
.
#ALL: Pt is s/p double cord blood SCT [**1-/2173**] complicated by
GVHD on immunosuppression, recently discharged on mycophenolate,
IV solumedrol and bactrim/acyclovir for prophylaxis. Her
mycophenolate dose was changed to 500 mg PO BID and she was
continued on this plus 60 mg IV solumedrol daily. She was on
Bactrim prophylaxis prior to admission, and this was increased
to therapeutic dosing while in the ICU.
#Hypotension. She was transiently IV fluid and pressor-dependent
with hypotension to 85/45 but maintained BP through most of her
ICU stay. Home nifedipine and lopressor were held.
#Anemia. Transfused 1U PRBC for Hct 22 on ICU day 2;
post-transfusion Hct 27.
# Hyponatremia. She was hyponatremic, likely due to diuresis
(which was stopped). No mental status changes prior to
intubation. Free water restricted.
# LFT abnormalities. Stable transaminases, with normal ALT and
AST mildly elevated. Unclear etiology, likely secondary to
hypoxia and end-organ underperfusion.
# Thrombocytopenia. Platelet count remained low but patient did
not show signs of coagulopathy.
Medications on Admission:
-acyclovir 400 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) Neb Inhalation every six (6) hours as needed for SOB,
wheezing
-digoxin 125 mcg Tablet One (1) Tablet by mouth EVERY OTHER DAY.
-ergocalciferol (vitamin D2)50,000 unit Capsule One (1) Capsule
by mouth 1X/week
-lorazepam 0.5 mg Tablet One (1) Tablet by mouth every six (6)
hours as needed for anxiety/nausea.
-methylprednisolone sodium succ Sixty (60) mg Intravenous once a
day.
-metoprolol succinate 50 mg Tablet Extended Release 24 hr, One
(1) Tablet Extended Release 24 hr by mouth once a day
-morphine [MS Contin]15 mg Tablet Extended Release One (1)
Tablet Extended Release by mouth twice a day.
-mycophenolate mofetil 500 mg Tablet Two (2) Tablet by mouth
twice a day.
-nifedipine 60 mg Tablet Extended Release One (1) Tablet
Extended Release by mouth once a day in the evening.
-NPH insulin human recomb Ten (10) units Subcutaneous twice a
day: Please administer 10 units before breakfast and 10 units
before dinner.
-omeprazole 40 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth once a day.
-ondansetron 4 mg Tablet, Rapid Dissolve [**2-6**] Tablet, Rapid
Dissolves by mouth three times a day as needed for nausea.
-oxycodone 5 mg Tablet One (1) Tablet by mouth every 4-6 hours
as needed for pain.
-sildenafil 20 mg Tablet Four (4) Tablet by mouth three times a
day.
-sulfamethoxazole-trimethoprim 400-80 mg Tablet One (1) Tablet
by mouth DAILY (Daily).
-torsemide 20 mg/2 mL (10 mg/mL) Solution Forty (40) mg
Intravenous once a day.
-voriconazole 200 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.
Discharge Medications:
Deceased
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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15076, 15134
|
8453, 13291
|
302, 322
|
15186, 15196
|
4567, 8430
|
15253, 15264
|
4019, 4102
|
15043, 15053
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15155, 15165
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13317, 15020
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15220, 15230
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4117, 4131
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4529, 4548
|
256, 264
|
350, 1942
|
4145, 4501
|
1964, 3766
|
3782, 4003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,935
| 116,770
|
29176
|
Discharge summary
|
report
|
Admission Date: [**2112-1-30**] Discharge Date: [**2112-2-8**]
Date of Birth: [**2053-10-2**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Felodipine / Benadryl / Iodine / Latex /
Levofloxacin Hemihydrate / Augmentin / Sulfa (Sulfonamides) /
Clindamycin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath.
Reason for MICU admission: severe septic shock and multiple
organ failure.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation.
History of Present Illness:
58F with metastatic colon cancer, recent admission for N/V/abd
pain with subsequent establishment of hospice, presenting to ED
with confusion x few days day and shortness of breath. She had
sudden onset of shortness of breath today, no chest pain;
persistent but unchanged abdominal pain. No recent diarrhea,
constipation, N/V. Husband notes patient taking increasing
doses of oxycontin (120 mg in 24 hour period - twice what is
prescribed - unclear if intentional). No HA, fever, cough.
In the ED, initial vs were: T97.7 rectal, P70, BP66/43 -> 93/53,
R13-20 O2 sats 80s on RA, 100% on 3L. Confused, sleepy. Very
icteric on exam. Bilateral coarse breath sounds. Guaiac
positive. 2+ edema. Patient was given ceftriaxone and
vancomycin; calcium gluconate, 1 gram, D50 and insulin,
kayexalate 60 g, and levophed gtt started for hypotension. BPs
dipping into 70s even after 3L so levophed gtt started (running
through port). BP in upper 90s. Lab abnls included lactate 10,
severe metabolic acidosis (bicarb 8, pH 7.24), WBCs 18.8 with
17% bands, elevated coags with low plts, ARF, hyperkalemia to
7.4, transaminitis with hyperbilirubinemia. QRS 106 on ECG, no
peaked T waves. Difficulty laying flat (dyspneic but not
de-satting).
On the floor, patient arrives altered, confused. Denies pain or
discomfort.
Past Medical History:
Metastatic colon cancer (brain/liver)
-[**2109-5-14**], colonoscopy due to anemia w/ fungating, friable and
infiltration mass (mets), at ascending colon w/ partial obs:
adenocarcinoma. Referred to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] for surgery.
-[**2109-5-23**], CCT, ACT: multiple bilateral pulmonary nodules, 7 mm.
Scattering smaller ones concern for mets; metastatic foci within
the liver also. 4.5 x 5 cm left hepatic lobe mets, 4.5 x 2.9 cm
& 4 cm x 3 cm right hepatic lobe mets
-[**6-10**] right palliative hemicolectomy
-[**2109-7-17**] FOLFOX started
-[**2109-8-28**] Avastin added
-[**2110-1-1**] Oxaloplatin held due to neuropathy
HTN
baseline Cr 0.9-1.2
celiac disease
OA - spine, right wrist
peripheral neuropathy from chemotherapy
recurrent vaginal abscesses
Asthma
Uterine fibroids
Iron deficiency anemia s/p transfusion during hospitalization in
[**11-12**]
VIN
lactose intolerance
hyponatremia
hypoalbuminemia with LE edema
Pul HTN
anterior wall abdominal hernia
postmenopausal bleeding s/p negative endometrial bx's
Social History:
Never smoked, never drank. Lived in [**State 4565**] 3 years ago.
Lives in [**Location 1468**] with husband. [**Name (NI) **] is a grad student at [**Hospital1 3278**].
She was something of an activist.
Family History:
Mother and father with CAD and CVA, sister with DM2.
Physical Exam:
On admission:
General: Somnolent though arousable, speech mostly confused when
awakened.
HEENT: Sclera mildly icteric, MM slightly dry
Neck: supple, JVD difficult to appreciate, no LAD appreciated.
Lungs: Bilaterally wheezy and rhonchorous, diminished at R base.
CV: Regular rate and rhythm, normal S1 + S2, distant beneath
breath sounds. R port in place.
Abdomen: Distended, bowel sounds present though ?hypoactive,
appears diffused tender throughout, ?slightly firm. no
apparently rebound tenderness or guarding. No clear ascites.
Ext: cool extrems on pressors, no clubbing, cyanosis. 2+ LE
edema, equal bilat.
Neuro: lethargic/somnolent, arousable, confused speech at times.
Unable to perform further neuro exam.
Pertinent Results:
137 102 73 AGap=34
------------- 73
7.4 8 4.1 ∆
K: Not Hemolyzed
Ck: 541 MB: 9 Trop-T: 0.10
Ca: 7.5 Mg: 3.6 P: 9.1 ∆
ALT: 448 AP: 1043 Tbili: 5.7 Alb: 2.5
AST: 1390 LDH: 9775 Lip: 36
10.2
18.8 ----146 ∆
34.7
Diff: N:75 Band:17 L:1 M:5 E:0 Bas:0 Metas: 1 Myelos: 1 Nrbc: 2
PT: 25.0 PTT: 39.0 INR: 2.4
Micro:
Blood cultures x 2 pending.
Images:
CXR: increased R sided pleural effusion. concerning for opacity
in R lower lung fields. Diffuse pulmonary nodules consistent
with known metastatic disease.
EKG: NSR at 75. poor baseline. LAD. slightly wide QRS (~100),
QTc 470, no peaked T waves. Poor RWP. Low voltage in
precordial and limb leads. Compared to prior, voltage lower,
RWP worse.
ECHO: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is a small pericardial
effusion
CT Torso: 1. Limited study without contrast with significant
progression of innumerable pulmonary and hepatic metastases with
massive enlargement of the liver causing volume loss in the
right lower lobe secondary to elevation of right hemidiaphragm.
2. Moderate abdominal and pelvic ascites with anasarca. No
significant pleural effusion noted.
Chest Xray: There is an endotracheal tube, right-sided central
venous catheter, and feeding tube which are unchanged in
position. The distal tip of the right- sided catheter is again
in the right atrium and could be pulled back a few centimeters
for more optimal placement. Diffuse opacities throughout both
lungs consistent with patient's extensive pulmonary metastases.
Superimposed consolidation cannot be entirely excluded. There is
a right-sided pleural effusion.
Brief Hospital Course:
58F with widely metastatic colon cancer, presenting with septic
shock and severe metabolic acidosis, ARF, hyperkalemia.
# Hypotension/Septic shock/MODS. Patient presented with septic
shock, Leukocytosis/Bandemia and severe metabolic acidosis and
multiple organ dysfunction including pulmonary, cardiac, heme,
hepatic, renal failure. While source of infection was
identified patient was covered broadly with Cefepime, Cipro,
Flagyl, and Vancomycin. Blood Cultures were negative throughout
hospitalization. Sputum culture only with MSSA. Urine Cultures
negative. UA positive covered with Cefepime. Levophed started
and titrated to maintain MAP of >60. During hospitalization pt
continued to reguire pressor support. Despite identification of
a MSSA pneumonia broad coverage was continued while discussion
regarding patients Code status was determined. Patient was made
CMO, antibiotics/pressors were stopped. Patient expired.
# Metabolic/lactic acidosis. With severe systemic hypoperfusion
and hypotension in the setting of sepsis. Pt started on levophed
which was required throughout hospitalization to maintain
adequate perfusion. Lactate trended down during hospitalization
and acidosis stabilized with stabilization of blood pressure and
antibiotic treatment.
# ARF/hyperkalemia. Secondary to ATN int the setting of
hypotension/sepsis. No known offending meds. During
hospitalization did not respond to fluids. Hyperkalemia without
ECG changes. Bicarb gtt started and DC'd with resolution of
metabolic acidosis. Dialysis was not initiated given the
patients very poor prognosis after long discussion with the
family. Throughout the hospitalization no meaningful return in
kidney function was attained.
# Coagulopathy/thrombocytopenia. Patient with increased INR and
decreased platelets during admission. Likely DIC given severity
of infection however Fibrinogen stable. During Admission
platelets improved/remained stable. INR continued to increase
during hospitalization. Patient had no active signs of bleeding.
# Transaminitis. Likely shock liver. Liver enzymes were
followed during hospitalization and trended down after blood
pressure was controlled.
# Hypoxia and respiratory distress. Evidence of pneumonia on
right. Also with wheezes. Respiratory distress reportedly
acute onset; would be at high risk for PE given malignancy,
however given patient's clinical status this was deferred.
Patient was intubated and vent settings were weaned throughout
the hospitalization to Pressure Support [**11-8**], until patient was
extubated when made CMO.
# ECG changes. Lower voltage, poor RWP compared to prior. No
clear elevation in JVD, not tachycardic, and sources other than
tamponade more likely playing a role in hypotension. TTE was
negative for pericardial effusion. On [**2-6**] EKG was performed for
hyperkalemia which should 1mm ST Elevation in V1-V2 and ST
Depression laterally. Enzymes were checked and were minimally
elevated. Repeat ECG with resolution in the height of ST
elevation in V1-V2. Given pt comorbidities these abnormalities
were not further evaluated.
Medications on Admission:
Reglan 5 mg three times a day as needed for nausea
Oxycodone SR 30 mg Q12H
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic colon cancer with lethal multiple organ failure.
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
|
[
"197.7",
"482.41",
"493.90",
"579.0",
"553.20",
"585.9",
"V10.05",
"038.9",
"276.7",
"356.9",
"721.90",
"287.5",
"218.9",
"280.9",
"518.81",
"787.3",
"584.5",
"286.9",
"403.90",
"275.41",
"276.2",
"995.92",
"197.0",
"416.8",
"715.93",
"570",
"785.52",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9542, 9551
|
6289, 9387
|
483, 523
|
9654, 9664
|
4019, 6266
|
9718, 9726
|
3205, 3260
|
9512, 9519
|
9572, 9633
|
9413, 9489
|
9688, 9695
|
3275, 3275
|
348, 445
|
551, 1871
|
3289, 4000
|
1893, 2966
|
2982, 3189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,078
| 160,307
|
46743
|
Discharge summary
|
report
|
Admission Date: [**2112-10-18**] Discharge Date: [**2112-10-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Placement of PICC line.
History of Present Illness:
84yo woman h/o DM2 (now diet controlled), severe dementia, h/o
CAD s/p CABG [**2090**], recurrent UTIs who presents with
hyperglycemia to 788. Pt remotely had been on metformin and NPH
for control of DM2. In at least past 2years, pt??????s BS controlled
by diet only, and FS checked qam, normally running b/w 100-200.
In past week, pt noticed to have gradually rising BS, from
200s->400s, increasing lethargy, anorexia along with +2-3days of
mild, nonproductive, cough. Her ROS was otherwise negative.
Husband told by PCP/[**Last Name (un) **] to start cipro for possible
infection. Four days prior to admission patient was seen by
podiatrist who stated that here was no evidence of infxn of
chronic R foot ulcer. Her antibiotics were changed from cipro to
keflex. On day of admission, pt noticed to have BS 590, brought
to ED by ambulance.
In [**Name (NI) **], pt afebrile, brady to 50s, normotensive, O2sat 89%on RA
when asleep. Na159([**Last Name (un) **] 170) GLU788. CXR clear, U/A clean.
Started on insulin drip, given 1LNS, then 1/2NS +40meq K
@75cc/h. On arrival to unit, pt's SBPs were between 80-100. She
was given NS with an increase of her BP to a systolic blood
pressure of 130. Her corrected sodium was elevated to 170. She
was started on an insulin drip with rapid control of her blood
sugars so she was started on SQ insulin. She also received
agressive fluid resucitation with correction of her serum
sodium.
*
With normalization of her blood sugars she was called out to the
medicine floor. On the day of transfer to the medicine floor the
patient developed a great deal of oral secretions and then
developed an oxygen requirement-requiring 40% face mask.
Past Medical History:
PAST MEDICAL HISTORY
DM2 ?????? diet controlled, daily BS normally 100-200.
Last hgBa1c 6.7 ([**12/2106**])
Previously on metformin, NPH, but no meds past 2y.
R ft ulcer ?????? [**2112-10-14**] per podiatrist, no evidence of infection
CAD ?????? s/p CABG [**2090**]
Echo [**1-5**] LAE, mild LVH, mild/mod MR, 1+TR, no RWMA EF>60%
Dementia ?????? multi-infarcts, does not speak x1y
HTN
Recurrent UTI
GIB ?????? slow GIB in [**1-5**], presumed UGI source. PPI
colonoscopy [**1-5**] w/ melena, no colonic pathology
PVD
Hypothyroidism
L carotid artery stenosis
Cataracts
Atrial myxoma ?????? s/p resection
H/o Bell??????s palsy
Cervical spondylosis
PAST SURGICAL HISTORY
L TKR ?????? [**11/2102**]
L radial fx closed reduction [**11/2103**]
L cataracts extraction
Social History:
Lives w/ husband @ home; requires daily nursing aid care. At
baseline does not speak, cannot ambulate, cannot perform ADLs.
Code status: DNR/DNI
Remote tobacco.
Physical Exam:
PHYSICAL EXAMINATION
VS: Tm 98.8 HR51 BP141/23 RR16 100%O2sat 2L nc
GEN: chronically ill-appearing, awake, responds to noxious
stimuli, but does not verbally communicate.
HEENT: mm dry, JVP6cm
PULM: crackles R base, crackles @ L base ext ?????? lung field.
CARDS: brady, regular nl s1 s2 2/6 SEM
ABD: soft, NT, no g/r. BS active. No HSM
EXT: skin tenting. Unhealed ulcer R foot on top of 4-5th MTP
joint, focal tenderness to palpation medial to ulcer, above 5th
MTP joint, no evidence of soft tissue infection. healing ulcer
of R Gr toe, no tenderness.
NEURO: rigid, spastic in 4 extremities.
Pertinent Results:
[**2112-10-18**] 11:17PM URINE HOURS-RANDOM CREAT-66 SODIUM-59
[**2112-10-18**] 11:17PM URINE OSMOLAL-639
[**2112-10-18**] 08:00PM GLUCOSE-57* UREA N-59* CREAT-1.7* SODIUM-170*
POTASSIUM-3.8 CHLORIDE-136* TOTAL CO2-26 ANION GAP-12
[**2112-10-18**] 08:00PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.1
[**2112-10-18**] 08:00PM OSMOLAL-357*
[**2112-10-18**] 06:11PM GLUCOSE-171* UREA N-58* CREAT-1.6*
SODIUM-171* POTASSIUM-3.2* CHLORIDE-134* TOTAL CO2-24 ANION
GAP-16
[**2112-10-18**] 06:11PM CK-MB-5 cTropnT-0.13*
[**2112-10-18**] 06:11PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.1
[**2112-10-18**] 06:11PM OSMOLAL-363*
[**2112-10-18**] 06:11PM WBC-5.2 RBC-3.30* HGB-10.1* HCT-31.2* MCV-95
MCH-30.5 MCHC-32.2 RDW-13.8
[**2112-10-18**] 06:11PM PLT COUNT-188
[**2112-10-18**] 03:00PM GLUCOSE-650* UREA N-66* CREAT-1.8*
SODIUM-165* POTASSIUM-3.5 CHLORIDE-131* TOTAL CO2-19* ANION
GAP-19
[**2112-10-18**] 12:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2112-10-18**] 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2112-10-18**] 12:25PM URINE RBC-0 WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0-2
[**2112-10-18**] 12:05PM GLUCOSE-762* NA+-160* K+-4.1 CL--130*
[**2112-10-18**] 11:55AM CK(CPK)-91
[**2112-10-18**] 11:55AM CK-MB-4 cTropnT-0.14*
[**2112-10-18**] 11:55AM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-2.3
[**2112-10-18**] 11:55AM TSH-0.89
[**2112-10-18**] 11:55AM FREE T4-1.3
[**2112-10-18**] 11:55AM WBC-7.3 RBC-3.63* HGB-11.0* HCT-33.7* MCV-93
MCH-30.4 MCHC-32.7 RDW-13.3
[**2112-10-18**] 11:55AM HYPOCHROM-1+
[**2112-10-18**] 11:55AM PLT COUNT-198
[**2112-10-18**] 11:55AM PT-12.9 PTT-29.3 INR(PT)-1.1
EEG:
IMPRESSION: This is an abnormal portable EEG obtained in
wakefulness
and drowsiness due to the presence of a disorganized and slow
background
rhythm in the 6 Hz theta frequency range. In addition, there is
scattered mixed delta and theta frequency slowing as well as
occasional
generalized delta frequency slowing. These findings suggest
widespread
subcortical dysfunction and are consistent with an
encephalopathy. No
lateralizing or epileptiform abnormalities were seen. Note was
made of
frequent ectopy on the cardiac monitor.
*
Head CT
FINDINGS: There is no intracranial hemorrhage, mass effect, or
shift of normally midline structures. There is stable
ventricular enlargement, consistent with moderate to severe
brain atrophy. There is stable extensive periventricular and
subcortical hypodensity, consistent with chronic microvascular
ischemic changes. The osseous and soft tissue structures are
unremarkable.
IMPRESSION: No significant interval change when compared with
the prior study of [**2111-11-2**]. Moderate to severe brain
atrophy
*
Chest AP:
FINDINGS: There is an increasing infiltrate in the left lower
lobe, and to a lesser extent at the right base, since [**2112-10-21**].
The heart is normal in size. Post-CABG changes are evident.
There are no other changes in the chest.
IMPRESSION: Bilateral lower lobe infiltrates, left more than
right.
Micro:
Blood and Urine cultures negative
[**2112-10-23**] 6:38 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2112-10-27**]**
GRAM STAIN (Final [**2112-10-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2112-10-26**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2414**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2112-10-23**] 11:53 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2112-10-24**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2112-10-24**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2112-10-22**] 3:28 pm SWAB Site: FOOT
Source: Right foot sub 4th/5th met head.
**FINAL REPORT [**2112-10-27**]**
GRAM STAIN (Final [**2112-10-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS
AND
CLUSTERS.
WOUND CULTURE (Final [**2112-10-24**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Please contact the Microbiology Laboratory ([**6-/2414**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2112-10-27**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
Brief Hospital Course:
84F w/DM2 (diet controlled), severe dementia, recurrent UTIs who
p/w nonketotic hyperosmolar hyperglycemia:
*
Nonketotoic hyperosmolar hyperglycemia:
The actual precipitant of her hyperosmolar hyperglycemia was
initially unclear. The patient had low grade temps which
suggested an occult infection but the patient's blood and urine
culture remained negative as did her Cdiff [**Doctor First Name **]. A swab of her
wound and her secretions eventually grew MRSA and the patient
was started on vancomycin. She was also noted to have a mild
troponin leak on admission but we thought that this was
secondary to demand ischemia in the setting of an occult
infection and not acute coronary syndrome. The patient is
DNR/DNI adn the family did not want to pursue agressive
interventions thus she was not ruled out for an MI.
*
New Oxygen requirement.
Pt now requiring 40% O2 via shovel mask. Our intial differential
was inability to handle secretions which had developed secondary
to fluid repletion vs CHF secondary to agressive fluid repletion
or aspiration pneumonia. She was given several doses of IV
lasix to which she responded with a fair urine outpu but there
was no improvement in her O2 saturation. We then thought that
her O2 requirement was most likely due to an aspiration
pneumonia secondary to her inability to handle her oral
secretions. She was started on IV levofloxacin, flagy and
vancomycin. Our suspicions were confirmed by an X ray which
demosntrated worsening bilateral lower lobe infiltrates.
*
Aspiration Precautions:
The patient was put on aspiration precautions, made NPO and all
of her medications were changed to IV.
*
Mental Status:
Despite our aggressive antibiotics the patient's mental status
only improved slightly despite an improvement in her O2
requirement. We thus thought that her decreased mental status
was most probably secondary to her severe advanced dementia. We
also obtained a neurology consult along with an EEG, and CT of
the head which confirmed this. In light of this the patient's
family, medical team thought it fitting that the patient be put
into the care of home hospice.
*
Disposition:
In light of her advanced dementia and her poor prognosis for
recovery of any function especially that of protecting her
airway, along with her previous wish to be comfortable at the
end of her life we, in close dicussion with the family and
palliative care team decided that it would be best for her to go
home with hospice.
Medications on Admission:
ASA 325 mg po qd
Atenolol 12.5 mg qd
FeSO4 325 [**Hospital1 **]
Lasix 20 mg po bid
Lipitor 10 mg po qd
Levothyroxine 50 mcg qd
Nifedipine 30 mg [**Hospital1 **]
Protonix 40 mg po qd
Ca, B12, MVI
Keflex 250 mg qid since [**10-14**]
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q 72 HRS PRN as needed for SECRETIONS.
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Opium 10 % Tincture Sig: Ten (10) Drop PO Q 4-6 HRS PRN as
needed.
Disp:*3 vials* Refills:*0*
3. Furosemide 8 mg/mL Solution Sig: Twenty (20) mg PO DAILY
(Daily).
Disp:*4 vials* Refills:*2*
4. Diphenoxylate-Atropine 2.5-0.025 mg/5 mL Liquid Sig: [**12-4**]
Tablets PO q 6hrs prn as needed: Please crush in applesauce or
custard. .
Disp:*30 tablets* Refills:*2*
5. Propranolol HCl 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day): Please give patient liquid form. .
Disp:*180 Tablet(s)* Refills:*2*
6. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Please crush in applesauce. .
Disp:*30 Tablet(s)* Refills:*2*
7. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Q 1HR
PRN.
Disp:*30 ML* Refills:*0*
8. Nystatin 100,000 unit/g Ointment Sig: [**12-4**] Appls Topical QID
(4 times a day) as needed.
Disp:*3 vials* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
1. Nonketotic hyperosmolar hyperglycemia
2. Aspiration pneumonia
3. Multi-infarct dementia
Secondary
DM2 ?????? diet controlled, daily BS normally 100-200.
R ft ulcer
CAD ?????? s/p CABG [**2090**]
Dementia ?????? multi-infarct, non verbal x 1year
HTN
Recurrent UTIs
Slow GI bleed [**1-5**] from a presumed UGI source.
PVD
Hypothyroidism
L carotid artery stenosis
Cataracts
Atrial myxoma ?????? s/p resection
H/o Bell??????s palsy
Cervical spondylosis
s/p left total knee replacement.
s/p L closed radial fracture reduction - [**2102**]
s/p L cataract extraction
Discharge Condition:
Fair. Close to baseline, non-verbal and totally dependent for
all activities of daily living.
Discharge Instructions:
Patient is going home with hospice and is currently DNR/DNI.
Followup Instructions:
Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 722**] [**Hospital 1947**] CLINIC Where: CC-2 [**Hospital 1947**]
UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2112-11-4**] 11:00
Please follow up with home hospice and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Telephone/Fax (1) 99216**] as needed.
|
[
"707.14",
"250.20",
"290.40",
"518.82",
"V45.81",
"401.9",
"041.11",
"427.31",
"507.0",
"437.0",
"244.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13653, 13731
|
9866, 11510
|
277, 303
|
14348, 14443
|
3598, 9843
|
14552, 14891
|
12613, 13630
|
13752, 14327
|
12358, 12590
|
14467, 14529
|
2984, 3579
|
224, 239
|
331, 2006
|
11525, 12332
|
2028, 2790
|
2806, 2969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,273
| 133,553
|
42805+58558+58559
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2175-12-21**] Discharge Date: [**2175-12-27**]
Date of Birth: [**2115-6-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Oxycodone / hydrochlorothiazide / trazodone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB, back pain, elevated trops, transferred for cardiac cath
Major Surgical or Invasive Procedure:
1. Urgent coronary artery bypass graft x4; left
inframammary artery to left anterior descending artery
and saphenous vein grafts to obtuse marginal, diagonal,
and posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
60 yo female with hx CAD (no interventions), bicuspid aortic
valve, peripheral arterial disease and cerebrovascular disease
with recent outpt abnormal ST presented to [**Hospital3 3583**] via
EMS with SOB, and R sided scapular back pain. Her shortness of
breath has been progressive over the past week. Today, had
associated back pain for which she took total of 8 sublingual NG
today with no relief prior to arrival at ED. Her pain was
associated with diaphoresis and was noted to have RR of 30 by
EMS. At [**Hospital1 46**], her initial EKG showed ST depressions in leads
I, avL, and V5-V6. Her first troponin was 0.6 with repeat of
3.26. She received morphine, lasix 40mg IV, aspirin, nitro
(which was then held for hypotension), and plavix. She was
transferred to [**Hospital1 18**] for cardiac cath. VS prior to transfer:
104./20, hr 70 sr, resp 16, sat 97% on 4L nc, afeb, 0/10 pain.
.
In the cath lab, pt noted to have severe 3VD not ammenable to
intervention. Pt was hypertensive so started on nitro drip.
However, after sheath was pulled, BP dropped to 60s systolic for
which she got atropine, fluids and dopamine. Within a few
minutes, pt was feeling well again.
.
At baseline, pt avoids strenous activity because of claudication
in her R leg. Her back pain has been considered her anginal
equivalent and she experiences this intermittently when exerting
herself (ie doing laundry, grocery shopping), usually resolves
with rest or SL NG. Pain is occasionally associated with
bilateral arm pain.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: hx of ?silent MI, no interventions
(inferolateral based on ECG), bicuspic aortic valve.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- PAD (claudication with R sided blockage)
- TIAs and s/p R CEA [**5-3**] (80%) with resulting subclavian steal
syndrome
- recurrent hyponatremia, questionably secondary to psychogenic
polydipsia vs medication effect?
- schizoaffective disorder
- anxiety, depression
- GERD
- proteinuria
Social History:
married, 2 sons; retired paralegal/legal secretary
-Tobacco history: last smoked 2 years ago, previously smoked for
40+ years, up to 2.5 ppd
-ETOH: [**1-26**] drinks/night
-Illicit drugs: denies
Family History:
father with MI x2, CABG
mother with alcoholism
Physical Exam:
Admission
Physical Exam
Pulse:89 Resp:18 O2 sat:94/RA
B/P Right:115/95 Left:132/81
Height:5'6" Weight:154 lbs
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema []none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Discharge:
VS: T: 98.2 HR: 80-96 SR BP: 140/58 Sats: 100% RA Wt: 73 Kg
General: 60 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decrease breath sounds with bibasilar crackles
GI: benign
Extr: warm trace edema
Incision: sternal clean, dry intact, no erythema, no discharge,
LLE vasview site clean dry intact
Neuro: awake, alert oriented
Pertinent Results:
[**2175-12-26**] Hct-29.3*
[**2175-12-26**] WBC-7.7 RBC-2.70* Hgb-8.6* Hct-25.4* MCV-94 MCH-32.0
MCHC-34.1 RDW-13.1 Plt Ct-198
[**2175-12-21**] WBC-9.2 RBC-3.53* Hgb-11.5* Hct-33.0* MCV-94 MCH-32.5*
MCHC-34.7 RDW-13.0 Plt Ct-236
[**2175-12-26**] Na-128* K-4.4 Cl-90*
[**2175-12-26**] Glucose-105* UreaN-13 Creat-0.6 Na-129* K-4.6 Cl-90*
HCO3-33
[**2175-12-24**] Glucose-126* UreaN-12 Creat-0.5 Na-123* K-5.2* Cl-90*
HCO3-21
[**2175-12-21**] Glucose-101* UreaN-8 Creat-0.4* Na-131* K-3.7 Cl-95*
HCO3-27
[**2175-12-21**] ALT-36 AST-47* AlkPhos-61 Amylase-28 TotBili-0.3
[**2175-12-26**] Mg-2.2
[**2175-12-24**] Osmolal-268*
[**2175-12-24**] TSH-5.3*
[**2175-12-24**] TSH-6.0*
[**2175-12-24**] Free T4-1.2
[**2175-12-24**] Free T4-1.0
[**2175-12-23**] freeCa-1.17
Urine:
[**2175-12-24**] Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2175-12-24**] URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2175-12-22**] RBC-4* WBC-27* Bacteri-FEW Yeast-NONE Epi-4 TransE-3
[**2175-12-24**] RANDOM Na-55 K-41 Cl-90
[**2175-12-24**] URINE Osmolal-458
CXR:
[**2174-12-26**]: PA & Lat CRX: small bilateral pleural effusions right
> left. Improved opacity at the right base.
[**2175-12-25**]: The cardiomediastinal silhouette is prominent, but
unchanged. Sternotomy wires again noted. There is decreased
pulmonary vascular plethora and interstitial marking, consistent
with markedly improved CHF findings. There is patchy opacity at
the left base, unchanged, with possible minimal blunting of the
left costophrenic angle. PLatelike atelectasis noted in left mid
zone. There is a small right effusion and opacity at the right
base which is new/progressed compared with the earlier film.
Possible soft tissue swelling in left supraclavicular area.
IMPRESSION:
1. Interval removal of tubes and lines. No pneumothorax
identified.
2. Stable cardiomediastinal silhouette.
3. Left lower lobe collapse and/or consolidation, unchanged.
Possible small left effusion.
Echocardiogram [**2175-12-22**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 40% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 6 mm Hg
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *1.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Moderate symmetric LVH. Top
normal/borderline dilated LV cavity size. Moderately depressed
LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**12-25**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was under general anesthesia throughout the procedure.
No TEE related complications. The patient appears to be in sinus
the patient.
Conclusions
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. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 40 %) with slightly
eorsened function of the inferior, inferolateral, inferoseptal
and distal anterior walls. The right ventricle displays moderate
hypokinesis of the mid and distal free wall. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
The left coronary cusp is more calcified and thickened than the
other two and displays more decreased excursion. There is mild
aortic valve stenosis (valve area 1.5 cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-25**]+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results in the operating room at the time of
the study.
POST BYPASS The patient is receiving epinephrine by infusion and
is atrially paced. The right ventricle displays improved
systolic function and is essentially normal. The left ventricle
continues to display inferior, inferoseptal, and inferolateral
hypokinesis but overall function is slightly improved (EF now
about 45%). The mitral regurgitation appears slightly improved -
now mild. The thoracic aorta is intact after decannulation.
Cardiac Catheterization [**2175-12-21**]:
1. Selective coronary angiography of this right dominant system
demonstrated severe 3 vessel coronary artery disease. The
coronary
arteries were heavily calcified. The LMCA was free of
angiographically
significant coronary artery disease. The mid LAD had sequential
90%
calcified lesions involving the origin of the diagonal branch
which
itself had diffuse mild disease. The LCX had a 100% distal
occlusion
and an 80% lesion at the origin of the OM2 branch which was
totally
occluded with collaterals. The proximal RCA had a 100%
occlusion with
right to right and left to right collaterals to the PDA.
2. Limited resting hemodynamics revealed severe systemic
arterial
hypertension with a central aortic blood pressure of 185/80. Of
note,
the patient's left arm cuff blood pressure was significantly
lower than
her central pressure at approximatley 140 mmHg systolic.
3. The patient was started on nitroglycerine IV due to
hypertension.
After her arterial sheath was pulled, she felt lightheaded and
was noted
to have a left arm blood pressure in the 60's sytolic. The
patient was
given atropine, IV fluids, and low dose dopamine. Within 10
minutes,
she was back to her baseline and feeling well. It was thought
that the
drop in blood pressure was due to increased vagal tone at the
time of
sheath pull and IV nitroglycerine.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systemic arterial hypertension with a large pressure
difference between central blood pressure and peripheral cuff
blood
pressure.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2175-12-22**] where the patient underwent Urgent
coronary artery bypass graft x4; left
inframammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal, diagonal and posterior
descending arteries. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. On POD 1 the
patient was extubated, alert, oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward her preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. Renal was
consulted for hyponatremia of 123 on [**2175-12-24**]. With Fluid
restriction of 1200 cc and low sodium diet her hyponatremia
improved with a Na+ level of 129. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD4 the patient was
ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged
home with VNA and follow-up Na+ with results faxed to her PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) 27598**] on Friday [**2174-12-29**].
Medications on Admission:
ASA 81 mg
NTG prn
losartan 100 mg
clonidine 0.1 mg
simvastatin 80 mg
omeprazole 40 mg
lurasidone 40 mg
lamotrigine 200mg
clonazepam 1mg TID
MVI
cholecalciferol (vit D3)
calcium + vit D
melatonin
diphenhydramine 50 mg qhs
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. lurasidone 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Outpatient Lab Work Electrolytes Friday [**2175-12-29**]
Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27598**] (F) [**Telephone/Fax (1) 92464**]
(O)[**Telephone/Fax (1) 26717**]
16. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-29**]
hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease
Hyponatremia
Hypertension
Dyslipidemia
Subclavian steal
Claudication with R sided blockage
tobacco abuse
bicuspid aortic valve
schizoaffective disorder/anxiety/depression
GERD
Proteinuria
Past Surgical History
Right Carotid Endartectomy [**5-3**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Follow-up appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2176-1-2**] 10:15 in
the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2176-1-30**] 1:15
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Follow-up with the [**Hospital 10701**] Clinic at [**Hospital1 18**] [**Telephone/Fax (1) 721**] with
Dr. [**Last Name (STitle) 118**] [**2176-1-10**] at 2:00pm [**Hospital Ward Name 121**] Building [**Location (un) **] [**Hospital **]
[**Hospital 7755**] Clinic
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27598**] [**Telephone/Fax (1) 26717**], Fax [**Telephone/Fax (1) 92464**].
Please call for an appointment
Cardiologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 92465**] in [**12-25**] weeks, Please call
for a follow-up appointment
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2175-12-26**] Name: [**Known lastname 11831**],[**Known firstname 6097**] Unit No: [**Numeric Identifier 14537**]
Admission Date: [**2175-12-21**] Discharge Date: [**2175-12-27**]
Date of Birth: [**2115-6-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Oxycodone / hydrochlorothiazide / trazodone
Attending:[**First Name3 (LF) 265**]
Addendum:
This patient stayed in the hospital for an additional day to
allow her to gain some strngth and endurance.
She was discharged home with visiting nurses on POD5.
A follow-up apppointment was arranged with renal service for
[**1-10**] w/Dr [**Last Name (STitle) 2592**].
Her fluid restriction was changed to 1000cc/day
Her medications were changed as outlined below:
1. Losartan was increased to 100mg daily
2. Lasix was extended 20mg [**Hospital1 **] until f/u w/Dr [**Last Name (STitle) 2592**]
3. folic acid 1 mg DAILY for 1 month.
4. ferrous sulfate 300 mg (60 mg iron) DAILY for 1 month.
5. ascorbic acid 500 mg DAILY for 1 month.
6. clonidine 0.1 mg DAILY
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2175-12-27**] Name: [**Known lastname 11831**],[**Known firstname 6097**] Unit No: [**Numeric Identifier 14537**]
Admission Date: [**2175-12-21**] Discharge Date: [**2175-12-27**]
Date of Birth: [**2115-6-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Oxycodone / hydrochlorothiazide / trazodone
Attending:[**First Name3 (LF) 265**]
Addendum:
Upon preparing for discharge the patient was noted to have
increased erythema at lower sternal pole and a small amount of
serous drainage. + Blanching of lower sternal pole erythema.
Pt was given rx for Keflex 500 mg QID x 5 days and instructed to
call with any increase in drainage, fever or increased pain or
erythema. Wound check scheduled for [**2176-1-2**] at 10:15 AM.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2175-12-27**]
|
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icd9cm
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[
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[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,977
| 196,460
|
7433
|
Discharge summary
|
report
|
Admission Date: [**2151-6-20**] Discharge Date: [**2151-6-21**]
Date of Birth: [**2111-4-13**] Sex: M
Service: MEDICINE
Allergies:
Viramune / Biaxin / Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
ETOH detox
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 12224**] is a 40yo M w/ h/o ETOH withdrawl seizures and
DTs, Hep C, HIV ([**2-21**] CD4 241), asthma and ankle osteomyelitis
who presented to the ED requesting ETOH detox after drinking 4
pints of vodka for the last 4-5 days. On presentation to the ED,
he was flushed, tremulous and tachycardic but not hypertensive.
He was given thiamine, 10mg valium IV, 5mg valium PO and 2mg
ativan IV with noted improvement in his symptoms. Vitals prior
to transfer out of the ICU were: 99.0 94 116/71 20 96% on RA.
.
On arrival to the ICU, the pt c/o chills, sweats and poor PO
intake for 1 wk. He states his last withdrawl seizure was last
month a [**Hospital1 112**].
Past Medical History:
1. HIV infection, followed by Dr. [**Last Name (STitle) 2148**]
- diagnosed in [**2135**] and on and off HAART since then.
- last CD4 241 and VL undetectable in [**2-/2151**]
2. Alcohol abuse, ongoing. Fatty liver/etoh hepatitis
- per pt has history of withdrawal seizures, DT's and states he
has been in ICU, intubated before
3. h/o IVDU "once"
4. h/o HSV
5. Asthma
6. Polysubstance Abuse
7. Hepatitis C, genotype 3, untreated
- VL 9,880,000 in [**8-/2150**]
8. h/o Right ankle fracture s/p ORIF in [**8-/2147**]
- complicated by osteomyelitis pseudomonas s/p 6 weeks of
cefipime and 2weeks of cipro until end of [**9-20**]
- recent notes indicate pt with Pseudomonas and Enterococcus
Cx's from osteomyelitis of R ankle, that was treated with 6wks
of IV Ampicillin through PICC and PO Cipro
9. ? Bipolar affective disorder
10. h/o multiple psychiatric hospitalizations, including suicide
attempts and mania.
11. UGIB X 1 [**10-21**], likely MW tear (in setting of n/v)
Social History:
Adopted, has mother/father (adopted), no children. Pt currently
living independently in apt and going to a day program. Has had
periods of sobriety, most recently was sober x1 month and before
that x3 months. For last several days has been having 4 pints
vodka daily Started drinking 23 yrs ago and PPD smoker x23 yrs.
Remote MJ, acid, endorses IVDU "once" and states he got HIV
through sexual contact.
.
Family History:
Adopted but does know some information about his biological
family
Biological mother - Bipolar affective disorder, "drug addict"
Biological father - Alcoholism
Biological brother - Schizophrenia
Physical Exam:
GEN: Slim young male. Shaky, diaphoretic
HEENT: Dry MM
LUNGS: Wheezing bilaterally
HEART: Tachy. Regular
ABD: NT/ND
EXTREM: No edema
NEURO: A+OX3. Tremulous.
Pertinent Results:
[**2151-6-20**] 03:05AM GLUCOSE-146* UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-20
[**2151-6-20**] 03:05AM ALT(SGPT)-140* AST(SGOT)-295* ALK PHOS-81 TOT
BILI-0.2
[**2151-6-20**] 03:05AM LIPASE-38
[**2151-6-20**] 03:05AM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2151-6-20**] 03:05AM LITHIUM-LESS THAN
[**2151-6-20**] 03:05AM ASA-NEG ETHANOL-273* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2151-6-20**] 03:05AM WBC-4.2 RBC-5.15 HGB-16.2 HCT-49.6 MCV-96
MCH-31.4 MCHC-32.6 RDW-15.9*
[**2151-6-20**] 03:05AM NEUTS-67.1 LYMPHS-21.7 MONOS-8.0 EOS-2.1
BASOS-1.0
[**2151-6-20**] 03:05AM PLT COUNT-146*#
Brief Hospital Course:
# ETOH abuse/ h/o withdrawl- Per pt, last withdrawl seizure last
mo at [**Hospital1 112**]. Was placed on valium (5mg) CIWA scale initially Q1H
and was able to wean down to Q4-5H. The patient then requested
(afer about 30 hours in hospital) to leave AMA. He wanted to get
to a day program instead. The risks of leaving prior to full
detox were explained to him but he insisted on leaving. He
understood the risks of leaving including worsening withdrawal
symptoms, seizure and death but continued to want to leave AMA.
He spoke with SW who were unable to convince him to stay either.
He signed the AMA paperwork, his IV was discontinued, and he
left.
# HIV- last CD4 [**2-21**] 241, VL undetectable- No signs of infection
at this time. He was continued on combivir, tenofovir.
# [**Name (NI) **] Pt with AST/ALT elevation on admission likely [**3-16**] binge
drinking and trended down through his admission.
#[**Name (NI) 8134**] pt wheezy on exam on admission but refused nebs.
Prefers his inhalers.
# FEN: No IVF, replete electrolytes, regular diet, folic acid,
MVI, thiamine
# Prophylaxis: Subcutaneous heparin
# Access: peripherals
# Communication: Patient
# Code: Full (discussed with patient)
Medications on Admission:
Pt notes he has not been taking any of his medications in the
last week.
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 4 hours as needed for asthma exacerbation
BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - Apply to facial
eczema daily
x 4 days. Do not use for more than 4 days at a time.
FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth DAILY (Daily)
FLUTICASONE - 50 mcg Spray, Suspension - Two sprays ea nostril
once daily.
GABAPENTIN - 300 mg Capsule TID
IBUPROFEN - 600 mg Tablet TID PRN
LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet [**Hospital1 **]
LITHIUM CARBONATE - 300 mg TID
LORAZEPAM - 0.5 mg daily PRN
MONTELUKAST [SINGULAIR] - 10 mg daily
TENOFOVIR DISOPROXIL FUMARATE - 300 mg daily
CETIRIZINE - 10 mg daily
.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
8. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for allergies.
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH withdrawal
Discharge Condition:
Patient left AMA. Was competent to make his own decisions.
Understood the risks of leaving AMA.
Discharge Instructions:
You were admitted with alcohol withdrawal. You were advised to
stay in the hospital for at least 72 hours but you wanted to
leave against medical advice. You were explained the risks of
leaving which include having withdrawal symptoms and seizures
which can be dangerous. You still wanted to leave.
Followup Instructions:
Please call your primary care physician to follow up in the next
few weeks. In addition please attend your day program and please
come back to the ED if you have symptoms of withdrawal.
|
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icd9cm
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|
2052, 2459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,758
| 156,517
|
5551
|
Discharge summary
|
report
|
Admission Date: [**2124-5-24**] Discharge Date: [**2124-6-1**]
Date of Birth: [**2060-6-24**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
perforated viscous
Major Surgical or Invasive Procedure:
[**2124-5-24**]
Exploratory laparotomy, right hemi colectomy, end ileostomy, G
tube placement, primary repair of ventral hernia
[**2124-5-28**]
left basilic PICC line
History of Present Illness:
Ms [**Known lastname **] is a 63yF with COPD who presented to an OSH with
chest pain. She had a R 9th rib fracture and was admitted for
approximately a week for treatment of COPD and pain. She was
discharged over the weekend and presented back to the hospital
today with nausea, flank pain, chills, diaphoresis. She denies
abdominal pain, dysuria. There, she had a leukocytosis to 30K
and
a CT demonstrating free air and contrast extravasation. She was
hypotensive in the 70's so she was transfered to [**Hospital1 18**] for
further management.
Of note she was started on prednisone for the COPD exacerbation
on the last admission and has been on a prednisone taper (?2mg
PO
daily). She has been taking ~800 ibuprofen daily for the last
several days for the flank/chest pain. She denies abdominal
pain.
She has a large chronically incarcerated ventral/umbilical
hernia
that is non-tender and unchanged in appearance.
Past Medical History:
PMH: obesity, chronic umbilical hernia incarcerated x 1 year,
COPD, HLD, HTN, depression
PSH: tonsillectomy as a child
Social History:
She is single, lives alone, has 4 adult children. Retired
teacher. Smokes 1ppd x 40 years, still smoking. Prior EtOH
abuse, sober > 10 years. Denies illicits. No known
environmental exposures. No known TB exposures. She does have
one dog at home.
Family History:
NC
Physical Exam:
T 96.3 HR 104 BP 71/55 RR 18 SAT 95%
Gen: A and O x 3, NAD
Card: RRR
Pulm: decreased BS B bases CTA
Abd: obese, soft, non-tender no rebound no guarding umbilical
hernia (unable to reduce) attenuated skin overlying the hernia
no
erythema no edema hernia non-tender
Ext: no edema
Pertinent Results:
[**2124-5-24**] 04:05PM WBC-19.4*# RBC-5.70* HGB-16.4* HCT-49.7*
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.6
[**2124-5-24**] 04:05PM NEUTS-76* BANDS-20* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-5-24**] 04:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2124-5-24**] 04:05PM PLT SMR-NORMAL PLT COUNT-252
[**2124-5-24**] 04:05PM PT-14.1* PTT-23.2 INR(PT)-1.2*
[**2124-5-24**] 04:05PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-69 TOT
BILI-2.2*
[**2124-5-24**] 04:05PM GLUCOSE-148* UREA N-31* CREAT-1.5* SODIUM-134
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-20
[**2124-5-24**] 10:53PM WBC-14.3* RBC-4.52 HGB-13.6 HCT-40.7 MCV-90
MCH-30.0 MCHC-33.4 RDW-13.4
[**2124-5-24**] 04:13PM LACTATE-3.0*
Brief Hospital Course:
On [**5-24**] the patient was taken to the OR and had a R
hemicolectomy, end-ileostomy and G tube placement. She was taken
to the TSICU post operatively for resuscitation as she was
intubated with a pressor requirement. On POD 1, her pressors
were weaned off and her vent settings were weaned to PS. On POD
2, the patient was extubated and she was started on a steroid
taper. She remained stable in the TSICU so she was transferred
to the floor.
Following transfer to the Surgical floor she was evaluated by
the Pulmonary service to assess the need for long term steroid
treatment. They recommended weaning her steroids quickly as she
was not on them long term and that would also help in wound
healing. Other than vigorous pulmonary toilet including chest
PT and incentive spirometry she will follow up with them as an
out patient for PFT's and further assessment of her COPD.
As her bowel function returned, her diet was gradually advanced
slowly and she tolerated it well. Her G tube remained clamped.
She did have daily drainage around the tube notable for dark
brown/black fluid which was odorless. There was no pain or
induration around the tube and her WBC was normal. This will be
followed closely. Her surgical wound had surrounding ecchymosis
but no drainage and retention sutures remained in place.
A PICC line was placed as she had poor venous access and
required a 10 day course of antibiotics as she was perforated
with a WBC of 30K on admission. Her vancomycin and Zosyn will
end on [**2124-6-3**]. Her last Vanco trough was 12.3 on [**2124-5-31**].
The ostomy nurse saw her on a regular basis for ostomy care and
teaching along with her daughters. She still needs instruction
and hopefully as she becomes more mobile she'll be better able
to do the care.
Due to her size, COPD and deconditioned state, the Physical
Therapy service recommended a short term rehab prior to
returning home and she was discharged on [**2124-6-1**].
Medications on Admission:
simvastatin 20 qhs, lisinopril 10', citalopram 40', singulair 10
qhs, HCTZ 12.5', advair 250/50, proair, prednisone 10', nicotine
patch
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing, poor airmovement, sob.
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. simethicone 80 mg Tablet, Chewable Sig: 1/2-1 Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
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. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 Gm.
Recon Solns Intravenous Q6H (every 6 hours): thru [**2124-6-3**].
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Gm
Intravenous Q 24H (Every 24 Hours): thru [**2124-6-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Perforated cecum
COPD
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.
*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 [**5-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 1 week.
Call the Pulmonary Clinic at [**Telephone/Fax (1) 612**] for a follow up
appointment in [**3-17**] weeks. You will need pulmonary function
studies prior to your appointment and the secretary will arrange
that for you.
Completed by:[**2124-6-1**]
|
[
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"287.5",
"995.92",
"557.0",
"276.2",
"496",
"038.9",
"518.0",
"785.52",
"401.9",
"311",
"272.4",
"278.00",
"305.1",
"V85.41",
"552.21",
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] |
icd9cm
|
[
[
[]
]
] |
[
"46.23",
"38.97",
"43.19",
"53.51",
"38.93",
"45.72"
] |
icd9pcs
|
[
[
[]
]
] |
6857, 6929
|
2966, 4924
|
294, 464
|
6995, 6995
|
2161, 2943
|
9047, 9393
|
1842, 1846
|
5110, 6834
|
6950, 6974
|
4950, 5087
|
7178, 8636
|
8652, 9024
|
1862, 2142
|
236, 256
|
492, 1411
|
7010, 7154
|
1433, 1554
|
1570, 1826
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,015
| 184,837
|
11823
|
Discharge summary
|
report
|
Admission Date: [**2141-2-9**] Discharge Date: [**2141-2-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F with DM, HTN p/w chest pain and shortness of breath.
Patient is poor historian, so history was obtained from patient
and patient's family.
.
At around 4 p.m. yesterday, the patient had just returned home
from a meal of chinese food when she walked up one flight of
stairs and experienced the acute onset of severe dyspnea. She
went to sleep for a couple of hours and awoke with mild chest
pain. The patient cannot characterize the chest pain further.
The patient's family reports that she also experienced nausea,
coldness, severe fatigue, and difficulty sleeping during the
night. The shortness of breath became worse in the morning,
leading the patient to present to the emergency room. The
patient vomited once in the car.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, abnormal
bleeding myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for baseline dyspnea with 1
flight of stairs. The patient sleeps her side. Denies PND. She
has had swelling in her feet/ankles, but not currently. No
palpitations or syncope.
.
In the ED, initial vitals were HR 124 BP 210/93 RR 38 Sat
97%/NRB. Placed on Bipap, started on nitro gtt at 6 mcg/min and
given lasix 40 mg IV. Given ASA. ECG showed inf lat st dep, STE
AVR and I. Trop elevated to 2.5. TTE showed apical hypokinesis.
Cards evaluated. Plavix 600 mg and heparin given. Breathing
improved and more comfortable. Vitals at time of sign-out were
HR 89, BP 138/80, RR 23, Sat 98% on Bipap 8/5. Just prior to
transfer, the patient was weaned down to 4L nasal canula with O2
sats in the mid 90s.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
-memory loss
-osteoarthritis knees, hands, finger
-microalbuminuria, chronic kidney disease
Social History:
Has 6 children (one died). Lives with son.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Multiple children with CAD. Son died of leukemia.
Physical Exam:
VS: T=97.6 BP=147/75 HR=91 RR=25 O2 sat=93%/4L
GENERAL: WDWN female in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: Supple. No carotid bruits.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Normal respiratory effort. Bibasilar rales.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2141-2-9**] WBC-13.2*# RBC-4.45 Hgb-12.5 Hct-39.6 MCV-89 MCH-28.1
MCHC-31.6 RDW-13.3 Plt Ct-267
[**2141-2-9**] Neuts-72.6* Lymphs-24.0 Monos-2.8 Eos-0.4 Baso-0.1
[**2141-2-9**] PT-11.0 PTT-23.9 INR(PT)-0.9
[**2141-2-9**] Glucose-406* UreaN-41* Creat-1.9* Na-133 K-4.6 Cl-100
HCO3-16* AnGap-22*
[**2141-2-10**] Calcium-9.6 Phos-4.0 Mg-2.0 Cholest-187
[**2141-2-10**] %HbA1c-7.1* eAG-157*
[**2141-2-10**] Triglyc-111 HDL-58 CHOL/HD-3.2 LDLcalc-107
.
Discharge labs:
[**2141-2-12**] 06:35AM BLOOD WBC-8.5 RBC-3.53* Hgb-9.9* Hct-30.3*
MCV-86 MCH-28.1 MCHC-32.6 RDW-13.3 Plt Ct-208
[**2141-2-12**] 06:35AM BLOOD Glucose-140* UreaN-74* Creat-2.2* Na-138
K-4.4 Cl-104 HCO3-23 AnGap-15
[**2141-2-12**] 06:35AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2
.
Cardiac enzymes:
[**2141-2-10**] 04:55AM CK(CPK)-838* CK-MB-80* MB Indx-9.5*
cTropnT-5.95*
[**2141-2-9**] 09:13PM CK(CPK)-1133* CK-MB-154* MB Indx-13.6*
cTropnT-6.65*
[**2141-2-9**] 03:10PM CK(CPK)-954* CK-MB-150* MB Indx-15.7*
cTropnT-2.56* proBNP-9711*
.
Urine:
[**2141-2-9**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2141-2-9**] URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-2-9**] URINE RBC-7* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
[**2141-2-9**] URINE CastHy-13*
[**2141-2-9**] URINE Hours-RANDOM UreaN-267 Creat-38 Na-98
.
Microbiology:
MRSA screen negative
.
EKG [**2141-2-9**]: Sinus tachycardia. Marked lateral ST segment
depression consistent with an acute ischemic process. No
previous tracing available for comparison.
.
Echocardiogram, transthoracic [**2141-2-10**]: The left atrium is normal
in size. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with septal
hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Regional LV systolic dysfunction c/w CAD.
.
CXR (portable AP) [**2141-2-9**]: Mild congestive heart failure.
.
CXR (PA and lateral) [**2141-2-10**]:
1. Improving pulmonary edema.
2. Basilar atelectasis versus pneumonia with right greater than
left pleural effusions.
3. Hilar prominence may represent vascular engorgement, although
attention should be paid to this area on followup.
Brief Hospital Course:
89 yo F with HTN and DM presents with acute shortness of breath
in setting of NSTEMI.
.
# NSTEMI: The patient presented with acute on chronic dyspnea
and lateral ST segment depressions that were suggestive of
ischemia. Her cardiac biomarkers were positive, with CK peaking
at 1133 and troponin peaking at 6.65 on the evening of [**2141-2-9**].
Echocardiogram showed regional wall motion abnormality in
anterior septum. The patient was treated with aspirin, Plavix,
nitroglycerin gtt, heparin gtt, Lipitor, and metoprolol. Cardiac
catheterization was deferred because of patient preference.
Heparin gtt was stopped after 48 hours. The patient was
discharged on aspirin, Plavix, Lipitor, and metoprolol. She was
also given a prescription for nitroglycerin. Lisinopril was
stopped due to acute renal failure. The patient's coronary
artery disease risk factors, which include hypertension,
hyperlipidemia, and diabetes, are discussed below. Primary care
and cardiology follow-up were arranged.
.
# Acute diastolic heart failure/shortness of breath: The patient
presented with shortness of breath, for which she was treated
with nitroglycerin, Lasix, and Bipap. The patient's respiratory
status improved rapidly, and she was able to be weaned off of
Bipap just prior to transfer from the emergency department to
the CCU. Echocardiogram showed septal hypokinesis, likely of
ischemic etiology. EF 45-50%. The patient's acute diastolic
heart failure was thought to be due to chronic hypertension and
acute MI, which was treated as above. The patient was discharged
on metoprolol succinate. No ACE inhibitor was prescribed due to
renal failure. The patient was advised to weigh herself daily
and adhere to a low-sodium diet.
.
# Acute on chronic kidney injury: The patient presented with
creatinine 1.9, increased from baseline 1.3. Creatinine peaked
at 2.4 and was 2.2 at the time of discharge. The acute component
of the patient's renal failure was thought to be pre-renal,
related to acute systolic heart failure. Consistent with this
idea, FeUrea was 33. The chronic component of the patient's
renal failure was thought to be related to her longstanding
diabetes and hypertension. Lisinopril and glyburide were both
discontinued due to the patient's renal failure.
.
# Diabetes mellitis: HbA1c was checked and was 7.1, improved
from 8.8 when last checked in [**2140-11-8**]. The patient was
treated with insulin sliding scale while in the hospital. She
was discharge on glipizide (with her glyburide discontinued due
to impaired kidney function). The patient was warned of the
signs and symptoms of hypertension and how to manage this.
.
# Hypertension: Lisinopril was distinued, and the patient was
started on metoprolol. She will follow up with her primary care
doctor and with cardiology for further management of her
hypertension.
Medications on Admission:
glyburide 1.25 mg PO daily
lisinopril 5 mg PO daily
ASA 81 mg PO intermittently
multivitamin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(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. Glipizide 5 mg Tablet Sig: one half Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 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*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: Place one tablet under your tongue for
chest pain. [**Month (only) 116**] repeat up to two times at 5 minutes intervals.
Go to the emergency room if you still have pain after 2 tablets.
Disp:*10 tablets* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
1. non-ST elevation myocardial infarction
2. Acute diastolic heart failure
.
Secondary:
1. Diabetes
2. Hypertension
Discharge Condition:
Alert and oriented. Hemodynamically stable. Chest-pain free.
Breathing comfortably. Satting well on room air.
Discharge Instructions:
You came to the hospital with difficulty breathing. You were
found to have a heart attack and congestive heart failure. You
were treated with medications, with improvement in your
breathing.
.
You had a decrease in your kidney function which was felt to be
related to your heart failure. You will need to follow up with
Dr. [**Last Name (STitle) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**] for close monitoring of your kidney
function.
.
Due to your decrease in kidney function, it is no longer safe
for you to take glyburide. You have been prescribed a different
medication call glipizide to take instead. Also, due to your
decreased kidney function, your lisinopril had been stopped.
Discuss these medication changes with Dr. [**Last Name (STitle) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**].
.
You should monitor your blood sugar at home. Monitor yourself
for symptoms of dizziness, confusion, or sweatiness, these can
be signs of a low blood sugar. Please call your primary care
phyisican if your blood sugar is <50 or >400.
.
There are some changes to your medications:
-START aspirin 325 mg daily
-START Plavix 75 mg daily
-START metoprolol XL 75 mg daily
-START Lipitor 80 mg daily
-START glipizide 2.5 mg daily
-STOP glyburide
-STOP lisinopril
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Eat a diet that is low in sodium.
.
You have appointments for cardiology, primary care, and podiatry
follow-up, as indicated below.
Followup Instructions:
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN, [**Name8 (MD) 16569**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1579**]
Date/Time:[**2141-2-15**] 1:30
.
Podiatry:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2141-2-15**] 3:00
.
Cardiology:
Dr. [**First Name (STitle) 37342**] [**Name (STitle) 37343**]/Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] Phone: [**Telephone/Fax (1) 62**]
Date/time: [**2-27**] at 1:20pm.
|
[
"427.31",
"414.01",
"250.00",
"584.9",
"428.31",
"585.9",
"428.0",
"410.71",
"272.4",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9816, 9887
|
5952, 8783
|
280, 287
|
10056, 10168
|
3124, 3124
|
11751, 12319
|
2559, 2610
|
8926, 9793
|
9908, 10035
|
8809, 8903
|
10192, 11298
|
3607, 3881
|
2625, 3105
|
2233, 2303
|
11327, 11728
|
3898, 5929
|
221, 242
|
315, 2125
|
3140, 3591
|
2334, 2427
|
2147, 2213
|
2443, 2543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,953
| 147,079
|
48723
|
Discharge summary
|
report
|
Admission Date: [**2115-8-9**] Discharge Date: [**2115-8-15**]
Date of Birth: [**2060-8-8**] Sex: F
Service: SURGERY
Allergies:
Reglan / Compazine / Gentamicin / Sulfa (Sulfonamide
Antibiotics) / Tigan / Meperidine / Prednisone / Cefotaxime /
Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Heparin Agents / Fluconazole / Meropenem /
Tizanidine / Ativan / Loperamide / Iodine Containing Agents
Classifier / Feraheme
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
facial swelling, nausea, headaches
Major Surgical or Invasive Procedure:
[**2115-8-9**]: Superior vena cava reconstruction with bovine
pericardial patch and superior vena cava endarterectomy
History of Present Illness:
54 year-old female with history of SVC syndrome with stenosis of
right subclavian, s/p s/p angioplasty by IR [**2101**], HIT s/p 30
days treatment with Fondaparinux, previously treated for similar
symptoms six weeks ago now
presenting with nausea, vomiting, headache and blurry vision
with
increased neck swelling. Patient states symptoms started several
days ago, and became worse this past weekend with increased
headache and blurry vision. She states symptoms were similar to
previous episodes, although she notes she does feel nauseous
with her Crohn's flares, which she is currently experiencing.
The
patient states symptoms worsen when she reclines or sits back,
and that nothing in particular has made it better. Pt states her
swelling and nausea increase when she lifts her arms above her
head. She otherwise has noted some increased swelling in her
arms and legs and significant swelling of her neck bilaterally.
She has a history of fibromyalgia and is on chronic pain
medication, but denied any isolated or new pain in her lower or
upper extremities.
Past Medical History:
1. Crohn's disease:
- Diagnosed [**2079**]
- S/p ~13 surgeries including transverse / ascending colectomy
- Rectovaginal fistula
2. Short bowel syndrome
3. History of multiple SBOs
4. SVC syndrome s/p angioplasty
- ~[**2101**]: episode of facial and neck swelling; noted to have
stenoses of right subclavian and SVC
- Angioplasty by IR
5. HIT+ Ab: s/p 30 days treatment with Fondaparinux
6. Mediastinal lymphadenopathy NOS: followed by Dr. [**Last Name (STitle) 575**]
7. Pulmonary nodules
8. Hypothyroidism
9. Parathyroid adenoma s/p removal
10. PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
11. Depression & Anxiety
12. Fibromyalgia
13. History of gastric dysmotility; has been on TPN in past
14. History of line/portocath infections (partic w/ coag neg
staph)
15. Fatty liver with mildly elevated LFTs at baseline
16. Anemia, iron deficiency
17. S/p TAH BSO
18. S/p cholecystectomy
[**23**]. S/p Right knee meniscal surgery [**3-/2114**]
20. S/p Left knee meniscal surgery [**4-/2114**]
21. nephrolithiasis
Social History:
The patient lives with her husband and she has 5 children (3
biologic, 2 step). She is currently disabled. Used to work as
pre-school and kindergarten teacher. Denies any history of
tobacco, ETOH or illicit drugs.
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
Exam on discharge:
Awake, alert and oriented x3, in no acute distress.
PERRLA, EOMI bilaterally, facial swelling much improved, no
plethora, no JVD.
Neck supple, no lymphadenopathy
Chest clear to auscultation bilaterally, regular rate any
rhythm, sternotomy site C/D/I, sternum stable.
Abdomen soft, mildly distended, with soft hematoma at LLQ,
mildly tender to palpation.
1+ edema b/L LE, pulses palpable, feet warm.
Pertinent Results:
[**2115-8-15**] 02:55PM BLOOD WBC-9.1 RBC-3.22*# Hgb-8.8* Hct-26.6*
MCV-83 MCH-27.5 MCHC-33.2 RDW-15.7* Plt Ct-330
[**2115-8-15**] 04:05AM BLOOD Na-143 K-2.9* Cl-106
[**2115-8-15**] 04:05AM BLOOD Mg-1.3*
[**2115-8-15**] 08:41AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2115-8-15**] 08:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Ms. [**Known lastname 1007**] is an unfortunate woman with long history of Crohns
disease, fibromyalgia, short gut syndrome, and many central
lines, ultimately resulting in widespread venous thromboses and
superior vena cava syndrome manifesting as severe facial and
shoulder swelling, nausea, and headaches. She had an attempted
venogram during her last hospitalization, which was aborted
because the SVC stenosis was too tight. Thus, she went to the
operating room on [**2115-8-9**] with the vascular and cardiothoracic
surgery services for a open SVC/ R subclavian thrombectomy and
patch angioplasty. The procedure was uncomplicated. PLease see
operative reports dictated by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**] for
details of the operation.
Postoperatively, she was extubated successfully and transferred
to the ICU. Her pain and anxiety were well controlled with IV
medications via a femoral venous line. Due to a history of
HITT, she was started on therapeutic fondaparinux on POD0. She
was also started on IV lopressor for hypertension, which was
converted to POs once she was tolerating a diet. She was
advanced to regular diet and was transferred to the VICU on
postoperative day two. She became somewhat anemic and was
transfused a unit of RBC for a Hct of 23. However, as the
infusion was running, she began complaining of severe LLQ
abdominal pain. Her gastroenterologist [**First Name4 (NamePattern1) 12556**] [**Last Name (NamePattern1) 79**] was called,
and recommended an abdominal CT scan to evaluate her bowel and
her left sided groin line. The CT scan revealed extravasation
of IV contrast from the groin line and a small hematoma in the
subcutaneous tissues. Thus her left groin line was pulled.
Chronic pain service was consulted to assist in PO pain
management, and recommended morphine elixer, which actually
controlled her pain relatively well. She was also restarted on
valium, benadryl, and phenergan PRN.
Her hematocrit continued to trend down slowly, to a low of 21.5
on POD 5. She also had some bowel movements that were
reportedly mixed with blood, and did have guaiac positive
stools. Cdif toxin was found to be negative. As she did not
have IV access, she was given a dose of subcutaeous Epogen and
oral lasix. Her hematocrit was found to be 26.5 at the time of
discharge. She was evaluated by physical therapy, who
determined that she was safe for discharge home. She will be
discharged with 6 days worth of her current pain/anxiety
medications, which are working pretty well for her. A followup
appointment has been made with her PCP [**Last Name (NamePattern4) **] 4 days to assess her
need for further pain medications, and check her hematocrit.
Medications on Admission:
Citalopram 40mg qd
cyanocobalamin 500mcg spray, 1 spray per nare per week
ergocalciferol 1,000 unit, 1 capsule q week for 8 weeks
estradiol 10mcg 1 tablet two times/week
fexofenadine 180mg, 1 tablet qd
hydromorphone 2mg tablet, 2 tablets q4hours prn pain
levothyroxine 50mcg 1 tablet qd
oxazepam 15mg capsule, 1 qam and 2qhs capsule(s) [**Hospital1 **]
tramadol 50-100mg TID prn pain
Discharge Medications:
1. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
Disp:*30 * Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO once a
day.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for insomnia.
8. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*25 Tablet(s)* Refills:*0*
9. promethazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for nausea.
Disp:*50 Tablet(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
11. 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:*11*
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
15. morphine 10 mg/5 mL Solution Sig: 7.5-15 mL PO Q3H (every 3
hours) as needed for pain.
Disp:*750 mL* Refills:*0*
16. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for anxiety.
Disp:*25 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA, Inc
Discharge Diagnosis:
Superior vena cava syndrome.
Discharge Condition:
Good condition
Pain controlled
Ambulating independently
Tolerating regular diet
Discharge Instructions:
You may shower; allow warm soapy water to run over incisions. No
no soaking tub baths x 6 weeks
Sternal precautions x 10 weeks total : no
pushing/pulling/lifting >10lbs. Remember to wear your post op
surgical bra.
No driving for at least four weeks, until cleared by surgeon.
You should never drive while taking narcotics.
Please call if you experience any of the following:
-Fever > 101.5
-Redness or drainage at your surgical incision site
-Chest pain or shortness of breath
-Acute pain or swelling in the extremities
Followup Instructions:
Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2115-8-21**]
10:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2115-9-2**] 1:15
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2115-9-3**] 1:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2115-8-19**] 11:20
Completed by:[**2115-8-15**]
|
[
"280.9",
"789.03",
"729.1",
"511.9",
"792.1",
"V14.8",
"453.77",
"459.2",
"244.9",
"453.76",
"401.9",
"579.3",
"453.75",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.15",
"00.40",
"37.49"
] |
icd9pcs
|
[
[
[]
]
] |
9022, 9086
|
4169, 6898
|
605, 727
|
9159, 9241
|
3727, 4146
|
9812, 10344
|
3162, 3274
|
7333, 8999
|
9107, 9138
|
6924, 7310
|
9265, 9789
|
3289, 3289
|
531, 567
|
755, 1820
|
3308, 3708
|
1842, 2914
|
2930, 3146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,423
| 115,466
|
5214
|
Discharge summary
|
report
|
Admission Date: [**2198-9-5**] Discharge Date: [**2198-9-13**]
Date of Birth: [**2129-6-11**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Respiratory Distress, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI - This is a 69 y/o Russian-speaking male with PMH
significant for metastatic renal CA to brain and lungs, s/p LLL
lobectomy, s/p TURP [**1-18**] prostate CA, colon CA s/p colectomy, who
presents to the ED from NH with respiratory distress. History is
limited by patient's non-verbal state and wife's limited
English. Per wife, patient has been in the [**Name (NI) **] since [**5-22**] [**1-18**] CVA
involving the right extremities. His mental status has been poor
at baseline and has increasingly worsened to a non-verbal state
approx one month ago. Beginning two nights ago, the patient was
noted to have some respiratory distress, requiring oxygen and
was started on Augmentin for a presumed PNA. However, his
respiratory status did not improve and was noted to have a
low-grade temp of 100.9, RR 30, HR 140, BP 155/88, SaO2 94% on
supplemental O2 (unknown amount), prompting the NH to send the
patient to the ED early this morning.
.
In the ED, he was noted to have a Tc of 103.8 (rectally), HR
134, BP 124/74, RR 42, SaO2 88%/NRB. His labs were notable for a
WBC of 27.9 (97% N, no bands) and lactate of 2. He received
combivent nebs, 1 gm tylenol pr, 500 cc of NS bolus, 1 gm
ceftaz, 500 mg IV flagyl, and 1 gm of vanc. His sats improved
while in the ED and he was weaned down to 4 L NC. ABG on 4L was
7.49/34/82/31.
Patient was admitted to the MICU and admitted on broad spectrum
antibiotics. Discussion was held with family and patient was
made DNR/DNI/no pressors.
Past Medical History:
PMH -
1. Metastatic renal CA - s/p right nephrectomy 17 yrs ago; s/p
immunotherapy in [**2193**], followed at [**Hospital1 336**]. Mets to b/l lungs and
brain, follows with neuro-onc at [**Hospital1 336**].
2. s/p LLL lobectomy - ?[**1-18**] mets from renal CA
3. s/p prostate resection [**1-18**] prostate CA - [**2191**]
4. s/p CVA [**5-22**], affecting right side
5. NIDDM
6. COPD
7. A fib
8. Colon ca, dx [**2197**] - s/p colectomy
Social History:
SH - Lives at [**Location **] since CVA [**5-22**]. Russian-speaking only. Former
smoker, quit in [**2191**]. Occasional EtOH, no illicits. Wife lives
in area, has children living outside of [**Location (un) 86**].
.
Family History:
.
FH - NC
Physical Exam:
VS: Tc , BP , HR , RR , SaO2 98%/3L NC
General: Non-verbal elderly male in NAD. Unable to clear
secretions and copious secretions [**1-18**] food noted.
HEENT: NC/AT, PERRL, able to track movements with eyes.
Anicteric sclerae. MM dry. Food noted in mouth.
Neck: supple, no JVD noted
Chest: Diffuse rhonchi b/l, with rales in RLL.
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, NT/ND, minimal BS. Midline abdominal scar noted.
Ext: no c/c/e, cool extremities. Pulses 2+ b/l
Neuro: Non-verbal, moves left side freely, withdraws to pain,
tracks movements purposefully with eyes.
.
Pertinent Results:
[**2198-9-8**] 12:28AM BLOOD calTIBC-144* Ferritn-1183* TRF-111*
[**2198-9-5**] 06:15AM BLOOD Glucose-135* UreaN-22* Creat-0.5 Na-147*
K-3.3 Cl-106 HCO3-29 AnGap-15
[**2198-9-11**] 04:40AM BLOOD Glucose-118* UreaN-44* Creat-2.2* Na-145
K-4.2 Cl-109* HCO3-27 AnGap-13
[**2198-9-13**] 04:58AM BLOOD Glucose-187* UreaN-53* Creat-2.0* Na-141
K-4.0 Cl-102 HCO3-27 AnGap-16
[**2198-9-13**] 04:58AM BLOOD WBC-19.0* RBC-3.32* Hgb-8.7* Hct-27.0*
MCV-81* MCH-26.3* MCHC-32.4 RDW-16.8* Plt Ct-580*
[**2198-9-5**] 06:15AM WBC-27.9* RBC-4.40* HGB-12.0* HCT-36.4*
MCV-83 MCH-27.4 MCHC-33.1 RDW-17.1*
.
[**2198-9-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2198-9-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, STAPH AUREUS COAG +} INPATIENT
[**2198-9-5**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-9-5**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL INPATIENT
[**2198-9-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
.
RENAL ULTRASOUND:
The patient is status post right nephrectomy. The left kidney
measures 13.4 cm. The calyces are mildly prominent throughout
the left kidney, however, there is no frank evidence of
hydronephrosis. No stones or masses are identified. The bladder
is catheterized and empty.
.
Video Swallow:
FINDINGS: Video oropharyngeal fluoroscopic swallowing evaluation
was performed in conjunction with speech and swallow pathology.
Patient was administered various consistencies of barium
including thin, nectar, thick, and ground cookie. Posterior oral
transit was moderately delayed. In addition, swallowing
initiation was severely impaired with significantly delayed
swallowing initiation to large boluses. When swallow was
initiated, there was some adequate epiglottic deflection, and
laryngeal valve closure. However, there was silent aspiration to
thin liquids. The patient had difficulties following commands
during the examination, and would not take cookie or straw.
IMPRESSION: Severe swallow initiation delay with aspiration to
thins. For further details, please consult the speech and
swallow pathology note.
.
CT Head:
CLINICAL INDICATION: Metastatic renal cell carcinoma with
somnolence, assess for intracranial hemorrhage.
There is a large hyperdense lesion involving the left frontal
lobe near the convexity measuring 4.2 x 4 cm and surrounded by
vasogenic edema, with mass effect seen over the left lateral
ventricle. There is minimal midline shift to the right. The
edema extends inferiorly into the left frontoparietal white
matter and the left temporal lobe. The ventricular system is not
dilated. There is no intraparenchymal or subdural hemorrhage.
The fourth ventricle remains in the midline. There is
heterogeneous hyperdense lesion abutting the right frontal
aspect of the calvarium along the midline. This could represent
volume averaging. No lytic lesions are identified. Chronic
mucosal thickening is seen within the paranasal sinuses.
.
IMPRESSION: 4-cm hyperdense necrotic mass lesion involving the
left frontal lobe surrounded by significant vasogenic edema and
associated with sulcal effacement and surrounding mass effect as
noted above. This is most likely metastatic in nature given the
history of renal cell cancer. No intraparenchymal hemorrhage was
seen.
.
CT Chest:
Multidetector CT of the chest was performed without intravenous
or oral contrast administration. Images are presented for
display in the axial plane at both 5-mm and 1.25-mm collimation.
.
There is near complete opacification of the remaining portion of
the left lung with only a small amount of residual aerated lung
at the apical portion. Assessment of the central airways
demonstrates complete obstruction of the left main bronchus just
beyond its origin. The contents within the obstructed bronchus
range from fluid to soft tissue attenuation. Superiorly, there
are some areas of consolidation and ground-glass superimposed
upon underlying areas of emphysema, but beginning in the mid
portion of the left lung, opacified lung is relatively
homogeneous without air bronchograms. An area of curvilinear
calcification is present in the lower left hemithorax
posteriorly and there are surgical clips present in the
paraaortic and perihilar regions.
.
The left lobe of the thyroid gland is markedly enlarged and
heterogeneous. The superior portion of the enlarged lobe is not
completely imaged on this scan, and it is difficult to exclude
adjacent areas of lymphadenopathy in the left neck as well. The
enlarged thyroid gland results in rightward displacement and
coronal narrowing of the trachea which is narrowed to
approximately 8 mm at the thoracic inlet level. There is bulky
mediastinal lymphadenopathy on both sides of midline, with the
right paratracheal lymph node measuring up to 3.6 x 2.7 cm and a
left prevascular node measuring up to 2.5 x 3.0 cm. A bulky left
lower paratracheal lymph node measures 3.1 x 2.0 cm. The left
hilum is difficult to assess without intravenous contrast but
there is probable left hilar lymphadenopathy as well.
.
There is left-sided pleural thickening contiguous with the area
of homogeneous opacification in the left lower lung region. This
is contiguous with an area of chest wall destruction involving a
lower left lateral rib which is partially destroyed by the mass.
Enlarged nodes are also present in the lower left paraaortic
region and in the left extrapleural space.
.
Within the imaged portion of the upper abdomen, there are bulky
lymph node masses which are incompletely imaged on this study.
These are in the region of the celiac axis anterior to the
aorta, measuring up to approximately 5.5 and 6.4 cm in greatest
dimension. A left anterior peridiaphragmatic enlarged node is
present as well as left retroperitoneal node enlargement. The
adrenal glands are incompletely imaged on this study. Calcified
gallstone is observed within the gallbladder. No definite
lesions are seen within the liver but lack of intravenous
contrast limits assessment.
.
As noted, the trachea is compressed and displaced by the thyroid
mass. Fluid level within the intrathoracic trachea is probably
due to retained secretions. Within the right lung, there are
several small pulmonary nodules present, some of which are well
circumscribed, and others of which are more poorly defined. The
largest individual nodule is a poorly defined lateral segment
right middle lobe nodule measuring 10 mm on image 31 of series
3. Respiratory motion limits assessment of the right lower lobe
and right middle lobe.
.
Skeletal structures reveal partial destruction of the left
seventh lateral rib as described above. Post-thoracotomy changes
are present just above this level. Healed lower right anterior
rib fractures are noted without definite associated lytic
lesions.
.
Finally, incidental note is made of a calcified granuloma in the
periphery of the right middle lobe.
IMPRESSION:
1. Complete obstruction left main bronchus. Although possibly
due to retained secretions, obstructing endobronchial lesion is
likely in this patient with history of renal cell carcinoma.
Correlative bronchoscopy would be helpful.
2. Postobstructive collapse/consolidation in left upper lobe
(status post left lower lobectomy). Associated soft tissue mass
with dystrophic calcifications, contiguous or adjacent to chest
wall mass with destruction of the left lateral seventh rib.
3. Bulky mediastinal and upper abdominal lymphadenopathy
consistent with metastatic disease. Dedicated contrast-enhanced
CT torso could be considered to more completely characterize the
extent of metastatic disease if warranted clinically.
4. Marked enlargement of left lobe of thyroid gland with
displacement and compression of trachea. It is difficult to
exclude adjacent lymphadenopathy in the left neck.
5. Left-sided pleural thickening and small amount of pleural
fluid.
6. Scattered nodules in the right lung, some of which are well
defined and likely reflect metastatic foci and others of which
are poorly defined and likely are related to the infection.
.
Brief Hospital Course:
Hospital course, by Problem:
#Respiratory Distress: initially thought to be d/t aspiration
PNA. Was intially treated with broad spectum abx (Vanc, CTX,
Flagyl). Blood and Urine Cx negative but sputum did grow MRSA.
To sort out whether the patient simply had aspiration
pnuemonitis vs PNA, a CT scan of the chest was obtained. This
showed almost complete collapse of the remaining portion of his
left lung from a L mainstem bronchus lesion, concerning for
metastatic disease. It also showed narrowing of the trachea to
approx 8 mm from an enlarged left lobe of the thyroid, which is
stable in size according to his outside oncologists. Because of
renal failure (see below), the patient was switched to Linezolid
to cover MRSA; CTX/Flagyl were continued to cover for ?
post-obstructive process. He will complete a today of a 10 day
course of antitiotics to end on [**9-15**].
.
#Acute Renal Failure: during his hosptial course, his Cr rose
from a baseline of 0.3-0.4 to a peak of 2.2. Renal U/S
negative. Urine indicies not c/w pre-renal state, Urine Eos
neagtive. Renal team consulted; felt to be secondary to ATN,
most likely from vancomycin. Cr now starting to improve (2.0 on
day of discharge).
.
#Cerebral Mets: on CT scan, there was noted to me marked
vasogenic edmema. The patients DMS was increased to 4 mg IV q 8
hours and should be continued indefinatley as the patient
appears to be more awake when on the higher dose. They can be
decreased should the patient develop agitation.
.
#ONC issues/goals of care: after the Left mainstem lesion was
discovered, both interventional pulmonary team and radiation
team were consulted. Both felt that bronchoscopy and radition
therapy would add little to his quality/quantity of life, given
his extremely poor performance status and prognosis. His wife
was in agreement that he should not receive any invasive
procedures in the future. She understood that should the
patient develop subsequent respiratory distress, she should not
be brought back to the hospital but should be given morphine and
ativan for comfort.
.
#Anemia: high ferrtin c/w Anemia of Chronic Disease. Stable.
.
#FEN: the patient had speech/swallow evaluation which showed
moderate-severe oropharyngeal dysphagia characterized by reduced
bolus control and formation as well as a significant pharyngeal
swallow initiation delay with mild silent
aspiration of thin liquids. The speech/swallow team
recommended Nectar thick liquids and pureed solids, PO meds
crushed in purees, along with 1:1 assistance for meals, strict
aspiration precautions.
Medications on Admission:
MEDS (per NH record)
1. Lantus 40 units qHS, Novolin SS
2. Omeprazole 20 mg qd
3. Senna [**Hospital1 **]
4. Klonopin 0.25 mg qd
5. Percocet prn
6. Augmentin 500 mg tid
7. Decadron 1 mg qod (taper)
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs inhalation* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) GM Intravenous Q24H (every 24 hours): course to end [**9-15**].
Disp:*qs qs* Refills:*0*
6. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours): course
to end [**9-15**].
Disp:*qs mg* Refills:*0*
7. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous every twelve (12) hours: course to end
[**9-15**].
Disp:*qs qs* Refills:*0*
8. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four (4)
gm Injection Q8H (every 8 hours).
Disp:*qs gm* Refills:*0*
9. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42)
units Subcutaneous at bedtime: titrate accordingly.
Disp:*qs units* Refills:*2*
10. Morphine Concentrate 20 mg/mL Solution Sig: One (1) cc PO
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
11. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for Respiratory distress or anxiety.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
1. Post-obstructive PNA vs Aspiration PNA
2. Acute Renal Failure, likely secondary to Vancomycin
3. 8 mm Tracheal Narrowing secondary to thyroid enlargement
4. Complete obstruction left mainstem bronchus; retained
secretions
vs obstructing endobronchial lesion
5. Metastatic chest wall mass with destruction of the left
lateral
seventh rib
6. Renal cell carcinoma with 4-cm hyperdense necrotic mass
lesion
involving the left frontal lobe surrounded by significant
vasogenic edema
Secondary Diagnoses
1. Metastatic renal CA
2. s/p LLL lobectomy - ?[**1-18**] mets from renal CA
3. s/p prostate resection [**1-18**] prostate CA - [**2191**]
4. s/p CVA [**5-22**], affecting right side
5. NIDDM
6. COPD
7. A fib
8. Colon ca, dx [**2197**] - s/p colectomy
Discharge Condition:
DNR/DNI/DNH
Discharge Instructions:
Please make sure that the patient is as comfortable as possible.
Please, note, the patient is DO NOT HOSPITALIZE (DNH) per
discussion with his wife. [**Name (NI) **] should be treated for his
pneumonia until [**9-15**] and receive steroids indefinatley for his
cerebral mets. Should he develop respiratory distress, he
should not to be brought back to the hospital (per Wife's
wishes). In this case, should be given Morphine and Ativan prn,
titrated to comfort.
.
He can continue to receive his blood pressure meds and his
insulin can be titrated accordingly.
Followup Instructions:
None
|
[
"V10.46",
"198.3",
"496",
"V10.05",
"250.00",
"584.9",
"519.1",
"198.89",
"438.12",
"E930.8",
"427.31",
"486",
"285.22",
"V66.7",
"V10.52",
"438.82",
"197.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15689, 15759
|
11256, 13842
|
301, 308
|
16597, 16611
|
3148, 5303
|
17223, 17231
|
2527, 2538
|
14090, 15666
|
15780, 16576
|
13868, 14067
|
16635, 17200
|
2553, 3129
|
234, 263
|
336, 1818
|
5312, 11233
|
1840, 2277
|
2293, 2511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,816
| 106,671
|
36417
|
Discharge summary
|
report
|
Admission Date: [**2137-6-26**] Discharge Date: [**2137-7-7**]
Date of Birth: [**2080-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Theophylline / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2137-6-26**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] mechanical) and
Two Vessel Coronary Artery Bypass Grafting(left internal mammary
to left anterior descending with vein graft to diagonal)
History of Present Illness:
This is a 56 year old male with known coronary artery disease
and aortic stenosis. The history of coronary disease dated back
to [**2126**] when he had an Inferior Wall myocardial infarction. At
that time, he received a bare metal stent to the RCA. He
remained stable until [**2134**], when he developed chest pain. Cath
at that time revealed stenosis of the LAD and he received a DES.
In [**2136-11-28**] he was hospitalized and treated for pulmonary
edema. Cardiac cath on [**2137-4-30**] revealed LM and two vessel CAD. He
is also found to have severe AS on echo. He was subsequently
referred for AVR/CABG. Of note, he recently completed a course
of antibiotics for pneumonia. Currently breathing much better.
No fevers, chills, or rigors.
Past Medical History:
-Coronary artery disease s/p IWMI [**2126**] s/p BMS of RCA s/p DES to
LAD [**2134**]
-Hodgkin's Lymphoma, s/p radiation to chest and abdomen [**2113**]
-History of Paroxysmal Atrial Fibrillation dx [**2115**]
-Dyslipidemia
-Diabetes Mellitus Type II
-Hypothyroidism
-Reactive airway syndrome
-s/p Laparotomy, splenectomy
-s/p Biopsy of left clavicular node
-s/p Tonsillectomy
Social History:
Race: Caucasian
Last Dental Exam: [**2136-12-29**], Dr. [**Last Name (STitle) **] in [**Location (un) 1887**]
Lives with: wife, 1 child
Occupation: works in software quality assurance for Tyco Safety
Tobacco: none
ETOH: none
Family History:
No premature coronary artery disease
Physical Exam:
PREOP EXAM
Pulse: 85 regular Resp: 16 O2 sat: 100%
B/P Right: Left: 111/62
Height: 6'2" Weight: 244lb
General: NAD, appears older than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [] ROM limited [**1-30**] XRT + kyphosis
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic, radiation
markers on chest, pectus excavatum noted
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] - well-healed mid-line abdominal scar
Extremities: Warm [x], well-perfused [x] hair loss laterally
and
distally
Edema: None
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: no bruit noted, no significant murmur noted
Pertinent Results:
[**2137-6-26**] Intraop TEE: Pre Bypass: The left atrium is mildly
dilated. The left atrium is elongated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The number of aortic valve leaflets cannot be
determined. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. There
is [**1-31**]+ mitral regurgitation with calcification of the anterior
mitral leaflet. Jet appears central. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Due to co-existing aortic
regurgitation, the pressure half-time estimate of mitral valve
area [**Known lastname **] be an OVERestimation of true mitral valve area. There
is no pericardial effusion.
Post Bypass: A mechanical prosthesis is seen in the aortic
position (#23 St. [**Male First Name (un) 923**] per surgeons). On initial seperation from
bypass, a significant paravalvular leak is noted between 9 and
12 o'clock position (where the native non coronary cusp would
have been). Surgeons notified immediately and bypass reiniatied.
On second bypass wean, this jet is no longer present; only
symmetric washing type jets are seen. Peak gradients measure
20-30 mm hg, mean 12-21 mm Hg with cardiac output [**6-4**] Lpm and
systemic pressures of 100-120 systolic. Valve leaflets could not
be visualized due to significant artifacts. MR is now [**12-30**]+.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
[**2137-6-26**] 07:53PM BLOOD WBC-14.1* RBC-3.33*# Hgb-10.2*#
Hct-29.4*# MCV-88 MCH-30.6 MCHC-34.7 RDW-13.8 Plt Ct-169#
[**2137-6-27**] 03:41AM BLOOD WBC-10.5 RBC-3.37* Hgb-10.0* Hct-29.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-14.0 Plt Ct-153
[**2137-7-5**] 05:48AM BLOOD WBC-20.9* RBC-3.22* Hgb-9.3* Hct-28.7*
MCV-89 MCH-29.0 MCHC-32.6 RDW-14.1 Plt Ct-708*
[**2137-7-6**] 04:45AM BLOOD WBC-17.6* RBC-3.15* Hgb-9.3* Hct-28.1*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.1 Plt Ct-768*
[**2137-6-26**] 07:53PM BLOOD PT-14.7* PTT-34.9 INR(PT)-1.3*
[**2137-6-26**] 09:00PM BLOOD PT-13.6* PTT-37.8* INR(PT)-1.2*
[**2137-7-3**] 07:46AM BLOOD PT-19.8* PTT-57.5* INR(PT)-1.8*
[**2137-7-3**] 04:07PM BLOOD PT-28.9* PTT-150* INR(PT)-2.8*
[**2137-7-4**] 05:30AM BLOOD PT-28.1* PTT-41.1* INR(PT)-2.7*
[**2137-7-5**] 05:48AM BLOOD PT-30.0* INR(PT)-2.9*
[**2137-7-6**] 04:45AM BLOOD PT-27.3* INR(PT)-2.6*
[**2137-6-26**] 09:00PM BLOOD UreaN-12 Creat-0.7 Na-140 K-3.5 Cl-109*
HCO3-28 AnGap-7*
[**2137-7-6**] 04:45AM BLOOD Glucose-136* UreaN-18 Creat-1.0 Na-137
K-5.2* Cl-101 HCO3-26 AnGap-15
[**2137-7-6**] 04:45AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
[**2137-7-7**] 05:40AM BLOOD WBC-16.1* RBC-3.21* Hgb-9.2* Hct-28.7*
MCV-89 MCH-28.8 MCHC-32.2 RDW-14.1 Plt Ct-826*
Brief Hospital Course:
Mr. [**Known lastname 116**] was [**6-26**] admitted and underwent a mechanical aortic
valve replacement and coronary artery bypass grafting surgery by
Dr. [**Last Name (STitle) **]. For surgical details, please see operative note.
Following surgery, he was brought to the CVICU for invasive
monitoring in stable condition. Within 24 hours, he was weaned
from sedation, awoke neurologically intact and was extubated
without incident. He remained in the CVICU receiving aggressive
pulmonary toilet for an additional day and was transferred to
the step-down for on post-op day two. Beta blockers and
diuretics were started and he was diuresed towards his pre-op
weight. Coumadin was initiated for mechanical aortic valve but
INR quickly rose to be supra therapeutic at 5.4. Coumadin was
held, he received vitamin K and INR trended down. Coumadin was
restarted the following day with a gentle titration. On post-op
day four he was transferred back to the CVICU due to rapid
atrial fibrillation with hypotension and no IV access. PICC line
was placed and he was given initially given Cardizem and then
Amiodarone. Rhythm converted back to sinus rhythm and later on
the same day he was transferred back to step-down floor. But he
did continue to have atrial fibrillation/flutter which was
appropriately treated, along with EP consult. Chest tubes and
epicardial pacing wires were removed per protocol. He developed
bilateral arm phlebitis with elevated white count and was
started on IV antibiotics which was eventually changed to oral.
He will continue antibiotics for 10 days. In addition warm
compresses and ace wraps were applied per vascular consult. Over
the next several days he continued to slowly improve while
working with physical therapy for strength and mobility. In
addition his INR slowly trended up and was therapeutic at
discharge, 2.2. On post-op day 11 he was ready for discharge
home with VNA services and the appropriate medications and
follow-up. MWHC will follow INR and adjust Coumadin accordingly.
Medications on Admission:
sotalol 80mg [**Hospital1 **]
digoxin 0.375mg daily
lisinopril 5mg daily
crestor 10mg daily
aspirin 325mg daily
metformin 850 [**Hospital1 **]
glipizide 5mg daily
levothyroxine 150mcg daily
ventolin inhaler prn
Vit C 1000 mg daily
Vit D3 1000 IU daily
Vit B12 1000 mcg daily
MVI daily
SL NTG prn
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. 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*
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take 200mg twice daily for 7 days. Then 200mg daily
until stopped by cardiologist.
Disp:*40 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication: Mechanical aortic valve,
atrial fibrillation
Goal INR 2.5-3
First draw - day after discharge [**2137-7-8**]
Results to [**Hospital 82499**] [**Hospital 197**] clinic phone: [**Telephone/Fax (1) 6256**] fax:
[**Telephone/Fax (1) 31080**]
13. metoprolol tartrate 50 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: dose will change daily for goal INR 2.5-3.0.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic valve
replacement and coronary artery bypass graft x 2
Past medical history:
Hodgkins Lymphoma
Paroxsymal Atrial Fibrillation
Dyslipidemia
Type II Diabetes Mellitus
Hypothyroidism
Reactive airway syndrome
s/p Laparotomy, splenectomy
s/p Biopsy of left clavicular node
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 2+
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
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2137-7-10**] 10:15
at [**Hospital Unit Name 82500**]
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2137-7-18**] 1:45
Cardiologist: [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**] [**8-8**] at 3pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) **] in [**4-2**] 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: Mechanical aortic valve,
atrial fibrillation
Goal INR 2.5-3
First draw - day after discharge [**2137-7-7**]
Results to [**Hospital 82499**] [**Hospital 197**] clinic phone: [**Telephone/Fax (1) 6256**] fax:
[**Telephone/Fax (1) 31080**]
Completed by:[**2137-7-7**]
|
[
"V70.7",
"427.31",
"788.20",
"998.31",
"999.2",
"244.9",
"E879.8",
"424.1",
"272.4",
"250.00",
"427.32",
"493.90",
"V10.72",
"414.01",
"V45.82",
"451.82",
"790.92",
"E934.2",
"412",
"458.29",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"86.04",
"35.22",
"36.15",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10482, 10531
|
6135, 8154
|
319, 539
|
10914, 11128
|
2929, 6112
|
11967, 12965
|
1969, 2007
|
8500, 10459
|
10552, 10661
|
8180, 8477
|
11152, 11944
|
2022, 2910
|
260, 281
|
567, 1311
|
10683, 10893
|
1727, 1953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,447
| 171,317
|
12889
|
Discharge summary
|
report
|
Admission Date: [**2181-11-14**] Discharge Date: [**2181-12-17**]
Date of Birth: [**2106-3-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Indomethacin / Quinidine / Ativan
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
volume overload
Major Surgical or Invasive Procedure:
[**2181-11-16**] Thoracentesis
[**2181-11-16**] Bedside wound debridement
[**2181-11-19**] Sternal debridement and VAC dressing placement
[**2181-11-22**] Sternal debridement, plating and closure
History of Present Illness:
75 yo F s/p tissue AVR on [**10-16**] presented to office for routine
post op check with severe fluid overload and opening at inferior
pole of MSI.
Past Medical History:
Aortic Stenosis s/p AVR
Congestive Heart failure, Diabetes Mellitus, Gastroesophageal
Reflux Disease, Atrial Fibrillation, Hypertension, Anemia
Social History:
Married. Lives with her husband. Smoked cigarettes for 15 years
1ppd, quit 20 years ago.
Family History:
No premature cardiac disease history.
Physical Exam:
HR 86 irreg BP 200/80
General Very SOB
Lungs Decreased at the bases
Cor Irreg
Abdomen benign
Extrem 2+ edema
Sternal incision with discharge at the lower pole
Left chest tube site with large amounts of serous drainage.
Pertinent Results:
[**2181-12-16**] 04:34AM BLOOD WBC-10.4 RBC-2.85* Hgb-8.8* Hct-27.3*
MCV-96 MCH-30.7 MCHC-32.0 RDW-17.9* Plt Ct-188
[**2181-12-17**] 01:52AM BLOOD PT-26.3* INR(PT)-2.6*
[**2181-12-16**] 04:34AM BLOOD PT-25.1* PTT-31.1 INR(PT)-2.5*
[**2181-12-15**] 03:57AM BLOOD PT-19.4* PTT-29.4 INR(PT)-1.8*
[**2181-12-14**] 03:12AM BLOOD PT-15.7* PTT-27.5 INR(PT)-1.4*
[**2181-12-16**] 04:34AM BLOOD Glucose-88 UreaN-62* Creat-1.6* Na-145
K-4.2 Cl-111* HCO3-25 AnGap-13
CHEST (PORTABLE AP) [**2181-12-12**] 11:39 AM
CHEST (PORTABLE AP)
Reason: CHF
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p closure of chest after sternal wound
dehiscence
REASON FOR THIS EXAMINATION:
CHF
AP PORTABLE CHEST [**2181-12-12**] AT 12:01
HISTORY: Post-closure of chest after sternal wound dehiscence.
COMPARISON: Multiple priors, the most recent dated [**2181-12-10**].
FINDINGS: Horizontally oriented malleable plates over the
sternum are again evident, consistent with the given history.
While there is improved aeration of both lungs, significant
interstitial and alveolar edema are evident, predominantly in
the perihilar distributions with a gradient worse in the lung
bases. Bilateral effusions are noted. The cardiac silhouette
size remains enlarged but stable. There is a tortuous
atherosclerotic aorta again noted. An endotracheal tube is
evident and its distal tip lies approximately 7.0 cm from the
carina. A left subclavian approach central line is stable in
course and position with the distal tip at the superior
cavoatrial junction.
IMPRESSION: While the lungs are better inflated on the current
study, there is possibly worse bilateral interstitial and
alveolar pulmonary edema with bilateral pleural effusions again
evident. Endotracheal tube as above. Consider advancing 2.0-3.0
cm for optimal placement.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 39622**]
(Complete) Done [**2181-11-19**] at 12:19:07 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-3-5**]
Age (years): 75 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: sternal debridement post AVR.
ICD-9 Codes: 786.05, 799.02, 440.0, V43.3, 424.1, 424.0
Test Information
Date/Time: [**2181-11-19**] at 12:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Small 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.
Conclusions
Patient presented with severe SOB, wound dehiscence, one month
post AVR.
No spontaneous echo contrast is seen in the left atrial
appendage.
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular systolic function is borderline
normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. Aortic Valve:
Not able to clearly see individual leaflets. No aortic
regurgitation is seen. A peak gradient of 16, mean of 9 is
measured.
The mitral valve leaflets are moderately thickened. Trivial
mitral regurgitation is seen.
There is a small pericardial effusion, and large bilateral
pleural effusions.
Brief Hospital Course:
She was admitted to cardiac surgery. She was diuresed with lasix
and her medications were adjusted for her hypertension. She
awaited normalization of her INR before bedside sternal
debridement and right thoracentesis for 100 ml of serosanguinous
fluid on [**11-17**]. CT chest showed sternal dehiscense, and her
breathing worsened, and she was taken to the operating room on
[**11-20**] where she underwent sternal debridement, vac dressing
placement and bilateral chest tube placement. She was
transferred to the ICU in stable condition. She remained sedated
and paralyzed until she was taken back to the operating room on
[**11-23**] where she underwent sternal plating, and pec flap. She was
followed by ID. Cultures grew MSSA and she was started on
nafcillin which was switched to vanco for increasing creatinine.
She comntinued to require some neo. She was extubated on [**11-27**]
but required reintubation for respiratory failure. She was
started on fluconazole for yeast in urine and cefepime for
?pneumonia. She was seen by renal for ARF. She was bronched on
[**11-28**]. She was maintained on tube feeds. She was started on
natrecor for diuresis. She was started on cipro then meropenum
for pseudomonas in urine and sputum, and flagyl for ? of cdiff.
She required frequent transfusions and was guaiac positive. She
became hypernatremic and was started on free water flushes. She
was extubated again on [**12-6**]. She was seen by speech and swallow
and began a diet of thin liquids and ground solids. She had some
areas of necrosis and drainage on her sternal incision, and
reclosure in the OR was planned. SHe was taken back to the OR on
[**12-12**] where her sternal wound was debrided and reapproximated. She
was transferred back to the ICU. Swallow evaluation recommended
thin liquids and regular consistency solids. She was extubated
post op but required bipap overnight. She was restarted on
coumadin. OR cultures grew VRE and vanco was changed to
linezolid. After discussing the antibiotic plan with the ID
service, it was decided to change the Linezolid to Daptomycin
for a 6 week course. She progressed and was ready for discharge
to rehab on [**12-17**].
Medications on Admission:
Carvedilol 6.25" Protonix 40' Colchicine 6' Valsartan 80'
Zocor 20' Warfarin 2' Glipizide 5" Furosemide 60' Amlodipine 5'
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
3. Colchicine 0.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Alprazolam 0.25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times
a day) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours) as needed.
8. Ferrous Gluconate 300 mg (35 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
10. Warfarin 1 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO ONCE (Once) for 1
doses.
11. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
12. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fifteen (15)
units
units Subcutaneous at bedtime.
13. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale
Subcutaneous four times a day.
14. Daptomycin 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg
Intravenous every other day for 6 weeks: until seen in [**Hospital **] clinic
on [**1-28**], Dr. [**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
sternal wound infection s/p sternal debridement and plating
sepsis
Congestive Heart failure (acute on chronic diastolic failure)
post-op acute on chronic renal failure
VRE in sternal wound
PMH: Aortic Stenosis s/p Aortic Valve Replacement, Diabetes
Mellitus, Gastroesophageal Reflux Disease, Atrial Fibrillation,
Hypertension, Anemia
Discharge Condition:
Stable.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2182-1-28**] 10:00
Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 13175**] in [**1-6**] weeks
Dr. [**Last Name (STitle) 39612**] in [**12-5**] weeks
Pt. was followed by the coumadin clinic at [**Hospital **] Medical in
[**Location (un) **].Please contact them when she is ready to be discharged
from rehab.
Labs: weekly vanco trough, chem 7, LFT, CBC results to [**Hospital **] clinic
Attn Dr [**Last Name (STitle) **] Fax # ([**Telephone/Fax (1) 1353**]
Completed by:[**2181-12-17**]
|
[
"997.5",
"998.31",
"585.9",
"285.9",
"038.11",
"584.9",
"403.90",
"995.92",
"276.0",
"511.9",
"518.5",
"250.00",
"427.31",
"428.33",
"428.0",
"998.59",
"V42.2",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"33.23",
"34.91",
"00.13",
"78.51",
"77.61",
"38.93",
"96.71",
"96.04",
"96.6",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
10181, 10253
|
6184, 8363
|
316, 514
|
10631, 10641
|
1275, 1814
|
11152, 11814
|
981, 1020
|
8537, 10158
|
1851, 1921
|
10274, 10610
|
8389, 8514
|
10665, 11129
|
1035, 1256
|
261, 278
|
1950, 6161
|
542, 691
|
713, 858
|
874, 965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,781
| 101,955
|
37145
|
Discharge summary
|
report
|
Admission Date: [**2113-11-9**] Discharge Date: [**2113-11-10**]
Date of Birth: [**2089-11-21**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypotension & lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
23 yo F brought to the ED from a correctional facility after
reporting sexual assault 5 days ago by unknown assailant. She
had been given unknown doses of clonidine, librium, and depakote
for symptoms of withdrawal from heroin, cocaine, and benzo.
.
On arrival to the ED, 98.1, 66, 92/48, 12, 99% ra. Pt was
lethargic but easily arrousable. Her BP trended down to 85/40
with HR=47. In total, she received 5L NS and received 1g of
Ceftriaxone IV. Urine output was not measured. At the time of
transfer to the MICU, her BP= 103/58 with HR=74.
.
Her initial labs were notable for a venous lactate of 1.1,
bicarb of 33, mild transaminitis, positive benzo/opitae/cocaine,
and positive UA. She did not receive "Rape Crisis Intervention
Protocol" in the ED.
.
Currently, she is sleeping in bed apparently comfortable. She is
arousable to voice and complains of abdominal cramping which she
attributes to withdrawal--that said, she falls back asleep
easily.
.
ROS negative for fevers, chills, sweats. She complains of mild
dysuria, duration unclear. She last used IV heroin and inhaled
cocaine 48 hours ago. She drinks daily & could not estimate her
total intake but denies hx of ETOH withdrawal.
.
She does not know the HIV status or identity of her assailant.
She denies trauma. Her menstrual cycle is regular and began two
days ago.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
.
Past Medical History:
Hepatitis C
Polysubstance abuse: cocaine, heroin, benzo, ETOH
Bipolar disorder?
Social History:
Recently section 12, reasons unknown. Actively abusing heroin,
cocaine (inhaled), ETOH and benzo.
.
Family History:
Denied any family hx of serious illness
Physical Exam:
VS at discharge: 114/58, HR=82, afebrile, 95% room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Sleepy but
very easily arousable to voice
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no appreciable JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
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:
[**2113-11-9**] 02:00PM BLOOD WBC-5.2 RBC-3.56* Hgb-10.6* Hct-32.3*
MCV-91 MCH-29.7 MCHC-32.8 RDW-14.1 Plt Ct-226
[**2113-11-10**] 09:32AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.7* Hct-31.2*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.1 Plt Ct-214
[**2113-11-9**] 02:00PM BLOOD Neuts-40.1* Lymphs-51.7* Monos-4.6
Eos-3.1 Baso-0.5
[**2113-11-9**] 02:00PM BLOOD PT-13.6* PTT-37.6* INR(PT)-1.2*
[**2113-11-9**] 02:00PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-141 K-4.0
Cl-105 HCO3-33* AnGap-7*
[**2113-11-10**] 09:32AM BLOOD Glucose-87 UreaN-4* Creat-0.6 Na-140
K-3.6 Cl-108 HCO3-26 AnGap-10
[**2113-11-9**] 02:00PM BLOOD ALT-57* AST-77* AlkPhos-93 TotBili-0.4
[**2113-11-10**] 09:32AM BLOOD ALT-64* AST-90* AlkPhos-160* TotBili-0.4
[**2113-11-9**] 02:00PM BLOOD Calcium-8.7 Phos-5.1* Mg-1.7
[**2113-11-10**] 09:32AM BLOOD Calcium-8.1* Phos-3.1# Mg-1.6
[**2113-11-10**] 09:32AM BLOOD HBsAg-PND HBsAb-PND IgM HBc-PND
[**2113-11-9**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2113-11-10**] 09:36AM BLOOD Type-[**Last Name (un) **] pO2-215* pCO2-39 pH-7.44
calTCO2-27 Base XS-2 Comment-GREEN TOP
[**2113-11-9**] 03:53PM BLOOD Lactate-1.1
[**2113-11-10**] 09:36AM BLOOD Lactate-0.6
.
BLOOD CULTURE, URINE CULTURE, HEPATITIS SEROLOGIES, HCV VIRAL
LOAD PENDING AT THE TIME OF DISCHARGE.
.
============================
CT ABDOMEN [**11-9**]
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
after
administration of IV contrast were submitted for interpretation.
.
ABDOMINAL CT WITH CONTRAST: The lung bases demonstrate
interstitial thickening and mild posterior ground-glass
opacities with intralobar and interlobar septal thickening. The
heart is not enlarged. There is no pericardial effusion. There
is a 2.2 x 0.7 cm nodule in the right cardiophrenic angle which
may represent a lymph node. Perihepatic fluid is noted.
Periportal edema is seen. The gallbladder demonstrates severe
wall edema and surrounding fluid; however, appears relatively
[**Name2 (NI) 19973**]. The spleen, adrenals, pancreas, kidneys are
grossly unremarkable. Abdominal [**Last Name (un) **] and iliac vessels
demonstrate no evidence of aneurysmal dilatation. here is no
bowel obstruction. Normal appendix is seen in the right lower
quadrant. There is no bowel wall thickening.
.
PELVIC CT WITH CONTRAST: The uterus, adnexa, urinary bladder,
and rectosigmoid colon are grossly unremarkable. A 1.6-cm area
of hypodensity posterior and to the right of the uterus (2:75)
likely represents small mount of free pelvic fluid. The right
ureter appears slightly thickened and there is mild periurethral
fat stranding. Evaluation for stones is limited due to IV
contrast, however, there is no hydronephrosis or evidence of
asymmetric renal enhancement.
OSSEOUS STRUCTURES: There is a small Schmorl's node in the
inferior endplate of T11 vertebral body.There is no fracture.
IMPRESSION:
1. Interstitial thickening at the lung bases with interlobular
and intralobular septal thickening. Differential diagnosis
includes pulmonary edema and/or drug reaction.
2. Periportal edema, gallbladder wall edema, as well as
perihepatic and pericholecystic fluid, may represent liver
failure/acute hepatitis. Clinical correlation is recommended.
The study and the report were reviewed by the staff radiologist.
.
=================================
CXR [**11-9**]
Heart, mediastinal, hila are normal. Bilateral increased
interstitial and reticular markings are present, especially in
the lower lobes. There is no pneumothorax or pleural effusion.
IMPRESSION: Bilateral interstitial opacities are most pronounced
within the lower lobes and may be due to interstitial pulmonary
edema or an atypical infection. Clinical Correlation is
recommended.
Brief Hospital Course:
23 yo F with polysubstance abuse s/p recent sexual assault
admitted through the ED s/p recovery from transient
hypotension/bradycardia which was likely medication related.
.
# Hypotension/bradycardia: Completely resolved at this point.
Limited fluid responsivene in the ED; probably resolved with
time. Clonidine dose and time given unknown. No EKG changes
concerning cardiogenic source. Nothing on labs to suggest infxn.
Avoid clonidine in the future.
.
# Lethargy: Reportedly with withdrawal symptoms at outside
facility. No signs of ETOH or Benzo withdrawal currently. C/o of
symptoms of heroin withdrwal, cramps, etc, but somnolent and
appears comfortable despite complaints. Held all sedating
medications including home seroquel and paxil. Can consider
restarting these as lethargy resolves.
.
# Lung Findings: See attached report. Seems attributlable to
chronic use of inhaled drugs. Pt requires f/u with a
Pulmonologist in [**12-23**] weeks and a repeat CT of the chest in [**2-24**]
months. Infectious process much less likely, but findings should
be re-visited if pt turns out to be HIV positive.
.
# S/p sexual assault: 5 days out. No evidence of trauma. Denies
Trauma. Currently menstruating, so does not require emergent
contraception. Outside of 72h window and thus not a candidate
for HIV ppx. Received flagyl 2000mg po x1, azithro 1000mg x1,
CTX 250mg IM. Known HepC+, HepB serologies pending. Pt should
have HIV checked now and again in 6 months.
.
# Transaminitis & peri-hepatic liver inflammation: AST>ALT but
not in ETOH ratio. [**Month (only) 116**] be the consequence of Hep C. Please trend
LFTs every other day until down-trending. HepC viral load
pending, please call our lab in [**2-23**] business days at
617-667-LABS. She should establish care with a hepatologist
within 2 weeks for further evaluation.
.
# Urinary Tract Infection: Uncomplicated. Prescribed 3 days of
po Ciprofloxacin. Please repeat UA if symptoms recur. Culture is
pending at the time of d/c and should be available at
617-667-LABS within a few days.
.
DISCARGE TO CORRECTIONAL FACILITY, PT SIGNED OUT TO MEDICAL
STAFF THERE BY PHONE.
Medications on Admission:
Paxil Oral, dose uncertain
Depakote Oral, dose uncertain
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
2. Paxil Oral
3. Depakote Oral
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] correctional fac
Discharge Diagnosis:
Medication induced hypotension and lethargy
Uncomplicated Urinary Tract Infection
Hepatitis C
Poly-substance abuse
Discharge Condition:
Medically stable for discharge
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the Medical ICU at [**Hospital1 **]
from [**Location (un) 47**] after you reported a sexual assault. There was
strong concern regarding your low blood pressure initially, but
this seems to have been an effect of ssome of the medications
you received prior to transfer, most likely clonidine.
There are a few issues which you need to follow-up on:
- Your abnormal Chest CT scan is likely the consequence of
inhaled drug use. You should stop smoking and should establish
care with a pulmonologist--this was communicated to the medical
staff at [**Location (un) 47**] and they will make arrangements. Should you
want to establish care with a pulmonologist at [**Hospital1 18**] you can do
so by calling ([**Telephone/Fax (1) 3554**].
- Your liver is showing signs of injury on CT scan and blood
tests. As you have Hepatitis C, you should see a hepatologist at
least once per year. Your liver funtion tests (blood test) will
be re-checked at [**Location (un) 47**] and they will make arrangements for
you to be seen by a liver specialist. Should you want to
establish care with a hepatologist at [**Hospital1 18**] you can do so by
calling ([**Telephone/Fax (1) 16687**].
- You have received Antibiotics to protect you from contracting
certain STDs. Unfortunately, since you presented 5 days after
your attack, you would not benefit from medications to prevent
HIV. The doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) 47**] [**Name5 (PTitle) **] test you for HIV now. You
should be tested for HIV again in 6 months.
- You need to take 3 days of oral ciprofloxacin for your urinary
tract infection.
Followup Instructions:
To be arranged at [**Location (un) 47**] with Pulmonary and Hepatology
within the next two weeks.
Completed by:[**2113-11-10**]
|
[
"780.79",
"E849.7",
"427.89",
"304.60",
"070.70",
"303.90",
"458.29",
"E947.8",
"304.20",
"304.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9304, 9368
|
6886, 9018
|
320, 327
|
9527, 9560
|
3137, 6863
|
11281, 11411
|
2162, 2203
|
9126, 9281
|
9389, 9506
|
9044, 9103
|
9584, 11258
|
2218, 2221
|
2235, 3118
|
258, 282
|
355, 1924
|
1946, 2028
|
2044, 2146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,209
| 111,018
|
30070
|
Discharge summary
|
report
|
Admission Date: [**2166-3-29**] Discharge Date: [**2166-4-13**]
Date of Birth: [**2145-10-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
gun shot wound
Major Surgical or Invasive Procedure:
[**3-29**] Exploratory laparotomy
aortogram with selective Right & Left hepatic angiogram, Left
gastric & Right renal angiogram
[**3-30**] Exploratory laparotomy and abdominal closure
[**4-1**] ERCP with biliary stent and sphincterotomy
Percutaneous drainage of biloma
History of Present Illness:
The patient is a young male
transferred from another hospital after sustaining multiple
gunshot wounds to the right thoracoabdominal area, as well as
the extremities. The patient was hemodynamically stable, but
had evidence on CT scan done at the other hospital that there
was a central liver injury with blood in the abdomen and
probable
blood in the gallbladder.
Past Medical History:
none
Social History:
n/c
Family History:
n/c
Physical Exam:
On admission:
hemodynamically stable
diminished breath sounds on the right
RRR
multiple gunshot wounds in right thoracoabdominal area
otherwise, abd soft, ND
ext: right leg gunshot wound
Pertinent Results:
[**2166-3-29**] 05:39PM HCT-34.9*
[**2166-3-29**] 07:54AM LACTATE-1.4
[**2166-3-29**] 07:39AM GLUCOSE-160* UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-23 ANION GAP-10
[**2166-3-29**] 04:15AM WBC-20.1* RBC-3.76* HGB-11.6* HCT-34.0*
MCV-91 MCH-30.9 MCHC-34.1 RDW-13.4
Brief Hospital Course:
Patient was brought in to the trauma bay after suffering
multiple gunshot wounds. He was hemodynamically stable but had
physical exam and CT evidence of penetrating abdominal wounds
and the decision was made to proceed to the OR. He underwent an
exploratory laparotomy, packing of liver hemorrhage, damage
control packing of right retroperitoneal hematoma. He was taken
to the trauma ICU postop in stable condition. On POD 2 he was
taken back to the OR. the abdomen was unpacked and there was no
further bleeding. To rule out esophageal injury he underwent
esophagoscopy. The right chest tubes placed at the outside
hospital were in poor position and were removed and replaced
with a single #28 chest tube. He was then taken back to the
trauma ICU in stable condition. He remained stable and was
extubated. The drain over the liver had very high bile output.
A dusctal injury in the bullet track was suspected. ERCP was
requested and a stent was placed. The drain output diminished
rapidly and the JP was removed about a week later. The chest
tube remained on pleurevac suction with serial chest xrays.
When the films showed no evidence of pneumothorax he was set to
waterseal. The next day, the xray showed an enlarged pnx and
the CT was set back to suction. The f/u CXR showed that pnx had
not diminished. A new apical #20 chest tube was placed. Position
confirmed to be in the area of the pnx. the lateral chest tube
was removed. At that point, no pneumothorax was identifiable on
the f/u CXR. The following day the tube was set to waterseal and
the f/u CXR showed no increase in pnx size. The CT was removed
the following day with no evidence of pnx.
The patient's other issue was an infected seroma next to the
porta hepatis. He developed a fever and was started on unasyn.
This was seen on CT and aspirated under CT guidance. Over the
next few days he defervesced and continued to be stable. He was
discharged on [**2166-4-13**] in stable condition, with no evidence of
pneumothorax and having been afebrile for several days. He
received adequate discharge and follow-up instructions.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple gunshot wounds
Pneumothorax
Liver laceration
Biliary leak
Renal laceration
Discharge Condition:
Good
Discharge Instructions:
Please call or return to the emergency room if:
-You experience fevers (>101.5degrees) or chills
-You have worsening abdominal pain
-You have ongoing nausea, vomiting, or diarrhea
-You have increasing redness, swelling, or draining from your
incision
-You have shortness of breath
-You have any other questions or concerns
Followup Instructions:
Please call for a follow-up appointment with Dr. [**Last Name (STitle) **] in 2
weeks. ([**Telephone/Fax (1) 22750**]
Completed by:[**2166-4-14**]
|
[
"E878.8",
"866.10",
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"868.12",
"860.1",
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"576.8",
"864.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"54.11",
"51.87",
"54.12",
"88.45",
"51.85",
"34.04",
"50.91",
"38.91",
"99.04",
"54.19",
"88.47",
"34.09",
"44.13"
] |
icd9pcs
|
[
[
[]
]
] |
4243, 4249
|
1611, 3717
|
330, 601
|
4377, 4384
|
1288, 1588
|
4755, 4905
|
1060, 1065
|
3772, 4220
|
4270, 4356
|
3743, 3749
|
4408, 4732
|
1080, 1080
|
276, 292
|
629, 995
|
1094, 1269
|
1017, 1023
|
1039, 1044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,981
| 125,955
|
30282
|
Discharge summary
|
report
|
Admission Date: [**2130-2-21**] Discharge Date: [**2130-3-11**]
Date of Birth: [**2073-11-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
CVA, possible endocarditis
Major Surgical or Invasive Procedure:
Trans-esophageal echocardiogram
History of Present Illness:
56 yof suddenley at work today had some difficulty with speaking
and presented to OSH ER found to have a subacute CVA with left
parietal infarct of inderminant age. Denied frank chest pain,
palpitaitions or other focal neurologic changes prior to today.
Initially presented and admitted to [**Hospital **] hosp.
.
OSH Course: Patient noted to have a loud systolic and diastolic
murmur and underwent transthoracic echocardiogram remarkable for
severe AS and 2+3+ AI, preserved LVEF, no gross vegetations. Pt
with WBC of 15.4 and febrile to 104.6. Blood cultures sent and
ID consulted and given vanc/gent/oxacillin.
.
At time of transfer she denies any complaints. Difficult for her
to express clearly. Able to ask for water by pointing but stated
"can I jet". Additional history obtained from husband over the
phone. Who states that she woke up and seemed normal at home
went to work at 6, however, he was called by her coworker at
6:15 who noted her to be acting inappropriate. Able to speak but
no coherent so called 911 and taken to [**Hospital **] hosp. Patient has
had a recent GI illness, nausea/vomiting/diahhrea over the past
1 week, which was improving the past two days. +chills but no
fevers. This AM was diaphoretic prior to transfer to hosp.
Denied any recent cp/sob/dizziness or lightheadedness.
Past Medical History:
HeartCardiac Risk Factors: Denies personal history of Diabetes,
Dyslipidemia, Hypertension
.
Cardiac History: none aside from history of murmur as child.
.
Percutaneous coronary intervention - None.
Pacemaker/ICD - None
murmur as a child
Social History:
Social history is significant for smoking 1 ppd. denies any
alcohol use or IV drug use. Lives with her husband at home who
also smokes.
Family History:
family history sig for fahter died at 76 and mother died of
alzheimer's in the 80s. one sister who is healthy in her 40s.
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
T 103.4 Blood pressure was 104/47 mm Hg while lying in bed.
Pulse was 104 beats/min and regular, respiratory rate was 22
breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was alert but not oriented.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of ~7 cm.
Carotids with no bruit but radiation of cardiac murmro to
carotids. There was no thyromegaly. The were no chest wall
deformities, scoliosis or kyphosis. The respirations were not
labored and there were no use of accessory muscles. The lungs
with bilateral wheezing.
CVR - RRR , nl s1, s2. +systolic murmor mid peaking III/VI over
LUSB also had a II/IV diastolic component heard best over LLSB.
Abdomen - Soft, obese.
.
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:
BLOOD CULTURE ISOLATES [**12-1**] FROM [**Hospital3 **] FOR ID.
ISOLATE FOR MIC (Preliminary):
RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES. FINAL
SENSITIVITIES.
Sensitivity testing performed by Sensititre.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism.
Results may not be reliable and must be interpreted
with caution.
CLINDAMYCIN. <=0.5 MCG/ML.
ERYTHROMYCIN. <=0.25 MCG/ML.
Levofloxacin. <=0.25 MCG/ML.
GENTAMICIN. <=2 MCG/ML.
Penicillin. <=0.06 MCG/ML.
VANCOMYCIN. <=1 MCG/ML.
SULFA X TRIMETH. <=0.5 MCG/ML.
VIRIDANS STREPTOCOCCI.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. STRAIN 1.
BEING ISOLATED FOR SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. STRAIN 2.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
PENICILLIN------------ 1 I
VANCOMYCIN------------ 1 S
.
[**2130-2-21**] 10:46 pm BLOOD CULTURE Source: Venipuncture.
AEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **] FA3 2:40PM [**2130-2-24**].
SENSITIVITY TESTING PER DR [**Last Name (STitle) 72089**].
RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism.
Results may not be reliable and must be interpreted
with caution.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. Sensitivity testing performed by
Sensititre.
FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND STRAIN.
FINAL SENSITIVITIES.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
Results may not be reliable and must be interpreted
with caution.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. Sensitivity testing performed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- S S
ERYTHROMYCIN----------<=0.25 S 0.5 S
GENTAMICIN------------ <=2 S <=2 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S
OXACILLIN-------------<=0.25 S <=0.25 S
PENICILLIN------------<=0.06 S <=0.06 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
.
.
Imaging:
CXR:
PORTABLE AP CHEST RADIOGRAPH: Mediastinal contours are normal.
No pleural effusion or pneumothorax seen. Pulmonary vasculature
is within normal limits. The lungs are clear. The soft tissue
and osseous structures are unremarkable.
IMPRESSION: No overt CHF or evidence of pneumonia.
.
TEE:
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the
procedure. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). No TEE related complications. 0.2 mg of IV
glycopyrrolate was given as an antisialogogue prior to TEE probe
insertion. The patient appears to be in sinus rhythm. Results
were reviewed with the Cardiology Fellow involved with the
patient's care.
CONCLUSION: The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch, descending thoracic aorta, and
abdominal aorta. The number of aortic valve leaflets cannot be
determined but the valve is probably functionally bicuspid (with
fusion of the left and non-coronary leaflets) with severe
thickening/deformity. Severe aortic stenosis is present.
Moderate to severe aortic regurgitation is seen.
Impression: Preserved left ventricular systolic function.
Functional bicuspid aortic valve with severely
thickened/deformed aortic valve leaflets. Severe aortic
stenosis. Moderate to severe aortic regurgitation. Moderately
thickened mitral valve leaflets with moderate mitral
regurgitation. No obvious vegetations seen although cannot
exclude given severity of valvular calcification and deformity.
.
Right LENIs:
RIGHT LOWER EXTREMITY DEEP VENOUS ULTRASOUND: Grayscale and
Doppler examination of the right common femoral vein,
superficial femoral vein and popliteal veins demonstrate normal
compressibility, augmentability and flow. No intraluminal
thrombus is identified.
IMPRESSION: No evidence of DVT in the right lower extremity.
.
MRI BRAIN [**2130-2-26**]: Compared with the examination from [**2130-2-21**], scan from an outside hospital, there has been evolution of
the left parietal lobe infarct in the territory of the middle
cerebral artery. There is gyriform enhancement as would be
expected with a subacute infarction. However, just anterior to
this region, in the posterior left frontal lobe, there is an
area with peripheral enhancement and a core of low T1 signal.
This core appears to have slow diffusion. This measures about
approximately 1 cm. Given the history of persistent fevers and
endocarditis with septic emboli, these lesion is concerning for
an abscess. There is increased T2 signal in the region of the
infarcted tissue as well as in the region of the abscess. There
are no areas of abnormal magnetic susceptibility. This case was
discussed by telephone with Dr. [**First Name (STitle) **] at the time of dictation.
IMPRESSION: 1-cm region of peripheral enhancement with central
slow diffusion worrisome for an abscess in the posterior left
frontal lobe.
Continued evolution of the left parietal lobe infarct.
.
MRI BRAIN [**2130-3-4**]: There is continued evolution of a large left
MCA infarction with increased parenchymal enhancement. A focus
of presumed abscess in the left frontal lobe has slightly
increased in size and currently measures 13 mm in greatest
dimension with increased surrounding edema. Intracranial flow
voids are maintained. Ventricles and sulci are stable.
IMPRESSION: Slight interval enlargement of presumed left frontal
lobe abscess. Continued evolution of left MCA infarct.
Brief Hospital Course:
56 yo F with no sig PMH who was transferred with a left parietal
infarct, fever and aortic stenosis and aortic insuff. Her
hospital course is as follows:
.
CVA: Her signs and symptoms are consistent with a left parietal
infarct in an end-artery distribution resulting in a mixed
aphasia. Given normal carotids by ultrasound and posterior
circulation on MRA at OSH, most concerning possible etiology
would be septic emboli from endocarditis (AI and AS on echo).
MRI images from the outside hospital were uploaded in radiology
and viewed by neuro confirming these findings. Neurology was
consulted and expressed their agreement with this assessment,
adding that the lesion may be an insular cortex lesion. She did
have mild sensory deficits in the RLE. Because of her potential
septic emboli, she was not anticoagulated given risk of bleed.
Her neuro exam improved over the hospital course but mixed
aphasia persisted. Speech and swallow evaluated the patient and
recommended liquids with full pills. She is not to be
anticoagulated with any blood thinners, including aspirin.
However, subcutaneous Heparin for DVT prophylaxis was thought to
be okay until patient is more ambulatory. She is being
discharged to an acute rehabilitation facility for agressive
speech therapy, physical therapy, and occupational therapy.
.
ENDOCARDITIS: Patient was admitted febrile and with AI murmur
concerning for endocarditis. She had no history of IV drug use
and no other risk factors for endocarditis. Her only source was
a recent GI illness. She was initially started on
Vanco/Nafcillin/Gentamicin. She triggered initially on the
floor for fever and tachypnea, as well as 7 beat run of NSVT.
Following housestaff evaluation, she was transferred to the CCU
for TEE. TEE demonstrated a functionally bicuspid aortic valve,
with severe AS and 2+ AI. No clear vegetations were seen,
though there was an area that could be suspect for infection.
Her condition is presumably secondary to endocarditis with
demolition of the aortic valve but no apparent vegetation. Her
Nafcillin was stopped after a body rash developed. With the
recommendations of the ID consult service, she was continued on
Vancomycin and Gentamycin, and Levaquin was added on [**2-24**]. OSH
grew 2 out of 3 bottles positive for GPC, and our cultures grew
[**12-1**] +GPC on [**2-21**] set. She remained febrile to 101. There was
concern for septic embolic spread and ? occult abscess in abd
and right foot. LE ultrasound and CT abd/pelvis were obtained
on [**2-24**] being negative for abscess. Her blood cultures
eventually grew resistant Strep viridans, micrococcus, and coag
neg staph. Her antibiotics were changed to
Vanco/Ceftriaxone/Gentamicin/Flagyl. A PICC line was placed on
[**2130-3-3**] by IR. She had intermittent low-grade fevers for the
duration of her hospital course but all screening blood cultures
were negative since [**2-28**]. She is discharged with the plan
for 6 weeks of treatment with each antibiotic and close
follow-up with the Infectious Disease and Cardiology services.
.
BRAIN ABSCESS: The patient continued to spike fevers well into
her hospital course despite broad-spectrum antibiotic therapy.
Prior imaging was negative for occult infection. However, the
patient underwent brain MRI which revealed a 1 cm lesion in the
left frontal [**Last Name (un) 14097**], concerning for abscess. At the time of
this initial detection, the lesion was considered to be too
small for intervention. Instead, her antibiotics were continued
to maximize CNS penetration. She underwent a 2nd MRI on [**2130-3-4**]
which showed enlargement of the lesion to 13 mm. At this time,
Neurosurgery was consulted and performed a stereotactic brain
biopsy for diagnostic purposes as it was very perplexing that
the lesion was continuing to increase in size despite
broad-spectrum antibiotics. Gram stain was reported as without
organisms. Final pathology report stated brain tissue showed
chronic reactive changes but no evidence of reactive or
neoplastic process. Based on some preliminary concern that this
might represent a glioma, Neurooncology was consulted who felt
there this was not consistent with neoplasm. At discharge, the
patient's neurologic defects were stable was scheduled for a
repeat MRI on [**3-16**] to reassess for interval change.
.
RASH: The patient experienced a body rash throughout her trunk.
It was thought due to Nafcillin. Once her nafcillin was
stopped, her rash gradually improved. She was given sarna
lotion for symptomatic relief with good effect.
.
NUTRITION: Patient was switched from full diet to liquids with
whole pills after swallow evaluation. She tolerated this well.
She will need speech therapy at rehab.
.
CODE STATUS: FULL CODE.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): subcutaneously.
continue until ambulating.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-29**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Until [**2130-4-13**] for total 6 week course.
7. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous
Q 12H (Every 12 Hours): 750 mg dose [**Hospital1 **]. To be taken until
[**2130-3-30**] for total 6 week course.
8. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) injection Intravenous Q12H (every 12 hours): 2g IV q12. To
be taken until [**2130-4-11**] for total 6 week course.
9. Gentamicin 40 mg/mL Solution Sig: Eight (8) units Injection
once a day for 6 weeks: Dose = 320 mg daily. Continue through
[**2130-4-13**] for total 6 week course. .
10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Northeast- [**Location (un) 38**]
Discharge Diagnosis:
Endocarditis
Embolic stroke
Brain abscess
Discharge Condition:
Persistently aphasic, afebrile
Discharge Instructions:
You have been diagnosed with endocarditis, an infection of the
heart valve. You also had a stroke affecting your ability to
speak. You will need 6 total weeks of antibiotics for your
infection. You will also need rehabilitation to re-build your
strength and speech.
.
You will be taking the following antibiotics: Vancomycin,
Ceftriaxone, Flagyl, Gentamicin for a total of six weeks each.
.
You will need to follow up with Infectious Disease, Cardiology,
and Neurology for your issues. You have also been set up with a
new primary care physician who will help to coordinate your
care.
Followup Instructions:
You are scheduled for a repeat MRI on [**3-16**] at 9:15 p.m.
(at night). You should go to the MRI unit in the basement level
of the Clinical Care Building on [**Hospital1 18**] [**Hospital Ward Name 517**]. Please call
[**Telephone/Fax (1) 327**] with questions.
.
You are scheduled to follow up with [**First Name8 (NamePattern2) 7618**] [**Name8 (MD) **], MD in the
Division of Infectious Diseases on [**3-21**] at 10:30 a.m.
Please call [**Telephone/Fax (1) 457**] if you need to reschedule. Her office
is located at [**Last Name (NamePattern1) 72090**].
.
You are scheduled to follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. in
the Division of Cardiology on [**4-11**] at 2 p.m. His office is
located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building on [**Hospital1 18**] [**Hospital Ward Name 5074**]. Please call [**Telephone/Fax (1) 127**] if you need to reschedule.
.
You are scheduled to follow-up with [**First Name8 (NamePattern2) 4267**] [**Name8 (MD) **], M.D. in the
Department of Neurology on [**4-12**] at 2 p.m. His office is
located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Please call
([**Telephone/Fax (1) 2528**] if you need to reschedule.
.
You are scheduled to follow-up with [**Doctor First Name **] [**Doctor Last Name 24417**], M.D. as
your new primary care physician on [**4-12**] at 3:30 p.m. Her
office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on
[**Hospital1 18**] [**Hospital Ward Name 516**] in the Central Suite. Please call
[**Telephone/Fax (1) 250**] if you need to reschedule.
|
[
"790.7",
"421.0",
"434.11",
"693.0",
"401.9",
"E930.0",
"396.8",
"324.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
17451, 17528
|
11219, 15983
|
342, 375
|
17614, 17647
|
3308, 11196
|
18284, 19955
|
2145, 2349
|
16038, 17428
|
17549, 17593
|
16009, 16015
|
17671, 18261
|
2364, 3289
|
276, 304
|
403, 1714
|
1736, 1976
|
1992, 2129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,076
| 109,205
|
11790+56289
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-12-21**] Discharge Date: [**2136-1-3**]
Date of Birth: [**2081-4-3**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient was transferred to
[**Hospital1 **] on [**2135-12-21**] and underwent exploratory
laparotomy and drainage of a pelvic abscess and loop
sigmoidoscopy.
The patient is a 54 year-old male with a history of
pancreatitis and cardiomyopathy from ETOH abuse with an
ejection fraction of 15% and coronary artery bypass graft in
[**2134-9-24**] and a history of coronary artery disease,
diabetes, chronic renal insufficiency, history of hepatic
abscess and cerebrovascular accident times two, pancytopenia,
chronic obstructive pulmonary disease, CRI, glaucoma. The
patient was admitted urgently on [**12-20**] to [**Hospital 2725**]
Hospital for abdominal pain and guarding for four days. He
had left lower quadrant pain, chills and rigors. CT scan
showed an ischemic bowel and liver abscess and edematous
bowel. The patient was transferred to the [**Hospital1 346**] on [**2135-12-21**].
HOSPITAL COURSE: On [**2135-12-21**] the patient was taken
by Dr. [**Last Name (STitle) 1305**] to the Operating Room and underwent an
exploratory laparotomy and a pelvic abscess was discovered
and that was subsequently drained and the cause of the
patient's acute abdomen was believed to be a perforated
diverticulitis, so a loop of sigmoid colon was brought out
through an ostomy a mature sigmoid colon and the intent was
to see if we could identify a leak meanwhile.
Postoperatively, the patient was transferred to the Intensive
Care Unit and was stable in the Intensive Care Unit and was
placed on antibiotics. The culture from the abscess grew out
E-coli that was pan sensitive and antibiotics were adjusted
accordingly. The patient's Intensive Care Unit stay was
uneventful. On [**12-24**] the patient was started on TPN and
on [**12-27**] the patient was transferred to the floor and
interventional radiology performed CT guided drainage of a
hepatic abscess on [**12-28**] and on [**12-29**] the patient
was stable on the floor and was afebrile with stable vital
signs and was deemed that the patient did not require a
sigmoidostomy and the patient was taken to the Operating Room
and underwent reversal of a matured loop sigmoidostomy on
[**2135-12-29**].
Postoperatively, the patient did well and recovery was
uneventful. Two days after reversal of the sigmoidostomy the
nasogastric tube was discontinued and the patient was put on
clear liquids. The patient had bowel movements and was
passing gas and tolerating regular po.
Physical examination prior to discharge, the patient was
afebrile. Vital signs were stable. Incision was clean, dry
and intact. Belly was nondistended. Nontender. The pigtail
drain for the hepatic abscess was in place. Prior to
discharge the patient had a CT scan to reassess the hepatic
abscess. Shows hepatic abscess has significantly decreased
in size. The culture from the pigtail drain was negative.
No organism was grown. The patient will be discharged on
[**2136-1-3**] to a rehab facility.
DISCHARGE MEDICATIONS: Levaquin 500 mg po q.d. times ten
days, Flagyl 500 mg po q 6 h. times ten days, Lopressor 50 mg
po b.i.d., Oxacillin 1 gram po q 6 h times ten days, Lasix 20
mg po b.i.d.
The patient will be discharged with a pigtail drain in the
right upper quadrant and the patient is told to follow up
with Dr. [**Last Name (STitle) 1305**] in one week for reassessment of the hepatic
abscess and the wound check.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2136-1-3**] 08:15
T: [**2136-1-3**] 08:25
JOB#: [**Job Number 37265**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6700**]
Admission Date: [**2135-12-21**] Discharge Date:
Date of Birth: [**2081-4-3**] Sex: M
Service: GOLD SURGE
ATTENDING:[**Last Name (NamePattern1) 6701**]
HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a
55-year-old male with diabetes, chronic renal insufficiency,
CHF, CAD, and alcoholic chronic pancreatitis, status post
exploratory laparotomy and closure of matured ostomy. The
patient had hepatic abscess that was drained on
[**12-28**], [**2135**]. The repeat CT scan on
[**1-2**], [**2135**], showed smaller abscessed cavity and
pigtail catheter was in the right position. However, there
was a separate small hepatic-abscessed cavity, which was
posterior to the first one. So, the catheter tip was
repositioned on [**2136-1-4**], prior to the patient's
discharge. The patient's discharge medication will be the
following:
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg p.o.q.d. times 28 days.
2. Flagyl 500 mg p.o. q.8h. times 28 days.
3. Lopressor 50 mg p.o.b.i.d.
4. Oxacillin one gram p.o. q.6h. times seven days.
5. Lasix 20 mg p.o.b.i.d.
6. NPH 12 units q.a.m. and 8 units q.p.m.
7. Sliding-scale insulin, regular insulin.
The patient was told to followup with Dr. [**Last Name (STitle) **] in one week.
The patient is to have a repeat CT scan to reassess the
hepatic abscess in 5 to 6 days. Please discontinue the skin
staples, [**2136-1-11**] and Steri Strip wound.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-164
Dictated By:[**Name8 (MD) 5162**]
MEDQUIST36
D: [**2136-1-4**] 10:30
T: [**2136-1-4**] 10:32
JOB#: [**Job Number 6702**]
|
[
"567.2",
"V45.81",
"496",
"572.0",
"250.00",
"425.5",
"428.0",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.91",
"99.15",
"46.03",
"46.52",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
4833, 5583
|
1091, 3125
|
176, 1073
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,904
| 106,561
|
53569
|
Discharge summary
|
report
|
Admission Date: [**2170-5-12**] Discharge Date: [**2170-5-28**]
Date of Birth: [**2146-1-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Intubation
Right sided tunneled line
Removal of right sided tunneled line
History of Present Illness:
24 y/o female with long-standing history of EtOH abuse and
pancreatitis (drinks approximately 1 gallon of vodka per day),
who has been attempting to self detox, transferred from [**Hospital **]
Hospital, after found down at home.
It appears that her mother may have called 911. When EMS
arrived, her house was noted to be disordered with feces on
floor. She was felt to be intoxicated, but arousable. She
reported her last drink as 12 pm today. She denied other toxin
ingestions. Vitals were HR 160s, SBP 80s for EMS. An IO was
placed in the right tibia. There was also ? of black stools and
coffee ground emesis.
She was transferred to OSH [**Hospital **] Hospital, where she was
tachycardic to HR 130s. She also had dark emesis and dark stool.
Quantitative hcG < 2. Head/Cspine negative. IO attempted to be
removed, but unable to be done. Reportedly, the plastic part was
broken off, but the metal needle remained in the tibia. She was
given zofran and benzodiazepines. She received a dose of zosyn
3.375 mg. Labs were notable for low potassium, high Cr.
As no ICU beds were available, she was transferred to [**Hospital1 18**].
Here, she was tachycardic, but not hypotensive. She was easily
arousable, answering questions appropriately, stating she "felt
unwell."
Urine sample here with ? infection. Stox and Utox negative. Hct
here 28.6, down from [**Hospital1 **] Hct 44.8. This Hct drop was felt to
be inappropriately low for the degree of IVF she received (4L
IVF). This in combination with her reported dark stool and
emesis, led to guiac exam here, which showed guaiac positive
stool. She was started on protonix gtt. NGT deferred given low
suspicion for active bleeding. Labs here notable for mildly
elevated lactate, bandemia, and given concern for sepsis, she
received vancomycin and clindamycin.
Toxic shock syndrome was considered as a diagnosis. Pelvic exam
showed no CMT or adnexal tenderness. Rectal probe was placed.
She received reglan, ativan 2 mg x 2 doses, 1 gram tylenol, and
4L IVF in our ED.
EKG notable for sinus tachycardia without ischemic changes.
CXR without evidence for infiltrate.
Vitals on transfer: 101.9, HR 130, RR 24, BP 140/86, 100% 2L NC.
Mental status: arousable, sleepy/somnolent
Access: 18 G, 20 G, 22 G
On arrival to the MICU, patient's VS: 101.6, HR 133, BP 161/91,
RR 24, 100% 2L NC
Past Medical History:
- EtOH abuse
- pancreatitis
- [**Last Name (un) **]-Calve-Perthes disease
Social History:
extensive history of EtOH use and abuse. Denies illicit drugs.
Not sexually active. Mother is currently hospitalized for etoh
related issues.
Family History:
ETOH abuse in mother. otherwise non-contributory
Physical Exam:
Admission exam
Vitals: 101.6, 133, 161/91, 16, 100% 2L NC
General: sleepy/somnolent, arousable, no acute distress
HEENT: anicteric sclera, MMM, OP clear, PERRL
Neck: supple, JVP difficult to estimate given body habitus but
not felt to be elevated, no LAD
CV: tachycardic, Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly distended, reports some discomfort upon
palpation of epigastric and RUQ region, bowel sounds present but
hypoactive, liver edge felt 1-2 cm below costal margin, no
rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, PERRL, grossly normal sensation,
not cooperative with strength exam due to sleepy/somnolence, no
neck stiffness, 2+ reflexes bilaterally, gait deferred.
Skin: erythematous blanching rash on waist
Discharge exam
Vitals: Temp: 99.3 BP: 166/114 (112/84-180/110) 120 (74-120) 93%
RA
I/O: 1688/1900+
General: Alert and oriented in no acute distress, slightly
tremulous
HEENT: anicteric sclera, MMM, OP clear, PERRL
Neck: supple, JVP no elevated, no LAD
Chest Wall: right sided tunneled line with blood around the
insertion site
CV: Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, No wheezes, rales,
ronchi
Abdomen: NABS, mildly distended, no tenderness to palpation,
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, 1+
edema
Neuro: CNII-XII grossly intact, no nystagmus noted, PERRL,
intact EOM, grossly normal sensation, strength 5/5 bil,
Pertinent Results:
On Admission:
[**2170-5-12**] 01:30AM WBC-5.5 RBC-2.78* HGB-9.4* HCT-28.6* MCV-103*
MCH-33.8* MCHC-32.9 RDW-13.9
[**2170-5-12**] 01:30AM NEUTS-83* BANDS-9* LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2170-5-12**] 01:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2170-5-12**] 01:30AM GLUCOSE-188* UREA N-23* CREAT-2.6*
SODIUM-132* POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-13* ANION
GAP-28*
[**2170-5-12**] 01:30AM ALT(SGPT)-209* AST(SGOT)-930* LD(LDH)-663*
CK(CPK)-2465* ALK PHOS-84 TOT BILI-5.0* DIR BILI-4.1* INDIR
BIL-0.9
[**2170-5-12**] 01:30AM LIPASE-4680*
[**2170-5-12**] 01:30AM ALBUMIN-3.5 CALCIUM-6.0* PHOSPHATE-1.5*
MAGNESIUM-1.4* IRON-78
[**2170-5-12**] 01:30AM TRIGLYCER-627*
[**2170-5-12**] 01:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-5-12**] 01:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-5-12**] 01:05AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2170-5-12**] 01:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-70 KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-TR
[**2170-5-12**] 01:05AM URINE RBC-1 WBC-47* BACTERIA-MANY YEAST-NONE
EPI-4 TRANS EPI-1
Trends:
[**2170-5-14**] 03:44AM BLOOD WBC-6.9 RBC-2.45* Hgb-8.3* Hct-26.6*
MCV-109* MCH-33.7* MCHC-31.0 RDW-15.0 Plt Ct-34*
[**2170-5-15**] 03:33AM BLOOD WBC-7.1 RBC-2.74* Hgb-8.8* Hct-28.3*
MCV-103* MCH-32.1* MCHC-31.1 RDW-17.8* Plt Ct-85*
[**2170-5-17**] 03:00AM BLOOD WBC-9.8 RBC-2.56* Hgb-8.2* Hct-26.4*
MCV-103* MCH-32.0 MCHC-31.0 RDW-18.2* Plt Ct-153
[**2170-5-18**] 01:25PM BLOOD WBC-11.5* RBC-2.69* Hgb-8.7* Hct-27.3*
MCV-102* MCH-32.6* MCHC-32.1 RDW-18.1* Plt Ct-175
[**2170-5-20**] 02:07AM BLOOD WBC-12.9* RBC-3.05* Hgb-9.6* Hct-30.0*
MCV-99* MCH-31.7 MCHC-32.1 RDW-18.5* Plt Ct-174
[**2170-5-12**] 08:12PM BLOOD Neuts-85* Bands-5 Lymphs-6* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2170-5-14**] 06:09PM BLOOD Neuts-80.7* Lymphs-9.3* Monos-5.9 Eos-3.5
Baso-0.5
[**2170-5-20**] 02:07AM BLOOD Neuts-77* Bands-1 Lymphs-8* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2170-5-21**] 04:01AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND
[**2170-5-12**] 01:15PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
[**2170-5-19**] 04:19AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-1+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-5-18**] 04:35AM BLOOD PT-13.4* PTT-28.7 INR(PT)-1.2*
[**2170-5-19**] 03:30PM BLOOD Plt Ct-164
[**2170-5-15**] 03:33AM BLOOD Glucose-86 UreaN-44* Creat-5.8* Na-142
K-3.2* Cl-105 HCO3-16* AnGap-24*
[**2170-5-17**] 03:00AM BLOOD Glucose-77 UreaN-62* Creat-8.1* Na-141
K-3.4 Cl-106 HCO3-13* AnGap-25*
[**2170-5-18**] 04:35AM BLOOD Glucose-106* UreaN-37* Creat-5.3* Na-140
K-3.1* Cl-98 HCO3-21* AnGap-24*
[**2170-5-19**] 04:19AM BLOOD Glucose-130* UreaN-47* Creat-6.4* Na-143
K-3.2* Cl-102 HCO3-27 AnGap-17
[**2170-5-20**] 02:07AM BLOOD Glucose-98 UreaN-26* Creat-4.6* Na-138
K-3.6 Cl-97 HCO3-24 AnGap-21*
[**2170-5-14**] 06:09PM BLOOD Glucose-69* UreaN-44* Creat-5.7* Na-138
K-3.6 Cl-113* HCO3-13* AnGap-16
[**2170-5-14**] 09:56PM BLOOD Glucose-151* UreaN-43* Creat-5.7* Na-139
K-3.3 Cl-103 HCO3-17* AnGap-22*
[**2170-5-20**] 02:07AM BLOOD Glucose-98 UreaN-26* Creat-4.6* Na-138
K-3.6 Cl-97 HCO3-24 AnGap-21*
[**2170-5-20**] 03:05PM BLOOD Glucose-96 UreaN-31* Creat-5.1* Na-137
K-3.7 Cl-97 HCO3-24 AnGap-20
[**2170-5-14**] 03:44AM BLOOD ALT-317* AST-942* CK(CPK)-1158*
AlkPhos-93 TotBili-3.5*
[**2170-5-15**] 03:33AM BLOOD ALT-191* AST-310* LD(LDH)-453*
AlkPhos-115* TotBili-3.6*
[**2170-5-16**] 04:00AM BLOOD ALT-131* AST-118* LD(LDH)-421*
AlkPhos-126* TotBili-2.1*
[**2170-5-17**] 03:00AM BLOOD ALT-91* AST-67* LD(LDH)-426* AlkPhos-123*
TotBili-1.7*
[**2170-5-18**] 04:35AM BLOOD ALT-70* AST-50* AlkPhos-141* TotBili-1.7*
[**2170-5-19**] 04:19AM BLOOD ALT-58* AST-41* LD(LDH)-459* AlkPhos-129*
TotBili-1.2
[**2170-5-20**] 02:07AM BLOOD ALT-52* AST-50* AlkPhos-122* TotBili-1.5
[**2170-5-12**] 01:30AM BLOOD Lipase-4680*
[**2170-5-12**] 01:15PM BLOOD Lipase-1734*
[**2170-5-12**] 08:12PM BLOOD Lipase-1270*
[**2170-5-13**] 03:04AM BLOOD Lipase-1052*
[**2170-5-14**] 03:44AM BLOOD Lipase-390*
[**2170-5-18**] 01:25PM BLOOD Calcium-8.7 Phos-1.1* Mg-1.9
[**2170-5-19**] 04:19AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8
[**2170-5-19**] 03:30PM BLOOD Calcium-8.9 Phos-1.8* Mg-1.8
[**2170-5-20**] 02:07AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.7
[**2170-5-20**] 03:05PM BLOOD Calcium-9.0 Phos-4.2# Mg-2.4
[**2170-5-12**] 01:30AM BLOOD calTIBC-200* Ferritn-1175* TRF-154*
[**2170-5-12**] 01:15PM BLOOD Ferritn-1531*
[**2170-5-12**] 01:30AM BLOOD Triglyc-627*
[**2170-5-12**] 08:12PM BLOOD Triglyc-771*
[**2170-5-13**] 03:04AM BLOOD Triglyc-704*
[**2170-5-14**] 03:44AM BLOOD Triglyc-269*
[**2170-5-12**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD IgG-626*
[**2170-5-12**] 08:12PM BLOOD HIV Ab-NEGATIVE
[**2170-5-15**] 06:47AM BLOOD Vanco-26.9*
[**2170-5-12**] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-5-17**] 06:18PM BLOOD Type-CENTRAL VE Temp-38.3 Rates-26/ Tidal
V-400 PEEP-5 FiO2-40 pO2-47* pCO2-32* pH-7.46* calTCO2-23 Base
XS-0 Intubat-INTUBATED
[**2170-5-18**] 06:06PM BLOOD Type-[**Last Name (un) **] Temp-37.7 Rates-/20 Tidal V-350
PEEP-0 FiO2-40 pO2-52* pCO2-46* pH-7.42 calTCO2-31* Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-5-20**] 02:22AM BLOOD Type-CENTRAL VE Temp-37.2 pO2-39* pCO2-35
pH-7.49* calTCO2-27 Base XS-3
[**2170-5-20**] 03:10PM BLOOD Type-CENTRAL VE Temp-38.1 Rates-/26
FiO2-40 O2 Flow-12 pO2-52* pCO2-43 pH-7.42 calTCO2-29 Base XS-2
Intubat-NOT INTUBA
[**2170-5-13**] 03:18PM BLOOD Lactate-1.0
[**2170-5-15**] 07:20AM BLOOD Lactate-1.0
[**2170-5-16**] 06:03AM BLOOD Lactate-0.5
[**2170-5-16**] 04:40PM BLOOD Lactate-0.6
[**2170-5-13**] 03:18PM BLOOD freeCa-1.12
[**2170-5-14**] 01:35PM BLOOD freeCa-1.22
[**2170-5-18**] 08:44AM BLOOD freeCa-1.08*
[**2170-5-16**] 05:07PM URINE RBC-18* WBC->182* Bacteri-FEW Yeast-NONE
Epi-31 TransE-1
[**2170-5-18**] 05:45AM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-MANY Epi-7 TransE-1
[**2170-5-20**] 10:10AM URINE RBC-32* WBC-61* Bacteri-FEW Yeast-NONE
Epi-2 TransE-2 RenalEp-<1
MICROBIOLOGY
[**2170-5-20**] URINE URINE CULTURE-PENDING INPATIENT
[**2170-5-20**] STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
[**2170-5-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2170-5-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2170-5-16**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2170-5-13**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-12**] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT
[**2170-5-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2170-5-12**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2170-5-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2170-5-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
RUQ US
IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other forms
of liver
disease including significant hepatic cirrhosis/fibrosis cannot
be excluded on this examination.
2. Splenomegaly.
3. Normal appearance of the gallbladder. No free fluid.
4. Normal ultrasound appearance of the kidneys.
.
CXR
FINDINGS: Single portable AP chest radiograph was obtained. Low
lung volumes accentuate interstitial markings and the pulmonary
vasculature. Despite these limitations, the lungs are clear. No
nodule, consolidation, effusion, or pneumothorax is present. The
heart and mediastinal contours are normal.
IMPRESSION: Low lung volumes.
Imaging
TIB/FIB (AP & LAT) RIGHT PORT Study Date of [**2170-5-12**] 1:20 AM
IMPRESSION: No evidence of osteomyelitis surrounding retained
intraosseous
needle.
ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2170-5-12**] 11:14
AM
IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other forms
of liver
disease including significant hepatic cirrhosis/fibrosis cannot
be excluded on this examination.
2. Splenomegaly.
3. Normal appearance of the gallbladder. No free fluid.
4. Normal ultrasound appearance of the kidneys.
CHEST (PORTABLE AP) Study Date of [**2170-5-17**] 2:06 AM
FINDINGS: As compared to the previous radiograph, the
endotracheal tube, the two feeding tubes, and the left internal
jugular vein catheter are unchanged.
The extent of bilateral pleural effusions has substantially
increased, leading to widespread and relatively severe
homogeneous opacification of the right and left hemithorax.
Extensive subsequent atelectasis must be suspected. Borderline
size of the cardiac silhouette, unchanged.
PORTABLE ABDOMEN Study Date of [**2170-5-17**] 6:30 AM
RESSION: Dobbhoff tube terminates in the second portion of the
duodenum.
RENAL U.S. PORT Study Date of [**2170-5-17**] 11:22 AM
PRESSION:
No evidence of perinephric abscess or fluid collection.
PORTABLE ABDOMEN Study Date of [**2170-5-17**] 12:29 PM
PRESSION: Dobbhoff tube terminates near the ligament of treitz
in the
proximal jejunum.
CHEST (PORTABLE AP) Study Date of [**2170-5-20**] 2:41 AM
Compared with [**2170-5-19**] at 7:18 a.m., the ET tube and
nasogastric-type tubes have been removed. Right IJ and left
subclavian central lines both overlie the distal SVC.
There are low inspiratory volumes. Cardiomediastinal silhouette
is prominent, but unchanged. There is upper zone
re-distribution, vascular plethora and diffuse vascular
blurring, consistent with CHF. There is increased opacity at the
left base, likely representing a combination of a moderate-sized
pleural effusion and underlying collapse and/or consolidation.
There is atelectasis at the right base and possible minimal
blunting at the right costophrenic angle.
Compared with the earlier film, the CHF findings are similar,
possibly
slightly worse. The changes at the left base are stable.
Chest X-Ray [**5-28**]:
IMPRESSION: Marked improvement since [**2170-5-20**], with
improved pulmonary vascular congestion, marked decrease in
pleural effusions, and improving aeration of both lung bases.
Discharge Labs:
[**2170-5-28**] 06:10AM BLOOD WBC-7.1 RBC-2.70* Hgb-8.6* Hct-27.6*
MCV-102* MCH-31.9 MCHC-31.2 RDW-15.8* Plt Ct-286
[**2170-5-22**] 02:21AM BLOOD PT-11.3 PTT-26.2 INR(PT)-1.0
[**2170-5-28**] 06:10AM BLOOD Glucose-107* UreaN-24* Creat-1.8* Na-140
K-4.3 Cl-110* HCO3-21* AnGap-13
[**2170-5-23**] 06:50AM BLOOD ALT-42* AST-47* AlkPhos-89 TotBili-1.0
[**2170-5-28**] 06:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.2*
Brief Hospital Course:
24 y/o female with history of EtOH abuse and pancreatitis
transferred after being found down at home, and noted to be
disoriented with fever, hypotension, tachycardia, oliguric acute
renal failure, with ? of black stools, and found to have severe
pancreatitis.
# Alcoholic Pancreatitis and Shock/Respiratory Failure: Pt
presented w/ severe pancreatitis, w/ BISAP score 4 (did not meet
age criteria). Also w/ hypoperfusion, elevated lactate, and
oliguric renal failure (for which HD was eventually started).
Given fever, altered mental status, and elevated bilirubin with
? RUQ discomfort, cholangitis and cholecystitis were initially
considered but a RUQ showed no abnl gallbladder. Also had a UTI
so urosepsis may have played some role, and she was treated with
Cefepime x4d then ceftriaxone x3 days. Blood cultures negative.
Given her very elevated lipase (4300) and shock picture,
pancreatic necrosis and/or infection was on the differential;
was initially given Vancomycin/Clinda in the ED. She was then
placed on Vancomycin/Cefepime/Flagyl and eventually received 2
days of Vancomycin, 3 days of Flagyl and 4 days of Cefepime plus
3 more days of ceftriaxone. Her hemodynamics were confounded by
alcohol withdrawal (likely contributed to her tachycardia and
hypertension).
On [**5-13**] she became tachycardic to 160's, desatted to low 70's
laying flat, in respiratory distress with withdrawal symptoms so
she was intubated for airway management. Post-pyloric tube feeds
started while intubated. Significantly fluid overloaded in the
setting of receiving IVF for her hypotension and shock,
complicated by ATN (see below) and poor urine output. Patient
was eventually started on dialysis and fluid was ultrafiltrated
off and she was able to be extubated on [**2170-5-19**] with this
intervetion. Patient initially continued to be hypertensive to
SBPs 150s, tachycardic to 120s and tachypneic in 40s after
extubation. Patient had been on midazolam and fentanyl while
intubated for sedation, thus concern patient may both be having
etoh and narcotic withdrawl. Patient's CIWA scale was adjusted
and was placed on clonidine with improvement of her vital signs.
By the time she was called out of the MICU, she was 80-90's
bpm's and frequency of CIWA > 10 was down, still mildly
hypertensive. She was discharge on clonidine 0.1mg twice a day
with planned follow up with her PCP on [**Name9 (PRE) 2974**] [**6-1**].
# Altered mental status: Initially a broad differential. CT head
without contrast at outside hospital prior to transfer was
without acute process. Patient's mental status improved
throughout her course with improvement of her electrolytes and
LFTs. Likely it was related to pancreatitis and toxic/metabolic
encephalopathy. She was mentating normally when called out of
the MICU and at discharge.
# Acute renal failure: likely ATN in setting of severe
pancreatitis/hypoperfusion. Her Cr peaked around 8. She was
started on hemo-dialysis while in the unit with a temporary HD
line. On the floor, she received a tunneled line with plans for
continued dialysis as an outpatient however the patient improved
and started making adequate amounts of urine. The tunneled line
was removed the day of her discharge. Her creatinine at the time
of discharge was 1.8 with no electrolyte abnormalities.
# Anion gap metabolic acidosis: likely multifactorial from
uremia, lactate, and EtOH. Respiratory compensation was adequate
initially. However, as her renal function worsened her acidosis
was managed by ventilation. After dialysis this improved. She
had no AG when called out of MICU and upon discharge.
# Elevated LFTs: likely alcohol induced, but differential
diagnosis also includes acute viral hepatitis as well as shock
liver. Stox and Utox are negative, and tylenol level negative.
At peak these were AST 1238 ALT 239. Hepatitis serologies were
sent are were negative. Abdominal US showed fatty liver vs
cirrhosis. These were trended and were well trended down when
she left the MICU (52/50). Her LFTs were last check on [**5-23**] and
her AST was 47 and ALT 47.
# ?GIB/Anemia: noted to have anemia and a reported history of
black stools at home. Suspect UGIB from chemical gastritis (i.e.
EtOH). Low suspicion for variceal bleed. Started on protonix gtt
in ED. Patient was maintain on IV protonix [**Hospital1 **] and HCTs were
trended she did required a total of 3 U PRBCs. Her HCT
stabilized over her MICU stay and was 29.1 on transfer to the
floor. Her Hct upon discharge was 27.6. She was discharged on
pantoprazole 40mg twice a day and was advised to follow up with
a gastroenterologist for possible endoscopy/colonoscopy.
# UTI. As above patient had positive UCx for E Coli treated with
Cefepime then Ceftriaxone for a week long course. Patient then
had several fevers in MICU, where her urine taken at that time
was + with >182 WBCs but urine cultures grew yeast x3. For this
she was given a 3 day course of fluconazole and her foley was
changed.
# Social issues: pt has unstable home situation and severe etoh
abuse (drinks 1 gallon vodka daily). Social work and psychiatry
were consulted. Social work felt that the patient was benefit
from an inpatient setting the patient preferred being treated as
an outpatient.
# Code: full this admission
===============================================
TRANSITIONAL ISSUES
# Patient has a follow up appointment with her PCP on [**Name9 (PRE) 2974**] [**6-1**]
and should have her electrolytes including creatinine checked at
that time.
# She will need to follow up with gastroenterology for suspected
GI bleed during her MICU course
# She will need to follow up with a nephrologist to ensure that
she will no longer need dialysis
# She plans on scheduling an outpatient psychiatry appointment
Medications on Admission:
- denies taking any medications with exception of intermittent
ativan
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*0
(Zero)
2. CloniDINE 0.1 mg PO BID
Please hold for SBP <100 or HR <60
RX *clonidine 0.1 mg twice a day Disp #*10 Tablet Refills:*0
(Zero)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Alcohol Withdrawal
- Acute Renal Failure requiring dialysis
- GI bleed
- Complicated UTI
- Pancreatitis
Secondary Diagnosis
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were were admitted to the hospital on [**5-12**] after you were
found unresponsive. You were transferred to the ICU and you
required a breathing tube. You were in the ICU for approximately
2 weeks. This occurred because of the amount of alcohol you were
consuming. You were going through severe withdrawal during your
time in the ICU. You have opted to go to an outpatient alcohol
treatment program. Please make an appointment as soon as
possible. You will be continued on Clonidine 0.1mg twice a day
for withdrawal and should continue until you meet with your PCP
on [**Name9 (PRE) 2974**] [**6-1**].
You were noted to have kidney failure. You required dialysis and
your kidney function improved. Prior to your dishcharge you did
not require any more dialysis. You should have your kidney
function/ creatinine checked during your visit with your primary
care doctor.
You were noted to have some gastrointestinal bleeding during
your hospitalization. You did not have any more bleeding after
you left the ICU. You should follow up with a gastroenterologist
as an outpatient.
Medications Changed:
Start Clonidine 0.1 mg [**Hospital1 **] (please discuss continuing this with
your PCP on [**Name9 (PRE) 2974**])
Start Pantoprazole 40mg [**Hospital1 **]
Followup Instructions:
You have an appointment with you PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42600**] MD [**First Name (Titles) **] [**Last Name (Titles) 30786**] [**6-1**] at the Beacon Family Practice.
Please call [**Doctor First Name **] at [**Telephone/Fax (1) 5685**] on [**5-29**] when your insurance has
started.
It is strongly recommended that you enroll in an out patient
alcohol treatment program. Please contact the following agency
to enroll:
Health and Education Services
[**Street Address(2) 110091**]
[**Location (un) 13011**], [**Numeric Identifier 83648**]
[**Telephone/Fax (1) 110092**]
Please make an appontnment with psychiatry as soon as possible.
You have information regarding scheduling this appointment.
Please make an appointment with a nephrologist as soon as
possible as well. Please make this appointment within 1 week of
discharge.
([**Telephone/Fax (1) 10135**].
Please make an appointment with gastroenterology as soon as your
insurance is processed.
Phone: ([**Telephone/Fax (1) 2233**]
Description: Gastroenterology
Department of Medicine Location: LMOB 8E/West Organization:
[**Hospital1 18**] Phone: ([**Telephone/Fax (1) 2233**]
|
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[
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"39.95",
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icd9pcs
|
[
[
[]
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21980, 21986
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15844, 18270
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
914
| 182,443
|
21159
|
Discharge summary
|
report
|
Admission Date: [**2177-12-24**] Discharge Date: [**2178-1-14**]
Date of Birth: [**2128-6-17**] Sex: M
Service:
PROCEDURES PERFORMED: Exploratory laparotomy, evacuation of
hematoma on [**2177-12-26**] and orthotopic hepatic
transplant on [**2177-12-24**].
DETAILS OF HOSPITAL COURSE: [**Known firstname **] [**Known lastname 56103**] is a 49-year-old
male with end-stage liver secondary to hepatitis C cirrhosis,
who presented on [**2177-12-24**] for a cadaveric liver
transplantation. He was taken to the operating room where he
underwent a liver transplantation that was unremarkable.
On postoperative day 2, he developed mild transient elevation
in his liver function tests. An ultrasound demonstrated poor
hepatic flow in the liver. Mr. [**Known lastname 56104**] deceased donor liver
procurement was complicated by the development of procurement
injury to the left hepatic artery such that it was absent and
also a hilar injury to the right hepatic artery. A subsequent
angio was performed on [**12-25**], which demonstrated very
poor flow to the liver and a very tight stenosis in the
vicinity of the anastomosis.
[**Known firstname **] was taken to the operating room on [**2177-12-26**],
where we reopened the abdomen and identified the hepatic
artery. The artery itself was widely patent. There was good
flow and thrill through the artery, and there appeared to be
a kink just distal to the anastomosis. We repositioned the
artery. We were able to demonstrate good Doppler signals in
the right and left lobes of the liver.
On [**12-27**], he underwent a Doppler ultrasound of the liver
demonstrating normal wave forms to the hepatic artery and
again, no left hepatic arterial flow was visualized. He
continued to improve. His liver function tests came back to
normal and on postoperative day 4 after his second procedure
while in the intensive care unit, he arose from a chair and
while moving to the bed, became significantly hypoxic and
hypotensive. He was immediately intubated. Received ACLS
protocol and was able to be resuscitated and normal blood
pressure returned. His initial pH was 7.1 on the blood gas
with significant hypoventilation. He underwent a CTPA which
did not demonstrate any evidence of a pulmonary embolus.
[**Known firstname **] subsequently developed a significant status epilepticus
with multiple tonic-clonic seizure disorder/seizure activity.
Neurology was consulted. CT scan of the head was performed,
which did not demonstrate any pathologic lesion. He was
started on antiseizure medications and eventually the
seizures were able to be controlled. Over the course of the
next several days, we were able to control his seizures and
wean him from the breathing machine. Upon extubation, [**Known firstname **]
was noted to have significant rigidity and myoclonus of upper
and lower extremities. His liver function tests remained
normal.
The rest of his hospital course was characterized primarily
by extensive physical and occupational therapy. Eventually on
[**2178-1-14**], he was able to be discharged to rehab for
ongoing care. He did have a rise in his liver function tests
on [**2178-1-5**] prompting a follow-up ultrasound which
demonstrated no hepatic arterial flow to the liver. At this
time, his liver function tests were normal. We did not
believe that additional surgical intervention or
interventional radiologic intervention was warranted. [**Known firstname **]
was discharged on [**2178-1-14**] with normal liver
function tests to rehabilitation facility for ongoing
physical and occupational therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2178-4-6**] 07:45:11
T: [**2178-4-6**] 08:21:44
Job#: [**Job Number 56105**]
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icd9pcs
|
[
[
[]
]
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307, 3849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,786
| 161,858
|
35154
|
Discharge summary
|
report
|
Admission Date: [**2171-9-23**] Discharge Date: [**2171-10-1**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
CODE STROKE for aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 89 year-old right-handed woman with a PMH of HTN who
presented to the ED with aphasia. Per her grand-daughter, she
was in her USOH this morning. She was then known to have a
conversation with a neighbor while in bed around 6-6:30 pm. It
she was reportedly not feeling well. It was a "brief
conversation" but no speech impairment was notice. Her family
then came to see her around 7:15pm and was found to be unable to
produce fluent sp each and with limited comprehension. She was
brought to the ED and a code stroke was called. Neurology was at
the bedside at 7:36pm.
I contact[**Name (NI) **] her [**Name (NI) 6435**] office, [**First Name8 (NamePattern2) **] [**Doctor Last Name 11456**], MD [**First Name (Titles) **] [**Last Name (Titles) 2177**]
([**Telephone/Fax (1) 11454**], her [**Medical Record Number 80244**] is [**Numeric Identifier 80245**]). I spoke with the
covering physician who reviewed her records and confirmed that
she has a hx of afib but was not anticoagulated given a history
of falls. No reported recent surgeries, bleeding or head
traumas.
Past Medical History:
- "heart condition"
- asthma/COPD
- HTN
- OA
- Vit D deficiency
- afib (per [**Hospital1 2177**] records in [**2170**] w/ nl echo)
- falls
- memory problems
- urinary incontinence
Social History:
-lives alone but requires some assistance with ADLS
-no EtOH, former tobacco, no drugs
Family History:
Unable to obtain.
Physical Exam:
NIH SS: 6
1a. Level of Consciousness: 0
1b. LOC questions: 1
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: UA
8. Sensory: UA
9. Best language: 2
10. Dysarthria: 1
11. Extinction and inattention: UA
Vitals: T: P:85 R: 19 BP: 153/75 SaO2: 95 % RA
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No pedal edema
Skin: no rashes
Neurologic:
-Mental Status: awake, inattentive, follows commands
inconsistently. + dysarthria, paraphasic errors, unable to read,
repeat or name. Only intact spontaneous speech is her name
"[**Known firstname **]" and "I don't know"
CN
I: not tested
II,III: pt does not cooperate with formal VFF testing, unclear
if decreased blink to threat (? L>R), no clear gaze deviation;
pupils 2mm->1mm bilaterally, unable to visualize fundi clearly
III,IV,V: EOMI, no ptosis. No nystagmus
V: UA
VII: ? R NLF flattening
VIII: UA (hearing aids in place)
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: turns head symmetrically
XII: tongue protrudes midline
Motor: Normal bulk and tone; pt does not cooperate with formal
strength testing. + motor impersistence throughout but
antigravity in all extremities; No clear pronator drift.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0------------ Mute
R 0------------ Mute
-Sensory: No withdrawal or grimace to pinprick or nox stim
throughout.
-Coordination: pt does not cooperate with formal testing but is
able to take a pen from the R hand without significant dysmetria
but does not try with the L hand
-Gait: deferred
Pertinent Results:
LABS:
[**2171-9-23**] 07:45PM BLOOD WBC-9.5 RBC-4.76 Hgb-13.8 Hct-41.8 MCV-88
MCH-29.0 MCHC-33.0 RDW-15.5 Plt Ct-324
[**2171-9-30**] 05:40AM BLOOD WBC-7.3 RBC-3.83* Hgb-11.4* Hct-33.0*
MCV-86 MCH-29.9 MCHC-34.6 RDW-15.9* Plt Ct-269
[**2171-9-23**] 07:45PM BLOOD PT-12.9 PTT-24.8 INR(PT)-1.1
[**2171-9-30**] 05:40AM BLOOD PT-32.2* PTT-38.6* INR(PT)-3.3*
[**2171-9-23**] 07:45PM BLOOD Glucose-117* UreaN-16 Creat-1.1 Na-136
K-3.7 Cl-102 HCO3-25 AnGap-13
[**2171-9-30**] 05:40AM BLOOD Glucose-103 UreaN-15 Creat-1.1 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2171-9-23**] 07:45PM BLOOD ALT-10 AST-15 LD(LDH)-204 CK(CPK)-70
AlkPhos-67 TotBili-0.4
[**2171-9-24**] 02:30AM BLOOD ALT-9 AST-13 LD(LDH)-187 CK(CPK)-61
AlkPhos-62 TotBili-0.6
[**2171-9-24**] 02:10PM BLOOD CK(CPK)-62
[**2171-9-23**] 07:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-9-24**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2171-9-24**] 02:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2171-9-23**] 07:45PM BLOOD Albumin-4.3
[**2171-9-25**] 01:45AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 Cholest-176
[**2171-9-25**] 01:45AM BLOOD Triglyc-74 HDL-57 CHOL/HD-3.1 LDLcalc-104
[**2171-9-24**] 02:30AM BLOOD %HbA1c-5.9
[**2171-9-23**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-9-24**] 12:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2171-9-24**] 12:21PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2171-9-24**] 12:21PM URINE RBC->50 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2171-9-29**] 03:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2171-9-29**] 03:40PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
MICRO:
Urine Cx ([**9-24**]): GRAM POSITIVE BACTERIA. ~1000/ML. SUGGESTING
STAPHYLOCOCCI.
Blood Cx ([**9-25**]): NGTD x2
Urine Cx ([**9-26**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
Urine Cx ([**9-28**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION INTERPRET RESULTS WITH CAUTION.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Urine Cx ([**9-29**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.
IMAGING:
ECG ([**9-23**]): Baseline artifact. Atrial fibrillation at a rate of
85 with wider complex beats which are ventricular versus
aberration.
CXR ([**9-23**]): FINDINGS: No previous images. Enlargement of the
cardiac silhouette with hyperexpansion of the lungs. Some
prominence of interstitial markings could reflect elevated
pulmonary venous pressure, chronic lung disease, or both.
No evidence of acute focal pneumonia.
CTA Head/Neck ([**9-23**]): IMPRESSION: Area of ischemia seen within
the left MCA territory. Narrowed region of left M2 segment with
a paucity of distal branches seen.
CT Head ([**9-24**]): IMPRESSION: No evidence of acute intracranial
hemorrhage.
EEG ([**9-24**]): IMPRESSION: Abnormal EEG due to diffuse slowing
with some leftsided accentuation at times with a moderate to
moderately severe diffuse encephalopathy with lateralization to
the left side and accentuation thereof.
TTE ([**9-24**]): The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%) in limited views. Right
ventricular chamber size and systolic function are probably
normal. The aortic valve leaflets are mildly thickened. There is
no aortic valve stenosis. No aortic regurgitation is seen.
Trivial mitral regurgitation seen in limited views. (Patient
unable to cooperate with completion of the test.)
MRI Head ([**9-24**]): IMPRESSION:
1. Multiple small acute infarcts within the left MCA territory
with associated stenosis of the M2 branches of the left middle
cerebral artery, better evaluated on prior CTA.
2. Mild thickening of the ligaments posterior to the dens
without cord compression- can be degenerative or inflammatory-
to correlate with past history.
Brief Hospital Course:
1. Stroke. The patient is an 89 year old right handed woman with
a history of atrial fibrillation and hypertension who presented
approximately 1 hour after developing global aphasia. CTA
head/neck on admission showed an area of ischemia within the
left MCA territory, narrowed region of left M2 segment with a
paucity of distal branches seen. She was given IV tPA at 9:45 pm
on [**9-23**], and admitted to the NeuroICU. MRI brain showed
multiple small acute infarcts within the left MCA territory with
associated stenosis of the M2 branches of the left middle
cerebral artery, and mild thickening of the ligaments posterior
to the dens without cord compression. Repeat head CT 24 hours
after tPA showed no evidence of acute intracranial hemorrhage.
TTE was of suboptimal image quality, but showed LVEF>55%. FLP:
Chol 176, TG 74, HDL 57, LDL 104, HgA1c: 5.9%, CEs: CK 70-61-62,
TropT <0.01x3. EEG was abnormal due to diffuse slowing with some
leftsided accentuation at times with a moderate to moderately
severe diffuse encephalopathy with lateralization to the left
side and accentuation thereof.
.
It was determined that the most likely cause of her stroke was
cardioembolic in the setting of atrial fibrillaion. She was
started on a heparin gtt for bridge to Coumadin. Her home ASA
was discontinued. She was started on Simvastatin 40 mg qhs. She
will follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Neurology as an
outpatient.
2. Atrial fibrillation. EKG on admission showed atrial
fibrillation. Given that her stroke was most likely
cardioembolic, her ASA was discontinued and she was started on
Coumadin. Her INR should be monitored daily in rehab, especially
given that she is also on antibiotics for a UTI (see below).
3. Hypertension. Her home blood pressure medications were
intially held in the setting of stroke to allow for
autoregulation. She was restarted on Norvasc 5 mg daily upon
discharge.
4. Urinary Tract Infection. Her UA on [**9-26**] showed 37 WBC and
moderate bacteria. Urine culture on [**9-28**] and [**9-29**] grew
pan-sensitive E. coli. She was started on Bactrim DS PO bid to
complete a 7 day course. Her INR should be monitored carefully
while on antibiotics.
5. Contacts: HCP is her daughter [**Name (NI) 71304**] [**Name (NI) **] (H) [**Telephone/Fax (1) 80246**]
(C) [**Telephone/Fax (1) 80247**]
-PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] at [**Hospital1 2177**] [**Telephone/Fax (1) 11463**]
Medications on Admission:
(confirmed with daughter and PCP [**Name Initial (PRE) 14453**])
-Tylenol 500mg, 1-2 tabs Q6H PRN
-Norvasc 5mg PO daily
-ASA 325mg PO daily
-Flovent aero 200mcg/act 2 puffs [**Hospital1 **]
-Albuterol 90 mcg 2 puffs Q4H PRN
-Lasix 20mg PO daily PRN
-Vitamin D 50,000 Q week x8 weeks (just started prior to
admission, had not yet started)
-MVI
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
Stroke-Left MCA territory, s/p IV tPA, likely cardioembolic
Atrial fibrillation
Hypertension
Urinary Tract Infection
SECONDARY:
Asthma
Discharge Condition:
Slight dysarthria, smile symmetric, no pronator drift, full
strength, gait narrow based and steady, walks with a cane
Discharge Instructions:
You were admitted to the hospital with difficulty speaking and
were found to have a stroke, and you received tPA IV. Your
stroke was most likely due to your irregular heart rhythm
(atrial fibrillation), so you were started on Coumadin. You were
initially in the NeuroICU, but were transferred to the Neurology
floor when your symptoms improved.
The following changes were made to your medications: Your
Aspirin was discontinued during this admission, and you were
started on Coumadin 2 mg QD. You were started on Simvastatin 40
mg every evening. You were found to have a UTI and were started
on Bactrim twice daily to complete a 7 day course.
If you develop weakness or numbness, difficulty speaking or
swallowing, decreased vision or blurry vision, or any other
symptoms that concern you, call your PCP or return to the ED.
Followup Instructions:
You will need to make a follow up appointment with your Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] (your PCP) at [**Hospital1 2177**] ([**Telephone/Fax (1) 11463**]) within the next 1
week.
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2171-11-11**] at 2:00 pm in the [**Hospital Ward Name 23**]
Center, [**Location (un) **]. You will need to call the office before the
appointment to update your information.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2171-10-1**]
|
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icd9cm
|
[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,418
| 142,997
|
2496
|
Discharge summary
|
report
|
Admission Date: [**2200-5-20**] Discharge Date: [**2200-6-14**]
Date of Birth: [**2156-7-12**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Cefazolin
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Epidural abscess
Major Surgical or Invasive Procedure:
s/p L2-L5 Laminectomy for epidural abscess
Right shoulder tap
s/p intubation x2
Central venous line placement
Arterial line placement
Dialysis catheter placement
Bronchoscopy
Transesophageal echocardiogram
History of Present Illness:
Mr. [**Known lastname 11060**] is a 43 year old man with h/o CKD (unknown baseline
Cr), who was admitted with epidural abscess.
The patient had a 1 week h/o back pain ([**5-12**]) on the left side
that radiated down to his left ankle. He presented to the
[**Hospital1 882**] ED at that time and was discharged on Ibuprofen and
Flexeril, with a likely diagnosis of sciatica. He then presented
to [**Hospital 1474**] Hospital 2 days later and was again discharged with
pain medications. The pain worsened during the week to the point
where the patient was having difficulty with ambulation and
getting out of bed. The patient was seen by his PCP the day
prior to admission and had an MRI, which was indeterminate [**1-28**]
to artifact. The PCP urged the patient to come to [**Hospital1 18**] for
further evaluation. The patient took 3 Tramadol and 4 Percocet
this AM prior to presentation. The wife noted that he was more
lethargic and was incoherent at times over the past day.
In the ED, initial vs were: T 96.9 P 87 BP 84/38 RR 10 O2 95%.
He was found to have LLE weakness and decreased rectal tone on
exam. He was hypotensive to the 80s and received 3LNS. Labs were
notable for Cr 6.0 (unknown baseline). Pt received Ativan prior
to MRI, which showed e/o epidural abscess. Patient was given
Ceftriaxone, Vanc, and Zosyn, has not received Flagyl yet at
this time. He was evaluated by neurosurgery, who was unable to
take the patient straight to the OR given his renal failure.
On the floor, the patient was lethargic, but arousable and
answering appropriately. He has pain in his right shoulder with
movement and some pain in his left lower back. He notes that he
has not had any urine output all day. No fevers or chills at
home, but the pt does endorse having sweats. Wife and daughter
with colds at home, but developed them after the patient's back
pain had already started. No recent travel or h/o IVDU.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, 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, or changes in
bowel habits. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
HTN - hospitalized with malignant hypertension in [**2197**],
difficult to control on multiple medications
anemia
asthma
Social History:
Married and lives with his lovely wife, [**Name (NI) **] and his two
daughters. [**Name (NI) 1403**] as a probation officer. Mr. [**Known lastname 11060**] is a
non-smoker, only occasionally drinks EtOH, and denies any drug
use, including IVDU.
Family History:
Mother with DM, HTN, lung cancer. Dad with Parkinson's disease,
DM, and HTN. Significant family history of hypertension, mainly
diagnosed in people in their 20s-30s.
Physical Exam:
ON ADMISSION:
Vitals: T: 98.3 BP: 97/55 P: 97 R: 19 O2: 97%4LNC
General: lethargic, arousable, answering appropriately, AOx3
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, SEM best heard at
LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place draining dark urine
Back: no tenderness to palpation
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; R shoulder with no erythema, warmth, or fluctuance, +ttp
Neuro: AOx3, lethargic but arousable, decreased strength RUE [**1-28**]
to pain, decreased strength LLE, sensory intact
AT TIME OF DISCHARGE:
Vitals: T: 97.6 (Tm: 100.3) BP: 150/100 P: 111 R: 20 O2: 100%
RA.
General: AOx3, NAD.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, SEM best heard at
LUSB.
Abdomen: NABS, soft, non-tender, non-distended, no rebound
tenderness or guarding.
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; Drain placed in psoas abscess draining clear
serosanguinous fluid.
Back: No ttp along spine. No CVA tenderness. Incision site
without evidence of infection, sutures removed. There is a small
open area without evidence of infection that we will monitor. No
rash on trunk.
Neuro: AOx3, decreased strength RUE [**1-28**] to pain, decreased
strength [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], sensory intact; LE strength improved
from baseline on medical floor.
Pertinent Results:
ADMISSION LABS:
[**2200-5-20**] 02:10PM WBC-28.2 RBC-4.07* Hgb-10.5*# Hct-32.0* MCV-79*
Plt Ct-198
[**2200-5-20**] 02:10PM Neuts-93* Bands-3 Lymphs-4* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-5-20**] 02:10PM PT-14.0* PTT-26.7 INR(PT)-1.2*
[**2200-5-20**] 02:10PM Gluc-121 UreaN-98* Cr-6.0*# Na-138 K-3.9 Cl-94*
HCO3-26
[**2200-5-21**] 01:46AM ALT-55* AST-80* LD(LDH)-330* AlkPhos-158*
TotBili-5.2*
[**2200-5-21**] 01:46AM Albumin-2.7* Calcium-7.8* Phos-5.8*# Mg-3.0*
[**2200-5-22**] 03:23AM Hapto-331*
[**2200-5-20**] 02:10PM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-POS
[**2200-5-20**] 04:19PM Lactate-1.5
URINE:
[**2200-5-20**] 11:56PM Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.023
[**2200-5-20**] 11:56PM Blood-MOD Nitrite-NEG Protein-25 Glucose-NEG
Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-SM
[**2200-5-20**] 11:56PM RBC-[**2-28**]* WBC->50 Bacteri-MOD Yeast-NONE Epi-0-2
[**2200-5-20**] 11:56PM CastGr-0-2 CastWBC-0-2
[**2200-5-20**] 11:56PM WBC Clm-FEW
[**2200-5-20**] 11:56PM Hours-RANDOM UreaN-298 Creat-243 Na-14
[**2200-5-24**] 09:12AM Eos-NEGATIVE
MICRO:
[**5-20**] BCx: [**Month/Year (2) **] [**Month/Year (2) 12777**]
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**5-20**] UCx: NEGATIVE
[**5-20**] MRSA Screen: NEGATIVE
[**5-21**] Abscess Cx: [**Month/Year (2) **] [**Month/Year (2) 12777**]
[**5-21**] Lumbar swab: [**Month/Year (2) **] [**Month/Year (2) 12777**]
[**5-21**] Sputum Cx: NEGATIVE
[**5-22**] UCx: NEGATIVE
All abscesses that were drained grew MSSA.
Daily surveillance blood cultures since [**2200-5-20**] were negative.
STUDIES:
[**5-20**] EKG:
Sinus rhythm. Prominent QRS voltage suggests left ventricular
hypertrophy, although is non-diagnostic and tracing may be
within normal limits.
[**5-20**] CXR: Low inspiratory lung volumes with probable left
basilar atelectasis.
[**5-20**] MR [**Name13 (STitle) 1093**]:
1. The findings suggest a 3-cm posterior epidural space
occupying lesions
centered at L3-4 resulting in severe canal narrowing with
moderate intrathecal crowding. Assessment is limited due to lack
of IV contrast administration, and this can be seen with
infection with or without hemorrhage, the latter component being
a possibility due to small foci of increased T1W signal. TO
correlate with labs and clinically and consider spine/NS
consult. Intradural extension cannot be excluded as the dura is
not clearly identifiable on the axial T2W images. Mass lesion is
less likely; however cannot be completely excluded given the
dark T2 siganl and lack of IV contrast. There are small fluid
collections throughout the left posterior paraspinal musculature
extending anteriorly into the left iliopsoas muscle. Follow up
if no intervention is contemplated. No bone marrow signal
abnormalities to suggest osteomyelitis.
2. Diffusely hypointense bone marrow signal abnormality likely
related to the patient's chronic kidney disease.
[**5-20**] R Shoulder XR:
Three views of the right shoulder obtained non-standing are
normal. No fracture, bone destruction, dislocation, or
diminution in the acromio-humeral soft tissues. Joint spaces are
normally maintained and the visualized right lung is clear.
[**2200-5-27**] TEE: The left atrium is normal in size. A patent foramen
ovale is present (very small left to right jet seen). Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. No
vegetation/mass is seen on the pulmonic valve. No abscess seen.
The thoracic aorta was not well visualized.
[**5-21**] CT Torso:
1. Large left psoas phlegmon with internal foci of gas,
concerning for early abscess formation. Further delineation is
limited without intravenous contrast. MRI is recommended for
further characterization and differentiation of soft tissue
versus fluid within psoas abnormality. No osteomyelitis.
2. Minimal left renal enlargement with thickening of Gerota's
fascia, suggstive of pyelonephritis
3. Possible liver cyst.
[**5-22**] RUQ U/S:
1. Two simple hepatic cysts. No solid liver lesion identified.
2. No gallstones or sludge, and no biliary dilatation. The
gallbladder wall is edematous but in the setting of low albumin,
this finding is nonspecific for cholecystitis.
[**5-22**] MR [**Name13 (STitle) **]:
Status post L2/L5 lumbar laminectomy and posterior evacuation of
the previously noted epidural abscess at L3 and L4 levels.
Apparently there is no evidence of residual epidural abscess,
however this is a limited examination without gadolinium
contrast, there are persistent small fluid
collections throughout the left posterior paraspinal
musculature, extending anteriorly into the left iliopsoas
muscle, continued followup is recommended. No bone marrow signal
abnormalities are detected to suggest osteomyelitis, the
intervertebral disc spaces are maintained.
[**5-22**] MR [**Name13 (STitle) 2853**]:
Multilevel degenerative changes most prominent at C3-C4 with
uncinate process hypertrophy on the left and mild left-sided
neural foraminal
narrowing at C3-C4.
[**5-23**] CT abd/pelvis:
1. Large left psoas abscess similar to the previous study. The
margins of
abscess are poorly defined due to lack of IV contrast. No
definitive
drainable collection.
2. Status post lumbar laminectomy with extra-axial gas and soft
tissue
stranding. Intrathecal contents are not well evaluated.
3. Bibasilar atelectasis and small pleural effusions. A small
component of
infection in the lung bases cannot be excluded.
4. Liver hypodensities, compatible with a cyst described in
prior ultrasound.
5. Mesenteric and retroperitoneal adenopathy as well as inguinal
adenopathy, likely reactive.
L-spine MRI [**2200-6-8**]:
IMPRESSION: Limited examination without intravenous gadolinium
contrast,
persistent and apparently stable multiple fluid collections in
the left
paraspinal musculature including the left psoas region and left
periphrenic area. Unchanged fluid collection abutting the
posterior thecal sac at the laminectomy site with no evidence of
intrathecal extension. Persistent edema is identified in the
left gluteal region. Multiple fluid collections in the posterior
paraspinal musculature as described above. The visualized aspect
of the conus medullaris apparently is normal, there is no
evidence of discitis or osteomyelitis and no significant neural
foramen is identified.
DISCHARGE LABS:
[**2200-6-13**] 04:38AM BLOOD WBC-11.3* RBC-2.47* Hgb-6.9* Hct-20.6*
MCV-84 MCH-28.0 MCHC-33.6 RDW-17.0* Plt Ct-385
[**2200-6-10**] 06:14AM BLOOD Neuts-84.1* Lymphs-9.2* Monos-4.1 Eos-2.3
Baso-0.4
[**2200-6-13**] 04:38AM BLOOD Plt Ct-385
[**2200-6-6**] 05:44AM BLOOD Ret Aut-3.4*
[**2200-6-13**] 04:38AM BLOOD Glucose-101* UreaN-37* Creat-1.8* Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
[**2200-6-6**] 09:13AM BLOOD LD(LDH)-363*
[**2200-6-12**] 05:48AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.8
[**2200-6-6**] 09:13AM BLOOD Hapto-366*
[**2200-5-28**] 03:57AM BLOOD Triglyc-493*
[**2200-6-4**] 06:05AM BLOOD TSH-2.2
[**2200-6-4**] 06:05AM BLOOD T4-4.2*
[**2200-6-13**] 04:38AM BLOOD Vanco-20.2*
PENDING: URINARY CATECHOLAMINES.
Brief Hospital Course:
Mr. [**Known lastname 11060**] is a 43 year old man with asthma, anemia, HTN, and
CRI, who was admitted with back pain, LLE weakness, decreased
rectal tone, and found to have a MSSA bacteremia and an epidural
abscess with extension to the L iliopsoas muscle. He is s/p
laminectomy and evacuation of the epidural abscess and s/p IR
drainage of L psoas abscess and L gluteal muscle abscess.
#1. Disseminated MS [**First Name (Titles) **] [**Last Name (Titles) 12777**] bacteremia: with epidural and
psoas abscess, recent sepsis requiring intial MICU stay. Pt with
MSSA bacteremia, s/p wash out of epidural abscess. TEE negative
for vegetations. Surveillance blood cultures remain negative
since [**2200-5-20**]. The patient also had a L psoas abscess that was
drained by IR on [**2200-6-4**] and a L gluteal muscle abscess drained
by IR on [**2200-6-9**]. The patient was initially treated with
Nafcillin and Levofloxacin then switched to vancomycin because
of drug rash with nafcillin. He was then switched to cefazolin
but developed a rash to this medication as well, so switched
back to vancomycin which he was on at time of discharge. Will
need to continue to renally dose vancomycin, based on daily
troughs with goal of 15-20, given improving renal function.
Tylenol prn for fever; trend fever curve. ID recommends [**8-5**]
weeks of IV antibiotics total (through [**2200-7-24**]); PICC placed RUE
[**2200-6-5**].
#2. Hypertension: Patient initially with extremely labile
pressures - alternating between labetalol gtt and phenylephrine
in the ICU. Labetalol gtt d/cd on morning of [**2200-6-3**], BPs now
better controlled on po antihypertensives. Continue hydralazine,
amlodipine, minoxidil, and metoprolol; BPs very well controlled
on this regimen. The patient has a strong family history of HTN,
was diagnosed at age 20, and had flushing, paroxysmal
lightheadedness, and other symptoms prior to this admission that
were concerning for possible pheochromocytoma. 24 hour urinary
catecholamines were collected this admission and are pending.
Plasma metanepherines resulted as follows:
Normetanephrine, Free 1.90 H < 0.90 nmol/L
Metanephrine, Free 0.22 < 0.50 nmol/L
Once the patient's acute issues are resolved, he may warrant
further endocrine evaluation as an outpatient.
#3. Acute on chronic renal insufficiency: Baseline Cr reported
to be 1.5 in [**1-/2199**]; 6.0 on admission. Likely ATN in the
setting of acute septic hypotension. The patient was on CVVH
[**2121-5-24**] and transitioned to HD starting [**5-27**]. Urine eosinophils
were negative which ruled out possible AIN from nafcillin.
Renal consulted. Patient's UOP improved off of HD, so this was
discontinued on [**2200-6-3**]. Creatinine improved at 1.8 prior to
discharge. Continue to renally dose all medications, monitor
BUN/Cr daily.
#4. Anemia: Patient has baseline iron deficiency anemia with
admission HCT of 32.5. Had slowly trended down since admission
and was stable at 22 for past week, thought to be reactive
anemia because of sepsis. Started iron replacement [**Hospital1 **]. Nadir
HCT during this admission was 18 which responded to 2u RBCs.
Concern existed for hemolysis but hemolysis labs were negative.
Non-contrast CT abd/pelvis to rule out bleed or hematoma post IR
drainage of multiple abscesses was negative. HCT at time of
discharge stable at 22.2. Trend HCT. Continue iron
supplementation.
#5. Upper GI Bleed: Pt noted to have abdominal distenstion
following oral contrast for CT scan with hypoactive bowels
sounds in MICU. KUB with no e/o obstruction. After placing NGT,
pt put out about 300 cc of coffee ground drainage. Hct remained
stable with no further e/o bleed. He was treated with IV PPI
[**Hospital1 **].
#6. R shoulder pain: Patient with acute onset R shoulder pain
since the day prior to admission. s/p aspiration with dry tap
in OR by orthopedics, no evidence of septic joint. Will require
PT and OT for increased motility in rehabilitation facility.
#7. Communication: Patient and wife who is HCP, [**Name (NI) **]:
(H):[**Telephone/Fax (1) 12778**], (W):[**Telephone/Fax (1) 12779**], (Cell): [**Telephone/Fax (1) 12780**].
Mr. [**Known lastname 12781**] code status was confirmed as FULL CODE during this
admission. He will have close PCP [**Last Name (NamePattern4) 702**]. His PCP has
requested that she see him as an outpatient and then she will
refer him to an infectious disease specialist for follow-up at
that time. In the interim, all laboratory results and questions
should be relayed to the infectious disease department at [**Hospital1 18**]
per the discharge page 1 worksheet.
Medications on Admission:
HCTZ 25mg PO daily
Minoxidil 5mg PO TID
Labetalol 400mg PO BID
Spironolactone 50mg PO daily
Tramadol 50-100mg PO q4-6h prn
Lisinopril 40mg PO daily
Percocet 1-2tabs q4-6h prn
Albuterol inh prn
Ibuprofen prn
Lidocaine patch
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID-
CAN GIVE WITHOUT MEALS ().
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. 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.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
14. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous every twelve (12) hours for 8 weeks: Please
adjust vancomycin dosing as renal function improves. Goal trough
is 15-20. Thank you.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
- MSSA bacteremia
- Abscesses of left psoas and left gluteal muscles
- Epidural abscess of L3-L4
- Hypertension, labile
- Acute kidney injury on stage 3 chronic kidney disease
- Anemia, chronic disease
- Upper gastrointestinal bleed
- Right shoulder pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 11060**], you were admitted to the hospital because of
intractable back pain. You were found to have a blood infection
called MSSA (methicillin sensitive [**Known lastname **] [**Known lastname 12777**]) which was
complicated by abscesses of your epidural space, left psoas
muscle and left gluteal muscle. Multiple abscesses were drained,
and you were treated with antibiotics and your condition
improved. You are now deemed medically stable for discharge to a
rehabilitation facility.
The following changes have been made to your medications:
1. START Vancomycin 750 mg IV every 12 hours for 8 weeks for
infection.
2. Dilaudid 2 mg by mouth every 6 hours as needed for pain.
3. Hydralazine 75 mg by mouth every six hours for blood pressure
control.
4. Minoxidil 2.5 mg Tablet. Take two (2) tablets by mouth 3
times a day.
5. Amlodipine 10 mg by mouth once per day for blood pressure
control.
6. Ferrous gluconate 325 mg by mouth twice per day for iron
deficiency anemia.
7. Metoprolol Succinate (Toprol XL) 100 mg by mouth daily for
blood pressure control.
It was a pleasure caring for you during this hospital admission
and we wish you well.
Followup Instructions:
Primary Care Doctor Appointment
Name: [**Last Name (LF) 12782**],[**First Name3 (LF) **]
When: TUESDAY, [**6-17**], 2:40PM
Location: [**Location (un) 2274**]
Address: [**Street Address(2) **]., [**Apartment Address(1) 12783**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 6803**]
Dr. [**Last Name (STitle) 12782**] will refer you for an appointment with an
infectious disease specialist for follow-up when you meet with
her.
|
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58,895
| 122,969
|
53849
|
Discharge summary
|
report
|
Admission Date: [**2171-4-26**] Discharge Date: [**2171-4-29**]
Date of Birth: [**2123-10-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Microsuspension laryngoscopy with micro flap excision of left
[**Last Name (un) 50614**] edema, awake fiberoptic intubation
History of Present Illness:
47M with hx of HLD, tobacco use, and occasional cocaine/crack
use who presented to [**Hospital3 **] on [**2171-4-24**] with increasing
shortness of breath concerning for cocaine-induced chest pain.
He initially presented to the ED on [**2171-4-23**] with dyspnea and was
treated with one dose of prednisone as well as albuterol
inhalers and then discharged home. He states that his shortness
of breath actually began approximately 1.5 months ago, which he
attributed to smoking, and then it spontaneously resolved. He
presented again the following day with severe dyspnea and
initially required a 100% non-rebreather. His pulmonary exam
revealed bilateral crackles and a chest x-ray revealed pulmonary
edema. He received Aspirin and Nitroglycerin initially. His EKG
was initially unremarkable. Cardiac troponins were elevated to
0.43 later that day. Cardiology was consulted and a TTE was
performed, the results of which were pending at the time of
transfer.
.
He continued to have persistent stridor and a bronchoscopy was
performed that revealed large papillomatous tumor originating
predominantly from the left but also the right vocal cord, but,
by report, the bronchoscope was able to be easily passed through
the vocal cords. Traces of blood were noted throughout the
airway, which were suctioned. Multiple bites were taken of the
tumor and sent for pathology. A complete debulking was not
performed out of concern for the recent NSTEMI though
approximately 20% of the obstruction was removed from the
posterior commissure.
.
Given the complexity of the case and the absence adequate
services, the decision was made to transfer the patient to [**Hospital1 18**]
for further management. Vital signs at transfer were 97.8, 102,
143/93, 18, 96% on 2L NC.
.
On arrival to the MICU, his VS were 98.2, 110, 149/92, 21,
96%RA. On further review, in addition to the details above, he
related that he felt that he was having so much trouble
breathing that he passed out at OSH. He states that he
occasionally uses crack and cocaine and last smoked crack
approximately the day prior to his admission to [**Hospital3 **].
He currently denies chest pain, shortness of breath, abdominal
pain, N/V/D, urinary symptoms, fevers, or chills.
.
Review of systems:
(+) Per HPI, otherwise negative.
Past Medical History:
Hypercholesterolemia
Chronic lower back pain
Cocaine abuse
Alcohol abuse
Tobacco abuse
Social History:
He is single and has one 13 y/o child. He works as a printer. He
has smoked one pack/day x 35 years. He drinks approximately [**5-12**]
beers/day, 6 days a week. He occasionally uses cocaine or crack.
He uses marijuana as well. He denies any injectable drug use.
He is currently in a custody battle with his ex-partner that has
lasted several years.
Family History:
His mother had an MI at the age of 69 and died in [**2168**] from lung
cancer. She was a smoker. He does not know his father's history.
He has two siblings who are alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
.
Vitals: 98.2, 110, 149/92, 21, 96%RA
General: Alert, oriented, no acute distress, hoarse, weak voice
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rales at bases bilaterally, otherwise clear
Abdomen: soft, obese, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
.
DISCHARGE PHYSICAL EXAM:
========================
.
VS: 97.4 136/84 59 98%RA
GENERAL: middle aged man in no acute distress
RESP: Clear b/l with good inspiratory effort
CV: normal s1 + s2, w/ no gallops, heaves, murmurs etc
Abd: soft, no TTP, no fluid, +ve BS
Neuro: grossly intact, AOX3
Pertinent Results:
ADMISSION LABS:
===============
.
[**2171-4-26**] 11:29AM BLOOD WBC-25.8* RBC-4.44* Hgb-13.3* Hct-41.7
MCV-94 MCH-29.9 MCHC-31.9 RDW-13.6 Plt Ct-230
[**2171-4-26**] 11:29AM BLOOD Neuts-94.0* Lymphs-3.3* Monos-2.2 Eos-0.4
Baso-0.1
[**2171-4-26**] 11:29AM BLOOD PT-10.4 PTT-37.0* INR(PT)-1.0
[**2171-4-26**] 11:29AM BLOOD Glucose-171* UreaN-14 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
[**2171-4-26**] 11:29AM BLOOD ALT-30 AST-21 LD(LDH)-215 CK(CPK)-85
AlkPhos-62 TotBili-0.2
[**2171-4-26**] 11:29AM BLOOD Lipase-43
[**2171-4-26**] 11:29AM BLOOD Albumin-4.0 Calcium-9.0 Phos-2.5* Mg-2.5
.
MICRO/PATH:
===========
.
[**2171-4-26**] MRSA SCREEN: PENDING
[**2171-4-26**] Left Vocal Fold Lesion Pathology: PENDING
.
IMAGING/STUDIES:
================
.
Portable CXR [**2171-4-26**]:
FINDINGS: Single AP portable view of the chest is provided. The
cardiac,
mediastinal silhouette and hilar contours are unremarkable. No
large pleural effusions are seen. There are no focal opacities
or consolidations. There is mild suggestion of cephalization of
the pulmonary vasculature consistent with mild vascular
congestion.
.
[**4-29**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
1 vessel coronary artery disease. The LM and RCA were free of
angiographically apparent disease. The LAD had 50-60% mid
stenosis. The
LCx had 40% mid stenosis.
2. Limited resting hemodynamics revealed normal left sided
filling pressures with an LVEDP of 14mmHg. There was normal
systemic arterial
pressure of 130/91mmHg.
FINAL DIAGNOSIS:
1. Moderate mid-LAD lesion best suited for continued medical
therapy.
2. Continue aspirin, statin, calcium channel blocker.
.
DISCHARGE LABS:
===============
[**2171-4-29**] 05:20AM BLOOD WBC-12.0* RBC-4.68 Hgb-13.6* Hct-43.3
MCV-93 MCH-29.0 MCHC-31.4 RDW-13.3 Plt Ct-218
[**2171-4-28**] 07:00AM BLOOD PT-10.5 PTT-23.6* INR(PT)-1.0
[**2171-4-29**] 05:20AM BLOOD Glucose-119* UreaN-18 Creat-0.8 Na-141
K-3.8 Cl-104 HCO3-28 AnGap-13
[**2171-4-29**] 05:20AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.2
Brief Hospital Course:
SUMMARY: 47 year old man with h/o cocaine abuse and a current
smoker admitted for laryngeal mass leading to stridor and
coronary vasospasm secondary to cocaine use.
.
# Laryngeal Mass S/p Excision: Patient presented on transfer
from OSH to MICU with stable vital signs, hoarse voice, and
inspiratory stridor. Given pt's drinking and smoking history
there was concern for new squamous cancer of the vocal cords.
Patient was evaluated urgently by ENT and taken to the OR for
left vocal fold lesion excision. Clinical impression of ENT team
was [**Last Name (un) **]??????s edema likely from EtOH, tobacco, and yelling loudly
during sporting events. Pathology pending from [**Hospital3 13347**] and [**Hospital1 18**] at time of discharge. He was evaluated the
following morning by laryngoscopy at bedside which showed patent
airway. He received 24 hours of steroids and was transferred to
the floor. On the floor, the patient's breathing was much
improved. He was evaluated by ENT who felt a repeat procedure
in the clinic 1-2 weeks after discharge was warranted to perform
a similar procedure on the opposite vocal cord.
.
# Coronary vasospasm: Lead to dynamic TWI's on I, II, V4-V6 with
TTE at OSH showing distal apical, septal, and anterior wall
hypokinesis with preserved EF >55%. Troponin trend at OSH and
[**Hospital1 18**] 0.01, 0.43, 0.27, 0.07, and 0.03 with normal CKMB. Patient
remained chest pain free during his stay. He had a cardiac
catheterization showing moderate mid-LAD disease, making CAD the
unlikely etiology of his chest pain. His elevated troponin
levels with flat CK-MB suggest demand ischemia in setting of
cocaine use. PCI was not done. The patient was started on
lisinopril for blood pressure control, low-dose statin for
hyperlipidemia, and nifedipine for vasospasm as well as 81mg ASA
daily for prophylaxis. He was not started on a beta-blocker
given his recent cocaine. He may benefit from repeat TTE on
future outpatient visits.
.
# Substance abuse: Patient with active cocaine use, alcohol
use, and tobacco abuse. Social work was consulted, and the
patient was counseled about abstaining from these substances.
.
# Lower back pain: Chronic. The patient was using a friend's
Gabapentin for relief. The patient was encouraged not to take
medications not prescribed to him, and he was given a short
course of gabapentin with instructions to follow-up with his
primary doctor.
.
# Hyperlipidemia: Not on medications as an outpatient. Was
started on low dose simvastatin, with instructions to follow-up
with primary care physician.
.
TRANSITIONAL ISSUES:
-F/u final pathology of vocal cord lesion.
-Needs f/u of chemistry panel post lisinopril initiation.
-Further smoking cessation and cocaine cessation counseling
should be reinforced.
-Statin may need titration.
-Consider repeat outpatient TTE.
Medications on Admission:
Gabapentin 800mg TID (not prescribed to him; he takes a friend's
supply)
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
5. Outpatient Lab Work
Please obtain a basic chemistry panel including potassium, BUN
and Creatinine and have the results sent to Dr. [**Last Name (STitle) **],[**First Name3 (LF) 640**] R.
[**Telephone/Fax (1) 86541**] within 1 week of discharge
6. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*30 patches* Refills:*0*
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary vasospam leading to coronary demand ischemia
Laryngeal mass causing stridor, biopsy results pending
Tobacco abuse
Chronic lower back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for chest pain and shortness of breath. You
had a procedure to look at the arteries around your heart, which
did not reveal a direct cause for your chest pain. The most
likely cause of your chest pain was related to cocaine, which
can cause vasospasm (clamping down of the arteries around your
heart). It will be very important for you to stop using cocaine
to prevent further damage to your heart.
You also had a procedure for the throat and breathing problems
you'[**Name2 (NI) **] been having. This was most likely related to swelling of
the area around your vocal chords, but the final results of the
biopsy are pending, and it will be very important for you to
follow-up with the ENT doctors (ear, nose and throat - the team
that did your procedure).
***You will need to follow-up in [**1-7**] weeks in the ENT office.
The doctors would [**Name5 (PTitle) **] to perform another procedure, which can
be done without putting you to sleep, and can be a same day
office procedure. If you do not follow-up within 1-2 weeks,
your symptoms could progress to the point where you would need
emergency surgery***
It is also imperative that you STOP SMOKING. Continuing to
smoke will increase your risk for future heart attacks, strokes,
and many other severe health complications.
It will be very important for you to follow-up at the
appointments listed below.
We are also starting you on several new medications. Please
note the following medication changes:
-Please START Aspirin 81mg daily
-Please START lisinopril 5mg daily, a medicine to reduce blood
pressure
-Please START nifedipine daily, a medicine to reduce blood
pressure and prevent vasospasm
- START simvastatin 10mg daily, to lower your cholesterol
- START a nicotine patch daily to help you stop smoking
We have also provided a prescription for a short course of
neurontin. It is VERY important that you only take medications
that have been prescribed to you. You should discuss whether to
continue this medication with your primary care doctor.
Please have bloodwork checked on [**2171-5-3**] with results sent to
Dr. [**Last Name (STitle) **]. Your bloodwork needs to be checked because we are
starting you on lisinopril, which can affect your kidneys and
electrolytes.
Please also be sure that your PCP follows up the results of your
biopsy.
Followup Instructions:
***Please call Dr.[**Name (NI) 81497**] (ENT) office at [**Telephone/Fax (1) 41**] to
schedule a follow-up appointment within 1-2 weeks of
discharge***
Name: [**Doctor Last Name 640**] [**Last Name (NamePattern4) **],MD
Specialty: Primary Care
When: [**5-10**] at 2:30pm
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 86541**]
Department: CARDIAC SERVICES
When: THURSDAY [**2171-5-30**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Phone: [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2171-4-29**]
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12,740
| 167,381
|
24330
|
Discharge summary
|
report
|
Admission Date: [**2189-5-12**] Discharge Date: [**2189-5-21**]
Date of Birth: [**2122-1-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Tracheostomy
Right above the knee amputation
Central Line placement
PEG tube placement
History of Present Illness:
67 y/o male with severe RA was transferred to [**Hospital1 18**] for a
tracheostomy. He initially was admitted to an OSH with
respiratory failure appromixately 6 weeks prior to admission to
[**Hospital1 18**], thought to be secondary to a viral illness, during which
time he was sucessfully intubated and extubated, and, upon
recovery, was transferred to a rehab facility. At the rehab, he
was involved in a wheelchair accident that resulted in a right
tibial fracture, for which he was re-admitted to the OSH and
underwent a successful ORIF. However, post-operatively he
developed hypercarbic respiratory failure; he was unable to be
intubated due to a difficult airway so underwent a nasotracheal
intubation. He was then transferred to [**Hospital1 18**] for tracheostomy.
On admission, he was afebrile and hemodynamically stable but was
found to have severe musculoskeletal deformities from his RA.
His lower extremities showed signs of severe skin changes and
necrosis (especially of the toes) with obvious super-infection.
Past Medical History:
Rheumatoid arthritis on chronic steroids
Hip and shoulder replacements
Recent respiratory failure from unknown viral infection
Social History:
Patient had previously been fairly independent, but with the
progressive worsening of his RA had become increasingly
dependent on family and health aides over the past few years.
No recent tobacco use.
Family History:
No family history of RA.
Physical Exam:
t 97.0, bp 94/62, hr 99, rr 16, spo2 97%
gen- pleasant male, with appearance of severe chronic illness,
multiple musculoskeletal deformities, with a nasotracheal airway
in place
heent- anicteric sclera, op clear with mmm
cv- soft heart sound, regular, no m/r/g
pul- distant breath sounds but moves air fairly well, no w/r/r
abd- soft, nt, nabs
extrm- severe deformities in all limbs, lower extremities with
signs of necrosis, especially about the toes, chronic venous
stasis changes, erythema and fungating lesions about the heels
neuro- awake, a&ox3. no focal cn deficits. does not move lower
extremities. upper extremities diffusely but not focally weak,
at about 4-/5. sensation intact.
Pertinent Results:
[**2189-5-12**] 06:00PM BLOOD WBC-22.0* RBC-3.34* Hgb-10.0* Hct-31.2*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.9* Plt Ct-484*
[**2189-5-15**] 03:02AM BLOOD WBC-29.0* RBC-3.07* Hgb-9.1* Hct-29.1*
MCV-95 MCH-29.7 MCHC-31.4 RDW-16.0* Plt Ct-373
[**2189-5-19**] 04:16AM BLOOD WBC-31.9* RBC-3.08* Hgb-9.2* Hct-28.9*
MCV-94 MCH-29.8 MCHC-31.6 RDW-15.7* Plt Ct-137*
[**2189-5-21**] 02:45AM BLOOD WBC-40.3* RBC-3.04* Hgb-9.0* Hct-30.4*
MCV-100* MCH-29.7 MCHC-29.6* RDW-16.0* Plt Ct-78*
[**2189-5-12**] 06:00PM BLOOD Glucose-101 UreaN-9 Creat-0.5 Na-139
K-3.7 Cl-108 HCO3-23 AnGap-12
[**2189-5-14**] 03:01AM BLOOD Glucose-116* UreaN-6 Creat-0.3* Na-141
K-3.8 Cl-112* HCO3-20* AnGap-13
[**2189-5-16**] 04:21AM BLOOD Glucose-76 UreaN-6 Creat-0.4* Na-135
K-3.9 Cl-110* HCO3-20* AnGap-9
[**2189-5-20**] 04:20AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-128*
K-4.3 Cl-106 HCO3-16* AnGap-10
[**2189-5-15**] 03:02AM BLOOD calTIBC-42* Ferritn-618* TRF-32*
.
.
.
[**2189-5-13**] 1:28 pm SWAB Source: rt lower leg/wound.
**FINAL REPORT [**2189-5-19**]**
GRAM STAIN (Final [**2189-5-13**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE [**Known lastname **](S).
WOUND CULTURE (Final [**2189-5-15**]):
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2189-5-19**]): NO ANAEROBES ISOLATED.
.
Brief Hospital Course:
67 y/o male with severe [**Hospital **] transferred from outside hospital for
tracheostomy and found to have lower extremity necrosis and
infection.
Mr. [**Known lastname **] initially had a succesfuly tracheostomy placement.
Given the appearance of his legs, especially the right side,
orthopedic, podiatric, and wound consults were called. As he
began growing out pseudomonas, he was started on ciprofloxacin
and gentamicin, given the sensitivities. He began to develop
signs of sepsis, with decreasing blood pressure, tachycardia,
and increasing WBC. Levophed was started to support his blood
pressure. In discussions with orthopedics, the patient, and his
family, it was decided that as his right lower extremity was the
likely nidus of infection, an amputation was indicated. He went
to the OR and had a succesful right AKA. Upon returing,
however, he showed little clinical improvement, remaining
pressor depedent. He also developed new onset afib with rapid
ventricular response; to investigate the cause, he had full
electrolytes drawn, and ecg was checked, he was ruled-out for
MI, and had a CTA to evaluate for pulmonary embolus, all of
which was negative. He was rate controlled with intermittent
diltiazem. However, Mr. [**Known lastname **] overall clinical picture
continued to deteriorate, with increasing pressor requirements
and declining mental status. His blood cultures grew out a
highly resistant E. faecium. A family discussion was held, and
they felt that given his baseline severe chronic illness, his
quality of life, even if an aggressive course of treatment for
his acute illness was successful, would remain quite poor.
Based on this discussion, support was withdrawn, Mr. [**Known lastname **] was
made comfortable, and he died shortly therafter.
Medications on Admission:
Protonix 40 qd
Heparin 5k SC tid
Prednisone 10mg daily
Zofran, tylenol prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Septic shock
Pseudomonas aeruginosa wound infection
Enterococcus bacteremia
Atrial fibrillation with rapid ventricular response
Secondary:
Rheumatoid arthritis
S/P hip and shoulder replacements
Chronic steroid therapy
Discharge Condition:
Expired
|
[
"519.02",
"038.3",
"V58.65",
"041.7",
"V43.65",
"117.9",
"998.83",
"518.84",
"427.31",
"714.0",
"V43.61",
"519.1",
"482.83",
"996.67",
"737.19",
"V43.64",
"511.9",
"008.45",
"995.92",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"43.11",
"00.17",
"96.6",
"96.72",
"33.21",
"84.17",
"33.22",
"93.59",
"97.23",
"31.1",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
6480, 6489
|
4566, 6354
|
291, 379
|
6770, 6780
|
2580, 4543
|
1825, 1851
|
6510, 6749
|
6380, 6457
|
1866, 2561
|
232, 253
|
407, 1440
|
1462, 1590
|
1606, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,856
| 122,406
|
9741
|
Discharge summary
|
report
|
Admission Date: [**2123-9-22**] Discharge Date: [**2123-10-2**]
Date of Birth: [**2042-7-30**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Lower extremity "oozing"
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
Endotracheal Intubation
History of Present Illness:
81 year old male with history of CAD s/p CABG [**2110**], CHF with EF
20%with h/o flash pulm edema and respiratory arrest, DM, newly
diagnosed Afib, and PVD who was transferred from [**Hospital3 **]
with right leg edema and weeping.
Per discharge summary from [**Hospital1 **], he was admitted to [**Hospital1 **] on [**2123-9-13**] for increasing shortness of breath. Per
report, a chest xray at [**Hospital1 **] showed COPD, a left lower lobe
infiltrate, and no evidence of CHF. BNP was 1510. He was
started on IV Levaquin and he had symptomatic improvement in his
dyspnea. He was given Lasix for diuresis and had an echo that
showed his EF had decreased from 40 to 20%. He was also noted
to be in new-onset atrial fibrillation and was started on
Coumadin (although per patient report, has not taken it) and
continued on Toprol XL 25mg po daily. He remained
rate-controlled. He was not started on an ACE-I due to
hypotension. He also had some asymptomatic hypoglycemic
episodes. He has known renal insufficiency and his creatinine
stabilized at the OSH at 1.7. He was discharged home on
[**2123-9-15**] and completed a course of Levaquin.
Per signout, he then returned to [**Hospital1 **] on [**2123-9-22**] with "right
foot pain." He was transferred for evaluation by Dr. [**Last Name (STitle) 1391**].
Per patient history, about one month ago his son was diagnosed
with prostate cancer. Since that time, he has had difficulty
eating and sleeping. He denies any changes in breathing and
states that he didn't know he had been diagnosed with pneumonia.
He also denies being given any Coumadin. He does endorse
increasing lower extremity edema with weeping of clear fluid.
He denies any lower extremity pain but does have some pain with
walking that has been stable for him since his prior bypass
surgeries in his leg. He denies any shortness of breath and
states he can walk multiple football fields without getting
short of breath as long as he does it slowly. He denies
orthopnea, PND, cough. He walks with a cane or walker.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
Insulin-dependent diabetes mellitus with neuropathy
Proteinuria
Chronic 5th metatarsal heal ulcer (no record of MRSA)
Elevated PSA with neg prostate biopsy [**2115**]
Peripheral vascular diseases/p right fem-below the knee [**Doctor Last Name **]
bypass with left cephalic and basilic vein in [**2116**] and left
common fem-DP bypass with in situ saphenous vein graft in [**2109**]
S/p basal cell carcinoma left check in [**2115**]
H/o infected right saphenectomy incision in [**2110**]
Sciatica
1. CARDIAC RISK FACTORS: + Diabetes, Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: CAD s/p silent MI [**44**] years ago. History of
CHF with flash pulmonary edema and respiratory arrest.
-CABG: 3v CABG with saphenous vein grafts in [**2110**].
-PERCUTANEOUS CORONARY INTERVENTIONS: PTCA to RCA and LAD in
[**2101**]
-PACING/ICD: None
Social History:
Married with two grown children. Former heavy smoker, quit 15
years ago. No current alcohol use. No other drugs.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother died of MI in 70's, father died of
[**Name (NI) 2481**] in 80's. Son with prostate cancer.
Physical Exam:
ADMISSION PE
VS: 97.3 128/65 103 20 97%RA
GENERAL: Awake, alert, 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 10cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular with 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. With crackles at the
bases bilaterally.
ABDOMEN: Soft, NT but slightly firm. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits. Some
pitting edema on back.
EXTREMITIES: Significant 4+ pitting edema bilaterally to the
level of the upper thigh, with some erythema over the calfs, and
weeping of clear liquid. Evidence of healed ulcers on right
leg. Keeps his hands raised and continually moves fingers due
to neuropathy.
PULSES: Right: Carotid 2+ Femoral 2+ Popliteal, Left: Carotid
2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+, Had pulses via doppler
on right and left DP and PT
Pertinent Results:
ADMISSION LABS:
[**2123-9-22**] 09:40PM WBC-10.1 RBC-5.50 HGB-16.9 HCT-49.9 MCV-91
MCH-30.7 MCHC-33.8 RDW-16.6*
[**2123-9-22**] 09:40PM PLT COUNT-211
[**2123-9-22**] 09:40PM PT-16.6* PTT-28.7 INR(PT)-1.5*
[**2123-9-22**] 09:40PM GLUCOSE-194* UREA N-69* CREAT-2.1*#
SODIUM-136 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-26 ANION GAP-20
[**2123-9-22**] 09:40PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-2.6
DISCHARGE LABS:
[**2123-9-22**] ECG:
Baseline artifact precludes definite assessment of the atrial
mechanism which could be atrial tachycardia or atrial flutter
with block. There is a single ventricular premature beat.
Intraventricular conduction delay with underlying inferior and
probable anterolateral myocardial infarction. Low limb and
lateral precordial lead voltage. Compared to the previous
tracing of [**2117-7-2**] atrial tachy-arrhythmia is new with previous
tracing showing sinus rhythm. Clinical correlation is suggested.
[**2123-9-22**] Chest Xray: No evidence of pulmonary edema, unchanged
moderate-to-severe cardiomegaly.
[**2123-9-23**] Transthoracic Echo:
The left atrium is moderately dilated. The right atrial pressure
is indeterminate. Left ventricular wall thicknesses and cavity
size are normal. There is severe regional left ventricular
systolic dysfunction with akinesis of the inferoseptum,
inferior, and inferolateral walls. Quantitative (biplane) LVEF =
10 %. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. 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 moderate thickening of the mitral
valve chordae. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
IMPRESSION:Severe biventricular systolic dysfunction. Moderate
mitral regurgitation.
CT/CTA abd/chest [**9-27**]:
1. No pulmonary embolism or acute aortic pathology. Significant
atheromatous
disease along the aorta and its major branches.
2. Prolonged presence of IV contrast in the right-sided
circulation,
resulting in suboptimal evaluation of CTA abdomen in the
arterial phase.
3. No discrete thrombus or stenosis in the SMA, SMV or celiac
trunk.
4. Non-specific mild colonic mucosal enhancement without colonic
wall
thickening. No pneumatosis or portal venous gas. No definite
evidence of
bowel ischemia.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Diffuse body wall anasarca.
7. Moderate bilateral pleural effusions.
CT head [**9-27**]:
1. No evidence of hemorrhage or vascular territorial infarct.
2. Overall, no change when compared to the recent study.
TEE [**9-28**]:
The left atrium is moderately dilated. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A thrombus is seen at
the tip of the left atrial appendage. Moderate to severe
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
The left ventricular cavity is dilated. There is severe regional
left ventricular systolic dysfunction . There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
IMPRESSION: Left atrial appendage thrombus. Severe biventricular
systolic dysfunction. Moderate mitral regurgitation. Severe
thoracic aortic atherosclerosis.
MR/MRA head [**9-28**]:
1. No MR evidence of acute infarction or hemorrhage. Mild
microangiopathic
ischemic white matter disease.
2. Atherosclerotic irregularity involving the cavernous portions
of both
internal carotid arteries with severe stenosis of the cavernous
left ICA.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
81 year old male with history of CAD s/p CABG [**2110**], CHF with EF
20%with h/o flash pulm edema and respiratory arrest, DM, newly
diagnosed Afib, and PVD who was transferred from [**Hospital3 **]
with lower extremity peripheral edema and oozing.
He was found to have significant evidence of volume overload on
physical exam with a very elevated JVP and 4+ pitting edema to
the level of the abdomen. He had a transthoracic echo which
showed biventricular systolic dysfunction and a left ventricular
ejection fraction of 10%. He was placed on a Lasix drip to
diurese on the floor. He had relative hypotension with SBP in
the 90's and had reportedly had episodes of hypotension after
being started on an ACE-inhibitor at an outside hospital. On
[**9-27**] the patient was found unresponsive and hypoxic and was
intubated and transferred to the cardiac care unit. At that
time he was found to have significant multiorgan failure and
shock requiring pressor support, afebrile. No infectious cause
could be elicited on cultures and imaging. Imaging was not
supportive of mesenteric ischemia or pulmonary embolism. The
patient was oliguric. It was felt that this was [**12-21**] cardiogenic
shock from end stage heart failure. CT head, MRI head showed no
evidence of a acute bleed. Neurology was consulted and an EEG
was performed. Based on imaging and EEG, neurology felt that
there was a poor but "not dismal" chance of neurologic recovery.
Additionally, it was felt that if he could be brought out of
atrial fibrillation, his heart failure might improve; however,
LA/LV thrombus was noted on TEE. No attempt was therefore made
for electrical/chemical cardioversion.
The patient continued to deteriorate, requiring additional
pressor support. After significant discussions with the family
over several days, it was agreed that the patient would be made
DNR/DNI as well as comfort measures only. The patient was
extubated and pressor support removed at approximately 11 AM on
[**10-1**].
At 8:05 on [**10-2**] the patient spontaneously went asystolic, a
thorough death confirmation exam was performed and the patient
was declared deceased.
Medications on Admission:
Lasix 40mg po daily
Tylenol 650mg po q4-6h prn for pain/fever
Elavil (amitriptyline) 25mg po qhs
Lantus 12 units daily at 11am (taking inconsistently based on
blood sugar)
Lopid (gemfibrozil) 600mg po bid with meals
Xanax 0.5mg po q8h prn for anxiety - not taking
Tylenol 3 - One tab po q6h prn for pain - not taking
Toprol XL 25mg po daily - taking every other day
Robitussin 600mg po daily prn for cough
ASA 81mg po daily
Advair 250/50 one inhalation twice a day
Coumadin 5mg po daily - not taking
Discharge Medications:
Not Applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
not applicable
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2123-10-2**]
|
[
"585.9",
"428.0",
"357.2",
"790.92",
"403.90",
"427.31",
"414.00",
"V45.81",
"486",
"707.22",
"428.23",
"785.51",
"427.41",
"799.1",
"238.4",
"250.60",
"707.03",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12223, 12232
|
9477, 11634
|
292, 348
|
12290, 12295
|
5326, 5326
|
12347, 12381
|
3973, 4160
|
12184, 12200
|
12253, 12269
|
11660, 12161
|
12319, 12324
|
5747, 9454
|
4175, 5307
|
3569, 3824
|
228, 254
|
376, 2941
|
5342, 5730
|
2985, 3548
|
3840, 3957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,609
| 195,159
|
35739
|
Discharge summary
|
report
|
Admission Date: [**2164-3-12**] Discharge Date: [**2164-3-13**]
Date of Birth: [**2099-3-2**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Augmentin / Lisinopril / Clindamycin / Morphine
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Hypertension, Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64F morbidly obese with past medical history significant for
diabetes, CHF, and hypercarbic respiraotry failure who was
transferred from Radius for respiratory distress. Pt became
acutely short of breath overnight and drop sats to 80s. The
patient was given 80g IV lasix and nebs at Radius and put on a
non-rebreather. Her sats pumped to 100% on non-rebreather. the
patient had been receiving IVFs that were turned off at the time
she became short of breath. Pt was transferred to [**Hospital1 18**] for
further evaluation and management.
Of note, Pt had been discharged from [**Hospital1 2177**] on [**2164-3-1**] following
admission for respiratory failure. Pt completed a course of vanc
and cipro on [**3-8**] for panniculitis.
.
In the ED, initial vs were: T 96.2 P 64 BP 180/66 R 20 O2 100%
15L NRB. Patient was placed in a nitro gtt. CXR read as
consistent with pulmonary edema in the ED. Troponin was .1 in
the setting of renal failure with no EKG findings suggestive of
STEMI. UA positive with 6-10 WBC and trace leuks. Pt arrived
with Foley in place.
.
On arrival to the ICU, pt vitals 96.0 64 144/53 17 99% NRB. Pt
was on a nitro gtt. Pt complained of right arm pain and low back
pain. She was difficult to understand. Pt had a Foley and PICC
in place.
Past Medical History:
OSA and pulmonary HTN - uses BiPAP/CPAP at night, with 2L O2
requirement during the day
Type I Diabetes with retinopathy, nephropathy, neuropathy
Morbid Obesity
Coronary Artery Disease
Hypertension
Chronic Kidney Disease
trochanteric Bursistis
Left Breast Cellulitis
Panniculitis
Hyperlipidemia
Asthma
Allergic Rhinitis
Fe Deficiency Anemia
Sigmoid Colon Tubular Adenoma
Gastroesophageal Reflux
Fibroids
Social History:
Lives by herself. Has home VNA. Sister, [**Name (NI) 81285**] is contact,
[**Telephone/Fax (1) 81286**]
Family History:
Mother - DM, HTN, HL
Father - [**Name (NI) **] clots
Physical Exam:
Vitals 97.6 67 141/47 19 94%on 3L
Gen: Morbidly obese female, NAD
HEENT: NC, AT, OP clear
Neck: Thick, unable to assess JVP
Resp: symmetric, clear but difficult to assess [**1-30**] body habitus
CV: RRR, difficult to assess, [**1-30**] body habitus
ABD: soft, NT, BS +, large pannus
EXT: Left BKA, right heel ulcer
SKIN: evidence of fungal infection under right breast -
indurated with white, cottage cheese-like deposits
Pertinent Results:
[**2164-3-12**] 03:50AM WBC-9.4 RBC-3.57* HGB-9.1* HCT-30.8* MCV-86
MCH-25.3* MCHC-29.4* RDW-14.6
[**2164-3-12**] 03:50AM NEUTS-78.8* LYMPHS-12.4* MONOS-3.3 EOS-5.4*
BASOS-0.2
[**2164-3-12**] 03:50AM PLT COUNT-173
[**2164-3-12**] 03:50AM CK-MB-NotDone proBNP-1042*
[**2164-3-12**] 03:50AM ALT(SGPT)-13 AST(SGOT)-11 CK(CPK)-44 ALK
PHOS-110 TOT BILI-0.4
[**2164-3-12**] 03:50AM GLUCOSE-106* UREA N-65* CREAT-2.0* SODIUM-143
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-34* ANION GAP-10
[**2164-3-12**] 03:55AM HGB-9.7* calcHCT-29 O2 SAT-98 CARBOXYHB-2 MET
HGB-0
[**2164-3-12**] 04:00AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2164-3-12**] 09:14AM LACTATE-0.7
[**2164-3-12**] 05:40PM CK-MB-3 cTropnT-0.06*
[**2164-3-12**] 05:40PM CK(CPK)-48
.
CXR [**3-12**] -
1. Moderate pulmonary edema, asymmetrically worse on the right
side.
2. Bibasilar and retrocardiac opacity, could reflect atelectasis
and/or
pneumonia in the right clinical setting.
3. Suggestion of a nodular opacity in the RUL, could represent
confluent
edema, repeat imaging after diuresis to exclude an underlying
pathology is
recommended
.
Shoulder [**3-12**] - A single, portable view is presented that is
extremely difficult to interpret due to scattered radiation
secondary to the size of the patient. No gross abnormality on
this extremely limited study. The scapula is not evaluated
properly. If there is any clinical suspicion for fracture, CT
would be necessary.
Brief Hospital Course:
65F with OSA, COPD, Pulmonary HTN and diastolic CHF who presents
with respiratory distress.
.
# Respiratory Distress - Likely COPD flair v flash pulmonary
edema in setting of diastolic CHF. Patient was somewhat
somnolent on nasal cannula. BNP > 1042. Torsemide was held and
patient was switched to 60mg lasix [**Hospital1 **]. She put out over 3L in
24 hours with improvement in her sats and mental status. Was
put on bipap intermittently and would recommend continued use at
night. Continued nebs and asthma meds
.
# CHF - EF from [**Hospital1 2177**] from [**2-6**] shows preserved EF, dysfunction
likely diastolic. ROMI negative. Pt diuresed as above.
Anti-hypertensives continued and hydral dose increased to 100mg
q6h. ASA increased to 213mg in setting of ROMI.
.
# Diabetes - Type I
Continued long-acting [**Doctor Last Name 360**] plus sliding scale
.
# Anemia - Epo dependent , receives qSaturday. Continued Fe
supplementation
.
# Hyperlipidemia - Continued statin
.
# R Shoulder Pain - chronic per patient, unable to lift arm.
Plain films difficult to interpret due to body habitus. Though
no fracture noted. CT v MRI for better imaging.
.
# Anti-coag - Patient on fondaparinux. OSH records reveals no
history of HIT but no heparing products given. Spaced out
fondaparinux in setting of renal failure to q48h.
.
# Right Heel Ulcer - Wound care per nursing.
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Amlodipine 10 mg PO DAILY
Lactulose 15 mL PO QID
Aspirin 81 mg PO DAILY
Montelukast Sodium 10 mg PO HS
Citalopram Hydrobromide 40 mg PO DAILY
Nephrocaps 1 CAP PO DAILY
Docusate Sodium 100 mg PO BID
Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID
Doxazosin 4 mg PO HS
Omeprazole 40 mg PO DAILY
Fexofenadine 60 mg PO BID
Os-Cal 500 + D *NF* 500 (1,250)-200 mg-unit Oral daily
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Oxycodone-Acetaminophen [**12-30**] TAB PO Q6H
Fluticasone Propionate NASAL 1 SPRY NU DAILY
Fondaparinux Sodium 2.5 mg SC DAILY
Senna 2 TAB PO HS
Furosemide 60 mg PO DAILY
Simvastatin 80 mg PO DAILY
Torsemide 10 mg PO BID
HydrALAzine 25 mg PO Q6H
Valsartan 120 mg PO DAILY
Hydrochlorothiazide 25 mg PO Q6H
Insulin
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours).
10. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QID (4
times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
17. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
19. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
22. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Four (4) Drop Otic TID (3 times a day).
23. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
24. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
25. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 units
Subcutaneous Q48H (every 48 hours).
26. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
27. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
28. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
29. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
30. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): continue for one ,more day and then decrease to
daily.
31. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
32. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease
OSA and pulmonary HTN - uses BiPAP/CPAP at night, with 2L O2
requirement during the day
Type I Diabetes with retinopathy, nephropathy, neuropathy
Morbid Obesity
Coronary Artery Disease
Hypertension
Chronic Kidney Disease
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for worsening shortness of
breath and a low oxygen saturation. You were treated with
non-invasive ventilation and lasix and your breathing improved.
The dose of your lasix was increased to twice a day. Please
continue to take lasix twice a day for one more day than return
to previous daily dose.
Please take all medications as prescribed and return to the
hospital for any chest pain, worsening shortness of breath or
any other symptoms that are new or of concern to you
Followup Instructions:
Please follow-up as needed with your primary care provider.
|
[
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"218.9",
"428.33",
"250.51",
"530.81",
"285.21",
"278.01",
"719.41",
"491.21",
"585.9",
"403.00",
"V58.67",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9395, 9450
|
4304, 5694
|
355, 361
|
9753, 9763
|
2745, 4281
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6617, 9372
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9471, 9732
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5720, 6594
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9787, 10298
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2291, 2726
|
282, 317
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389, 1654
|
1676, 2082
|
2098, 2205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,133
| 116,011
|
40196
|
Discharge summary
|
report
|
Admission Date: [**2154-2-1**] Discharge Date: [**2154-2-7**]
Date of Birth: [**2079-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
AMS, intubated
Major Surgical or Invasive Procedure:
Extubation
History of Present Illness:
Patient is a 66 yo F with a history of CVA, HTN, HLD who was
transferred from an OSH with altered mental status. Per report,
the patient had a fall 2 days ago after slipping on ice after
the snowstorm and falling on her right side. She was diagnosed
with R sided rib fractures during an urgent care visit at the
[**Hospital 6598**] [**Hospital **] Clinic the next day. She was prescribed vicodin
and asked to come back for CT scan. Family states the patient
took [**1-20**] a tablet of vicodin last night, but did not become
altered until this morning. When they came to see her at home,
they found she was more altered; she was lying on the couch,
more lethargic, not taking good POs or any of her medications,
and complaining of a headache. She was brought into the OSH
([**Hospital1 **]/[**Hospital1 6136**]) for further evaluation. There, the patient
was given Narcan without good effect. She was reportedly
intubated for a GCS of 6 and for airway protection in the
setting of vomiting. Labs at the OSH significant for Hct of
42.9, Plts 221, INR of 1.0, Na 139 K 3.9, Cre: 1.3, negative
EtOH, tylenol, and ASA levels . Pt was guaiac negative, and
gastric occult negative. Head CT at OSH was also negative for
acute new infarct. Received Zosyn 3.25 mg IV x1. She was placed
on propofol for sedation, but subsequently noted post-intubation
to become hypotensive, required 1 L IVFs and was started on
peripheral dopamine and transferred to [**Hospital1 18**] for further
evaluaton.
.
In the ED, admission VS were 88 141/78 (dopa) 20 100% (PS [**10-28**]
PEEP of 5). Pt received a fentanyl boluses with midazolam gtt.
Her dopamine was quickly weaned with 2 L of IVFs. Labs sig for
Cre of 1.3, WBC of 15.8, Hct of 32.9, and urine toxicology
screen positive for benzos and methadone. Vancomycin 1 gram IV
x1 given. Patient noted to be interacting appropriately on
minimal sedation. Trauma series was performed (CT Head, CT
C-spine, CT Torso) which showed a LLL consolidation and rib
fractures but no obvious bleed or C-spine fractures. Head CT
negative for acute intracranial process but does show old
MCA-PCA watershed infarct. C-collar was placed. Trauma Surgery
was consulted and will be following for tertiary survey in AM
and clearance of C-spine in AM.
.
On the floor, patient was alert and interactive. Able to
indicate pain from her rib fractures.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
PAST MEDICAL HISTORY:
h/o CVA in [**2151**]
Hypertension
Hyperlipidemia
.
Past Surgical History:
s/p hysterectomy
s/p carotid endarterectomy
Social History:
Lives alone. Ambulates independently without a walker but has
had some difficulty walking recently after her stroke. +tobacco
(1 ppd); occasional EtOH use; no illegal drugs or IVDU (per
sister)
Family History:
unknown
Physical Exam:
Exam: 97.6, HR 73, BP 126/55, 94% (88-94%) on 4Lnc
GEN: elderly F looking younger than stated age
HEENT: PERRLA. pinpoint pupils, ~ 1 mm in diameter, MMM.
NECK: neck supple
PULM: bibasilar rales
CARD: RRR S1/S2 present. no m/g/r.
ABD: soft NT +BS
EXT: wwp no edema
NEURO: AAOX3 but in and out of responsiveness, could not say
months of year backwards
Pertinent Results:
[**2154-2-1**] 08:41PM TYPE-ART PO2-86 PCO2-49* PH-7.32* TOTAL
CO2-26 BASE XS--1
[**2154-2-1**] 08:41PM LACTATE-0.8
[**2154-2-1**] 08:19PM TYPE-[**Last Name (un) **] TEMP-36.7 PEEP-5 PO2-35* PCO2-57*
PH-7.28* TOTAL CO2-28 BASE XS--1 INTUBATED-INTUBATED
[**2154-2-1**] 07:49PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2154-2-1**] 07:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2154-2-1**] 07:49PM URINE RBC-3* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2154-2-1**] 07:48PM GLUCOSE-122* UREA N-26* CREAT-1.2* SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
[**2154-2-1**] 07:48PM CK(CPK)-291*
[**2154-2-1**] 07:48PM CK-MB-5 cTropnT-0.04*
[**2154-2-1**] 07:48PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-1.9
IRON-14*
[**2154-2-1**] 07:48PM calTIBC-278 VIT B12-516 FOLATE-GREATER TH
FERRITIN-170* TRF-214
[**2154-2-1**] 07:48PM WBC-ERROR DISR RBC-ERROR DISR HGB-ERROR DISR
HCT-ERROR DISR MCV-ERROR DISR MCH-ERROR DISR MCHC-ERROR DISR
RDW-ERROR DISR
[**2154-2-1**] 02:30PM UREA N-30* CREAT-1.3*
[**2154-2-1**] 02:30PM estGFR-Using this
[**2154-2-1**] 02:30PM LIPASE-22
[**2154-2-1**] 02:30PM URINE HOURS-RANDOM
[**2154-2-1**] 02:30PM URINE HOURS-RANDOM
[**2154-2-1**] 02:30PM URINE GR HOLD-HOLD
[**2154-2-1**] 02:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2154-2-1**] 02:30PM WBC-15.8* RBC-3.73* HGB-11.6* HCT-32.9*
MCV-88 MCH-31.2 MCHC-35.5* RDW-14.1
[**2154-2-1**] 02:30PM PLT COUNT-195
[**2154-2-1**] 02:30PM PT-12.9 PTT-23.1 INR(PT)-1.1
[**2154-2-1**] 02:30PM FIBRINOGE-512*
[**2154-2-1**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2154-2-1**] 02:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2154-2-1**] 02:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**12-8**]
[**2154-2-1**] 02:30PM URINE GRANULAR-0-2 HYALINE-[**6-28**]*
[**2154-2-1**] 02:30PM URINE AMORPH-FEW
Brief Hospital Course:
#. Altered mental status: Patient was initially found to have
altered mental status after slip and fall on ice. She sustained
R sided rib fractures which were treated with vicodin. She was
found by family to be altered and brought to OSH where she was
intubated for GCS 6. She had also had a URI prior to OSH
presentation. Initial AMS was likely multifactorial due to
infection (pneumonia, likely acquired in setting of splinting
from rib pain [**2-20**] fractures), medication induced from narcotics
(received vicodin for pain control) but urine toxicology screen
also positive for methadone, and ABG showed an acute respiratory
acidosis concerning for respiratory depression. Toxicology
screen negative at OSH for EtOH, APAP, and ASA. No evidence of
new ICH or stroke on head CT. No evidence of UTI on urine
analysis. Cardiac etiology was ruled out with cardiac enzymes
negative x 2. Patient was extubated with good mental status but
subsequently became increasingly altered, thought to be
associated with morphine use for pain control. This delirium
resolved upon avoiding opioid medications such as morphine and
oxycodone.
.
# Respiratory Failure: Pt initially hypoxic with pna and
splinting from pain, intubated [**2-20**] altered mental status. The pt
was extubated after transfer from [**Hospital1 18**], with decreasing O2
requirement. She was found to have a pneumonia and was started
on Levaquin for presumed CAP. However, patient continued spiking
despite abx. Given sputum cx stained 2+ GPC in pairs and chains,
2+ [**Name (NI) **], pt was broadened to Vanc/Zosyn (pt is allergic to
penicillins but has tolerated zosyn in the past). Abx were
continued for an eight day course (last day [**2-9**]). She was also
encouraged to use incentive spirometer and pain was controlled
as below.
.
# [**Last Name (un) **], prerenal, hypovolemic: pt??????s cr increased from nadir 1.0
to 1.5. Cr improved with ivf hydration. Cr was 1.2 by next day.
.
# normocytic anemia: Hct down to 32.9 from 42 at OSH. HCT slowly
trending down. No evidence of intra-abdominal bleed on CT scans.
Iron studies [**Location (un) 381**] levels, showing element of iron
deficiency, likely mixed with anemia of chronic disease. no
colonoscopy in system. B12 and folate nl.
.
#. Rib fractures: s/p fall with R sided rib fractures from
T3-T7. Pain control with standing tylenol, lidocaine patch x3
for rib fractures, oxycodone prn pain. Patient initially treated
with morphine however it was felt to contribute to here AMS.
Patient's pain controlled with around the clock Tylenol and
lidocaine patches.
.
# Mediastinal Lymphadenopathy: CT scan showed areas of
mediastinal lymphadenopathy thought to be less consistent with
reactive process. Could be sarcoid vs. malignancy. Should be
followed up with an outpatient biopsy to assess for malignancy.
Patient scheduled for Interventional Pulmonology clinic on [**2-18**]
at noon. MD made aware at facility.
.
# Adrenal nodule: Incompletely visualized. Should be followed up
outpt with a dedicated adrenal MR [**First Name (Titles) **] [**Last Name (Titles) **].
.
#. Clearing C-spine: clinically cleared per trauma
.
#. Hypertension: home antihypertensives
.
#. Hyperlipidemia: continue statin
.
# Anxiety: held ativan for protection of respiratory status
Medications on Admission:
(per [**Hospital3 **] Records and confirmed with pt's pharmacy
(Stop and Shop in [**Location (un) 6598**] #([**Telephone/Fax (1) 88247**])
Folic Acid
Aspirin 81 mg PO daily
Amlodipine 5 mg PO daiy
Metoprolol Tartrate 50 mg PO BID
Vicodin 5-500 mg 1 tablet prn:pain
HCTZ 12.5 mg PO daily
Ativan 0.5 mg PO QHS
Trazadone 150 mg [**1-20**] tablet PO QHS
Mevacor 20 mg PO daily
.
OLD MEDS:
Buspirone (old, filled last back in [**2152**])
Combivent Inhaler (filled last back in [**2152-3-19**])
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Please complete on
[**2154-2-9**].
12. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours): Please complete on
[**2154-2-9**].
13. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
metabolic encephalopathy
community-acquired pneumonia
Rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 88248**],
You were transferred to our hospital to care for a pneumonia
that was the result of a probable aspiration event during a
state of altered mental status. We believe the pain medications
in the opioid class (including morphine, vicodin, codeine)
worsen your mental status and make you delirious. Please AVOID
TAKING THESE MEDICATIONS. We treated your probable pneumonia
with antibiotics, that should be completed on [**2154-2-9**]. We
placed a special i.v. into your arm that can be used for these
medications.
Also of note, a CAT scan at the beginning of your visit here
showed a left lower lobe infiltrate consistent with pneumonia.
However, it also showed a couple abnormalities that will require
followup. This includes:
1) Mediastinal lymphadenopathy - size is less compatible with
reactive nodes, and may be compatible with metastatic nodes or
sarcoidosis.
2) Left adrenal nodule, incompletely characterized - a dedicated
adrenal CT
Please follow up with our pulmonologists and your primary doctor
to set up these examinations to further evaluate these findings.
We controlled your pain from your rib fractures with Tylenol and
lidocaine patches, since other medications worsened your mental
state. Please continue to take these as needed for your pain.
Followup Instructions:
Please follow up with your primary care physician as soon as you
can after discharge
Please also follow up with our pulmonary clinic to follow up on
the abnormal CAT scan findings. You have an appointment with the
interventional pulmonology clinic here at [**Hospital1 18**] [**Hospital Ward Name **] at
12 PM on [**2154-2-18**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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324, 2679
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3258, 3453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,929
| 125,041
|
34156
|
Discharge summary
|
report
|
Admission Date: [**2122-6-11**] Discharge Date: [**2122-6-21**]
Date of Birth: [**2064-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin Hcl
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2122-6-16**] CABG x 3 (LIMA to DIAG, SVG to LAD, SVG to RAMUS)
History of Present Illness:
57 yo M with intermittent chest pressure several times a day.
Cardiac cath showed 3VD and he was referred for surgery.
Past Medical History:
PMH: CAD w/ MIs in '[**06**], '[**14**], stents in RCA, diag, LAD x2, htn,
gerd, DM2, diabetic neuropathy, COPD, anxiety, insominia,
erectile dysfunction
PSH: b/l knee surgery, cholecystectomy, L breast lumpectomy
Social History:
disabled
tobacco 1 ppd x 20 years, quit [**2106**]
no etoh
Family History:
NC
Physical Exam:
HR 65 RR 16 BP 116/73
NAD
Lungs CTAB
Heart RRR
Abdomen benign
Extrem warm, no edema
5'[**25**]" 95 kg ( weight day of OR)
Pertinent Results:
[**2122-6-21**] 06:20AM BLOOD WBC-7.3 RBC-3.46* Hgb-9.9* Hct-29.3*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.0 Plt Ct-336
[**2122-6-20**] 11:00AM BLOOD Neuts-71.6* Lymphs-15.6* Monos-6.3
Eos-6.1* Baso-0.4
[**2122-6-21**] 06:20AM BLOOD Plt Ct-336
[**2122-6-21**] 06:20AM BLOOD Glucose-175* UreaN-10 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
[**2122-6-21**] 06:20AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.3
[**2122-6-12**] 09:25AM BLOOD %HbA1c-9.9*
Conclusions
PRE-BYPASS:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. There is no pericardial effusion.
Post-bypass:
Pt was removed from cardiopulmonary bypass AV paced.
1. Biventricular function is preserved.
2. Mitral regurgitation remains mild. Other valves are as
described pre-bypass.
3. Thoracic aortic contour is intact.
3. Aortic contours are intact post-decannulation.
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) **] [**2122-6-18**] 11:24
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2122-6-19**] 11:14 PM
CHEST (PORTABLE AP)
Reason: eval for source of fever
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with recent CABG now febrile with no obvious
source
REASON FOR THIS EXAMINATION:
eval for source of fever
HISTORY: Febrile after CABG.
IMPRESSION: AP chest compared to [**6-18**]:
Lungs grossly clear aside from improving mild left basal
atelectasis. Small left pleural effusion stable. Right lung
clear. Heart size normal.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SAT [**2122-6-20**] 2:08 PM
Brief Hospital Course:
He was admitted to cardiac surgery and awaited plavix washout
prior to surgery. He was started on a heparin drip. He had some
nausea and vomiting along with abdominal pain and he was seen by
general surgery. He was found to ahve a partial small bowel
obstruction. An NGT was placed. His symptoms improved and he was
started on clears. He tolerated clears and his diet was
advanced. He was taken to the operating room on [**6-16**] where he
underwent a CABG x 3. He was transferred to the ICU in stable
condition on a propofol drip. He was extubated the morning of
POD #1. His NGT was clamped, he tolerated clear liquids and he
was transferred to the floor on POD #1. He went into Afib and
converted ito SR with additional beta blockade. Chest tubes and
pacing wires removed without incident.[**Last Name (un) **] team continued to
follow him postop.
Amiodarone started for recurrent Afib. Cleared for discharge to
home with services on POD #5. Pt. is to make all follow-up
appts. as per discharge instructions.
Medications on Admission:
asa 325', neurontin 600''', lopid 600'', novolog 15u qAM, qPM,
novolog 20u p lunch & dinner, humalog-n 85u qAM, lopressor
25''', nitropaste 1in q8hrs, protonix 40', actos 15', trazadone
300', plavix 75'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Disp:*21 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
****spoke to [**Doctor Last Name 402**] at VNA on Monday [**6-22**]: she was instructed
to have him reduce his amiodarone to 200 mg daily starting on
Monday [**6-29**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care of RI
Discharge Diagnosis:
CAD now s/p CABG
postop A fib
PMH: CAD s/p MI, HTN, GERD, DM, COPD, Anxiety, ED,
PSH: CCY,Arthroscopic knee, lft Breast lumpectomy
Discharge Condition:
Good.
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medication as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] in [**3-15**] weeks
Dr [**Last Name (STitle) **] in 4 weeks call for appt. [**Telephone/Fax (1) 170**]
Completed by:[**2122-6-22**]
|
[
"427.31",
"496",
"250.62",
"997.1",
"E879.9",
"560.89",
"272.4",
"411.1",
"530.81",
"443.9",
"357.2",
"278.00",
"401.9",
"V70.7",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"36.15",
"39.63",
"36.12",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6142, 6204
|
3351, 4365
|
291, 359
|
6381, 6389
|
1000, 2798
|
6590, 6791
|
837, 841
|
4618, 6119
|
2835, 2903
|
6225, 6360
|
4391, 4595
|
6413, 6567
|
856, 981
|
241, 253
|
2932, 3328
|
387, 507
|
529, 745
|
761, 821
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,225
| 138,677
|
128
|
Discharge summary
|
report
|
Admission Date: [**2197-11-27**] Discharge Date: [**2197-12-1**]
Date of Birth: [**2130-8-26**] Sex: M
Service: MEDICINE
Allergies:
Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Somnolence.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 67 y.o male with bladder cancer with large pelvic
masses, recent chemo tue (taxol, gemzar) now presenting with
n/v/d/ new afib with RVR, metastatic disease. Pt is HD m/w/f
.
Pt denies pain, but is unable to report other ROS. States he's
tired.
.
In the [**Name (NI) **], pt at first refused IV, got EJ, removed it, an
another was placed. Pt s/p 3L IVF. HR 100-170's, not given any
nodal agents for rate control. PT found to be neutropenic.
RUQ-new liver masses/sacral/iliac, R.sided hydroureter, has
neobladder. Pt given vanco, cefepime, flagyl. Somnolent, head CT
negative. Tmax 100.2
.
Past Medical History:
CAD
HTN
Hyperlipidemia
ESRD on HD
Bladder Cancer in [**2181**]
Depression
Restless Leg Syndrome
Social History:
Patient lives at home with girlfriend; no smoking history, no
etoh. Uses marijuana for appetite. Son lives in [**State 531**]. Has 2
daughters one of whom is expecting in [**Name (NI) 404**].
Family History:
Dad died of CVA in his 90s, no hx of MI in family.
Physical Exam:
Vitals: T. 98.2 BP 104/67, HR 115, RR 20, sat 92% on 4L
GEN: lying in bed, somnolent, arousable to sternal rub,
HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM,
OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, s1s2 3/6 systolic flow murmur.
PULM: Lungs b/l coarse inspiratory rhonchi. no w/r
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/2+E, no palpable cords
NEURO: somnolent, squeezes hand to commands.
Pertinent Results:
Admission labs
[**2197-11-26**] 10:30PM BLOOD WBC-0.4*# RBC-2.98* Hgb-8.0* Hct-26.2*
MCV-88 MCH-27.0 MCHC-30.7* RDW-18.1* Plt Ct-52*#
[**2197-11-26**] 10:30PM BLOOD Neuts-41* Bands-1 Lymphs-32 Monos-24*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2197-11-26**] 10:30PM BLOOD PT-44.7* PTT-46.3* INR(PT)-5.0*
[**2197-11-26**] 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-52*#
[**2197-11-26**] 10:30PM BLOOD Gran Ct-130*
[**2197-11-26**] 10:30PM BLOOD Glucose-100 UreaN-98* Creat-6.6* Na-139
K-4.8 Cl-92* HCO3-27 AnGap-25*
[**2197-11-26**] 10:30PM BLOOD ALT-71* AST-114* LD(LDH)-501* CK(CPK)-127
AlkPhos-256* TotBili-3.8* DirBili-2.7* IndBili-1.1
[**2197-11-26**] 10:30PM BLOOD CK-MB-5
[**2197-11-26**] 10:30PM BLOOD cTropnT-0.09*
[**2197-11-26**] 10:30PM BLOOD Albumin-2.3* Calcium-7.1* Phos-8.8*#
Mg-2.0
[**2197-11-26**] 10:37PM BLOOD Lactate-1.8 K-4.8
Pertinent Radiology:
[**2197-11-26**] Liver Gallbladder US:
IMPRESSION:
1. Multiple hepatic masses, the largest of which measures over 4
cm, and is suspicious for metastatic disease given the history.
2. Unchanged severe right hydronephrosis.
3. No gallbladder distention or CBD dilation.
[**2197-11-27**] CT ABD/Pelvis:
IMPRESSION:
1. Marked progression of metastatic disease, with new metastases
in the liver as well as iliac and sacral bones.
2. Severe right hydroureteronephrosis, as in the prior study.
3. Limited evaluation of the central abdomen due to marked
streak artifact
from numerous surgical clips.
4. Bilateral lower lobe subsegmental atelectasis, as well as
incompletely
imaged nodular opacities suspicious for metastatic disease given
the history.
[**2197-11-27**] CT HEAD:
IMPRESSION: No evidence of acute intracranial process. If there
is high
clinical suspicion for metastatic disease, MRI is more
sensitive.
[**2197-11-27**] LENI:
IMPRESSION: Normal examination of the bilateral lower
extremities. No
evidence of DVT.
[**2197-11-28**] CXR:
Since [**2197-11-26**], cardiomegaly is unchanged. Prior
sternotomy and
abdominal clips are unchanged.
Bilateral small pleural effusions are new. Bilateral increase in
interstitial markings and hilar haziness are consistent with
pulmonary edema. More confluent left lower lobe opacity could be
due to pneumonia.
Incidentally, old left rib fractures are unchanged.
[**2197-11-28**] EKG:
Atrial fibrillation with rapid ventricular response.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing of [**2197-11-27**] no significant change.
Brief Hospital Course:
A/P: Pt is a 67 y.o male with h.o bladder cancer now presenting
with altered mental status and tachycardia.
.
MICU COURSE:
1) Tachycardia: patient presented with Afib. No obvious
explanation. Assess for myocardial infarction. With
thrombocytopenia and prolonged INR and renal failure, a PE is
less likely. Would check A-a gradient on room air and obtain
LENI's with peripheral edema. Also check thyroid function.
-monitor on tele
-ROMI
.
2) Fever with neutropenia: concern about infection with
neutropenia. CXR not impressive for infiltrate but there may be
slight increase in markings at right base and left base. On
broad spectrum antibiotics; will repeat CXR in AM. Blood
cultures pending/urine cx pending.
-neutropenic percautions.
.
3) Anemia: probably related to marrow suppression. No evidence
of GI bleeding. Guaiac stool. PIVs. IRON studies.
.
4) Thrombocytopenia: likely related to bone marrow suppression.
No evidence of bleeding now. Continue to monitor. Consider HIT
ab.
.
5) Hypotension: patient with hx of hypertension. Present BP
likely relatively hypotensive now. Has dry mucus membranes and
decreased tissue turgor. Will give additional fluids now. With
renal failure, would watch bicarbonate with normal saline fluid
resuscitation. Would not give lactated ringers because of
anuria. [**Month (only) 116**] need D5W with bicarb as part of fluid resuscitation
if serum bicarb begins to drop.
.
6) Metastatic bladder ca: discuss future therapy with oncology.
.
7) Altered mental status: ETiologies include intracranial
mass/bleed but r/o with CT head. Other possibilities include
toxic-metabolic including uremia/acute liver failure. Other
possibilities include infection such as sepsis/meningitis. Other
possibility includes medication/narcotic effect. Patient given
narcan with some improvement. He is on narcotics at home and may
have taken extra doses or may now have delayed metabolism
because of liver [**Month (only) 1364**] and abnormal LFT's. Continue with narcan
for now. Uremia may also be contributing to altered mental
status.
-toxic metabolic w/u and correction
-frequent neuro exams
-antibiotics
-infectious w/u
-consult renal for HD.
.
8) Chronic renal failure: electrolytes and acid-base status
acceptable. Mental status may be due, in part, to uremia. No
volume overload now. No immediate need for dialysis. renal on
board.
.
9) Acidosis: combined anion gap acidosis, probably from uremia,
and metabolic alkalosis, likely from volume depletion and
vomiting.
.
Fen-NPO, lytes prn
access-PIVs
ppx-pneumoboots, PPI, bowel reg
communication-pt's family
code-DNR/DNI
disp- ICU for now.
.
[**11-27**]
-Bili mostly direct (2.7 out of 3.8)
- Given now widespread [**Month/Year (2) 1364**] on CT abd/pelvis. Family met with
Dr. [**Last Name (STitle) 1365**] (heme), [**Doctor Last Name 1366**] (renal) and has decided to make pt
DNR/ DNI. Will most likely go to comfort care but would like to
wait a few days and see if the pt "comes out of this" ie change
in MS
- EKG without change
-FFP 4u given in afternoon
-Pt with very limited access. Currently has 1 working PIV.
Family not opposed to central access at this time but as it will
excalate care at this time with risks of infxn and coagulopathy,
will not place.
-Pt with A fib and HR into 180's off and on in the afternoon.
Started on Metoprolol 5IV Q 4hrs but still with intermittent
tachycardia. Currently in sinus.
- LENI's negative
-Stools grossly bloody and guaiac +. Hct stable.
-CE trending down
-Considered starting lactulose to possibly improve MS [**First Name (Titles) **] [**Last Name (Titles) 1364**]
to liver and liver damage seen in coagulopathy but d/c'd as pt
already having considerable diarrhea- C diff pending
-Per renal, if family still wishes, will do HD in am
-Got just 1L IVF bolus during evening. O2 Sat 95% on 2LNC and pt
putting out little uring by ostomy (must be cathed by nursing)
[**11-28**]
- Family discussion -> decided to proceed with HD - bedside HD
per renal yesterday
- transfused 2 U with appropriate increase in Hct
- Urine Cx with GNR >100K
- Patient with pain in abd last night, given small dose morphine
with good effect
[**11-29**]
- Pt made CMO overnight.
- Pt given IVF and Morphine PRN
.
OMED COURSE
Patient was transferred to OMED service from [**Hospital Unit Name 153**] on Thursday
[**11-30**]. At the time of transfer the goals of care were comfort
measures only. He was kept on a morphine drip, titrated to
respiratory comfort. He was also started on Ativan prn for
agitation. Palliative care consult was obtained. He passed
away on the night of Friday [**12-1**] at approximately 6:15 PM.
Immediate cause of death was respiratory failure. Secondary
cause of death was metastatic bladder cancer.
Medications on Admission:
tylenol-codeine 300-30mg [**1-18**] Q4h prn
ambien 10mg QHS
amlodipine 5mg daily
lipitor 40mg daily
nephrocaps
neurontin 300mg qhs
imdur 60mg SR daily
megace 15mg po daily
toprol xl 50mg 0.5mg daily
morphine 15mg [**Hospital1 **]
ms [**Last Name (Titles) 1367**] 15mg SR [**Hospital1 **]
nitro 0.4mg
protonix 40mg daily
mirapex 0.25mg qhs
compazine 10mg Q6Hprn
renagel 800mg , 2 tabls TID
aspirin 81mg daily
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Bladder Cancer.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2197-12-2**]
|
[
"403.91",
"288.00",
"276.50",
"198.5",
"599.0",
"427.31",
"285.9",
"585.6",
"197.6",
"572.2",
"591",
"197.7",
"780.60",
"458.9",
"272.4",
"292.81",
"311",
"333.94",
"276.2",
"414.01",
"V10.51",
"E937.8",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9624, 9633
|
4393, 5881
|
345, 352
|
9704, 9716
|
1906, 3534
|
9774, 9908
|
1326, 1378
|
9590, 9601
|
9654, 9683
|
9156, 9567
|
9740, 9751
|
1393, 1887
|
294, 307
|
380, 980
|
3543, 4370
|
5896, 9130
|
1002, 1100
|
1116, 1310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,032
| 194,492
|
2782
|
Discharge summary
|
report
|
Admission Date: [**2129-9-16**] Discharge Date: [**2129-9-17**]
Date of Birth: [**2093-4-22**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Tylenol / Motrin / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Upper endoscopy.
History of Present Illness:
Ms. [**Known lastname 13676**] is a 36 y/o woman with PMH notable for polycystic
kidney disease and Carolis disease with resultant ESRD s/p
combined liver-kidney transplant in [**2112**] who presented to
[**Hospital3 **] on [**9-13**] after having bloody diarrhea.
Patient noted vague abdominal pain the day of admission and
proceeded to have several dark maroon stools. She went to
[**Hospital1 13677**] Hospital where she was evaluated by the
gastroenterologists and admitted to the ICU.
.
At [**Hospital1 13677**] Hospital, the patient received 1 U platelets on
[**9-14**] and 2 U PRBCs on [**9-14**]. She was monitored closely and also
treated with pantoprazole gtt. She received IV
ampicillin/sulbactam for coverage of intra-abdominal infection.
She remained hemodynamically stable per report and tolerated
dialysis on Wednesday and Friday. She was also treated with
zofran prn for nausea. She is being transferred for endoscopy as
pediatric gastroenterologists did not feel comfortable
performing this at their facility.
.
On arrival to the ICU, the patient reports ongoing right and
left flank pain. She denies any hematemesis or further blood in
stools. She reports no current lightheadeness or dizziness.
Past Medical History:
* Autosomal recessive polycystic kidney disease with ESRD
* Caroli's disease s/p combined liver/kidney transplant in [**2112**],
did not take immunosuppression after kidney failed
* peptic ulcer disease with life-threatening bleed in [**2127**]
* anxiety/depression
* gout with joint deformities
* secondary hyperparathyroidism
* s/p cholecystectomy & appendectomy
Social History:
Lives with father. Denies alcohol, tobacco, drug use.
Family History:
Reports no other family members with medical problems.
Physical Exam:
VS: BP 124/75 HR 82 RR 18 98% on RA
GEN: alert, interactive, no acute distress
HEENT: PERRL, EOMI, sclerae pale, no scleral icterus,
RESP: clear bilaterally without wheezes, rhonchi, or rales
CV: RRR, loud 3/6 systolic murmur at LUSB
ABD: distended but soft, nontender throughout, normoactive bowel
sounds, + splenomegaly, midline abdominal scar well-healed
EXT: trace peripheral edema, DP pulses 2+ bilaterally, fingers
small and swollen, left elbow swollen, left arm AV fistula with
palpable thrill
SKIN: no rash
NEURO: alert, interactive, answers questions appropriately,
moving all extremities, face symmetric, speech clear
Pertinent Results:
[**2129-9-16**] 07:19PM WBC-1.4* RBC-3.79* HGB-12.0 HCT-35.7* MCV-94
MCH-31.6 MCHC-33.5 RDW-18.6*
[**2129-9-16**] 07:19PM NEUTS-64.2 LYMPHS-25.2 MONOS-7.1 EOS-2.6
BASOS-0.9
[**2129-9-16**] 07:19PM ALBUMIN-4.8 CALCIUM-10.2 PHOSPHATE-4.9*#
MAGNESIUM-2.2
[**2129-9-16**] 07:19PM LIPASE-43
[**2129-9-16**] 07:19PM ALT(SGPT)-80* AST(SGOT)-95* LD(LDH)-222 ALK
PHOS-476* AMYLASE-82 TOT BILI-1.1
[**2129-9-16**] 07:19PM GLUCOSE-88 UREA N-37* CREAT-6.0*# SODIUM-143
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-33* ANION GAP-18
[**2129-9-16**] 07:19PM PT-12.4 PTT-23.7 INR(PT)-1.0
(from [**Hospital1 13677**] Hospital)
[**9-16**]
WBC 1.51
Hgb
Hct 29.8 <-- 35 <-- 33.5 <-- 32.1
Plt 51,000
PT 11 / INR 1 / PTT 21 / fibrinogen 220
Na 139 / K 4.6 / Cl 96 / CO2 28 / glucose 75 / BUN 69 / Cr 7.4
Ca 9.8 Phos 5.5 M 2.1
C diff A & B negative
Brief Hospital Course:
36 y/o woman with caroli's disease and polycystic kidney disease
now on HD for ESRD admitted with GI bleeding.
.
# GI bleeding: Patient with melena at outside hospital and Hct
30 down from 35 yesterday. ? if source of bleed is esophageal
varices versus recurrence of ulcer disease (though no abdominal
pain presently which she had with prior ulcer disease).
Hematocrit here stable, 31.4 [**9-17**]. EGD demonstrated gastritis
with mild esophageal varices. As Hct stable over several days
and EGD reassuring, okay to d/c home with close follow up
(dialysis [**Month/Year (2) 766**]). No need for antibiotics as per GI consult.
.
# Caroli's disease: Patient is s/p liver transplant with recent
liver biopsy to evaluate pathology.
- LFTs stable. Will have close follow up in Transplant Center.
.
# ESRD on HD: Patient dialyzed through left AVF on MWF.
- Renal aware
- due for dialysis next on [**Month/Year (2) 766**]
.
# Pancytopenia: Likely related to liver disease/splenomegaly and
seems to be chronic. Was stable.
.
# Anemia: Monitor Hct q6h, awaiting intake labs here.
- continue epo with dialysis
.
# Gout: Continue allopurinol & colchicine when able to take PO
meds.
.
# Anxiety/depression: Typically takes trazodone, klonopin at
home prn.
.
#PPx: Kept on pneumoboots and bowel meds prn while in MICU
.
#CODE: FULL, confirmed with patient and father
.
#COMMUNICATION: with patient and her father
.
#DISPO: okay to discharge to home, will have close follow up
with Liver Center (transplant)-they will contact her on [**Name (NI) 766**],
will be dialyzed [**Name (NI) 766**] and should have repeat hematocrit at
that time
Medications on Admission:
epo 10,000 U with dialysis
calcitriol .25 mcg daily
protonix 40 mg [**Hospital1 **]
phoslo 667 po TId
allopurinol 100 mg daily
colchicine 0.6 mg daily
trazodone 150 mg po qhs prn insomnia
nephrocap daily
simethicone 125 mg po q6h prn
colace 100 mg po prn constipation
miralax 17 g prn
kayexalate prn
klonopin 0.5-1.5 mg po prn anxiety
effexor 75 mg daily
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for Insomnia.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
4. Effexor 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. Klonopin 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety.
6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. Epogen 10,000 unit/mL Solution Sig: 10,000 U Injection QMWF:
with dialysis.
8. Miralax 100 % Powder Sig: Seventeen (17) g PO once a day as
needed for constipation.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
10. Simethicone 125 mg Capsule Sig: One (1) Capsule PO every [**4-3**]
hours as needed for indigestion.
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Grade I esophageal varices and gastritis, Caroli's disease,
end-stage renal disease on hemodialysis.
Discharge Condition:
Stable vital signs. On room air.
Discharge Instructions:
You have been evaluated for your gastrointestinal bleeding
(blood in your stools). Your endoscopy showed inflammation of
the stomach lining, which can be treated with medication.
It is important to have your blood count re-checked on [**Month/Day (3) 766**] at
dialysis. We will try to contact your dialysis doctor to arrange
this, but please also show them the prescription for lab work to
be done.
Please take all medications as prescribed. Please keep all
follow-up appointments. Please return to the emergency
department if you experience further bleeding, abdominal pain,
shortness of breath, or any symptoms that concern you.
YOu should not drive after taking benzodiazepine medications
(like klonopin) because they can make you sleepy and endanger
other drivers.
Followup Instructions:
Please follow-up with your primary care physician, [**Name10 (NameIs) **]
hepatologist, and your nephrologist within 2 weeks of discharge.
The Transplant Center (Liver) will contact you on [**Name (NI) 766**] with
information regarding an appointment for follow up.
Completed by:[**2129-9-18**]
|
[
"996.82",
"585.6",
"578.1",
"535.50",
"456.21",
"274.9",
"572.3",
"751.69",
"276.7",
"V42.0",
"284.1",
"E878.0",
"753.13",
"588.81"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
302, 321
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,567
| 132,380
|
45548
|
Discharge summary
|
report
|
Admission Date: [**2148-10-11**] Discharge Date: [**2148-10-13**]
Date of Birth: [**2077-10-1**] Sex: F
Service: MED
Allergies:
Penicillins / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
paracentesis
intubation
History of Present Illness:
Ms. [**Known lastname 9700**] is a 71 y.o lady w/ R heart failure, COPD, pulm
fibrosis, pulm HTN, CRI, remote breast ca who presented to the
ED with increasing abdominal distention x 2 days, severe diffuse
abdominal pain, and productive cough. In ED, mildly hypotensive
w/ new vs. worsened ascites, 19% bands. Admitted to [**Hospital Unit Name 153**] for
worry of early sepsis.
Past Medical History:
-pulmonary hypertension
-R sided heart failure
-severe long- standing mitral regurgitation after radiation and
chemotherapy for breast cancer [**2127**]
-cri
-hypothyroidism
-obesity
-sleep apnea
Social History:
has 7 children. used to be employed at [**Hospital1 18**].
Family History:
noncontributory
Physical Exam:
pt has no respiratory effort, no corneal reflexes, no pulse, all
c/w brain death.
Pertinent Results:
[**2148-10-13**] 05:43AM BLOOD WBC-20.5* RBC-5.95* Hgb-12.4 Hct-47.9
MCV-81* MCH-20.8* MCHC-25.8* RDW-23.0* Plt Ct-290
[**2148-10-10**] 08:35PM BLOOD WBC-8.7 RBC-6.00* Hgb-12.1 Hct-42.6
MCV-71* MCH-20.2*# MCHC-28.5* RDW-21.5* Plt Ct-503*
[**2148-10-10**] 08:35PM BLOOD Neuts-71* Bands-19* Lymphs-3* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2148-10-13**] 01:01PM BLOOD PT-28.8* PTT-67.0* INR(PT)-5.2
[**2148-10-11**] 03:15AM BLOOD PT-16.0* PTT-27.5 INR(PT)-1.6
[**2148-10-12**] 03:15PM BLOOD FDP-10-40
[**2148-10-12**] 11:20AM BLOOD Fibrino-683*
[**2148-10-11**] 03:15AM BLOOD D-Dimer-2800*
[**2148-10-13**] 01:01PM BLOOD Glucose-126* UreaN-75* Creat-4.0* Na-136
K-6.5* Cl-96 HCO3-6* AnGap-41*
[**2148-10-10**] 08:35PM BLOOD Glucose-114* UreaN-67* Creat-2.8*#
Na-128* K-GREATER TH Cl-91* HCO3-22
[**2148-10-13**] 05:43AM BLOOD ALT-48* AST-237* LD(LDH)-540*
AlkPhos-123* TotBili-2.8*
[**2148-10-13**] 01:01PM BLOOD Calcium-6.5* Phos-12.3* Mg-2.7*
[**2148-10-13**] 01:21PM BLOOD Type-ART Temp-37.1 Rates-27/ Tidal V-650
O2-60 pO2-64* pCO2-27* pH-6.96* calHCO3-7* Base XS--26
Intubat-INTUBATED
[**2148-10-13**] 05:58AM BLOOD Type-ART Temp-36.7 Rates-28/2 O2 Flow-60
pO2-84* pCO2-28* pH-7.04* calHCO3-8* Base XS--22 -ASSIST/CON
Intubat-INTUBATED
[**2148-10-13**] 12:15AM BLOOD Type-ART Temp-37.2 Rates-28/ Tidal V-600
PEEP-5 O2-60 pO2-106* pCO2-24* pH-7.07* calHCO3-7* Base XS--22
-ASSIST/CON Intubat-INTUBATED
[**2148-10-13**] 01:21PM BLOOD Lactate-11.1*
[**2148-10-13**] 05:58AM BLOOD Lactate-13.4*
[**2148-10-13**] 12:15AM BLOOD Lactate-13.2*
[**2148-10-10**] 11:27PM BLOOD Lactate-3.3*
CT of chest/abd/pelvis:
1. Significantly limited study, but no evidence of free air or
bowel dilatation. The oral contrast is only seen within the
stomach. Ascites. Probable umbilical and ventral hernias,
without evidence of bowel dilatation to indicate obstruction.
These findings were discussed with Dr. [**Last Name (STitle) 97153**] and the surgical
resident at 12:30 p.m. on [**2148-10-13**].
2. Bilateral lower lobe collapse/consolidation. Underlying
pleural effusions cannot be excluded.
3. Bilateral emphysematous change.
4. Mediastinal lymph adenopathy.
[**2148-10-11**] 04:49PM ASCITES WBC-1625* RBC-[**Numeric Identifier 24440**]* Polys-91*
Lymphs-2* Monos-7*
Brief Hospital Course:
Ms. [**Known lastname 9700**] was felt to be septic on admission. Her urine cx
grew E coli, and her blood and peritoneal cultures were
negative. It was felt likely that she had E coli sepsis despite
the negative blood cx, and she had peritonitis given the large
amt of WBCs on her ascitic fluid. She became hypoxic the night
after admission and required intubation. She became hypotensive
and was maxed out on three pressors. Her lactate steadily rose,
and she went into anuric renal failure. She had a
chest/abd/pelvic CT on [**10-13**] to look for free air, but it was
negative. Renal was consulted with the idea of starting
dialysis, but at that time she became progressively hypotensive
and her pressors were maxed out. After a discussion with all
seven of her children, it was decided not to pursue dialysis.
She became progressively more hypotensive and bradycardic, and
died Sunday afternoon with all of her children at her side.
Medications on Admission:
ASPIRIN E.C. 325 MG--Taking one daily to protect heart
AZELASTINE HCL 137MCG--[**1-19**] squirts in each nostril up to twice a
day as needed for nasal congestion or eustacean tube dysfunction
FUROSEMIDE 80 MG--Take 2 tablets (=160 mg) daily for fluid
LEVOXYL 75MCG--Take one tablet every day to replace thyroid
hormone; brand name medically necessary/dispense as written
NASALIDE SPRAY --Two sprays in affected nostril(s) twice a day
for nasal congestion
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
sepsis
Discharge Condition:
poor
Discharge Instructions:
none
Followup Instructions:
none
|
[
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icd9cm
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[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,370
| 197,532
|
42903
|
Discharge summary
|
report
|
Admission Date: [**2118-7-31**] Discharge Date: [**2118-8-2**]
Date of Birth: [**2068-7-13**] Sex: M
Service: NEUROLOGY
Allergies:
aspirin / Penicillins / bee sting / epinephrine
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
Seizures / Status Epilepticus
Major Surgical or Invasive Procedure:
Intubated for airway protection
History of Present Illness:
The patient is a 50 year-old right handed man with history of
seizures (multiple status epilepticus episodes in the past), CAD
(2 MIs, stents placed), PD, GERD, HPL, anxiety, depression, who
was transferred here after being intubated for airway protection
and status epilepticus control status post receiving a total of
6 mg ativan and 10 mg of valium at [**Hospital3 4107**].
On the evening of [**7-30**], he was involved in an altercation at a
bar (had 4 beers over the course of 3 hours). Following this
altercation (~ 5 minutes), chest pain developed. The pain was
crushing and tight, central in his chest, no radiations, [**6-21**],
anxious. An ambulance arrived for him and transported him to
[**Hospital3 **]. He was told that he had a seizure (generalized
tonic clonic) prior to EMS arriving (it resolved without any
intervention)-he has no recollection of this. He was transferred
to [**Hospital3 4107**], where he received an EKG, CXR and CE test
(all normal results. At [**Hospital1 **], he developed 1 episode of
generalized tonic clonic seizure which was responsive to 2 mg of
Ativan. After this episode he had a cluster of seizures in an
unknown period of time, not controlled by 4 mg of Ativan and 10
mg of Valium. Then he was intubated for airway protection,
loaded with dilantin and started on propofol and Rocuronium.
[**Hospital **] transferred to [**Hospital1 18**].
With regards to his epilepsy, he has a long-standing history
since the age of 17 (with presentation of GTC, and myoclonic
jerks); believed to be most likely primary generalized epilepsy.
He states that his seizures can be varied in their presentation,
from generalized tonic clonic to episodes of staring. He always
experiences a LOC, has confusion following the events and
headaches afterwards. He can go 6 months sometimes without
having a seizure. He thinks that stress and flashing lights are
triggers for his events. He experiences an aura of seeing sun
spots approximately 1 min before his events. He states that for
the most part he is compliant with his epilepsy medication, only
missing a dose on evenings when he goes for a drink (after which
he takes his dose when he arrives home). Prior to admission, he
was on depakote 1000mg qid; he has been compliant with his
medication, apart from missing one dose on [**7-30**]. Of note, he
states that his last hospitalization for seizure was last month
to [**Hospital3 417**] Hospital in [**Hospital1 1474**], MA. He believes this was
status epilepticus. Prior to this, he had gone from [**11/2117**]
without seizures. He was admitted to [**Hospital1 18**] Epilepsy service
twice in [**11/2117**] (once with status epilepticus in the setting of
medication noncompliance (undetectable Depakote level) and
alcohol ingestion. Has also been on phenytoin in the past which
gave him headaches (plan to stop and begin another AED).
Past Medical History:
-Epilepsy:
Diagnosed at the age of 17, described above. States that his
baseline for seizures is approximately [**12-13**]/year.
-Parkinson's Disease:
Diagnosed in [**2115**] with tremor, problems writing (Dr.
[**Name (NI) 92604**])
- CAD s/p 2 MIs: 1st-[**7-/2116**] 2nd-[**11/2117**] and 8 stents
-Hypercholesterolemia-familial
-Restless leg syndrome
-GERD
-Sciatica
-Anxiety
-Depression
Social History:
-He lives with his girlfriend.
-Has a daughter, concerned about her drug abuse (oxycodone) and
potential upcoming incarceration-this is a significant source of
stress to him.
-Is currently on disability (due to diagnosis of PD, seizures at
work), since [**2114**]. Was a contractor prior to this.
-Has not driven since [**2114**]-walks everywhere.
-He smokes cigars, with a 20 pack year history.
-EtOH- denies abuse, states approximately 7 drinks/week.
-Denies illicit drug use.
Family History:
Family history of DM, HTN, MI, strokes and EtOH abuse on both
maternal and paternal sides. Sister with epilepsy.
Physical Exam:
ADMISSION EXAM:
***************
Vitals: T:98.7 P:87 R:18 BP: 92/45 SaO2: 100%
General: intubated, has NG tube.
HEENT: NC/AT, no scleral icterus noted, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally with crackles in the left side.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
- Mental Status:
In deep coma not responsive to painful stimuli
- Cranial Nerves:
I: Olfaction not tested.
II: pupils 1.2 mm to 1 and brisk( small but reactive to light).
Funduscopic exam was not successful.
III, IV, VI: No eye movement in Doll test, no nystagmus
V,VII: corneal reflex intact.
VII: No facial droop
IX, X: GAG reflex intact.
- Motor: Normal bulk, tone throughout. No movement in response
to painful stimuli
- Sensory: No reaction to painful stimuli
- DTRs:
BJ SJ TJ KJ AJ
L 2 2 2 2 1
R 2 2 2 2 1
There was 2 beats of clonus bilaterally. Plantar response was
extensor b/l.
- Coordination: deferred
- Gait: deferred
DISCHARGE EXAM:
***************
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**2-12**] at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Labs on Admission:
[**2118-7-31**] 04:15AM BLOOD WBC-7.8 RBC-4.23* Hgb-13.1* Hct-39.6*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.5 Plt Ct-217
[**2118-7-31**] 09:58AM BLOOD Glucose-101* UreaN-21* Creat-1.2 Na-143
K-4.5 Cl-112* HCO3-22 AnGap-14
[**2118-7-31**] 09:58AM BLOOD CK(CPK)-144
[**2118-7-31**] 04:15AM BLOOD Lipase-46
[**2118-7-31**] 04:15AM BLOOD cTropnT-<0.01
[**2118-7-31**] 04:15AM BLOOD Phenyto-4.8* Valproa-25*
[**2118-7-31**] 04:34AM BLOOD Tidal V-550 PEEP-5 FiO2-100 pO2-422*
pCO2-48* pH-7.27* calTCO2-23 Base XS--4 AADO2-244 REQ O2-48
-ASSIST/CON Intubat-INTUBATED
[**2118-7-31**] 04:34AM BLOOD Glucose-105 Lactate-2.6* Na-139 K-3.8
Cl-108
[**2118-7-31**] 04:34AM BLOOD freeCa-1.11*
Imaging:
CT head w/o contrast [**7-31**]
FINDINGS: There is no evidence of infarction, hemorrhage,
edema, masses, or mass effect. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. The
ventricles and sulci are mildly prominent, consistent with mild
involutional changes. The basal cisterns are normal. There is
near-complete opacification of bilateral ethmoid and imaged
right maxillary sinus. Moderate mucosal thickening is seen in
both frontal and sphenoid sinuses. The mastoid air cells and
middle ear cavities are clear.
IMPRESSION: Paranasal sinus inflammatory changes, otherwise
normal study.
CT C spine w/o contrast [**7-31**]
CERVICAL SPINE CT WITHOUT INTRAVENOUS CONTRAST: No fracture or
malalignment. The lateral masses of C1 are symmetric about the
dens. Assessment for prevertebral soft tissue edema is limited
secondary to intubation and nasoenteric catheter. However, no
definite prevertebral soft tissue edema is identified. There
are mild degenerative changes of the cervical spine with loss of
height and disc space at multiple levels. There is mild
anterior and posterior osteophyte formation at C6-C7. The
visualized outline of the thecal sac is within normal limits
without evidence of critical canal stenosis. The thyroid
appears inhomogeneous without a definite nodule. This appearance
may be due to overlying artifact. If further evaluation is
indicated, an ultrasound may be helpful. Imaged mastoid air
cells appear well aerated. Lung
apices are not included within the field of view.
IMPRESSION: No evidence of fracture or malalignment. Possible
thyroid
nodules.
Chest x-ray [**7-31**]
FINDINGS: The endotracheal tube ends approximately 2 cm above
the carina. The cardiomediastinal and hilar contours are within
normal limits. No consolidation, pleural effusion or
pneumothorax is seen.
IMPRESSION: ET tube 2 cm above the carina, needs to be
retracted.
Labs on Discharge:
[**2118-8-2**] 04:35AM BLOOD WBC-6.0 RBC-4.37* Hgb-13.6* Hct-40.7
MCV-93 MCH-31.1 MCHC-33.4 RDW-14.6 Plt Ct-209
[**2118-8-2**] 04:35AM BLOOD Plt Ct-209
[**2118-8-2**] 04:35AM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-14
[**2118-8-1**] 02:09AM BLOOD CK-MB-1 cTropnT-<0.01
[**2118-8-1**] 02:09AM BLOOD Albumin-3.4* Calcium-7.9* Phos-3.6 Mg-2.2
[**2118-8-2**] 04:35AM BLOOD Valproa-83
Brief Hospital Course:
The pt is a 50 year-old man with history of seizure and multiple
status epilepticus episodes in the past, who was transferred
here after being intubated for airway protection and status
epilepticus control.
# NEUROLOGIC:
Cause of status epilepticus most likely secondary to
noncompliance with medications as valproic acid level was
subtherapeutic at 25 on admission. Also, given frequency of
seizures, his regimen of valproic acid 1000mg qid was likely not
adequate as a single [**Doctor Last Name 360**]. No electrolyte abnormality was
present. Alcohol W/D versus intoxication is also on the
differential. Head CT was w/o acute process. He was continued on
home dose of Depakote and also started on Dilantin initially.
Patient was successfully extubated on [**7-31**]. He did say that he
was on Depakote 1000mg qid at home. Has also been on Dilantin in
the past which gave him headaches and caused him to be unsteady
on his feet causing him to discontinue and start Keppra 500mg
[**Hospital1 **] instead. Of note, on am of [**8-1**], patient had blinking of
eyes b/l. At this time, he had no evidence of seizure activity
on EEG. Of note, pt was on Diazepam 10mg TID per home dosing and
CIWA protocol. He was also hydrated with banana bag on admission
and then transitioned to PO folic acid and thiamine.
Follow up conversation with Mr. [**Known lastname 69467**] [**Last Name (Titles) 92605**] the need
for medication compliance, with neurology appointment follow-ups
at [**Hospital1 18**]. Depakote and Valium were both continued upon
outpatient discharge.
# PSYCHIATRIC:
Pt with history of being abused and 4 suicide attempts in the
past. During admission in ICU, endorsed passive SI but did not
have a plan to hurt himself. Psychiatry evaluated Mr. [**Known lastname 69467**]
noting his features of depression and PTSD; they noted the
patient would likely benefit from psychotherapy as well as
possible medication adjustment (esp higher dose SSRI); however,
no safety concerns were reported for the patient. Of note, the
patient also refused placement or any psychiatric counseling.
# CARDIOLOGY:
Monitored on telemetry. No abnormal rhythm was noted.
# TRANSITIONS OF CARE:
- Patient will follow up with Dr. [**Last Name (STitle) 851**], [**Hospital1 18**]
Neurology, and Dr. [**First Name4 (NamePattern1) 6339**] [**Last Name (NamePattern1) **] his PCP.
Medications on Admission:
Nexium 80 mg po daily
Ranitidine 300 mg po daily
Depakote 1000 mg po qid daily
pramipexole 0.25 mg po TID
Ezetimibe 10 mg po daily
Plavix 75 mg po daily
Rosuvastatin 40 mg po daily
Percocet 5/325 mg po q 4
Colchicine 0.6 mg po daily
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Divalproex (DELayed Release) [**2105**] mg PO BID
4. NexIUM *NF* (esomeprazole magnesium) 80 mg Oral daily
5. Rosuvastatin Calcium 40 mg PO DAILY
6. pramipexole *NF* 0.25 mg Oral TID Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
7. Ezetimibe 10 mg PO DAILY
8. Diazepam 10 mg PO TID
RX *diazepam 10 mg 1 tablet by mouth three times a day Disp #*9
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were cared for at [**Hospital1 69**] for
your seizure disorder. On admission from [**Hospital3 **], you
were transported to our Neurology ICU intubated for airway
protection. Over the course of the next 24 hours, your mental
status and breathing function improved allowing removal of your
breathing tube. You were transferred from our ICU to general
floors for further workup and EEG monitoring of any additional
events. Over the course of your EEG monitoring, no events were
recorded which corresponded with any epileptiform activity.
You should continue to take your anti-epileptic medication,
Depakote, at the prescribed dosage, as well as all other
prescribed medications. A follow up appointment has been
scheduled with Dr. [**First Name4 (NamePattern1) 6339**] [**Last Name (NamePattern1) **] on Thursday, [**8-4**] at
2:00pm. A follow-up appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 851**]
will be scheduled with you in four (4) weeks; you will receive a
phone call from [**First Name9 (NamePattern2) **] [**Location (un) **] regarding this appointment.
Followup Instructions:
Please follow-up with your PCP, [**Name10 (NameIs) **] Thursday, [**8-4**] at
2:00pm
Dr. [**First Name4 (NamePattern1) 6339**] [**Last Name (NamePattern1) **]
[**Street Address(2) **]
[**Location (un) **], [**Numeric Identifier 23881**]
([**Telephone/Fax (1) 92606**]
Completed by:[**2118-8-2**]
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icd9cm
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[
[
[]
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[
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"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14078, 14084
|
10863, 13028
|
339, 373
|
14137, 14137
|
7789, 7794
|
15401, 15699
|
4205, 4320
|
13516, 14055
|
14105, 14116
|
13258, 13493
|
14288, 15378
|
6466, 7770
|
4335, 4874
|
5539, 5834
|
270, 301
|
10429, 10840
|
401, 3272
|
4954, 5523
|
7809, 10409
|
14152, 14264
|
13049, 13232
|
3294, 3692
|
3708, 4189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,322
| 159,006
|
11950
|
Discharge summary
|
report
|
Admission Date: [**2150-2-9**] Discharge Date: [**2150-2-16**]
Date of Birth: [**2078-5-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 71 year-old
male first seen on [**11-20**] for evaluation of 6.7 cm mass
in the central portion of solitary right kidney. The
patient's ganglia was removed in [**2139**] for a P2NMO papillary
renal carcinoma. The patient received postoperative
radiation therapy and did well. Recently the patient
complained of bladder outflow obstruction symptoms and IDP
was performed with the finding of a subjective mass confirmed
by ultrasound and CT scan. The patient's baseline BUN and
creatinine is BUN 26 and creatinine 1.2 and alkaline
phosphatase was 103.
MEDICATIONS: The patient was on Alprazolam, Amitriptyline,
Finasteride, Norvasc, Prednisone, Lipitor and Zantac at home.
PAST MEDICAL HISTORY: Significant for polymyalgia rheumatica
and hypertension.
PAST SURGICAL HISTORY: Left nephrectomy, pilonidal cyst
repair.
HOSPITAL COURSE: The patient was taken to the Operating Room
and underwent a partial right nephrectomy on [**2150-2-9**]. Postoperatively, the patient was placed in the
Intensive Care Unit. While in the Intensive Care Unit the
patient's BUN and creatinine was monitored. Postoperative
creatinine was maxed out at 5.80. On postoperative
creatinine was gradually elevating and on postoperative day
number three reached a peak of 5.0 and nephrology was
consulted at that time due to worsening renal function, but
was not unsuspected given the patient's solitary right kidney
and the procedure. The patient was otherwise stable.
Nephrology was consulted. Hemodialysis was not initiated and
over the next few days his creatinine began to gradually
decrease. The patient's nasogastric tube was discontinued on
postoperative day number four when the patient demonstrated
some bowel function when he passed some flatus.
Because the patient was on Prednisone at home a loading
stress dose Prednisone was given a Prednisone taper was
initiated and the patient will be continued on a Prednisone
taper at home. On postoperative day number four the patient
was stable enough to be transferred to the floor. The
patient received 7 units of transfusion for low hematocrit.
The patient's chest tube was discontinued on postoperative
day number three with a small right apical pneumothorax. The
right apical pneumothorax resolved on postoperative day five
on repeat chest x-ray. The patient has demonstrated no
respiratory compromise. The patient did well on the floor on
postoperative day number six and seven. Levaquin was started
initially on postoperative day number four for a suspicious
sputum and some rales and pleural effusion bilaterally and
Levaquin was discontinued on postoperative day seven. The
patient prior to discharge the patient was afebrile with
stable vital signs. Chest was clear. Heart was regular rate
and rhythm. Abdomen was soft, nontender, nondistended. The
incision was clean, dry and intact and he has been passing
gas and having small bowel movements. The patient's JP was
discontinued, however, his Foley remained in place and right
nephrostomy tube also remained in place and the patient will
be discharged home with VNA Services and with the Foley and
nephrostomy tube.
DISCHARGE MEDICATIONS: Zocor 20 mg po q.d., Lopressor 12.5
mg po b.i.d., Terazosin 2 mg po q.h.s., Finasteride 5 mg po
q.d., Amlodipine 5 mg po q.d. and Zantac 150 mg po b.i.d. and
Prednisone 15 mg po q.d. for [**2-17**] and [**2-18**] and 10 mg po
q.d. for [**2-19**] and [**2-20**], and starting on [**2-21**] the
patient is to take 5 mg po q.d. and Cipro 250 mg po b.i.d.
starting one day prior to the next follow up visit with Dr.
[**Last Name (STitle) **]. The patient is to take Cipro for seven days.
The patient is discharged home with VNA and prior to
discharge the patient underwent Foley teaching and
nephrostomy tube care and teaching.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern1) 37610**]
MEDQUIST36
D: [**2150-2-16**] 10:40
T: [**2150-2-16**] 10:48
JOB#: [**Job Number **]
|
[
"530.81",
"584.5",
"189.0",
"725",
"553.3",
"276.2",
"512.1",
"401.9",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
3333, 4240
|
1018, 3309
|
958, 1000
|
158, 853
|
876, 934
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,917
| 116,633
|
16966
|
Discharge summary
|
report
|
Admission Date: [**2132-6-3**] Discharge Date: [**2132-6-5**]
Date of Birth: [**2073-12-9**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: This is a 58-year-old female
with multiple cardiac risk factors but no prior cardiac
history who presented to an outside hospital the day prior to
presentation to [**Hospital6 256**]
complaining of intermittent chest pain radiating to both
arms. The patient describes the onset of pain in her arms
which does spread across her back and ended up in her chest.
The EKG was not impressive for ischemia, but troponins were
elevated. Spiral CT scan was negative for dissection. No
relief of chest pain with nitroglycerin. Aspirin, heparin,
Aggrastat, and Dilaudid were started. The symptoms returned
intermittently throughout the night. Repeat enzymes on the
morning of transfer to [**Hospital6 256**]
were CK 42, troponin 0.38. The patient was transferred to
[**Hospital6 256**] for catheterization.
Urgent catheterization showed 90% middle RCA stenosis and 70%
proximal LAD stenosis. The right coronary artery was stented
and normal flow was noted to the LAD. The procedure was
complicated by nausea, vomiting, and lethargy, presumably
from narcotic administration prior to the procedure. The
patient was given Narcan and flumazenil. The patient went
into atrial fibrillation with a rapid ventricular response at
150 beats per minute.
After the procedure, Lopressor IV initially controlled the
rate and then broke the arrhythmia. The patient was
transferred to the CCU for close observation. No further
nausea, vomiting, lethargy, or atrial fibrillation in the
unit. No complaints at the time of examination in the unit.
PAST MEDICAL HISTORY:
1. Fibromyalgia.
2. Chronic lymphocytosis, questionable.
3. Status post nephrectomy for nephrolithiasis, right
kidney.
4. Status post appendectomy and cholecystectomy.
5. History of colon cancer, status post partial colectomy.
6. Hypercholesterolemia.
7. Hypertension.
8. History of tobacco use.
9. Family history of coronary artery disease in the
patient's mother.
ADMISSION MEDICATIONS:
1. Norvasc 5 mg p.o. q.d.
2. Lisinopril 10 mg p.o. q.d.
3. Lasix 80 mg p.o. q.a.m., 40 mg p.o. q.p.m.
4. Celexa 5 mg p.o. q.a.m.
5. Tagamet.
6. Colace.
7. Amitriptyline 50 q.h.s.
MEDICATIONS AT TRANSFER:
1. Aspirin.
2. Plavix.
3. Aggrastat drip.
4. Nitroglycerin drip.
ALLERGIES: Augmentin causes nausea and vomiting.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.1, pulse 69, respirations 18, blood pressure 125/49,
oxygen saturation 94% on 3 liters nasal cannula. Neurologic:
No focal neurological deficits. The patient was alert and
oriented times three. Cardiovascular: Regular rate and
rhythm, no murmurs, rubs, or gallops. No jugular venous
distention. No peripheral edema. Abdomen: Soft, nontender,
nondistended. Pulmonary: Lungs clear to auscultation.
Groin catheterization site is covered, clean, dry, and
intact, no hematoma, no bruit.
LABORATORY/RADIOLOGIC DATA: Potassium 3.0, creatinine 0.7.
Hematocrit 30.6. Blood gas 7.30, 52, 68.
HOSPITAL COURSE: The patient's remaining hospital course was
uneventful. She had no recurrent chest pain or shortness of
breath or other ischemic symptoms in-house. She was able to
ambulate with PT without a problem and without onset of
symptoms. Her Lasix was initially held around the time of
catheterization. It was restarted on the day after the
catheterization. She was started on a beta blocker, statin,
and ACE inhibitor and Plavix. Her aspirin and ACE inhibitor
were continued. Her beta blocker and ACE inhibitor were
increased as tolerated. The nitroglycerin drip was weaned
off overnight on the night of the catheterization. Aggrastat
was continued after the catheterization until the morning
after when it was discontinued.
DISCHARGE STATUS: The patient is stable for discharge home.
FOLLOW-UP: The patient is to follow-up with the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]. She will need to return for
cardiac catheterization in three to four weeks for possible
intervention on her left anterior descending artery lesion.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Atorvostatin 10 mg p.o. q.d.
4. Lisinopril 10 mg p.o. q.d.
5. Metoprolol 25 mg p.o. b.i.d.
6. Lasix 80 mg p.o. q.a.m., 40 mg p.o. q.p.m.
7. Celexa 5 mg p.o. q.a.m.
8. Amitriptyline 50 mg p.o. q.h.s.
DISCHARGE DIAGNOSIS: Non ST elevation MI, status post right
coronary artery stent.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2132-6-5**] 12:44
T: [**2132-6-8**] 15:08
JOB#: [**Job Number **]
|
[
"427.31",
"272.0",
"V10.05",
"410.71",
"414.01",
"401.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.07",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
4245, 4510
|
4533, 4867
|
3162, 4222
|
2150, 2504
|
148, 1729
|
2519, 3144
|
1751, 2127
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,302
| 196,487
|
1539
|
Discharge summary
|
report
|
Admission Date: [**2134-9-16**] Discharge Date: [**2134-9-19**]
Date of Birth: [**2067-5-18**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
hypotension after hemorrhoidectomy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a 67 year old female who complains of UNABLE TO
URINATE, HYPOTENSION. Pt s/p hemorrhoidectomy on [**2134-9-15**]. She
came to the ER for complaints of lightheadedness and decreased
urine output. No fever, no abd pain. No CP or SOB.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY: HTN, DM, anxiety,
hypothyroidism, narcotic abuse
PSH: Cholecystectomy, T&A, dental surgeries, sinus surgery.
Social History:
She is divorced, lives at home. She has two children. She used
to work at the [**Hospital1 18**] concierge desk
Family History:
Mom died recently of Alzheimer at 91. Father has had a stroke,
he is [**Age over 90 **]. A brother died of a brain tumor and a first cousin
died of a brain tumor. Her sister died, had diabetes, hepatitis
and was a drug addict.
Physical Exam:
VITALS: Pain score [**8-31**] T 96.5 HR 85 BP 85/42 RR 18 O2 sat 98
GEN: Alert, oriented, pleasant, appropriate
LUNGS: Clear to auscultation
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs
gallops
ABDOMEN: Obese, soft, non-tender, non-distended
EXTREMITIES: Warm and well perfused. No edema
RECTUM: Clean, appropriately tender, no visible hemorrhoidal
tissue, scant drainage present
Pertinent Results:
[**2134-9-17**] ECHO
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mildly dilated ascending aorta
[**2134-9-17**] CT ABDOMEN W/O CONTRAST
IMPRESSION:
1. No drainable intra-abdominal fluid collections or abscesses
are detected.Left flank subcutaneous stranding without
collection may be from positioning for surgery; please
correlate.
2.Trace bilateral pleural effusions, with atelectasis in the
right lower
lobe.
3. Contrast in the esophagus suggest GERD or esophageal
dysmotility.
4. Diffuse fatty deposition in the liver.
5. Calcified uterine fibroid.
[**2134-9-16**] 01:45PM BLOOD WBC-10.9 RBC-3.85* Hgb-11.5* Hct-35.4*
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.2 Plt Ct-212
[**2134-9-16**] 09:07PM BLOOD WBC-10.1 RBC-3.75* Hgb-11.0* Hct-33.8*
MCV-90 MCH-29.3 MCHC-32.5 RDW-14.2 Plt Ct-203
[**2134-9-16**] 01:45PM BLOOD PT-13.0 PTT-28.3 INR(PT)-1.1
[**2134-9-16**] 01:45PM BLOOD Plt Ct-212
[**2134-9-16**] 09:07PM BLOOD Plt Ct-203
[**2134-9-16**] 09:07PM BLOOD
[**2134-9-16**] 01:45PM BLOOD Glucose-140* UreaN-36* Creat-1.8* Na-139
K-5.2* Cl-105 HCO3-25 AnGap-14
[**2134-9-16**] 09:07PM BLOOD Glucose-124* UreaN-29* Creat-1.4* Na-136
K-4.9 Cl-107 HCO3-23 AnGap-11
[**2134-9-16**] 01:45PM BLOOD CK(CPK)-80
[**2134-9-16**] 01:45PM BLOOD CK-MB-4
[**2134-9-16**] 01:45PM BLOOD cTropnT-<0.01
[**2134-9-16**] 09:07PM BLOOD CK-MB-3 cTropnT-<0.01
[**2134-9-17**] 04:28AM BLOOD CK-MB-4 cTropnT-<0.01
[**2134-9-16**] 09:07PM BLOOD Calcium-8.0* Phos-3.5 Mg-1.6
[**2134-9-16**] 01:58PM BLOOD Lactate-2.4*
[**2134-9-16**] 05:22PM BLOOD Lactate-1.7
[**2134-9-17**] 04:28AM BLOOD WBC-8.6 RBC-3.47* Hgb-10.5* Hct-30.6*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.2 Plt Ct-195
[**2134-9-17**] 04:28AM BLOOD Plt Ct-195
[**2134-9-17**] 04:28AM BLOOD Glucose-121* UreaN-25* Creat-1.1 Na-137
K-4.3 Cl-108 HCO3-23 AnGap-10
[**2134-9-17**] 04:28AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7
[**2134-9-17**] 04:28AM BLOOD T4-8.2
[**2134-9-17**] 04:28AM BLOOD TSH-0.48
[**2134-9-17**] 04:28AM BLOOD Cortsol-3.7
[**2134-9-18**] 04:53PM BLOOD Cortsol-4.0
[**2134-9-18**] 05:48PM BLOOD Cortsol-26.1*
[**2134-9-18**] 06:18PM BLOOD Cortsol-33.1*
[**2134-9-18**] 02:53AM BLOOD WBC-8.0 RBC-3.36* Hgb-10.1* Hct-30.4*
MCV-91 MCH-30.0 MCHC-33.2 RDW-14.3 Plt Ct-199
[**2134-9-18**] 02:53AM BLOOD Plt Ct-199
[**2134-9-18**] 02:53AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
[**2134-9-18**] 04:53PM BLOOD Cortsol-4.0
[**2134-9-18**] 05:48PM BLOOD Cortsol-26.1*
[**2134-9-19**] 03:55AM BLOOD WBC-7.8 RBC-3.60* Hgb-10.9* Hct-33.3*
MCV-93 MCH-30.2 MCHC-32.7 RDW-13.5 Plt Ct-205
[**2134-9-19**] 03:55AM BLOOD Plt Ct-205
[**2134-9-19**] 03:55AM BLOOD Glucose-238* UreaN-21* Creat-1.0 Na-141
K-4.6 Cl-108 HCO3-28 AnGap-10
Brief Hospital Course:
This patient is a 67 year old female s/p hemorrhoidectomy one
day go who came to the ER with inability to urinate and
hypotension. She was admitted to the ICU from the ER. She
recieved aggressive hydration with RL and she was started on
phenylephrine drip.Her cardiac enzymes were ordered which turned
out to be normal. Her cardiac echo [**Last Name (un) **] an EF of 60%.Her CT
abdomen and pelvis was unremarkable for any source of
bleeding/abcess formation.She was started on vancomycin and
Piperacillin-Tazobactam.She was also started on miconazole for
suspected fungal infection in the perineal region.Over the next
24 hours her blood pressure improved significantly.She was
advanced to a regular diet which she tolerated well.She was
weaned off pressors, vancomycin was d/ced and on the 28th,she
was transferred to the surgical floor.She continued to make good
progress.Her foley was removed on the 29th and her IV fluid was
dc'ed.She was able to void spontaneously making adequate amount
of urine,and continued to maintain blood pressures within a
normal range. She was ambulating well,AVSS and tolerating a
regular diet when she was discharged on the 29th and would
follow up with Dr [**Last Name (STitle) **] in 1 month.
Medications on Admission:
Atenolol 25 mg [**Hospital1 **],
Lexapro 20 mg a day,
Glipizide extended release 2.5 mg [**Hospital1 **],
Vit D 50,000 Weekly, Lantus 30 units once a day,
Synthroid 112 mcg once a day,
Metformin XR 500 mg three times a day,
Seroquel 175 mg at bedtime,
Simvastatin 20 mg a day,
Diovan 80 Daily,
aspirin 81 mg a day,
Scopolamine Base [Transderm-Scop] 1.5 mg/72 hour Patch 72 hr
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*50 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as
needed) as needed for pain.
Disp:*1 * Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 5 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO three times a day.
11. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous once a day.
14. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime: To
be taken with 75mg.
15. Seroquel 25 mg Tablet Sig: Three (3) Tablet PO at bedtime:
To be taken with 100mg.
16. Motrin 400 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the General Surgery Inpatient Unit and
underwent hemorrhoidectomy. You have tolerated a regular diet
and your pain is adequately controled and you are ready to be
discharged home. Monitor your bowel function closely.
If you have any of the following bowel symptoms please call the
office or go to the emergency room if severe: increasing
abdominal distension, increased abdominal pain, abdominal,
nausea, vomiting, inability to tolerate food or liquids.
You will be given a prescription for pain medication to take as
directed. Please donot drive or operate heavy machinery while
you are on your pain meds.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow-up in 1 month with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 9011**].
Please also schedule a follow-up appointment with your PCP, [**Last Name (NamePattern4) **].
[**Known firstname 2048**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 133**]) within the next two weeks.
Completed by:[**2134-9-19**]
|
[
"272.0",
"V45.79",
"V45.89",
"401.9",
"V58.67",
"244.9",
"788.20",
"455.3",
"278.01",
"455.0",
"300.00",
"V85.4",
"276.51",
"584.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"49.45"
] |
icd9pcs
|
[
[
[]
]
] |
7487, 7493
|
4334, 5568
|
309, 316
|
7561, 7561
|
1570, 4311
|
8869, 9204
|
905, 1136
|
5995, 7464
|
7514, 7540
|
5594, 5972
|
7712, 8341
|
8356, 8846
|
1151, 1551
|
235, 271
|
344, 594
|
7576, 7688
|
616, 759
|
775, 889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,470
| 185,471
|
33101
|
Discharge summary
|
report
|
Admission Date: [**2194-2-7**] Discharge Date: [**2194-3-12**]
Date of Birth: [**2134-3-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
necrotizing fasciitis
Major Surgical or Invasive Procedure:
s/p multiple debridements left leg,
IVF filter placement,
STSG
VAC placement
History of Present Illness:
Mrs. [**Known lastname 76935**] is a 59 year old woman with hx thyroid disease who
presented initially to [**Hospital 8641**] hospital on [**2-4**] with 2-3 week
history of swelling and redness in area of ingrown hair on left
thigh. She attempted to use black tar over the area without
improvement. The are became "purplish black" She
had concomitant confusion per family, weakness, nausea, although
denied fever. On initial evaluation she had a 12x4cm abscess in
the perineum with areas of necrosis as per ED charts, a WBC of
14.9 with 31% bands and glucose of 452. She was started on Zosyn
and taken to the OR for debridement, where "an enormous amount
of necrotic subcutaneous tissue... and pockets of pus all the
way to
medial aspect of the thigh" was noted in the OR note. She
initially improved, however on [**2-7**] she developed worsening
elevated WBC and fever and the patient was taken back to the OR
for a second debridement where "extensive pus and probable
necrotizing fasciitis" was noted. She required vasopressors,
clindamycin was added and the patient was medflighted to [**Hospital1 18**]
for further management.
Past Medical History:
Hypothyroidism s/p radioablation
Social History:
Lives with boyfriend in [**Name (NI) 76936**]
+ ETOH
+ 1 ppd cigarette smoking
Works at [**Company 2486**]
Family History:
CAD
Physical Exam:
T: 100.4 P: 89 R: 16 BP: 111/49 99% AC 20/300/40/5
General: Intubated, sedated
Neck: No LAD
Cardiovascular: RRR no murmurs
Respiratory: Coarse vented breath sounds
Gastrointestinal: Decrease BS, obese, soft, no masses
Genitourinary: Foley in place, candidal rash in vaginal fold
Musculoskeletal: Extensive incision extending from lateral
aspect
of superior thigh, medially to groin and caudally to mid thigh,
draining clear yellow fluid. + erythema, warmth and nonpitting
edema of left calf. + erythematous rash right groin. Bilateral
subclavian CVLs without erythema.
Pertinent Results:
[**2194-2-7**] 09:18PM BLOOD WBC-29.4* RBC-3.26* Hgb-9.3* Hct-28.9*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.8 Plt Ct-397
[**2194-2-8**] 03:27AM BLOOD WBC-30.3* RBC-3.24* Hgb-9.3* Hct-28.1*
MCV-87 MCH-28.7 MCHC-33.0 RDW-14.7 Plt Ct-399
[**2194-2-8**] 01:08PM BLOOD WBC-29.6* RBC-3.00* Hgb-8.5* Hct-26.5*
MCV-88 MCH-28.4 MCHC-32.2 RDW-15.0 Plt Ct-347
[**2194-2-9**] 04:32AM BLOOD WBC-33.1* RBC-2.74* Hgb-7.8* Hct-23.9*
MCV-88 MCH-28.6 MCHC-32.6 RDW-14.9 Plt Ct-303
[**2194-2-12**] 03:26AM BLOOD WBC-16.3* RBC-3.19* Hgb-9.5* Hct-28.0*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.1 Plt Ct-293
[**2194-2-7**] 09:18PM BLOOD Neuts-62 Bands-12* Lymphs-8* Monos-6
Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-3* Promyel-1* Other-1*
[**2194-2-9**] 04:32AM BLOOD Neuts-59 Bands-17* Lymphs-11* Monos-1*
Eos-2 Baso-1 Atyps-1* Metas-5* Myelos-2* Promyel-1*
[**2194-2-7**] 09:18PM BLOOD ALT-13 AST-13 AlkPhos-577* Amylase-13
TotBili-0.6
[**2194-2-11**] 02:44AM BLOOD T4-2.1* T3-39* Free T4-0.19*
[**2194-2-11**] 02:44AM BLOOD TSH-5.5*
[**2194-2-10**] 10:11AM BLOOD Cortsol-34.5*
[**2-10**]: CT -1. Findings suggesting pyelonephritis with the
possibility of a focal (non-drainable) abscess within the right
kidney as detailed above. Additionally, fluid collection
identified within the posterior pararenal space as well as
within the right psoas muscle.
2. Post-surgical changes related to extensive debridement of the
left lower extremity. Emphysema is identified within fascial
planes primarily about the surgical site as noted above.
3. Trace free fluid is seen within the peritoneal cavity.
4. Small effusions and adjacent areas of passive atelectasis
noted.
[**2194-3-3**] 03:30AM BLOOD WBC-13.8* RBC-4.13* Hgb-12.5 Hct-37.4
MCV-91 MCH-30.2 MCHC-33.3 RDW-16.4* Plt Ct-692*
[**2194-2-27**] 05:05AM BLOOD Glucose-139* UreaN-9 Creat-0.8 Na-138
K-4.4 Cl-108 HCO3-23 AnGap-11
[**2194-3-1**] 04:36AM BLOOD ALT-17 AST-16 AlkPhos-580* Amylase-27
TotBili-0.4
[**2194-3-1**] 04:36AM BLOOD Lipase-22
[**2194-2-27**] 05:05AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0
[**2194-2-11**] 02:44AM BLOOD TSH-5.5*
[**2194-2-11**] 02:44AM BLOOD T4-2.1* T3-39* Free T4-0.19*
[**2194-2-10**] 10:11AM BLOOD Cortsol-34.5*
[**2194-2-10**] 11:05AM BLOOD Cortsol-22.1*
[**2194-2-10**] 11:55AM BLOOD Cortsol-38.6*
.
Cytology Report FNA, BREAST Procedure Date of [**2194-2-10**]
REPORT APPROVED DATE: [**2194-2-12**]
SPECIMEN RECEIVED: [**2194-2-10**] [**-8/5024**] FNA, BREAST
SPECIMEN DESCRIPTION: Received 4 air dried slides and 1 tube of
Cytolyt. Prepared 1 ThinPrep slide.
Total 5 slides.
CLINICAL DATA: 59 yo female in SICU, S/p debridement for
necrotizing
fasciitis, a 6-7 cm (R) breast mass was found
incidentally.
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSIS: FNA, Breast mass, left: POSITIVE FOR MALIGNANT CELLS,
consistent with adenocarcinoma.
Cellular specimen with atypical epithelioid cells in
clusters and singly with nuclear pleomorphism, nuclear
membrane irregularities and prominent nucleoli; some
cells with intracytoplasmic vacuoles.
.
CT HEAD W/O CONTRAST [**2194-3-2**] 10:19 AM
IMPRESSION:
1. No intracranial hemorrhage or mass effect. Note that
non-contrast CT is less sensitive for detection of small
parenchymal metastases in comparison with contrast-enhanced CT
or MRI.
2. Opacification of several left mastoid air cells and fluid
level in the sphenoid sinus, likely inflammatory in etiology. No
evidence for osseous erosion.
3. Left middle cranial fossa arachnoid cyst.
.
MRA BRAIN W/O CONTRAST [**2194-3-6**] 9:57 AM
IMPRESSION:
1. Irregularity of the right distal vertebral artery with focal
outpouching could represent focal aneurysm or pseudoaneurysm or
area of dissection. CTA is recommended for further evaluation.
This was discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**].
2. Stable left middle cranial fossa arachnoid cyst.
3. Air-fluid level within the sphenoid sinus, fluid/mucosal
thickening within the mastoid air cells, and fluid within the
right middle ear cavity.
.
CTA NECK W&W/OC & RECONS [**2194-3-8**] 8:41 PM
CONCLUSION: Confirmation of aneurysm within the distal right
vertebral artery, which may well represent a component of
dissection. The contiguous portion of the right vertebral artery
is quite narrowed at this location.
ADDENDUM: There is ossification of the posterior longitudinal
ligament posterior to the C4 vertebral body, as well as
prominent disc space narrowing and probable reactive sclerosis
involving the C4-5 and C5-6 disc spaces.
.
Brief Hospital Course:
The patient was admitted to the ICU from an OSH.
Neuro: The patient received appropriate sedation and pain
medications. She was intubated in the ICU for her multiple left
leg debridements.
She had persistent post-op ICU confusion. A Head CT showed no
intracranial hemorrhage or mass effect.
A Neurology consult was obtained and they requested a MR of her
brain. MR brain showed irregularity of the right distal
vertebral artery with focal outpouching could represent focal
aneurysm or pseudoaneurysm or area of dissection.
Next, a CTA on [**2194-3-9**] confirmation of aneurysm within the
distal right vertebral artery, which may well represent a
component of dissection. The contiguous portion of the right
vertebral artery is quite narrowed at this location.
Neurosurgery was consulted and felt the incidence of rupture is
2% per year, most likely she will need stent assisted coiling
with antiplatelet treatment electively
once she recovers from her present illness. Follow up with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] in 1 month, [**Telephone/Fax (1) 1669**], will likely need stenting
with coiling.
Neurology felt the most likely diagnosis is Alzheimer's
dementia.
.
CV: stable
Pulm: On ventilator support, which was weaned as tolerated.
GI: The patient received tube feeds, and was put on famotidine.
Once extubated her PO diet was advanced.
GU: The patient had a Foley catheter, and her urine output was
routinely monitored
Heme: The patient's cbc was routinely monitored
ID: The patient was put on vancomycin, zosyn, clindamycin,
fluconazole for necrotizing fasciitis as well as a perineal
yeast infection in close proximity to her wound. Multiple
cultures were obtained, and ID was consulted for further
evaluation. She initially had clinical deterioration on Zosyn
and culture + for E. fergisonii and group B strep. Her infection
is likely mixed aerobic / anaerobic and it is unclear that
previous culture results represent all pathogenic organisms.
Would favor broadening antibiotic coverage for B-lactamase
producing anaerobes as well as possible toxin producing strep
and staph species. No GAS isolated yet, but given hemodynamic
instability, may consider IVIG, would hold for now as data is
somewhat limited.
For her Ecoli and viridans strep, she continued on Zosyn and
this will end on [**2194-3-14**].
Micro/Path:
[**2-20**]: Sputum - GNR mod growth
[**2-12**]: Wound cx - E.Coli (R to amp)
[**2-9**]: Wound cx - E.Coli (R to amp, cefazolin), Strep viridans
[**2-9**]: Breast bx: malignant cells c/w adenocarcinoma
[**2-8**]: Sputum - Yeast, Stenotrophomonas Maltophilia
[**2-8**]: Wound Cx - E. Coli (R to amp)
Necrotizing fascitis L groin: s/p multiple debridements left
leg. She then went to the OR with Plastic Surgery on [**2194-2-21**] for
rectus flap to cover femoral vessels with VAC placement. Her
wounds were stable, C/D/I and were covered with gauze.
After wound closure by Plastics, she was allowed to get OOB with
PT. She will require further PT at rehab.
Endo: The patient was put on a sliding scale of insulin, and her
blood sugars were closely monitored. She is a new diabetic and
will need follow-up.
Proph: The patient was put on subcutaneous heparin and had
pneumoboots. s/p IVF filter placement ([**2-17**])
Breast CA: She had a biopsy of a breast mass and has a new
adenocarcinoma of breast. She will follow-up with the Breast
surgeons for further care.
Medications on Admission:
vanc, zosyn, clinda @ OSH
none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
Constipation.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
7. Curafil Gel Wound Gel Sig: One (1) Topical qday ():
cover wound Topical qday .
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Monitor TSH. [**Month (only) 116**] need to increase dose.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
Units Subcutaneous once a day.
12. Insulin Regular Human 100 unit/mL Solution Sig: SS
Injection four times a day: See sliding scale.
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 2 days: thru
[**2194-3-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
necrotizing fasciitis
Deconditioning
Prolonged post-op confusion
short-term memory impairment
?Alzheimer's dementia
Irregularity of R distal vertebral artery w/focal outpouching
Newly diagnosed Breast adenocarcinoma (needs follow-up)
Discharge Condition:
good
Discharge Instructions:
Incision Care: Keep clean and dry.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please take any new meds as ordered.
* Continue with PT several times per day.
* No heavy ([**11-26**] lbs) until your follow up appointment.
Followup Instructions:
Please follow-up with Plastic surgeon, Dr. [**First Name (STitle) **]. in 2 weeks.
Call([**Telephone/Fax (1) 10820**] to schedule an appointment.
Please follow-up with Neurology, Dr. [**Last Name (STitle) 724**] in [**4-15**] weeks. Call
([**Telephone/Fax (1) 6574**] to schedule an appointment.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Neurosurgery) in 1 month. Call
[**Telephone/Fax (1) 1669**] to schedule an appointment.
Please follow-up with Breast service regarding your
adenocarcinoma of your breast. Call ([**Telephone/Fax (1) 76937**]
Completed by:[**2194-3-12**]
|
[
"276.2",
"293.9",
"331.0",
"250.00",
"174.8",
"682.2",
"038.9",
"995.91",
"728.86",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"83.45",
"83.39",
"86.69",
"86.04",
"38.7",
"38.93",
"83.87",
"83.32"
] |
icd9pcs
|
[
[
[]
]
] |
11773, 11843
|
6983, 10407
|
333, 412
|
12121, 12128
|
2384, 6960
|
13444, 14053
|
1771, 1776
|
10488, 11750
|
11864, 12100
|
10433, 10465
|
12152, 12152
|
12168, 13421
|
1791, 2365
|
272, 295
|
440, 1573
|
1595, 1630
|
1646, 1755
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,090
| 165,925
|
48247
|
Discharge summary
|
report
|
Admission Date: [**2181-6-16**] Discharge Date: [**2181-6-29**]
Date of Birth: [**2104-2-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Shortness of breath,hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 77 year old male with multiple myeloma
diagnosed in [**Month (only) 116**] s/p recent hospitalization ([**Date range (1) 17333**]) for a
T10 mass, treated with XRT on [**5-22**] and [**5-29**] and recent
chemotherapy who presents with one day of intermittent pleuritic
chest pain. The pain began on [**2181-6-15**] when the patient was at
rest and was accompanied by shortness of breath. The pain was
localized to the lower left chest near the costal margin. He
thinks that the shortness of breath started first, followed by
the pain. He denies any fevers or chills, but did have a cough
productive of clear sputum, which is new for him. He then
experienced a 1 hour long pain-free period and delayed going to
the ED. The pain returned today with increased intensity, and
he decided to call EMS.
.
In the ED, initial vitals in triage were: T 99.8, HR 106, BP
115/63, RR 20, and SpO2 100% on 10L NC. He had already been
given a NS bolus in the ambulance for hypotension (to SBP 90)
and tachycardia (to 120). He triggered for hypoxia (to 80% when
decreased to 4L NC), tachypnea, and tachycardia. Exam showed no
evidence of peripheral edema or DVT. He was placed on 100%
non-rebreather, satting 100%, and his tachycardia and tachypnea
resolved.
.
Differential diagnosis included pneumonia vs. PE vs. ACS. After
taking blood and sputum cultures, empiric antibiotics for HCAP
were started with Vancomycin, Levofloxacin, and Cefepime. He
was given Aspirin 325 mg and placed on a Heparin gtt. EKG
showed no acute ischemic changes, initial Troponin was negative,
and CXR showed chronic interstitial opacities with no evidence
of superimposed pneumonia. Labs were notable for D-dimer [**Numeric Identifier **],
proBNP 1484, bicarb 19, lactate 1.7, and platelets 71.
.
There was significant concern for PE given his cancer history
and presentation. No evidence of DVT was seen on physical exam.
CTA was not performed due to increased risk of contrast
nephropathy in patients with active multiple myeloma. A heparin
drip was started empirically for possible PE. He was admitted
to the ICU for further management and inpatient V/Q scan.
.
On reaching the ICU, he reported feeling somewhat better. His
chest pain had resolved and his breathing was less labored, but
still significantly worse than his baseline. He reported that
he does not use any oxygen or inhalers at home. He is not aware
of having lung disease, despite ILD noted in medical history and
on CXR. He has never experienced a similar episode before. He
notes that he was staying in bed most of the time since
completing chemotherapy a few weeks ago. He has not had any
fevers or chills. He is not aware of any recent sick contacts.
Past Medical History:
# Diabetes Mellitus (Borderline)
# Multiple myeloma -- recent admission ([**Date range (3) 101666**])
-- Diagnosed in [**2181-3-25**] after presenting with bone pain
-- Spike on SPEP and bone marrow biopsy with 25-30% plasma
cells.
-- Negative mets x-ray series [**2181-4-17**]
-- Left hip MRI showed no lytic lesions [**2181-5-1**]
-- T10 soft tissue mass extending into canal surrounding spinal
cord, with extensive bony lysis of T10 vertebral body and L>R
pedicle.
-- Tissue biopsy [**2181-5-11**] consistent with a small-cell variant of
plasma cell myeloma.
-- Treated with steroids and XRT on [**5-22**] and [**5-29**] (Dr.
[**Last Name (STitle) 3929**].
# Abdominal Aortic Aneurysm
# Interstitial lung disease
-- No home O2 requirement
# Hypercholesterolemia
# Hypertension
# Elevated PSA
# Mild CKD (baseline Cr 1.3) -- proteinuria
Social History:
The patient lives with his wife and daughter.
# Tobacco: Quit many years ago.
# Alcohol: None
# Illicit: None
Family History:
No family history of DVT, PE, or clotting disorders. No family
history of early CAD.
# Mother: lived to age 83
# Father: died from cancer (unsure of type) at age 46
# Siblings: two sisters with diabetes
Physical Exam:
ADMISSION EXAM
Vitals: T 98.3, BP 136/81, HR 80, RR 21, SpO2 92-97% on 6L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Decreased air movement and tight breath sounds. Wheezes
and squeaks throughout all lung fields. Fine crackles at bases.
CV: Irregularly irregular. Normal S1, S2. No murmurs, rubs,
gallops
Abdomen: Bowel sounds present. Soft, non-tender, non-distended.
No rebound tenderness or guarding. No organomegaly.
GU: no foley
Ext: Warm, well perfused. Pulses 2+. No lower extremity edema.
No calf tenderness.
DISCHARGE EXAM
General: Patient sitting in bed in no acute distress
HEENT: MMM, oropharynx clear, pupils are equal round and
reactive to light b/l
CV: RRR. No M/R/G
LUNGS: Clear to auscultation bilaterally with minimal end
expiratory wheezes, no rubs or crackles
ABDOMEN: BS+. Soft. NT/ND
EXT: No pitting edema bilaterally. No clubbing or cyanosis.
Pertinent Results:
[**2181-6-16**] 06:05PM WBC-4.3# RBC-3.53* HGB-12.6* HCT-36.0*
MCV-102* MCH-35.8* MCHC-35.1* RDW-14.8
[**2181-6-16**] 06:05PM NEUTS-60.1 LYMPHS-35.7 MONOS-2.3 EOS-0.6
BASOS-1.3
[**2181-6-16**] 06:05PM PLT SMR-VERY LOW PLT COUNT-71*
[**2181-6-16**] 06:05PM proBNP-1484*
[**2181-6-16**] 06:05PM cTropnT-<0.01
[**2181-6-16**] 06:05PM GLUCOSE-142* UREA N-29* CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-19* ANION GAP-15
[**2181-6-16**] 06:23PM LACTATE-1.7 K+-4.1
[**2181-6-16**] 06:53PM D-DIMER-[**Numeric Identifier **]*
[**2181-6-16**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0
LEUK-NEG
[**2181-6-16**] 09:30PM URINE COLOR-DkAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2181-6-16**] 09:30PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2181-6-16**] 09:30PM URINE MUCOUS-RARE
MICRO
[**6-16**] Blood cultures x2--no growth
[**6-17**] MRSA Screen
-[**2181-6-17**] 2:08 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2181-6-19**]**
MRSA SCREEN (Final [**2181-6-19**]): No MRSA isolated.
IMAGING
[**6-18**] CTA
PULMONARY ARTERIES: The main pulmonary artery proximal to the
bifurcation
measures 3.5 mm and is dilated. There is a large filling defect
in the right main, lobar and segmental pulmonary arteries of the
right lower lobe
suggestive of a massive pulmonary artery embolism. On the left
side pulmonary emboli are in the segmental pulmonary arteries of
the left lower lobe, however, the left main pulmonary artery is
devoid of any filling defects. However, there is no evidence of
any septal bulge or cardiac strain. There is minimal left
pleural effusion and adjacent basal atelectasis. Bilateral lungs
showing moderate-to-severe emphysema changes with diffuse
subpleural interstitial thickening and fibrosis, which is lower
lobe prominence. Diffuse heterogeneity of the lungs is
attributed to the air trapping. The features are suggestive of
emphysema with chronic interstitial lung disease.
Mediastinum: Imaged thyroid gland is normal. There are multiple
enlarged
mediastinal lymph nodes at all stations, for example, the right
upper
paratracheal lymph node measures 1.6 x 1.4 cm. No pathologic
enlargement of supraclavicular and axillary lymph nodes. There
is mild-to-moderate
cardiomegaly without pericardial effusion. Calcification in the
coronary
arteries and the aortic arch is mild-to-moderate .
ABDOMEN: Study is not tailored for evaluation of the abdomen;
however,
limited views revealed non-calcified plaque measuring 1.7 x 0.9
cm in the
abdominal aorta (3:75) along the posterior wall causing less
than 50%
narrowing of the aortic lumen. Limited views of liver, spleen,
both kidneys and pancreas are unremarkable.
BONES: Bones are of diffusely low density with multiple small
osteolytic
lesions involving multiple ribs bilaterally.
There is reduction in the height of T10 vertebral (< 30%) body
with a large osteolytic lesion involving the posterior body and
left pedicle and soft tissue component causing narrowing of the
spinal canal. All these changes were previously seen and better
characterized on the MR imaging of spine dated [**2181-5-7**] and
are consistent with known underlying clinical diagnosis of
multiple myeloma.
IMPRESSION:
Massive right main pulmonary artery embolism extending into the
lobar and
segmental branches of the right lower lobe and emboli involving
the left lower lobe segmental arteries. Dilated main pulmonary
artery and mild-to-moderate cardiomegaly consistent with
pulmonary artery hypertension.
Moderate-to-severe emphysema
Diffuse subpleural interstitial thickening with fibrosis is
suggestive of
diffuse interstitial disease.
Multiple enlarged mediastinal lymph nodes.
Non-calcified plaque in the abdominal aorta causing less than
50% reduction in the diameter.
Osteolytic lesions involving the T10 vertebral body and multiple
ribs. The
extent of the lytic vertebral lesions with soft tissue component
was better characterized in the previous MR of spine dated [**5-7**], [**2180**].
.
[**6-18**] LENIS
FINDINGS: Doppler and [**Doctor Last Name 352**]-scale son[**Name (NI) 1417**] performed of the
bilateral lower extremities. Normal compressibility, flow and
augmentation is seen throughout the bilateral common femoral,
superficial femoral and popliteal veins. Posterior tibial and
peroneal veins are not well visualized.
IMPRESSION: No evidence for deep vein thrombosis bilaterally.
.
[**6-16**] CXR
There are coarsened interstitial markings again noted within the
lungs, most notable in the right upper lobe, left lower lung,
which likely represent scarring related to interstitial lung
disease. Compared with the prior exams, there has been no change
in the pattern of interstitial opacity, though there may be mild
left basilar atelectasis. The cardiomediastinal silhouette
appears normal. The imaged osseous structures are unchanged.
IMPRESSION: Interstitial opacities, likely chronic. No evidence
of
superimposed pneumonia.
.
[**6-17**] CXR
Heart size is normal. Mediastinum is unchanged in appearance.
There is
slightly increased prominence of the right lower lobe pulmonary
artery as
compared to [**2181-4-9**]. The findings might represent
lymphadenopathy or
potentially increase in the pulmonary artery due to interval
development of pulmonary embolism. Note is made that this study
neither exclude nor confirm the presence of pulmonary embolism.
Diffuse interstitial process seen on the multiple prior
radiographs dating
back to [**2181-4-10**] appears to be unchanged and most likely
reflects chronic interstitial changes. On the other hand ongoing
infectious process cannot be excluded in particular in the left
lower lobe. There is no pleural effusion or pneumothorax seen.
.
[**6-18**] CXR
The lungs are low in volume and show bilateral diffuse
interstitial opacities. A slightly more confluent opacity in the
left lower lobe has recently developed. Cardiac silhouette is
top normal. The mediastinal silhouette is normal. Both hila are
prominent. No definite pleural effusion is present.
IMPRESSION: A more confluent opacity in the left base could
represent atelectasis or pneumonia superimposed on interstitial
lung disease. Both hila are prominent likely related to
pulmonary hypertension.
.
[**6-15**] EKG : Sinus arrhythmia. Leftward axis. Otherwise, normal
tracing. Compared to the previous tracing of [**2181-5-8**] no change
except rate is faster.
.
DISCHARGE LABS (including last 2 days COAGULATION LABS):
[**2181-6-29**] 05:15AM BLOOD WBC-5.3 RBC-3.13* Hgb-11.1* Hct-32.2*
MCV-103* MCH-35.4* MCHC-34.5 RDW-16.1* Plt Ct-141*
[**2181-6-29**] 05:15AM BLOOD PT-25.0* PTT-42.7* INR(PT)-2.4*
[**2181-6-28**] 05:10AM BLOOD PT-20.9* PTT-33.3 INR(PT)-1.9*
.
* PENDING ONCOLOGY STUDIES*
-SPEP, immunoglobulins, B2 microglobulin and serum free light
chains
.
Brief Hospital Course:
77 year old male with multiple myeloma diagnosed in [**2181-3-25**] who
is now status post recent hospitalization ([**Date range (1) 17333**]) for a T10
mass attributed to myeloma and treated with XRT on [**5-22**] and [**5-29**].
Mr. [**Known lastname 101667**] also underwent recent chemotherapy for multiple
myeloma. On this admission he presented from home with one day
of intermittent pleuritic chest pain and shortness of breath
with severe hypotension noted in the emergency room. Patient
ultimately diagnosed with new massive pulmonary embolism which
worsened his already baseline dyspnea from known COPD,
interstitial lung disease. Please see below for hospital course
details by problem.
.
ACUTE ISSUES BY PROBLEM:
# Pulmonary Embolus: His history and presentation with acute
onset pleuritic chest pain were very concerning for PE. D-Dimer
was 16,856. He did not undergo CTA on admission due to risk of
contrast nephropathy with his underlying multiple myeloma and
renal disease, but subsequently CTA showed large PE after
aggressive pre-treatment for iodine contrast load. Initial ABG
showed respiratory alkalosis with 7.48/20/53, improved at
7.42/34/162 with supplemental oxygen. LENI study negative for LE
DVT. In the ICU he was started on a heparin drip. He received
supplemental oxygen and kept O2 sats >93%. Patient was bridged
initially with heparin but changed to lovenox due to fluctuating
PTT levels between 56 and 114. For the three days up to his
discharge, the INRs were 1.8, 1.9, 2.4. The plan for outpatient
is to maintain Lovenox overlapped with therapeutic INR for at
least 48 hours total.
.
# Hypoxia. On admission, patient's lungs were diffusely wheezy
with poor air movement, suggesting an additional process such as
asthma, atypical pneumonia. As above, pulmonary emboli related
dyspnea was felt to be major contributing cause of his worse
hypoxia status and CTA confirmed massive pulmonary emboli over
right side lung (minimal left sided involvement). He does have a
long smoking history with known severe COPD and interstitial
lung disease which created a very poor baseline pulmonary
reserve making his recuperation especially challenging. He was
treated with nebulizers and a steroid burst in the ICU with
excellent improvement. Lung exam improved and patient felt more
comfortable. On the floor he continued to receive prednisone.
His respiratory O2 saturation slowly recovered. On discharge,
he sated at 100% on 4L and was able to ambulate with oxygen.
Plan was for a slow prednisone taper as follows: 40mg from
[**Date range (1) 47643**], then 30mg from [**7-3**] to [**7-5**] and then drop to 20mg daily
[**7-6**] to [**7-8**], then 10mg daily until PCP [**Name9 (PRE) 702**] in late
[**Month (only) 216**]. Also discharged with PRN orders for ipratropium and
albuterol nebulizers. He will hopefully continue to wean his O2
NC 3-4L supplemental oxygen over coming weeks, but may need
eventual home oxygen.
.
CHRONIC ISSUES BY PROBLEM
.
# Thrombocytopenia: He had Plt 71 in the ED, which was stable
at 67 in the ICU and similar to recent prior values. Low Plt
count initially thought to be related to his multiple myeloma
and recent chemotherapy, but primary oncologist suggested it may
also be secondary to bactrim, which was recently stopped as
outpatient prophylactic therapy. For now, he will plan to
continue Atovaquone instead of bactrim for ongoing prophylaxis.
No sign of active bleeding. His platelets slowly recovered on
transfer to the medicine floor and maintained. No signs of
bleeding on the floor. At the time of discharge his platelet
count was 141.
.
# Multiple Myeloma: He was recently treated with chemotherapy
and XRT for his multiple myeloma and a T10 mass, but this is not
an active issue on this admision. He was followed by his primary
oncologist while inpatient. He will continue to receive
atovaquone for PCP prophylaxis, allopurinol for gout ppx, and
acyclovir for viral ppx. SPEP, immunoglobulin, serum light
chains, and b2-microglobulin were pending at discharge, value to
be followed up by medical oncologist. Medical oncology
recommends that Mr. [**Known lastname 101667**] receives an mean platelet volume
check (MPV) as outpatient. Please note in rehabilitation
facility on [**2181-6-30**] he should receive pamidronate 90mg IV over 90
minutes. He will follow up with medical oncologist Dr. [**First Name (STitle) **]
[**Name (STitle) **].
.
# Hypertension: Patient with recored history of hypertension
with lisinopril and HCTZ listed as daily medications. Per
patient report does not take anti-hypertensives so compliance
was questioned on admission. Daughter and wife unable to provide
medication reconcillation. However, given his extreme
hypotension from recent massive pulmonary emboli and
normotensive pressures off of these medications he was
discharged without need for ongoing HCTZ or ACE-I but he can
plan to discuss restart with his PCP if BP changes emerge.
Pressures monitored in house. Remained stable in the
120s-130s/60s-70s without medication.
.
# Type II Diabetes: Patient with history of borderline diabetes
not on any outpatient medications. His blood glucose became
elevated after he was started on prednisone. While in house he
had one episode of FBG at 328 and several 200s, but otherwise
had normal FBGs. Glucose will be managed at his outpatient
facility per Humalog sliding scale insulin. Full sheet with
current SSI instructions for meal times and QHS are enclosed.
Medications on Admission:
Dexamethasone 2 mg PO daily for one week
-- taper to 1 mg daily for one week
-- then 1 mg every other day for one week
Bactrim DS 1 tab PO daily on MWF
Acyclovir 400 mg PO daily
Allopurinol 200 mg PO daily
Hydrochlorothiazide 12.5 mg PO daily
Lisinopril 40 mg PO daily
Omeprazole 20 mg PO daily
Tamsulosin 0.4 mg PO QHS
Oxycodone 5 mg PO Q6H PRN pain
Acetaminophen 325-650 mg PO Q6H PRN pain
Calcium Carbonate-Vitamin D3 (500mg-200unit) 1 tab PO BID
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO once a day.
2. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
5. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. oxycodone 5 mg Tablet Sig: [**11-26**] to 1 Tablet PO every eight
(8) hours.
8. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
9. prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO AS
DIRECTED: Take 4 tablets (40mg)from [**Date range (1) 47643**], then 3 tablets
(30mg)from [**7-3**] to [**7-5**] and then drop to 20mg daily [**7-6**] to [**7-8**],
then 10mg daily until PCP [**Last Name (NamePattern4) 702**] .
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
Constipation.
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB or wheeze.
13. Insulin Treatment
Please follow attached Humalog Sliding Scale Insulin
as outlined on attached Sliding Scale Form
14. warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Please continue to monitor for INR goal [**12-28**] and adjust PRN,
monitor [**Date range (1) 11067**] daily and then space 2x weekly for monitoring .
15. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous
twice a day for AS INSTRUCTED days: If INR 2-3 range 8/6,
overlap for an additional 24 hours then discontinue. IF INR [**6-30**]
is <2, need to continue until have 2 consecutive INR daily
levels 2-3 range.
16. INR INSTRUCTIONS
If INR 2-3 range 8/6, overlap enoxaparin 100mg SC BID for an
additional 24 hours then discontinue. IF INR [**6-30**] is <2, need to
continue until have 2 consecutive INR daily levels 2-3 range and
then may discontinue with patient managed on Coumadin alone with
ongoing monitoring.
.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
18. pamidronate 90 mg/10 mL (9 mg/mL) Solution Sig: One (1)
Intravenous ONCE for 1 days: PLEASE GIVE PATIENT HIS ONE TIME
DOSE OF 90mg Pamidronate on [**2181-6-30**], infuse over 90 minutes.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary Diagnoses:
-Pulmonary embolism
-Hypotension
-Multiple Myeloma
-Severe COPD
-Interstitial lung disease
-Diabetes mellitus
.
Secondary Diagnoses:
-Hyperlipidemia
-BPH
-Abdominal aortic aneurysm
-Mild CKD (baseline Cr 1.2-1.3)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 101667**],
It was a pleasure caring for you during your stay at [**Hospital1 771**]. You were seen in the emergency room
for chest pain and subsequently admitted into the intensive care
unit for low blood oxygen levels and low blood pressure. While
in the emergency room your oxygen level dropped to 80% which was
managed with oxygen and a non-rebreather mask. From a chest
x-ray and your difficulty breathing, you received antibiotic
treatments for suspected infections while in the emergency room.
You were admitted into the intensive care unit because of your
low oxygenation and concerns for pulmonary embolism, an illness
involving a blood clot in the lungs that causes the heart to
work harder and prevents the body from getting enough oxygen.
The antibiotics were stopped. You received nebulizers and
steroids while in the intensive care unit, and your breathing
and tissue oxygenation improved. You received a chest CT which
confirmed the diagnosis of pulmonary embolism. You began to
receive anticoagulation medications to treat and prevent
pulmonary embolism. These blood clots often come from veins in
the legs, so you received an ultrasound of both legs to look for
them. Ultrasound revealed no clots in either leg. Once your
heart and lungs stabilized, you were transferred to the
inpatient medicine floor.
You continued to improve on the floor without chest pain or
trouble breathing at rest. You were transitioned from
intravenous heparin to lovenox, then finally to Coumadin, an
oral anticoagulant. You will continue to take Coumadin as
outpatient. While you are in the hospital outpatient
oncologist's colleagues also aided us in caring for your
multiple myeloma. Your blood pressure and heart rate were
consistently within the normal range. Your oxygen levels were
routinely checked and managed using steroids until it became
stable on oxygen. Your steroids will decrease slightly over
time on a scheduled called a taper. You will start on 40mg of
prednisone initially, decreasing by 10mg every three days. You
will eventually be taking 10mg of prednisone until your
appointment with Dr. [**Last Name (STitle) 31097**], your primary care physician.
MEDICATIONS:
1) Please STOP taking your dexamethasone, as you completed your
recent sessions of radiation therapy.
2) Please STOP taking Bactrim
3) Please START taking atovaquone
4) DECREASED oxycodone to 2.5mg or 5mg ([**11-26**] or 1 tablet) q8hours
PRN
5) ADDED Colace and Senna
6) ADDED 1 x dose of Pamidronate 90mg to be given [**6-30**]
7) ADDED ipratropium and albuterol nebulizers
8) ADDED daily warfarin
9) ADDED lovenox injections to be taken for a few days until
your warfarin is therapeutic
10) ADDED prednisone taper -- 4 tablets (40mg)from [**Date range (1) 47643**], then
3 tablets (30mg)from [**7-3**] to [**7-5**] and then drop to 20mg daily
[**7-6**] to [**7-8**], then 10mg daily until PCP [**Last Name (NamePattern4) 702**].
11) HELD usual hydrochlorothiazide and lisinopril medications
given your recent low blood pressures
12) Otherwise, please continue to take your other medications as
prescribed by your doctors.
.
APPOINTMENTS:
medical oncologist. Please see below for specific information.
Followup Instructions:
1) Please follow-up with Dr. [**Last Name (STitle) 31097**] on [**2181-7-23**] at 2:40pm.
2) Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **]. You have three
appointments with Dr. [**First Name (STitle) **]: [**2181-7-2**] at 1:30pm, [**2181-7-5**] at
1:30pm, and [**2181-7-31**] at 12pm.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2181-6-30**]
|
[
"272.4",
"585.9",
"458.9",
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"287.5",
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"799.02",
"403.90",
"V15.3",
"415.19",
"250.02",
"600.00",
"492.8",
"203.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20821, 20917
|
12245, 17732
|
336, 342
|
21193, 21193
|
5330, 12222
|
24599, 25067
|
4106, 4311
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18232, 20798
|
20938, 21069
|
17758, 18209
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21344, 24576
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4326, 5311
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21090, 21172
|
265, 298
|
370, 3099
|
21208, 21320
|
3121, 3962
|
3978, 4090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,791
| 129,626
|
40655
|
Discharge summary
|
report
|
Admission Date: [**2114-5-29**] Discharge Date: [**2114-6-7**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
s/p fall with low platelets
Major Surgical or Invasive Procedure:
R TFN
History of Present Illness:
This is an 88 y.o. female transfers from [**Hospital3 **] for
ortho eval. Patient had a mechanical fall earlier that was
reported as a fall from standing. She was reaching up to grab
some tea when she slipped and fell. Her sister was in the house
and heard her fall. She was awake when she found her. No LOC.
She was taken to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she was found to have
sustained a right hip/humerus fx. CT of neck + spine cleared.
Her plt count was noted to be 2 and hct was 24 (? previously
29). She was sent to [**Hospital1 18**] for tertiary care.
.
In the ED initial labs were 97.8 70 122/51 14 96%. Exam was
significant for known injuries to right hip and right arm.
Ortho was consulted and recommended fixing the hip when plts
were improved. Heme was consulted for ITP and anemia. Heme
recommended starting IVIG and prednisone to increase plts for
preparation for surgery.
On transfer 70, 106/50, 16, 98%ra.
.
Review of systems: Limited given difficult communicating.
Patient did report pain on right side of body. She denied
fever, chills, shortness of breath and cough. Did endorse
minimal chest pain, but unclear history. Reported able to walk
up one flight of stairs without chest pain.
Past Medical History:
ITP - previously treated with plt transfusions, but not recently
HTN
MI in [**11/2113**]
CHF (EF 35%)
Social History:
No Tob
No EtOH
Family History:
NC
Physical Exam:
On admission:
General: Alert, oriented, no acute distress; hard of hearing
without hearing aids
HEENT: EOMI, PERRLA, ecchmyoses over nasal bridge, right cheek,
few petecchiae on buccal mucosa with no ulcerations
Neck: supple, JVP not elevated, no cervical LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**2-18**] holosystolic
murmur at LLSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: thin, multiple ecchymoses on different stages of healing on
upper extremities, no petechiae/rashes; tender over R humerus
and R hip; 1+ distal pulses.
.
On discharge:
97.9 135/35 68 18 97%RA (SBP 100s-130s)
General: NAD, thin elderly lady with ecchymoses on arms and
bruises on her face
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: S1 and S2, no murmur
Neuro: sensation to light touch grossly intact, able to lift
both arms above head, lifts legs off bed but left side is
stronger, moving toes, extremities warm, R sided ecchymosis on
lateral thigh.
.
Pertinent Results:
Admission labs:
===============
[**2114-5-29**] 09:05PM BLOOD WBC-13.7* RBC-2.54* Hgb-7.7* Hct-23.3*
MCV-92 MCH-30.3 MCHC-33.0 RDW-16.8* Plt Ct-8*
[**2114-5-29**] 09:05PM BLOOD Neuts-93.6* Lymphs-4.9* Monos-1.1*
Eos-0.3 Baso-0.2
[**2114-5-29**] 09:05PM BLOOD PT-12.3 PTT-22.8 INR(PT)-1.0
[**2114-5-30**] 03:37AM BLOOD Ret Aut-3.4*
[**2114-5-29**] 09:05PM BLOOD Glucose-169* UreaN-45* Creat-1.1 Na-136
K-5.1 Cl-103 HCO3-23 AnGap-15
[**2114-5-29**] 09:05PM BLOOD ALT-13 AST-20 LD(LDH)-196 AlkPhos-67
TotBili-0.2
[**2114-5-30**] 01:36AM BLOOD CK-MB-5 cTropnT-<0.01
[**2114-5-30**] 01:36AM BLOOD calTIBC-387 VitB12-614 Folate-18.9
Ferritn-92 TRF-298
[**2114-5-29**] 09:05PM BLOOD Hapto-81
[**2114-5-30**] 01:36AM BLOOD Calcium-8.7 Phos-5.2* Mg-1.7 Iron-29*
.
Discharge labs:
===============
Imaging:
========
R hip x-ray: Three AP views of the right hip and pelvis
demonstrate an impacted intertrochanteric fracture of the right
hip with slight overriding and varus angulation of the distal
fragment. The hip joint is aligned. The pelvis is notable for
marked osteopenia, which limits evaluation for fracture, though
none is seen. There are marked arterial calcifications.
.
Right shoulder x-ray: Three views of the right shoulder
demonstrate a mildly impacted, comminuted fracture through the
surgical neck of the right humerus, extending with a vertical
component through the greater tuberosity. The glenohumeral joint
remains aligned.
.
CXR: Mild cardiomegaly, no acute chest pathology.
.
CT pelvis:
1. Ill-defined hematoma within the right gluteus maximus.
2. Cystic structure within the pelvis. This should be correlated
for surgical history, and if the patient still has her ovaries,
this should be further evaluated with pelvic ultrasound to
exclude malignancy.
3. Redemonstration of intertrochanteric right femoral fracture.
4. Marked degenerative change of the visualized lumbar spine.
.
Repeat R shoulder x-ray: Again seen is a mildly impacted
fracture through
the right humeral surgical neck with extension into the greater
tuberosity in unchanged alignment. The humeral head appears
congruent with the glenoid fossa. There is a small 7-mm
inferiorly and medially displaced fracture fragment. Overall,
the appearance is unchanged.
.
Brief Hospital Course:
This is an 88 year old female with a history of untreated ITP
who sustained a mechanical fall and was found to have right hip
and humerus fracture now s/p R TFN.
.
# R hip and humeral fracture: patient with mechanical fall and
resultant hip and humerus fractures. Followed by orthopedics who
recommended sling for R proximal humeral fracture and non-weight
bearing, and surgery. In order to be safe for surgery, a
platelet count >50 and hct >28 was required. Hematology was
consulted regarding increasing plt count and anticoagulation in
this patient with fracture and DVT risk but complicated by ITP
as below, they recommended IVIG x2days ([**Date range (1) 83069**]) and
prednisone 1mg/kg (40mg) daily. They endorsed initiation of
standard anticoagulation once platelets were >50 and the pt was
started on metoprolol 12.5mg [**Hospital1 **] to decrease peri-operative
mortality. The pt was transfused to goal levels and on [**6-1**]
underwent R hip TFN. She subsequently had q8h CBC and was
initially transfused to plts >50 and hct >25, with heparin sc
TID given as DVT ppx. However, the pt's plts were incredibly
unstable and would fluctuate from 90s to <10 over the course of
several hours. Therefore, in discussion with heme and the pt it
was decided that it is not safe to DVT prophylax her at present
as the plts are consistently below 50 despite transfusion and
adding heparin or lovenox onto this would represent a
significant risk of hemorrhage which outweighs the risk of clot.
The pt was made aware of these risks and agreed with the plan.
Further it was decided to hold off on transfusions unless plts
fall below 30 or pt has significant hct drop. After about 10
days post-op the hope is that the risk of bleeding will
significantly decline and at that point the blood checks and
transfusions will cease assuming the pt remains hemodynamically
stable. The hematology team is also looking into the possibility
of giving N-plate. The pt will be discharged to LTAC where her
blood counts will continue to be monitored as detailed below.
She will follow-up with hematology as an outpatient.
.
# ITP: patient has history of ITP previously treated with rare
platelet transfusions and she has declined treatment for ITP in
the past. Platelet count was 8 on admission which improved to 32
s/p 1U platelets, then drifted down to 17. Heme/onc was
consulted and she was started on IVIG x2 days and prednisone
40mg daily with goal platelets >50 pre-operatively. After
surgery her plts were initially transfused to goal of >50 in
order to allow DVT ppx however given the instability of the plt
levels she was unable to continue ppx and instead was transfused
to goal >30 in order to decrease risk of bleeding. She will
continue with transfusions until her hct is stable despite low
plts. The pt received a total of 14 units of plts.
.
# Anemia: HCT of 19 on admission with unclear baseline. There
was initially concern for development of hematoma given low
platelets in setting of fracture and CT pelvis was done showing
R gluteal hematoma. No evidence of hemolysis on labs. She was
transfused to goal hct >25 given cardiac risk factors and
received a total of 6u RBCs during admission. At discharge her
hct was 28.
.
# Leukocytosis: Likely related to fractures and stress response,
possibly exacerbated by steroids. BCx were sent, u/a was clean,
with ucx pending, CXR showed no evidence of infiltrate and
surgical site looked clean and nonerythematous. No need for
antibiotics now. Possibly response to plt and blood
transfusions.
.
# Acute renal failure: Baseline ~1 with Cr 1.2 on admission,
resolved after transfusions to 0.7.
.
# Incidental finding: CT with cystic structure within the
pelvis. Can f/u as an outpt.
.
# HCP: [**Name (NI) **] [**Name (NI) 174**] (sister) [**Telephone/Fax (1) 88938**]
.
# Code: DNR/DNI
.
# Dispo: Pt will be dispoed to LTAC.
.
Dispo planning: The pt will be discharged to an LTAC with plt
transfusion abilities. She will have q8h CBCs through Monday
[**6-11**] with goal plts >30 and goal hct >25. After Monday the
patient will continue q8h CBC checks for one day without
transfusing plts. If the hct drops greater than 3 points or
there is evidence of active bleeding, then platelet transfusions
will resume with goal of >30 for another 48h at which point
stopping transfusions will again be attempted. If the pt's hct
remains stable and the pt remains hemodynamically stable despite
low plts then she can have daily CBC checks instead. If the pt
drops her hct >3 points or has evidence of bleed then q8h checks
and transfusions of plts to >30 will again commense. If at some
point the pt's plts stabilize >50 for 48h in absence of
transfusion (which currently seems unlikely) DVT ppx should be
initiated with heparin sc TID. After [**6-11**] her prednisone should
beb tapered by 10mg every 3 days until it is off. The pt has
required occasional doses of Lasix 10mg IV for pulmonary edema
with transfusions (every few days). If she becomes hypoxic or
develops crackles, a dose of lasix should be considered. The pt
will have follow-up with hematology and orthopedics.
Medications on Admission:
nitro transdermal patch 0.2 mg daily
vit b12 500 po daily
zocor 20 mg po daily
aldactone 25 mg po daily
atenolol 50 mg po daily
lasix 20 mg po daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: pt should take 60mg daily until [**6-11**], and subsequently
decreased by 10mg every 3 days until steroids are off. .
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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: One (1)
dose PO DAILY (Daily) as needed for constipation.
12. furosemide 10 mg/mL Solution Sig: Ten (10) mg Injection PRN
as needed for volume overload/pulmonary edema.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
R fx humerus and femur
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive (hard of hearing)
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 696**],
It was a pleasure participating in your care. You were
admitted for fall resulting in R hip fracture and R arm
fracture. You had surgical repair of your R hip. You also have
low plts and therefore required multiple transfusions to prevent
bleeding. You are being sent to a facility that will continue to
transfuse you as needed to prevent bleeding and you will
continue to work with physical therapy to improve your mobility.
Please call or return to the hospital if you develop chest
pain, shortness of breath, lightheadedness, dizziness, or any
other symptoms that concern you.
--------------------
Please START the following medications:
-acetaminophen
-oxycodone
-calcium carbonate
-vitamin d
-pantoprazole
-prednisone taper
-metoprolol
-colace
-senna
-miralax
.
Please STOP the following medications:
-nitro
-zocor
-spironolactone
-atenolol
-betamethasone
.
The following medication has CHANGED:
-lasix should now be given 10mg IV as needed for volume overload
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2114-6-22**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2114-6-26**] at 1:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2114-6-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"287.31",
"V49.87",
"428.32",
"584.9",
"294.8",
"401.9",
"E885.9",
"428.0",
"820.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
11711, 11793
|
5172, 10279
|
278, 285
|
11860, 11860
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2906, 2906
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1750, 1754
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|
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211, 240
|
313, 1289
|
2922, 3662
|
1783, 2437
|
11875, 12029
|
1598, 1701
|
1717, 1734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,825
| 164,481
|
52613
|
Discharge summary
|
report
|
Admission Date: [**2136-11-26**] Discharge Date: [**2136-11-30**]
Date of Birth: [**2057-2-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname 11622**] is a 79F with ESRD on HD (TThSa),sCHF (EF 20%) w/ LV
thrombus on coumadin, recent admission for altered mental status
now admitted with AMS. She was in her usual state of health at
rehab last night according to her daughter. When her daughter
saw her this morning, she was less awake and responsive than
usual, and complained of feeling generally unwell. The patient
took a nap, and after that was nearly unarousable. FSBS 23. EMS
was able to give glucagon and D50.
Initial vitals in the ED were 97 74 150/86 16 94% RA. Labs
were notable for WBC 5, HCT 35 83%, Plt 193, Cr 5.2, BUN 37 and
Lactate 15.7. UA showed >182 RBC and >182 WBC with no epithelial
cells. TropT 0.04 CKMB 2. She received cefepime and vancomycin
in the ED. Vitals on transfer were 96.8 66 134/62 24 97%RA.
On arrival to the MICU, the patient appeared comfortable and
is without additional complaints.
Past Medical History:
- dementia
- hypertension
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure EF 20%
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
- hypothyroidism
- back pain
- Upper GI bleed
SURGERIES:
-TAH BSO
-appendectomy
Social History:
Came from rehab. Goes to [**Last Name (un) **] for HD. uses a walker
intermittently.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: pleasant, well appearing female, laying comfortably in
bed getting HD
HEENT: NC/AT, PERRLA, EOMI
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR S1 S2, 3/6 SEM heard loudest at LUSB
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, no CVA
EXTREMITIES: warm, well perfused, no LE edema, 2+ DP pulses, dry
LE skin; LUE fistula with thrill and bruit
NEURO: alert and oriented x2 (not to time, year [**43**]-something,
c/w baseline), appropriate, no visual hallucinations. moving all
extremities spontaneously
DISCHARGE PHYSICAL EXAM
Vitals: T 98.3 BP 117/68 P 77 RR 20 97% RA
General:elderly woman sitting in bed in NAD, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV:[**3-5**] diastolic mummur LSB, normal S1 + S2,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, left AV fistula with palpable thrill
2+ pulses DP pulses, no clubbing, cyanosis or edema
Skin: no rashes or lesions noted
Neuro: Alert. Oriented to Person. Place ( knows she is in a
hosptial in [**Location (un) 86**]). does not know year. able to identify watch,
cup, and pen.
Pertinent Results:
ADMISSION LABS
[**2136-11-26**] 05:30PM BLOOD WBC-5.0 Hct-35.0* Plt Ct-193
[**2136-11-26**] 05:30PM BLOOD Neuts-83* Bands-1 Lymphs-14* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2136-11-26**] 05:30PM BLOOD Glucose-132* UreaN-37* Creat-5.2* Na-139
K-4.7 Cl-91* HCO3-8* AnGap-45*
[**2136-11-26**] 05:30PM BLOOD ALT-83* AST-128* CK(CPK)-50 AlkPhos-214*
TotBili-1.1
[**2136-11-26**] 05:30PM BLOOD cTropnT-0.04*
[**2136-11-26**] 05:30PM BLOOD Albumin-4.2 Calcium-10.1 Phos-7.5*#
Mg-2.4
[**2136-11-26**] 05:40PM BLOOD Glucose-104 Lactate-15.7* Na-142 K-4.7
Cl-105 calHCO3-11*
[**2136-11-26**] 07:05PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2136-11-26**] 07:05PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-URINE CULTURE
RELEVANT LABS:
[**2136-11-26**] 05:30PM BLOOD ALT-83* AST-128* CK(CPK)-50 AlkPhos-214*
TotBili-1.1
[**2136-11-29**] 08:24AM BLOOD ALT-282* AST-356* AlkPhos-172*
TotBili-0.7
[**2136-11-27**] 11:38AM BLOOD Type-ART pO2-80* pCO2-26* pH-7.23*
calTCO2-11* Base XS--15
Discharge labs
[**2136-11-30**] 06:52AM BLOOD WBC-4.9 RBC-3.54* Hgb-10.6* Hct-34.6*
MCV-98 MCH-30.0 MCHC-30.7* RDW-18.2* Plt Ct-186
[**2136-11-30**] 11:40AM BLOOD PT-39.0* INR(PT)-3.6*
[**2136-11-30**] 06:52AM BLOOD Glucose-104* UreaN-19 Creat-3.5*# Na-135
K-4.7 Cl-99 HCO3-21* AnGap-20
[**2136-11-30**] 06:52AM BLOOD ALT-239* AST-257* AlkPhos-163*
TotBili-0.8
[**2136-11-30**] 06:52AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
MICRO
URINE CULTRE(Final [**2136-11-27**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
[**2136-11-26**] 6:40 pm BLOOD CULTURE
Blood Culture [**2136-11-27**]", Routine (Preliminary): STAPHYLOCOCCUS,
COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED ON REQUEST.. Isolated from only one set
in the previous five days.
IMAGING:
[**2136-11-26**]
CXR IMPRESSION:
1. Patient is rotated to the right. Moderate-to-marked
enlargement of the cardiac silhouette.
2. Central pulmonary vascular engorgement.
3. Areas of linear patchy bibasilar opacity most likely
represent
atelectasIS
[**2136-11-26**]- CT HEAD-IMPRESSION: No acute intracranial process.
Chronic involutional changes.
[**2136-11-30**]
Right Upper quandrant ultrasound
1. Sludge in the gallbladder with no evidence of gallbladder
wall edema to
suggest cholecystitis. No biliary dilation.
2. Complex cystic lesion within the lower pole of the right
kidney measuring
2.3 x 2.3 x 2.7 cm. Recommend MRI for further evaluation as
malignancy cannot
be excluded.
3. Additional bilateral simple renal cysts.
4. Bilateral pleural effusions.
Brief Hospital Course:
79F w/ PMH of dementia, sCHF w/ LV thrombus, ESRD on HD who
presents with AMS, and elevated lactate
#Coagulase negative staph Bacteremia:The patient was growing
coagulase negative staph in [**1-30**] bottles. It was likley a
contaminant. She was empircally treated with vancomycin, which
was subsequently discontinued once the gram positive cocci were
speciated as coagulase negative staph.
# AMS/dementia: Patient has known dementia with recent worsening
of baseline. Patient was recently discharged on [**2136-11-13**] for
worsened dementia with increased hallucinations. Her acute
worsening of AMS likely related to hyoglycemic epidsode at home.
It is unclear why she was hypoglyemic. It is possible that she
has imparied gluconeogenesis from her congestive hepatopathy and
renal failure. Unclear if patient had an underlying infection,
leading to hypoglycemia. Her CXR was negative, blood cultures
were growing a contaminant. Her UA is difficult to interpret in
the setting of oliguira and urine Cx grew mixed bacterial flora.
She received a few doses of cefepime and levaquin for ?
urosepsis, although unclear if the patient has a true urinary
tract infection, and if an infection was the cause of her
hypglycemia. Given her improvement in mental status, after
receiving antibiotics, the patient will be discharged on
ciprofloxacin for treatment of complicated UTI.
# Complicated UTI- ( see above) will treat with ciprofloxacin.
last day of antibiotics [**2136-12-5**]
# right kindey mass- On right upper quadrant ultrasound the
patient was found to have a complex cystic lesion within the
lower pole of the right kidney measuring.2.3 x 2.3 x 2.7 cm.
Radiology recommend MRI for further evaluation as malignancy
cannot be excluded.
# Congestive hepatopathy- The patient has a history of
transaminitis with increased AST/ ALT, Alk [**Doctor Last Name **] and normal nl
bili noted inially in [**2136-9-29**]. LFTs reached almost 3x
baseline during this admission. Her LFTs are consistent with
hepatocellular injury. Her work up for transaminities included
hepatitis serologies on a previous admission which were
negative. A RUQ ultrasound showed no evidence of CBD diliation
or cholecystitis. It likley that her transaminits is from
hepatic congestion if the setting of her systolic heart failture
with ( EF of 20%). Transminases will likley improve with
optimization of her heart failure regimen.
Will need to check LFTs on [**2136-12-3**]
# Coagulopathy: -The patient is on Coumadin for LV thrombus. She
was admitted with an elevated INR 5.0 ( goal [**3-2**]). Her
supratherpeutic levels are likley related to here congestive
hepatopathy. Coumadin has been held during this h hospital
course, as her INRs have been persistently elevated. INR at
time of discharge is 3.6. Her coumadin should be restarted on
[**12-1**] at 1mg and the patient should have her INR checked on [**12-3**]
# Systolic CHF ( EF 20%) with LV thrombus: Patient had recent
diagnosis of LV thrombus on prior admission. ( see above). Her
CHF is likley contributing to her transamnitis ( see above). Her
metoprolol was decreased form 75 mg [**Hospital1 **] to 25 [**Hospital1 **] and she was
started on Isosorbide Mononitrate 30mg TID. She was continued on
losartan. The patient has follow up with in Heart Failure
clinic with Dr. [**First Name (STitle) 437**] on discharge
# ESRD on HD: HD on T,Th,Sat schedule. Continued on nephrocaps
and typical HD schedule.
# Hypothyroid: Continued home levothyroxine.
# Hypertension: continued on and losartan. Isosrbide added to
help decrease afterload in setting of poor EF
# Hyperlipidemia- simvastatin was held in setting of
transmintis. ( see above) can restart once AST and ALT less
than 100
TRANSITIONAL ISSUES
# follow up MRI for further evaluation of complex mass on right
kidney mass
# recheck LFTs, restart simvastatin once AST and ALT are below
100
# restart Coumadin on [**12-1**] 1 mg daily
# recheck INR on [**2136-12-3**]
# full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 125 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Sarna Lotion 1 Appl TP TID:PRN Itchying
11. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
12. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
13. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Sarna Lotion 1 Appl TP TID:PRN Itchying
9. Sertraline 100 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
12. Ciprofloxacin HCl 250 mg PO Q24H Duration: 5 Days
dose after HD
13. Warfarin 1 mg PO DAILY16
14. Isosorbide Mononitrate 20 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Altered Mental status
Coagulopathy
Congestive Heart Failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 11622**],
It was pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital with altered mental status. You had a
CT scan of your head which was normal. We found no evidence of
infection in your lung to causes a change in mental status. Your
blood cultures grew a bacteria (coagulase negative staph) which
is likely a contaminant. Your urine showed evidence of an
infection although the urine culture showed contaminants. We
will treat you empirically for urinary tract infection with
antibiotics (Ciprofloxacin). Your change in mental status was
likely from your low blood sugar, which may be related to a
urinary tract infection.
You were also admitted with an elevated INR. Your Coumadin has
been held since admission since your INR is still elevated.
Your INR will need to be re-checked on [**2136-12-3**] at rehab. You
should restart Coumadin on [**2136-12-1**] at a lower dose( 1mg).
You were found to have a mass on the right kidney that is
concerning for a cancer of the kidney. Please follow up with
your doctor at rehab and PCP to discuss these results further.
You were also found to have an increase in your liver function
tests. We think this may be related to your heart failure. We
made some changes to your medications, but it is important to
follow up in Heart Failure clinic at the appointment listed
below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2136-12-10**] at 3:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2136-12-14**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"428.22",
"995.91",
"E934.2",
"403.91",
"790.92",
"V58.61",
"294.10",
"189.0",
"244.9",
"585.6",
"599.0",
"429.89",
"348.30",
"285.21",
"276.2",
"038.9",
"272.4",
"428.0",
"584.9",
"570",
"331.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11442, 11507
|
5966, 9954
|
316, 322
|
11611, 11611
|
3314, 5943
|
13298, 13973
|
1837, 1855
|
10702, 11419
|
11528, 11590
|
9980, 10679
|
11793, 13275
|
1870, 3295
|
267, 278
|
350, 1259
|
11626, 11769
|
1281, 1663
|
1679, 1821
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,863
| 108,806
|
26555
|
Discharge summary
|
report
|
Admission Date: [**2135-5-16**] Discharge Date: [**2135-5-19**]
Date of Birth: [**2066-6-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Nausea/Vomiting --> Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 m with type 1 DM, congenital solitary kidney, CRI, HTN,
gastritis, presents with nausea/vomiting and DKA.
Reports 2-3 days of "stomach upset", with nausea and occasional
non-bloody, non-bilious vomiting. Began to have anorexia so
decreased insulin doses. He took 12 units the night PTA, and
then none the morning he presented because he felt too unwell
with subjective fevers and sweats. Denies cough, SOB, chest
pain, myalgias, dysuria but has had a few loose stools after
taking ExLax for constipation. No sick contacts, unusual food,
travel. Of note patient was admitted [**2135-3-23**] for DKA with
identical symptoms, cause was unknown but thought to have some
element of medication non-compliance. Per prior notes, he has
also had intermittent nausea and vomiting for several months.
On arrival to ED, afebrile but tachycardic with SBP 100s,
comfortable
occ vomiting guaiac positive brown stool given normal saline
and 10 units regular insulin IV labs notable for anion gap 31,
normal WBC count.
Past Medical History:
1.Type I DM - dx [**2106**], HbA1c on [**3-24**] was 8.9
2. Hyperlipidemia
3. One kidney, congenital
4. Legally blind in L eye [**3-5**] MVA
5. CRI - baseline 1.3-1.4
6. Hypertension
7. Lumbar radiculopathy (L5?)
8. H. Pylori gastritis ([**3-11**]) s/p triple therapy treatment
9. Gastritis, duodenal ulcer ([**3-11**])
Social History:
Patient lives in [**Location (un) 4398**] w/ partner [**Name (NI) **]. Recently retired
school administrator, retired now as a consultant. Prior 15-pk
year history, quit 30+ years ago. [**2-2**] EtOH drinks/day, no
illicits.
Family History:
Mother 77 d colon CA, father 86 d CAD s/p MI; 9 siblings: 1 d
lung CA, 1 d colon CA (none under 50). Diabetes runs in the
family.
Physical Exam:
VS: Temp: 98.2 HR: 117 BP: 119/62 RR: 26 O2sat: 100% on RA
GEN: pleasant and talkative, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, scant b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, 2+ DP/PT pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. No focal deficits
Pertinent Results:
[**2135-5-16**] 06:37PM GLUCOSE-GREATER TH K+-5.1
[**2135-5-16**] 06:20PM GLUCOSE-576* UREA N-24* CREAT-1.7* SODIUM-140
POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-18* ANION GAP-36*
[**2135-5-16**] 06:20PM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-193 ALK
PHOS-110 AMYLASE-52 TOT BILI-1.5
[**2135-5-16**] 06:20PM LIPASE-19
[**2135-5-16**] 06:20PM ALBUMIN-4.9* CALCIUM-11.3* PHOSPHATE-2.8
MAGNESIUM-2.2
[**2135-5-16**] 06:20PM WBC-10.6# RBC-4.41* HGB-13.8* HCT-40.3 MCV-91
MCH-31.3 MCHC-34.3 RDW-12.5
[**2135-5-16**] 06:20PM NEUTS-82* BANDS-0 LYMPHS-11* MONOS-3 EOS-0
BASOS-1 ATYPS-3* METAS-0 MYELOS-0
[**2135-5-16**] 06:20PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2135-5-17**] 12:15 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2135-5-19**]**
URINE CULTURE (Final [**2135-5-19**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Labs on Discharge:
[**2135-5-19**] 05:50AM BLOOD Glucose-111* UreaN-10 Creat-1.1 Na-140
K-4.1 Cl-100 HCO3-29 AnGap-15
Brief Hospital Course:
68 m with type 1 DM, congenital solitary kidney, CRI, HTN,
gastritis, presents with nausea/vomiting and DKA.
# Diabetic Ketoacidosis: The patient presented with
nausea/vomiting and was found to have a glucose 500s with an
anion gap of 31. Unclear precipitant - gastroenteritis,
gastroparesis, other infection though infectious workup has been
negative. The patient was started on an insulin gtt, and as the
AG closed, he was switched to SSI and NPH [**Hospital1 **] , FSBS was
subsequently well controlled. [**Last Name (un) **] was consulted and felt the
patient should change from his prior 75/30 regimen to the above
in an effort to increase his compliance around variable po
intake. He will see the NP at [**Last Name (un) **] Center the day following
discharge and a follow up appointment has been scheduled with a
[**Last Name (un) **] Fellow in the near future. By the time of discharge the
patient was tolerating a regular diet with BG in the low 100s.
# Acute Kidney Injury on CKD: Baseline chronic kidney disease
with a creatinine of 1.2 - 1.3. Admission Cre 1.7, likely
prerenal due to volume depletion from poor PO intake and
vomiting. Cr below baseline at 1.1 after hydration. Taking POs
without difficulty.
# Nausea/Vomiting: History of persistent nausea and vomiting
despite normal gastric emptying study ([**3-11**]). Recently treated
for H. Pylori. Likely secondary to gastritis, pt completed h.
pylori tx but did not continue PPI after, also possible viral
gastroenteritis vs gastroparesis (despite negative gastric
emptying study). Continued PPI and metoclopramide for nausea
vomiting and gastritis and discharged on omeprazole.
# Hypertension: Will restart home dose [**Last Name (un) **] now that renal
failure resolved.
# Hyperlipidemia: [**Last Name (un) 7396**] and ASA.
# Radiculopathy: Renally-dosed Neurontin.
Medications on Admission:
1. Valsartan 160 mg daily
2. Rosuvastatin 80 mg daily
3. Aspirin 81 mg daily
4. Gabapentin 600 mg tid
7. Reglan 10mg tid with meals
8. Humalog Mix 75-25 17 u AM, 17 u PM
9. Humalog 100 sliding scale per carb counts
Discharge Medications:
1. Neurontin 600 mg Tablet Sig: Two (2) Tablet PO three times a
day.
2. Rosuvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous twice a day.
Disp:*5 vials* Refills:*6*
4. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: Per sliding scale.
Disp:*3 vials* Refills:*5*
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Omeprazole 20 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*
8. Humalog sliding scale
Please use attached sliding scale, checking your FS four times
daily
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
DM Type I
gastritis
Discharge Condition:
stable
Discharge Instructions:
You were admitted with DKA that responded to IV fluids and
insulin. You must be diligent about checking your blood glucose
regularly. We have also changed your insulin regimen. Please
call your PCP or return to the ER if you develop any further
nausea, vomiting, fevers or new symptoms.
Followup Instructions:
[**Last Name (un) **] Nurse educator, [**Last Name (un) **] Center [**5-20**] 10:00AM
[**Last Name (un) **] fellow [**5-30**] at 3:00 PM
Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2135-6-2**]
3:10
Please call Dr.[**Name (NI) 20819**] office at [**Telephone/Fax (1) 2393**] for a follow
up appointment in [**3-7**] weeks. At that time you can discuss
restarting your ASA.
|
[
"276.50",
"403.90",
"535.51",
"753.0",
"584.9",
"250.13",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6723, 6729
|
3763, 5620
|
357, 364
|
6815, 6824
|
2695, 3620
|
7162, 7610
|
2006, 2138
|
5886, 6700
|
6750, 6794
|
5646, 5863
|
6848, 7139
|
2153, 2676
|
276, 319
|
3640, 3740
|
392, 1402
|
1424, 1746
|
1762, 1990
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,502
| 123,058
|
43462
|
Discharge summary
|
report
|
Admission Date: [**2167-4-22**] Discharge Date: [**2167-5-8**]
Service: MEDICINE
Allergies:
Atorvastatin / Ibuprofen / Rosuvastatin
Attending:[**First Name3 (LF) 2891**]
Chief Complaint:
Back pain; Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain.
Patient states she has chronic back pain which has gotten
significantly worse the last 3 days, reported refractory to
tylenol but pt says she doesn't take pain meds much at home (at
most one tylenol a day). Patient denies fever, chills, numbness,
weakness. She denies urinary retention or bowel incontinence.
She states she otherwise feels well. She's been using icy hot
patches to control the back pain. She denies abdominal pain or
diarrhea, but reports some constipation. She initially thought
her back pain was due to this, but it didn't resolve when she
had a large BM this AM. She denies dysuria or difficulty
urinating.
In the ER, she also reported worsening shortness of breath that
began earlier today. Denied chest pain. Shortness of breath was
for approximately 2 hours earlier today. Now improved with nasal
cannula per ER report. On further questioning about this, she
says she is mildly short of breath at baseline going on walks or
rushing to bathroom at night. When pressed she says this has
actually worsened somewhat over last month and became acutely
worse today. However, this was not the reason she came to the
ER. She also reports a productive [**Year (4 digits) **] for roughly one month
with whitish sputum. She thought maybe she had bronchitis
because she gets bronchitis every year but hasn't had it yet
this year.
In the ED, initial VS: 99.6 74 162/88 26 99% 2L Nasal Cannula.
Trop was 0.02 (have been higher in past) and Cr 2.1. Due to SOB
D-dimer drawn and was elevated at 906. Lactate 1.2. CXR was
clear. CT torso showed -> question of early PNA with Right lower
lobe ground glass opacities so she was given CTX/Azithro after
blood cultures drawn. Given [**Year (4 digits) **]/Tylenol for back pain and or
ACS. Pt was admitted from the ER for V/Q scan due to concern for
PE in pt with elevated Cr. Back pain was considered
musculoskeletal in nature. VS on admission 98.7 ??????F (37.1 ??????C),
Pulse: 63, RR: 19, BP: 135/56, O2 sat 98% on 1L NC
Currently, pt feels much better than earlier today. She says the
main thing that has changed is that her back pain is better with
the meds she got in the ER (325mg [**Year (4 digits) **] and 325mg Tylenol).
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-CAD- s/p PCI to mid-[**Year (4 digits) **] and PCTA to OM1 ([**2165**])
-CHF- last [**Year (4 digits) 113**] [**2165-3-11**] prior to stenting, EF 40%
-Hypertension
-Diabetes mellitus II- diet controlled
-Dyslipidemia
-Chronic renal failure, stage IV
-GERD
-h/o breast cancer ([**2145**]), s/p lumpectomy
-s/p TAH for fibroids(age 39)
-s/p cataract surgery
Social History:
Lives alone in [**Location (un) 55**]. Walks with a cane. Has aids at
home to help. She has three children, two of which live close
by. HCP is daughter [**Name (NI) 553**]. [**Name2 (NI) 1139**]- <1ppd for 20 years, quit in
[**2144**].
Alcohol- denies, Illicits- denies
Family History:
Mother- died at age [**Age over 90 **]
Father- hypertension, died in 60s
Sister- age [**Age over 90 **], high blood pressure, CAD.
Physical Exam:
Admission exam:
VS - Temp 98.2F, BP 149/68, HR 66, R 18, O2-sat 99% on 2L NC, wt
106.7lbs
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, mid-systolic murmur
loudest at heart base
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
BACK - mildly TTP over lower thoracic/upper lumbar spine, also
with some paraspinal muscle tenderness to R of this area
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal neuro deficits
Discharge Physical Exam:
VS: 98.3 133/63 68 18 96% RA weight 46.3 kg
General: NAD, tired but alert and oriented x3
HEENT: EOMI, PERRL, anicteric, MMM, OP clear
CV: RRR, nl S1 S2, [**3-16**] mid-systolic murmur
Resp: CTAB, no wheezes or rhonchi, rales right base
Abd: soft, non-tender, non-distended, no HSM
Ext: warm, well-perfused, no edema, 2+ DP
Pertinent Results:
Admission labs:
[**2167-4-22**] 02:40PM BLOOD WBC-9.1# RBC-4.14* Hgb-13.5 Hct-36.8
MCV-89 MCH-32.7* MCHC-36.8* RDW-13.8 Plt Ct-188
[**2167-4-22**] 02:40PM BLOOD Neuts-80.6* Lymphs-12.6* Monos-4.9
Eos-1.2 Baso-0.7
[**2167-4-22**] 07:49PM BLOOD PT-12.2 PTT-30.2 INR(PT)-1.1
[**2167-4-22**] 02:40PM BLOOD Glucose-211* UreaN-52* Creat-2.1* Na-136
K-4.2 Cl-96 HCO3-26 AnGap-18
[**2167-4-22**] 02:40PM BLOOD ALT-19 AST-44* LD(LDH)-303* CK(CPK)-63
AlkPhos-108* TotBili-0.4
[**2167-4-22**] 02:40PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-[**Numeric Identifier 35383**]*
[**2167-4-22**] 02:40PM BLOOD Albumin-4.3
[**2167-4-22**] 05:50PM BLOOD D-Dimer-906*
[**2167-4-22**] 06:03PM BLOOD Lactate-1.2
Cardiac Enzymes:
[**2167-4-24**] 07:18AM BLOOD CK-MB-2 cTropnT-0.04*
[**2167-4-26**] 06:50AM BLOOD CK-MB-3 cTropnT-0.09*
[**2167-4-26**] 03:30PM BLOOD CK-MB-4 cTropnT-0.11*
[**2167-4-26**] 11:53PM BLOOD CK-MB-4 cTropnT-0.14*
[**2167-4-27**] 06:00AM BLOOD CK-MB-4 cTropnT-0.14*
[**2167-4-27**] 02:11PM BLOOD CK-MB-4 cTropnT-0.15*
[**2167-4-28**] 02:28AM BLOOD CK-MB-6 cTropnT-0.21*
[**2167-4-28**] 01:57PM BLOOD CK-MB-7 cTropnT-0.26*
[**2167-4-29**] 03:00AM BLOOD CK-MB-4 cTropnT-0.27*
[**2167-4-30**] 03:31AM BLOOD CK-MB-3 cTropnT-0.25*
Discharge Labs:
[**2167-5-8**] 06:55AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.5* Hct-33.6*
MCV-97 MCH-30.3 MCHC-31.3 RDW-16.4* Plt Ct-379
[**2167-5-4**] 07:10AM BLOOD Neuts-75.9* Lymphs-14.1* Monos-5.5
Eos-3.9 Baso-0.7
[**2167-5-8**] 06:55AM BLOOD Glucose-218* UreaN-116* Creat-3.1*
Na-126* K-3.9 Cl-81* HCO3-33* AnGap-16
[**2167-5-8**] 06:55AM BLOOD Calcium-9.4 Phos-5.1* Mg-3.7*
[**2167-4-22**]:
ECG:
Sinus rhythm. Borderline prolongation of the P-R interval. Left
atrial
abnormality. Left axis deviation. Left bundle-branch block.
[**2167-4-22**]:
CXR:
1. Confluent right lung base opacity, increased in conspicuity
since
[**2167-3-6**] exam, which may represent atelectasis, assymetric
edema or infection in the appropriate clinical setting.
2. Moderate cardiomegaly and perihilar vascular congestion,
unchanged.
[**2167-4-22**]:
CT torso w/o contrast:
1. Centrilobular ground-glass opacities, predominantly in basal
segments of
the right lower lobe, new since [**2164**] exam, suggestive of an
infectious or
inflammatory etiology. Punctate opacities in the left upper lobe
are also new since prior and may represent same underlying
infectious/inflammatory process.
2. Extensive calcified atherosclerotic disease of the aorta and
its branches without associated aneurysmal changes. Assessment
for dissection is limited, given lack of intravenous contrast.
High-grade stenosis of the
intra-abdominal aorta is likely given calcification pattern,
which is largely unchanged since [**2166-12-31**] exam.
3. Small hiatal hernia.
4. Marked atrophy of the right kidney, unchanged. Left renal
cyst.
5. Scattered sigmoid colon diverticula. No associated
inflammatory changes.
[**2167-4-25**]:
CXR:
1. Centrilobular ground-glass opacities, predominantly in basal
segments of
the right lower lobe, new since [**2164**] exam, suggestive of an
infectious or
inflammatory etiology. Punctate opacities in the left upper lobe
are also new since prior and may represent same underlying
infectious/inflammatory process.
2. Extensive calcified atherosclerotic disease of the aorta and
its branches without associated aneurysmal changes. Assessment
for dissection is limited, given lack of intravenous contrast.
High-grade stenosis of the
intra-abdominal aorta is likely given calcification pattern,
which is largely unchanged since [**2166-12-31**] exam.
3. Small hiatal hernia.
4. Marked atrophy of the right kidney, unchanged. Left renal
cyst.
5. Scattered sigmoid colon diverticula. No associated
inflammatory changes.
[**2167-4-26**]:
CXR:
As compared to the previous radiograph, the signs indicative of
pulmonary edema are seen in unchanged manner. The pre-existing
right pleural effusion has slightly increased in extent. The
pre-existing left pleural effusion is constant. No newly
occurred focal parenchymal opacities.
[**4-30**]:
CXR:
FINDINGS: In comparison with the study of [**4-29**], there is
continued
substantial enlargement of the cardiac silhouette with vascular
congestion and bilateral pleural effusions, more prominent on
the left with associated compressive atelectasis at the bases.
No evidence of acute focal pneumonia, though this could well be
hidden in the retrocardiac region on this single frontal view.
[**5-4**]:
CXR:
The heart is moderately enlarged. Bilateral pleural effusions
are enlarged since [**2167-5-1**]. There is slighlty increased
bibasilar atelectasis, severe on the left. There is no
pneumothorax.
IMPRESSION: Worsening bilateral pleural effusions and persistent
left lower lobe collapse.
MICROBIOLOGY:
Sputum culture [**4-24**]:
GRAM STAIN (Final [**2167-4-24**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2167-4-26**]):
SPARSE GROWTH Commensal Respiratory Flora.
Urine culture [**4-22**], [**4-26**], [**4-27**], [**4-30**], [**5-1**] negative
Blood cultures 3/14, [**4-24**], [**4-26**] negative; [**5-1**] NGTD
Brief Hospital Course:
[**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain and DOE with a [**Year (4 digits) **]. Imaging
consistent with PNA and CHF. Hospital course complicated by
worsening CHF exacerbation and difficulty with diuresis [**3-12**] CKD
requiring transfer to the MICU for agressive diuresis.
.
# Acute on Chronic Systolic CHF: *****PATIENT'S DRY WEIGHT IS 46
KILOGRAMS***** Patient has known CAD with past PCIs and an
ischemic cardiomyopathy. Most recent [**Month/Day (2) **] prior to this
admisison showed 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] 40%, found to be worsened to 30%
with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **] during this admission. Her home dose of
Lasix is 80 mg [**Hospital1 **]. Initial exam was notable for elevated JVP
and bilateral crackles. CXR consistent mostly with PNA with
mild vascular congestion. During the first few days of
admission, patient did not respond to Lasix 80 mg IV or 120 mg
IV (output ~200-250 to each dose). She initially had mild
improvement in symptoms but had increasing O2 requirement to
4LNC overnight on [**4-24**]. CXR showed worsening of bilateral
vascular congestion. This may have been in the setting of
elevated SBP in the 160-170s. BP control with nitropaste and
uptitration of amlodipine to 10mg (from 7.5) daily and imdur to
90mg (from 60mg) daily and carvedilol to 25mg (from 12.5mg) [**Hospital1 **].
Patient not on [**Last Name (un) **]/ACE-i due to history of hyperkalemia on [**Last Name (un) **].
More aggressive diuresis attempted with 10mg metolazone
followed by 100mg torsemide, with only mildly better results.
On [**4-27**] morning, the patient was noted to desat to 80% on
4.5LNC, 74% on RA and 90% on NRB and was sent to the MICU. In
the MICU she was placed on a lasix gtt, in addition to
continuation of metolazone 10 mg [**Hospital1 **], averaging net negative one
liter per day. This diuresis was augmented by decreasing her
carvedilol dose to 12.5 mg [**Hospital1 **] in an attempt to increase cardiac
output. Her oxygen requirement decreased to 2-3L NC on transfer
out of the MICU and she was breathing much more comfortably.
There was discussion of possible UF session to remove fluid or
placement of a BIV pacer, but the patient declined both of these
procedures. *****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
.
On the floor, her diuresis was held due to worsening kidney
function. Gentle diuresis with Lasix was restarted for several
days to help her reach her dry weight, which clinically appears
to be 46kg. As her Cr increased again, her diuretics were again
held and she remained close to euvolemic thereafter. She is not
being discharged on diuretics in order to allow further recovery
of her renal function. It has been observed that she naturally
diureses when her HR is over 70, thus her carvedilol was reduced
in order to maintain her heart rate and improve her urine
output. If her weight goes up while her HR is > 70, she may
require diuresis. However, given her renal dysfunction, this
should be carefully considered in cooperation with her PCP and
Nephrologist to avoid future HD.
.
# Community Acquired Pneumonia: Patient presented with chronic
DOE, but much worse from baseline in the week prior to
presentation. In the ED, there was concern for PE and patient
underwent non-contrast CT (due to baseline CKD) which showed no
evidence of PE. Leukocytosis (WBC 13.3 with PMN predominance),
CXR with hazy right lung base opacity and CT showing
perivascular infiltrates/ground glass appearance all suggested
pneumonia. She was treated for CAP (although she has been
hospitalized in [**2-/2167**]) and mild CHF exacerbation (see above).
Urine legionella antigen was negative. She was treated with
ceftriaxone (x8 days) and azithromycin (x5 day). Her dry,
congestive [**Year (4 digits) **] responded well to albuterol nebulizers,
expectorants and chest PT. She continued to [**Year (4 digits) **] at discharge,
although without fever or leukocytosis to indicate continued
infection. We anticipate this dry, occasionally productive
[**Year (4 digits) **] with wheezing will resolve over the next 1-2 weeks with
continued nebulizer treatments and [**Year (4 digits) **] suppressants.
.
# Chest pain/troponin elevation: Dyspnea was occasionally
accompanied by anterior chest pain, reproducible with palpation,
that resolved with improvement in respiratory status. Unlikely
coronary origin. However, patient did have a troponin bump to
0.21 (from 0.02 on admission) on [**4-29**] in the setting of acutely
worsening CHF, h/o CAD and CKD. Troponins remained stable in
the low .2's. CKMB negative. Patient was continued on aspirin
81mg daily.
.
# Back Pain: Patient has chronic back pain, had worsened over 3
days prior to admission. Patient has h/o spinal stenosis and
pain was similar in quality to baseline. Per patient, she only
takes at most one tablet of tylenol per day for fear of it
injuring her kidneys. Pain well-controlled on standing tylenol
650mg q8h.
.
# Chronic Kidney Disease: Baseline creatinine 1.9-2.1. Arrived
at baseline and increased with diuresis, peaking at 3.3. This
was likely due to poor forward flow from CHF exacerbation and
diuresis. Diuresis was paused with improvement in creatinine to
3.1. The Nephrology team was consulted and felt that the
patient would likely recover over time, although possibly to a
lower baseline. She was discharged with planned outpatient
Renal follow-up. As diuresis worsens her renal function, it is
important to avoid diuresis if possible by controlling fluid
input and heart rate.
.
# HTN: Blood pressure mildly elevated, usually worsening in the
evening and overnight to SBP 160s and then stabilizing in SBP
130s-140s after morning home medications. In the setting of CHF
exacerbation and MR, BP control tightened. Nitropaste used prn
and home meds uptitrated. Patient not on ACE/[**Last Name (un) **] at baseline,
had history of hyperkalemia.
.
# Hyponatremia: Likely due to CHF exacerbation and renal
injury. Controlled with fluid restriction.
.
# Constipation: Patient reported chronic mild constipation at
home, was taking docusate. Responded to colace and senna.
Patient experienced mild nausea when constipated, resolved with
bowel regimen.
.
# Altered mental status: Patient had an episode of
disorientation and agitation, likely hospital-acquired delirium,
perhaps exacerbated by uremia. Famotidine and benzodiazepines
held.
.
# Groin rash: Mild irritation secondary to having restricted
ambulation. Miconazole topical started.
.
# Thrush: Patient was found to have mild thrush, treated with
Nystatin, viscous lidocaine.
.
# Diabetes: Type II, controlled with diet at home. The patient
had persistent hyperglycemia in the 200s. We started her on NPH
prior to discharge for improved control, but this will likely
need continued titration.
.
# GERD: Continued home famotidine until episode of delirium,
then held.
Transitional Issues:
- If the patient's weight increases > 1 kg from her dry weight
of 46kg, please check her heart rate. If HR < 70, please reduce
her carvedilol to improve her cardiac output and thus her
natural UOP. If HR > 70, please contact the patient's PCP Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] (covered by Dr [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] until [**5-16**]) to discuss
appropriate balance between diuresis and renal function in this
fragile patient. Drs [**Last Name (STitle) 3029**] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] be reached at [**Company 191**],
[**Telephone/Fax (1) 2010**].
- Determination of home diuresis regimen to maintain weight and
respiratory status.
- Renal follow-up in [**3-13**] weeks to determine new baseline CKD,
adjust medications accordingly.
- The patient will likely have continued [**Last Name (LF) **], [**First Name3 (LF) **] require
support from bronchodilators and [**First Name3 (LF) **] suppressants, monitoring
for worsening symptoms that might indicate recurrent PNA.
Please discontinue [**First Name3 (LF) **] suppressants after 1 week. Please
continue nebulizer treatments for periodic shortness of breath
and wheeze.
- The patient has episodic nausea, likely due to heartburn and
constipation. Please maintain an aggressive bowel regimen
titrated to 2 soft stools daily.
- Please continue insulin sliding scale and NPH to ensure no
hyperglycemia.
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
Medications on Admission:
1. amlodipine 7.5 mg PO Qd
2. carvedilol 12.5 mg PO BID
3. isosorbide mononitrate 60mg XR PO Qd
4. aspirin 162mg Qd
5. furosemide 80 mg PO BID
6. famotidine 20 mg PO Qd
7. nitroglycerin 0.3 mg Tablet, Sublingual PRN chest pain
8. lidocaine 5 %(700 mg/patch) 1 daily to site
9. docusate sodium 100 mg PO BID
10. lorazepam 0.5 mg PO HS (PRN anxiety)
11. Tramadol 50mg PO Q8h5s PRN pain - pt says she is not taking
Discharge Medications:
1. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed: take at onset of exertional chest pain;
may repeat every 5 minutes up to three times.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for [**First Name3 (LF) **], congestion.
Disp:*100 ML(s)* Refills:*0*
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours):
Hold for HR > 90. may hold in middle of night if pt sleeping
comfortably and non-hypoxic .
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane four times a day as needed for sore throat.
11. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): Hold for SBP<90.
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours): may hold in middle of night if
pt sleeping comfortably and non-hypoxic .
13. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane Q4H (every 4 hours) as needed for mouth/throat pain:
swish and swallow .
14. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day): swish and swallow.
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
17. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Tablet(s)
18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: start [**5-8**]. Tablet(s)
19. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Six (6) units Subcutaneous twice a day.
20. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: 150-200 2 units
200-250 4 units
250-300 6 units
300-350 8 units
350-400 10 units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Pneumonia
Acute on Chronic Systolic Heart Failure
Chronic Kidney Disease
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:
Ms. [**Known lastname 3659**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted because you had difficulty breathing. We found that
you had pneumonia and an exacerbation of your heart failure. We
treated you with antibiotics. We also treated you with
medications to help remove excess fluid from your lungs to
assist your breathing.
You also had back pain, which is an ongoing issue. We treated
you with Tylenol around the clock and your back pain improved.
You can take up to 3 tablets of 650mg tylenol each day when you
go home for back pain.
You have continued to have occasional mild nausea and heartburn.
This may be related to constipation, so we recommend using
laxatives to ensure [**2-9**] bowel movements/day.
Weigh yourself every morning. If your weight goes up by 3
pounds, please call Dr.[**Name (NI) 93519**] office.
We made the following changes to your medications:
STOP amlodipine, a blood pressure medication
STOP lidocaine patch and tramadol, used for back pain
STOP lorazepam and famotidine, which can worsen delirium
STOP furosemide, a diuretic
START Tylenol for pain
START hydralazine for blood pressure
START senna and Miralax as needed for constipation
START albuterol nebulizers, ipratropium nebulizers, guaifenesin
syrup, benzonatate, and cepacol for [**Name (NI) **]
START lidocaine and Nystatin swish and swallows for thrush
START miconazole cream for fungal rash
START insulin for high blood sugar
START [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic, for 3 days for urinary tract
infection
REDUCE carvedilol and aspirin doses
Please follow-up with your physicians as listed below.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2167-5-19**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appt in the with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the 2-3 weeks. You will be called at the facility with the
appointment. If you have not heard or have questions, please
call ([**Telephone/Fax (1) 10135**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
[]
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,260
| 110,601
|
15738
|
Discharge summary
|
report
|
Admission Date: [**2164-1-11**] Discharge Date: [**2164-1-16**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole / Shellfish / Bee Pollen
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
gastrointestinal bleeding
Major Surgical or Invasive Procedure:
EGD
TIPS dilatation
History of Present Illness:
Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis
s/p TIPS, active alcoholism, and prior UGIB attributed to
duodenal varix who presents with dark red blood per rectum since
2AM. She has had approximately 4-5 episodes of bleeding
overnight. This AM, felt lightheaded and called EMS; she was
brought into ED by ambulance. Of note, last alcoholic drink was
at ~3AM.
In the ED, initial VS were T 98.2, HR 110, BP 90/60, RR 16, O2
sat 100% 4L Nasal Cannula. After arrival, BP dropped to 70s/40s
and patient received 1L IVF with NS; she was then ordered for 1
unit universal pRBCs and T&C for additional 4 units (2nd unit on
standby at time of signout). Hct returned at 20 from remote
baseline in upper 20s-low 30s, and INR was 2.0. Gastric lavage
was negative. Hepatology consult was called, and the patient was
started on pantoprazole and octreotide gtt and received one dose
of ceftriaxone. RUQ U/S with Doppler was performed; no report
available at the time of signout. BPs were back in 90s/60s at
time of signout. Current access is 4 peripheral IVs: 20G, 22G,
16G, 18G.
.
On arrival to the MICU, patient reports feeling overall poorly,
though no pain except at site of left antecube IV. Endorses
nausea. No other symptoms. Transport staff report she has filled
two hats with what looks like "pure blood" since arrival in the
ED.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
Alcoholic cirrhosis
s/p cholecystectomy [**2153**]
Gastroesophageal reflux disease
Bipolar disorder
Htn
Depression/anxiety
Social History:
She lives with her husband and 2 children, ages 16 and 17.
Smokes 1pack every few weeks. Used to be an accountant. Denies
other drug use. Currently requests that husband and [**Name2 (NI) **] not
be allowed to call her room and not be told any information.
Family History:
Non-contributory.
Physical Exam:
Discharge Exam
Vitals: T: 99.6 98.3 BP: 103/58 P: 83 R:16 O2:99% RA
General: Alert, oriented X 3, no acute distress. Smells of
[**Name2 (NI) **].
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP flat, no LAD
CV: Regular rate and rhythm (borderline tachycardic), normal S1
+ S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: No foley.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No tremor/asterixis.
Skin: Grafting to the first and second digits of the hands
bilaterally.
Left arm has large bicep hematoma and swelling with
discoloration, 2 + left and right radial pulses with no
numbness, and good motor function of fingers.
Pertinent Results:
Admission Labs
[**2164-1-11**] 11:58PM D-DIMER-1732*
[**2164-1-11**] 10:21PM GLUCOSE-124* UREA N-13 CREAT-0.5 SODIUM-129*
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-10
[**2164-1-11**] 10:21PM LD(LDH)-178
[**2164-1-11**] 10:21PM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-2.6
[**2164-1-11**] 10:21PM HAPTOGLOB-<5*
[**2164-1-11**] 10:21PM WBC-4.8 RBC-3.14* HGB-9.5* HCT-26.2* MCV-84
MCH-30.2 MCHC-36.1* RDW-16.2*
[**2164-1-11**] 10:21PM PLT COUNT-72*
[**2164-1-11**] 10:21PM PT-16.3* PTT-28.8 INR(PT)-1.5*
[**2164-1-11**] 10:21PM FIBRINOGE-131*
[**2164-1-11**] 06:18PM GLUCOSE-142* UREA N-13 CREAT-0.4 SODIUM-128*
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-10
[**2164-1-11**] 06:18PM CALCIUM-7.0* PHOSPHATE-3.4 MAGNESIUM-2.9*
[**2164-1-11**] 06:18PM WBC-3.5* RBC-2.97* HGB-8.9*# HCT-24.6* MCV-83
MCH-29.9 MCHC-36.0* RDW-15.9*
[**2164-1-11**] 06:18PM PLT SMR-VERY LOW PLT COUNT-68*
[**2164-1-11**] 06:18PM PT-18.1* PTT-28.3 INR(PT)-1.7*
[**2164-1-11**] 04:03PM HCT-26.3*#
[**2164-1-11**] 03:45PM URINE HOURS-RANDOM
[**2164-1-11**] 03:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-1-11**] 08:57AM COMMENTS-GREEN TOP
[**2164-1-11**] 08:57AM LACTATE-2.2*
[**2164-1-11**] 08:51AM GLUCOSE-120* UREA N-16 CREAT-0.5 SODIUM-128*
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-22 ANION GAP-15
[**2164-1-11**] 08:51AM ALT(SGPT)-28 AST(SGOT)-64* ALK PHOS-125* TOT
BILI-3.1*
[**2164-1-11**] 08:51AM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.8
MAGNESIUM-1.3*
[**2164-1-11**] 08:51AM ASA-NEG ETHANOL-238* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-1-11**] 08:51AM WBC-3.6*# RBC-2.42*# HGB-6.7*# HCT-20.2*#
MCV-84 MCH-27.7 MCHC-33.2 RDW-17.4*
[**2164-1-11**] 08:51AM NEUTS-73.3* LYMPHS-17.8* MONOS-7.8 EOS-0.5
BASOS-0.6
[**2164-1-11**] 08:51AM PLT COUNT-120*#
[**2164-1-11**] 08:51AM PT-21.4* PTT-36.2 INR(PT)-2.0*
.
Discharge Exam
[**2164-1-16**] 06:05AM BLOOD WBC-2.7* RBC-3.39* Hgb-10.4* Hct-29.1*
MCV-86 MCH-30.6 MCHC-35.6* RDW-18.1* Plt Ct-43*
[**2164-1-15**] 02:58PM BLOOD Hct-28.2*
[**2164-1-15**] 06:20AM BLOOD WBC-2.3* RBC-3.69* Hgb-11.3* Hct-32.0*
MCV-87 MCH-30.6 MCHC-35.3* RDW-16.3* Plt Ct-46*
[**2164-1-14**] 05:44PM BLOOD Hgb-10.7* Hct-29.9*
[**2164-1-14**] 06:35AM BLOOD WBC-2.6* RBC-3.46* Hgb-10.2* Hct-28.4*
MCV-82 MCH-29.4 MCHC-35.8* RDW-16.1* Plt Ct-40*
[**2164-1-13**] 05:00PM BLOOD Hct-27.4*
[**2164-1-13**] 12:53PM BLOOD Hct-26.2*
[**2164-1-11**] 08:51AM BLOOD Neuts-73.3* Lymphs-17.8* Monos-7.8
Eos-0.5 Baso-0.6
[**2164-1-16**] 06:05AM BLOOD Plt Ct-43*
[**2164-1-16**] 06:05AM BLOOD PT-20.2* PTT-34.9 INR(PT)-1.9*
[**2164-1-15**] 06:20AM BLOOD PT-18.0* PTT-31.7 INR(PT)-1.7*
[**2164-1-14**] 06:35AM BLOOD Plt Ct-40*
[**2164-1-14**] 06:35AM BLOOD PT-19.0* PTT-33.3 INR(PT)-1.8*
[**2164-1-13**] 02:31AM BLOOD Plt Ct-47*
[**2164-1-12**] 02:36AM BLOOD Plt Ct-60*
[**2164-1-12**] 02:36AM BLOOD PT-15.7* PTT-25.0 INR(PT)-1.5*
[**2164-1-12**] 01:46PM BLOOD Fibrino-191
[**2164-1-12**] 02:36AM BLOOD Fibrino-178*
[**2164-1-11**] 10:21PM BLOOD Fibrino-131*
[**2164-1-16**] 06:05AM BLOOD Glucose-126* UreaN-5* Creat-0.5 Na-133
K-3.0* Cl-99 HCO3-27 AnGap-10
[**2164-1-15**] 06:20AM BLOOD Glucose-112* UreaN-8 Creat-0.7 Na-134
K-3.4 Cl-101 HCO3-19* AnGap-17
[**2164-1-14**] 05:44PM BLOOD Glucose-116* UreaN-9 Creat-0.6 Na-137
K-3.4 Cl-101 HCO3-27 AnGap-12
[**2164-1-16**] 06:05AM BLOOD ALT-18 AST-37 LD(LDH)-184 AlkPhos-102
TotBili-4.3*
[**2164-1-15**] 06:20AM BLOOD ALT-19 AST-44* LD(LDH)-285* AlkPhos-89
TotBili-4.9*
[**2164-1-12**] 02:36AM BLOOD ALT-20 AST-45* LD(LDH)-183 AlkPhos-81
TotBili-5.8*
[**2164-1-15**] 06:20AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.1
Mg-1.4*
[**2164-1-14**] 05:44PM BLOOD Calcium-8.0* Phos-2.9 Mg-1.6
[**2164-1-14**] 06:35AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-1.6
[**2164-1-11**] 11:58PM BLOOD D-Dimer-1732*
[**2164-1-11**] 08:51AM BLOOD ASA-NEG Ethanol-238* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-1-12**] 02:49AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2164-1-11**] 08:57AM BLOOD Lactate-2.2*
[**2164-1-12**] 02:49AM BLOOD Lactate-0.8
.
Reports
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MICU-7 [**2164-1-11**] 5:41 PM
MESSENERTIC Clip # [**Clip Number (Radiology) 45330**]
Reason: Please perform a mesenteric angiograms and perform
coiling o
Contrast: OMNIPAQUE Amt: 145
[**Hospital 93**] MEDICAL CONDITION:
43 year old woman with history of alcoholic cirrhosis s/p
TIPS, active
alcoholism, who presents with lower GI bleed
REASON FOR THIS EXAMINATION:
Please perform a mesenteric angiograms and perform coiling of
any bleeding
vessels
Final Report
PROCEDURES:
1. Portal venogram via the TIPS shunt.
2. Pressure measurements in the portal and systemic venous
circulation across
the TIPS shunt.
3. Transcatheter coil embolization of the bleeding duodenal
varix.
4. Stenting and balloon angioplasty up to 10 mm of the right
hepatic vein
stenosis.
CLINICAL INDICATION: 43-year-old woman with history of alcoholic
cirrhosis
status post TIPS with active alcoholism who presents with acute
lower GI
bleeding.
Informed consent for the procedure was obtained from the
patient's husband,
[**Name (NI) **] [**Name (NI) 45209**] after risks, benefits, and potential
complications had been
discussed. The patient was placed on the angiographic table in
supine
position and was intubated and sedated per MICU protocol. Skin
of the right
anterior neck was prepped and draped in a sterile manner.
Timeout protocol
and huddle protocol were carried out prior to the procedure
according to the
[**Hospital 18**] hospital policy.
ANESTHESIA: Local, 1% lidocaine.
Under real-time ultrasound guidance, using the high-frequency
linear array
transducer, Dr. [**Last Name (STitle) 45331**] punctured the patent and fully
compressible right
internal jugular vein using the 21 gauge micropuncture needle.
Over a 0.018
guidewire, 21 gauge micropuncture needle was exchanged for a 4
French
micropuncture sheath followed by advancement of 0.035 Bentson
guidewire into
the infrarenal inferior vena cava. Over a Bentson guidewire, a
9.0 French 35
cm [**First Name8 (NamePattern2) **] [**Last Name (un) 2493**] Tip sheath was advanced into the inferior vena
cava.
Cannulation of the right hepatic vein was expedient using a
combination of 5.0
French MPA 1 catheter in combination with angled tip 0.035
Glidewire. The
Glidewire was exchanged for a 0.035 Amplatz guidewire through
the MPA catheter
and MPA catheter was exchanged for a 5 French straight flush
catheter over the
Amplatz guidewire. Portal venogram was obtained. TIPS shunt was
noted to be
patent. Pressure measurements demonstrated 17 mmHg portosystemic
gradient;
with 25 mmHg pressure measurements throughout the TIPS shunt and
in the portal
venous basin, 18 mmHg in the right hepatic vein and 8 mmHg in
the right
atrium. Massive duodenal varices are demonstrated on portal
venogram. Large
duodenal varix was cannulated expediently using 5.0 French Cobra
gliding
catheter. Cobra catheter entered the duodenal [**Last Name (un) 2432**] varix in
tandem with 0.035
angled tip Glidewire. Injection of the varix demonstrated active
bleeding
into the C-loop of the duodenum. Coil embolization of the
bleeding varix was
performed using stainless steel coils of 3 cm x 8 mm profile and
8 cm x 10
profile, respectively. Following coil embolization, active
bleeding stopped
on followup contrast injection. Through the 5.0 French Cobra
gliding
catheter, Amplatz guidewire was reintroduced into the portal and
splenic vein.
A 10 mm x 42 mm Wallstent was deployed in a telescopic manner
through the TIPS
shunt and across the right hepatic vein stenosis. Balloon
angioplasty was
performed using 8 mm x 2 cm high-pressure balloon within the
lumen of the TIPS
shunt and 10 mm x 2 cm balloon outside the lumen of the TIPS
shunt in the free
right hepatic vein. Portosystemic pressure gradient was reduced
to 10 mmHg
following stenting and balloon angioplasty.
Hemostasis at the puncture site was achieved without difficulty
by manual
compression. Sterile dressing was applied.
CONCLUSION:
1. Portosystemic gradient of 17 mmHg was detected. No
intra-stent gradients
were present.
2. Right hepatic vein outflow stenosis.
3. Stenting and balloon angioplasty of the right hepatic vein
stenosis
resulted in reduction of the portosystemic gradient to 10 mmHg.
4. Massive duodenal varices with active bleeding in to the third
portion of
the duodenum demonstrated upon selective injection of the
megavarix.
5. Successful stainless steel coil embolization of the bleeding
duodenal
varix.
The study and the report were reviewed by
CXR [**2164-1-12**]
FINDINGS:
Portable semi-upright view of the chest demonstrates low lung
volumes, which
accentuate bronchovascular markings. There is no pleural
effusion, focal
consolidation or pneumothorax. Perihilar vascular congestion is
noted. There
is no pulmonary edema. Heart size is normal.
There is interval removal of endotracheal tube. Multiple
surgical clips and
TIPS shunt catheter project over right upper abdomen.
IMPRESSION:
Low lung volumes following ET tube removal. No focal
consolidation to suggest
pneumonia.
Brief Hospital Course:
43F with a history of alcoholic cirrhosis (still actively
drinking), history of prior UGIB though now s/p TIPS, who
presents with several episodes of dark red blood per rectum,
drop in BP, and Hct of 20 concerning for active upper vs. lower
GIB.
# Respiratory Failure: She was intubated on admission to the ICU
for airway protection for her EGD and [**Last Name (un) **]. When these were
negative, she remained intubated for her CTA and angio
procedure. After the angio procedure, she was extubated in early
PM, and performed well, but had prolonged sedation following
extubation so PO was not started. She was given 40 mg IV Lasix
for volume overload on her CXR, with a plan to restart her home
Furosemide regimen on the floor. Was on room air on discharge
with no respiratory symptoms.
# GI BLEED: Negative [**Last Name (un) **] and EGD,except for medium non-bleeding
grade 1 internal & external hemorrhoids were noted on [**Last Name (un) **] with
BRB, and therwise normal EGD to jejunum
. Had duodenal varices on CTA. S/p IR guided coiling of duodenal
varices, balloon dilation of TIPS, and stenting of the Rt
hepatic vein, reducing portosystemic pressure from 15 mg to 10
mg. GI bleed apprears to have stopped. She got a total of 11 U
pRBC, 2 U plt, 1 U FFP, 2 U Cryo. She was given CTX, started on
an IV PPI, as well as IV octreotide. Upon leaving the ICU, her
octreotide was DC'ed, and she was placed on CTX and IV PPI.
Ceftriaxone discontinued on [**2164-1-16**] and she was discharged on
home PPI.
.
# PANCYTOPENIA: Likely secondary to liver cirrhosis. Plts and
WBC count are comparable to prior values; Hct baseline is upper
20s-lower 30s as above.
.
# ALCOHOLIC CIRRHOSIS: TIPS, portal vein are patent. Current
MELD is 18-22 and Child-[**Doctor Last Name 14477**] class B-C. She remains an active
drinker. Followed by Dr. [**Last Name (STitle) 497**] though no recent visit in our
system. Transaminases, alk phos are roughly at her baseline;
Tbili and INR are higher than prior baseline. [**1-11**] US reveals
Patent TIPS
Continued lactulose for [**1-22**] BM per day. Restarted home
aldactone and Lasix,
# ACTIVE ALCOHOLISM: Active drinker, no known history of
DTs/seizure. Blood alcohol 238 on arrival to ED.
.
Transitional Issues
Of note her potassium was 3.0 on discharge, she was
supplemented, her primary care physician was called to follow up
on electrolytes on Friday [**2164-1-19**] and they are aware of the low
potassium.
Medications on Admission:
Reglan 10 mg PO TID PRN
- Omeprazole 40 mg PO daily
- Trazodone 100 mg QHS
- Furosemide 60 mg PO daily
- Spironolactone 150 PO BID
- Lidoderm 5% patch last few months
- thiamine HCl 100 mg PO DAILY
- folic acid 1 mg PO DAILY
- lactulose 10 gram/15 mL 30 ML PO QID
- Lorazepam 0.5 mg PO PRN
- multivitamin 1 Tablet PO DAILY
Meds on D/C summary [**6-/2163**]:
- rifaximin 550 mg PO BID (per pt no longer taking)
- risperidone 1 mg PO BID (per pt no longer taking)
Discharge Medications:
1. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety : Do not drive a vehicle with
this medication .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gastrointestinal Bleeding
Alcohol Hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of bleeding in the
gastrointestinal tract. This bleeding was caused by your active
alcohol abuse. Please do not drink alcohol as it is life
threatening.
.
We made no changes to your home medication list.
.
Please follow up with the outpatient appointments below:
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital6 **]
Address: [**First Name8 (NamePattern2) **] [**Last Name (un) 45332**] BLDG, 5TH FL, [**Location (un) **],[**Numeric Identifier 45328**]
Phone: [**Telephone/Fax (1) 45333**]
Appointment: Friday [**2164-1-20**] 10:00am
Department: LIVER CENTER
When: WEDNESDAY [**2164-1-25**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
[
"305.1",
"530.81",
"459.2",
"780.60",
"291.81",
"296.80",
"276.1",
"303.91",
"572.3",
"537.89",
"286.9",
"578.1",
"455.3",
"456.8",
"284.19",
"571.2",
"571.1",
"455.0",
"999.9",
"E879.8",
"401.9",
"280.0",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.44",
"00.45",
"39.90",
"45.13",
"45.23",
"00.40",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
16443, 16449
|
12719, 15171
|
337, 359
|
16555, 16555
|
3428, 7872
|
17086, 17819
|
2573, 2592
|
15684, 16420
|
7912, 8031
|
16470, 16534
|
15197, 15661
|
16706, 17063
|
2607, 3409
|
1765, 2136
|
272, 299
|
8063, 12696
|
388, 1746
|
16570, 16682
|
2158, 2282
|
2298, 2557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,125
| 161,239
|
4991+55627
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-8-1**] Discharge Date: [**2175-8-5**]
Date of Birth: [**2093-5-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2175-8-1**] - Coronary artery bypass grafting x3, left internal
mammary artery graft, left anterior descending, reverse
saphenous vein graft to the posterior descending artery in the
first marginal branch.
History of Present Illness:
82yo Italian speaking male with c/o chest tightness on exertion.
Stress echo was abnormal, showing Inferior Myocardial Infarction
of indeterminate age in the Right Coronary Artery distribution
and ischemia in the Left Anterior Descending Artery
distribution. Cardiac cath reveals severe 3 vessel and left main
coronary artery disease. He is referred for surgical evaluation.
Past Medical History:
coronary artery disease
hypertension
hyperlipidemia
diabetes mellitus type II
osteoarthritis bilateral knees
h/o cataracts
Social History:
Lives with: wife, [**Name (NI) **] and daughter
Occupation: dental technician, works full time
Tobacco: quit 15yrs ago
ETOH: none
Family History:
None Noted
Physical Exam:
Pulse: 45 Resp: 16 O2 sat: 99%RA
B/P Right: 155/59 Left:
Height: 5'8" Weight: 70.3kg
General: NAD, appears stated age
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [] EOMI [x] bilateral lens implants
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] (brady) Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2175-8-1**] ECHO
PREBYPASS
The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mitral regurgitation varies
depending on loading conditions. With a systolic blood pressure
> 160 mmHg, moderate (2+) mitral regurgitation is seen. When the
systolic blood pressure is 100-160 mmHg, the mitral
regurgitation decreases to mild-to-moderate (1+). There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at the time of the study.
POSTBYPASS
The patient is A-paced and is on a phenylephrine infusion.
Overall left ventricular systolic function continues to be
normal without regional wall motion abnormalities. Mitral
regurgitation continues to vary from mild to moderate depending
on loading conditions. Mild aortic regurgitation persists. The
thoracic aorta is normal.
Admission:
[**2175-8-1**] 07:59AM HGB-12.9* calcHCT-39
[**2175-8-1**] 07:59AM GLUCOSE-133* LACTATE-1.0 NA+-138 K+-3.9
CL--107
[**2175-8-1**] 11:50AM PT-14.8* PTT-32.3 INR(PT)-1.3*
[**2175-8-1**] 11:50AM WBC-13.3*# RBC-3.29*# HGB-9.8*# HCT-29.1*#
MCV-89 MCH-29.7 MCHC-33.6 RDW-13.9
[**2175-8-1**] 11:50AM PLT COUNT-130*
[**2175-8-1**] 01:29PM UREA N-15 CREAT-0.6 SODIUM-143 POTASSIUM-4.2
CHLORIDE-116* TOTAL CO2-24 ANION GAP-7*
Discharge:
[**2175-8-3**] 05:40AM BLOOD WBC-8.7 RBC-3.01* Hgb-9.1* Hct-26.1*
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.0 Plt Ct-64*
[**2175-8-3**] 05:40AM BLOOD Plt Ct-64*
[**2175-8-2**] 02:35AM BLOOD PT-14.7* PTT-31.7 INR(PT)-1.3*
[**2175-8-3**] 05:40AM BLOOD Glucose-144* UreaN-26* Creat-0.7 Na-135
K-4.2 Cl-105 HCO3-27 AnGap-7*
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-8-2**] 5:39
PM
[**Hospital 93**] MEDICAL CONDITION: 82 year old man s/p cabg and ct
removal
Preliminary Report
No pneumothorax. Bilateral effusions, bibasal atelectasis are
unchanged.
cardio-mediastinal contours are stable
Brief Hospital Course:
Mr. [**Known lastname 20672**] was admitted to the [**Hospital1 18**] on [**2175-8-1**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative report for
details. In summary he had: Coronary artery bypass grafting x3,
left internal mammary artery graft, left anterior descending,
reverse saphenous vein graft to the posterior descending artery
in the first marginal branch. His cardiopulmonary bypass time
was 92 minutes with a crossclamp time of 64 minutes. He
tolerated the operation well and postoperatively he was taken to
the cardiac surgical intensive care unit for monitoring. Over
the next severall hours, he awoke neurologically intact and was
extubated. He remained hemodynamically stable through the night
and was transferred to the stepdown floor on POD1. All tubes
lines and drains were removed per cardiac surgery protocol. Beta
blockade, aspirin and a statin were resumed. He had a brief
episode of post-operative afib and was started on po amiodarone
with out further episodes. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. The
remainder of his hospital course was uneventful, he continued to
progress in his activity and on POD4 was discharged home with
visiting nurses. He is to follow up with Dr [**Last Name (STitle) **] in 3
weeks-the appointment has been scheduled.
Medications on Admission:
Plavix 75', Flovent 2 spray QD, Vicodin 5/500 1 Tab Q4-prn,
Lopressor 25", Nitroglycerin 0.4 Sl/prn, ACTOS 30', ASA 325'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): 400mg tid for 5 days then [**Hospital1 **] for 7days the daily for 7
days then 200mg po daily.
Disp:*180 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*55 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease- s/p CABGx3
hypertension
hyperlipidemia
diabetes mellitus type II
osteoarthritis bilateral knees
h/o cataracts
Discharge Condition:
Sternal Precautions:
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be cleared to drive
No lifting more than 10 pounds for 10 weeks
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2175-8-31**] 1:15
Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on [**9-7**] at 1pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] in [**3-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2175-8-5**] Name: [**Known lastname 3452**],[**Known firstname 885**] Unit No: [**Numeric Identifier 3453**]
Admission Date: [**2175-8-1**] Discharge Date: [**2175-8-5**]
Date of Birth: [**2093-5-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Mr [**Known lastname **] was also sent home on potassoum 20meq [**Hospital1 **] x 10days
with 10 days of lasix 20mg po bid.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2175-8-5**]
|
[
"997.1",
"427.31",
"E878.2",
"414.2",
"413.9",
"715.96",
"250.00",
"272.4",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9573, 9753
|
4397, 5935
|
330, 541
|
7368, 7592
|
1996, 4164
|
8432, 9550
|
1256, 1268
|
6107, 7108
|
4201, 4374
|
7210, 7347
|
5961, 6084
|
7616, 8409
|
1283, 1977
|
280, 292
|
569, 945
|
967, 1092
|
1108, 1240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,338
| 167,232
|
28144
|
Discharge summary
|
report
|
Admission Date: [**2131-4-5**] Discharge Date: [**2131-4-13**]
Date of Birth: [**2069-9-12**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Admitted electively for cycle #6 high-dose methotrexate for CNS
lymphoma.
Major Surgical or Invasive Procedure:
- IVC filter placement [**2131-4-11**].
- Left Craniotomy for subdural hematoma [**2131-4-10**]
History of Present Illness:
61 yo with CNS lymphoma admitted electively for Cycle #6 of high
dose MTX. SInce her last chemotherapy at the end of [**Month (only) 956**],
she was admitted with foot pain and swelling due to bilateral
lower extremity DVT's and found to have multiple PE's on CTA for
minimal pleuritic chest pain. She was started on enoxaparin [**Hospital1 **]
and reports both her foot pain and her left anterior pleuritic
pain on deep inspiration have completely resolved. Her CTA
suggested infiltrates consistent with a pneumonia so the patient
was also treated with an outpatient course of azithromicin. She
continues to taper her steroids. On ROS she denies fevers,
sweats, chills, productive cough, hemoptysis, chest pain,
pleuritic pain, leg or calf pain or swelling. She denies abd
pain, diarrhea, constipation, dysuria. She has no new neurologic
symptoms including weakness, numbness, tingling, seizure, change
in vision. She does report a transient left anterior head pain
with cough or standing rapidly from a sitting position. All
other ROS is negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Patient initially presented to [**Hospital1 18**] [**Location (un) 620**] for abnormal brain
MRI findings. She had been seen for chronic headache by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68413**] when she had noticed a facial droop, timeline of
onset unclear. [**Name2 (NI) **] MRI ordered and patient noted to have
thalamic lesion. Patient admitted with R sided facial droop,
headache, and underwent sterotactic brain biopsy on [**2131-1-12**] at
[**Hospital1 18**] with results c/w CNS lymphoma.
- [**2131-1-14**] Cycle #1 high-dose MTX 3500mg/m2.
- [**2131-1-26**] Cycle #2 high-dose MTX 3797mg/m2 (=6000mg total).
- [**2131-2-8**] Cycle #3 high-dose MTX 6000mg/m2.
- [**2131-2-22**] Cycle #4 high-dose MTX 6000mg/m2.
- [**2131-3-8**] Cycle #5 high-dose MTX 6000mg/m2, complicated by
bilateral DVT/PE and pneumonia.
- [**2131-4-5**] Cycle #6 high-dose MTX 6000mg/m2.
.
OTHER PAST MEDICAL HISTORY:
-Diverticulosis.
-Migraine, on verapamil PPx.
-MGUS.
-Glaucoma.
-Chronic dry eyes.
-Constipation.
-Benign ovarian tumor s/p resection.
-Breast lumps.
-L4/L5 radiculopathy.
-Bilateral DVT/PE, 3/[**2131**].
-Pneumonia, 3/[**2131**].
Social History:
She is single and lives with her sister.She is a part-time
teacher of English as a foreign language at the SHOA Institute
in [**Location (un) 538**]. She does not smoke. She uses alcohol rarely
and denies illicit drug use.
Family History:
Notable for idiopathic pulmonary fibrosis, colorectal cancer and
HIV in her father, [**Name (NI) **] granulomatosis in a sister. B-cell
lymphoma in aunt. She does not have children.
Physical Exam:
ADMISSION EXAM:
VS: T 98.2F, BP 102/58, HR 69, RR 18, O2 sat 94% RA,
wght 133.3 lbs, ht 63in.
Gen: A&O, NAD.
HEENT: Anicteric sclerae, PEARLA, EOM intact, CNs intact, MMM,
normal oropharynx, supple neck. No bruits, no JVD
LN: No cervical, supraclavicular, axillary, or inguinal LAD.
CVS: RRR, no MRG. Port non-erythematous, non-tender.
Resp: CTA. No accessory muscle use. Normal excursion. No
wheezing or rhonchi.
Back: No spine/rib tenderness.
Ab: Soft, NT, ND, no HSM, + BS.
Ext: Trace right dorsal foot edema, no calf tenderness, no
finger clubbing.
Neuro: Strength 5/5 except [**4-19**] at right foot plantar
flexion,sensation normal to touch, down-going plantar reflexes,
normal finger-thumb pointing.
Skin: No rashes.
Psych: Calm and appropriate.
Pertinent Results:
ADMISSION LABS:
[**2131-4-5**] 02:01PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2131-4-5**] 02:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2131-4-5**] 10:13AM GLUCOSE-97 UREA N-14 CREAT-0.5 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-29 ANION GAP-11
[**2131-4-5**] 10:13AM ALT(SGPT)-57* AST(SGOT)-48* LD(LDH)-269* ALK
PHOS-93 TOT BILI-0.2
[**2131-4-5**] 10:13AM ALBUMIN-3.7 CALCIUM-9.8 PHOSPHATE-4.4
MAGNESIUM-2.0
[**2131-4-5**] 10:13AM WBC-7.9# RBC-3.55* HGB-10.7* HCT-34.4* MCV-97
MCH-30.3 MCHC-31.2# RDW-15.4
[**2131-4-5**] 10:13AM NEUTS-58.4 LYMPHS-28.3 MONOS-11.5* EOS-1.2
BASOS-0.6
[**2131-4-5**] 10:13AM PLT COUNT-269#
[**2131-4-5**] 10:13AM PT-11.8 PTT-38.3* INR(PT)-1.1
.
[**2131-4-5**] CXR: suspected early pneumonic infiltrates in right
infrahilar and lower lobe position are less prominent but some
residuals exist. Similarly, some hazy densities in the left
lower lobe persist and appear to be stable when comparison is
made with the previous study. No new acute parenchymal
infiltrates are seen. There is no pneumothorax in the apical
area. The lateral and posterior pleural sinuses are free from
any fluid accumulation.
.
[**2131-4-6**] MRI BRAIN: IMPRESSION: Left-sided subdural hematoma,
which is new since the previous CT of [**2131-3-17**] and measures
approximately 20 mm in maximum width. The hematoma has
components of acute, subacute and hyperacute blood products
indicating continued hemorrhage. Enhancement along the dura on
post-gadolinium images likely represent dural inflammation from
hematoma but associated tumor infiltration cannot be completely
excluded. Mass effect is seen on the left
cerebral hemisphere with midline shift, but no subfalcine
herniation or basal cisterns herniation seen. No hydrocephalus.
Post-therapy changes are visualized in the left thalamus and
basal ganglia region. No enhancing brain masses identified. No
acute infarct is seen.
.
[**2131-4-7**] CT HEAD: IMPRESSION:
1. Acute/subacute moderate left hemispheric subdural hematoma
with 9-mm rightward shift of midline structures, allowing for
differences in technique, is stable since earlier study of
[**2131-4-6**].
2. No new parenchymal bleed.
3. Stable hyperdense left thalamic lesion.
[**2131-4-10**] CT Head: IMPRESSION: Status post left frontal
hemicraniectomy and drainage of left frontal subdural hemorrhage
with expected post-surgical changes and interval improvement of
rightward shift of midline structures. Residual left frontal
subdural hematoma is present. Followup CT may be obtained for
further evaluation.
[**2131-4-11**] CT head
Stable
Brief Hospital Course:
# New RUE dysmetria: in setting of migraine, but also
anticoagulated for recent DVT's and PE's. DDx includes
complicated migraine, tumor progression, hemorrhagic CVA or
stroke
- reviewed with Dr. [**Last Name (STitle) 724**]
- will obtain MRI with contrast
- neuro checks Q2H
- hold enoxaparin until rule out intracranial bleed
.
# Migraine headache: Continued verapamil and riboflavin PPx and
PRN butalbital-acetaminophen-caffeine (Fioricet), rizatripan,
acetaminophen. Dilaudid prn.
.
# CNS lymphoma: Given high-dose MTX 6g/m2 [**2131-4-5**]. Did not
receive Decadron premed intitially but added this with her
nausea and vomiting last PM.
- Leucovorin rescue 24hrs later.
- Bicarb: 1meq/kg IV prior to MTX, 25meq IV with chemo, 150meq/L
IVF, and 1300mg PO q6hr + additional bicarb to maintain urine pH
>8 to enhance MTX excretion.
- Follow MTX levels daily.
- Leucovorin 20mg PO/IV q6hrs starting 24hrs after MTX.
- Anti-emetics prn.
- [**Month (only) 116**] need to change fluids to 75meq biacrb in 1/2NS at 150cc/hr
if elevated blood sugars due to a combination of D5 IVF and
dexamethasone pre-meds similar to previous admissions.
- Monitor weight and consider furosemide.
- [**Month (only) 116**] need to increase Dexamethasone taper since last taper
triggered severe migraines
.
# Recent DVT and PE: held lovenox 60 mg [**Hospital1 **] in light of new sdh
/ pt had IVCF placed.
# Recent Pneumonia: no symptoms of an infection after
azithromicin course. CXR does not show any new or progressive
infiltrates. Follow physical exam. Consider more detailed
imaging if she spikes or develops respiratory symptoms
.
# Anemia: Chemo-induced. Will monitor.
.
# Hyperglycemia: As above. IVF changed and will follow blood
sugars.
.
# Transaminitis: Worse this am. Likely due to MTX. Trend daily
and consider further work up if they increase further.
.
# Glaucoma/dry eyes: Continue home timolol, cyclosporine gtts,
artifical tears, and lubricant.
.
# Chronic constipation: Continue bowel regimen.
.
# FEN: Regular MTX/cardiac diet No carbonated beverages, vitamin
C, or citric acid to promote alkalosis. Replete hypokalemia. IV
fluids per protocol. Metabolic alkalosis secondary to
administered bicarb.
.
# DVT prophylaxis: Ambulation./ Boots / IVCF
.
# GI prophylaxis: Continued outpatient H2 blocker and bowel
regimen.
.
# Lines: Port.
.
# Precautions: None.
.
# CODE: FULL.
61yo woman with CNS lymphoma admitted for cycle #6 high-dose
methotrexate. The night of HD 1 she developed severe Migraine
headache with nausea and vomiting. Headache and nausea resolved
the next afternoon, but she was noted to have new RUE dysmetria.
Her enoxaparin was held, neuro checks were started and an MRI
with contrast was obtained. This showed a SDH on the right. She
was transferred to the Neurosurgery service and underwent a left
sided craniotomy. Surgery was without complication and she
tolerated it well. Post operative head CT revealed evacuated SDH
with small residual acute blood. The patient was continued to
have right facial and hand weakness. The following day, she had
an IVC filter placed given her history of PE/DVT. Her subdural
drain was pulled in the afternoon. She had a CT head that showed
expected post operativ echanges. Her diet and activity were
advanced. Her RUE motor strength continued to improved. She was
seen by speech and swallow for pocketing of food in the right
cheek. They recommended to continue a regular diet and 1:1
assist with all meals. She was DC'd to rehab in stable
condition.
Medications on Admission:
butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One PO
Q8H prn.
Restasis 0.05 % Dropperette Sig: 1 drop in each eye twice a day.
dexamethasone 0.5 mg Tablet PO EVERY OTHER DAY
gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
Maxalt 10 mg Tablet Sig: One (1) Tablet PO twice a day prn
headache.
timolol maleate 0.5 % Drops DAILY (Daily).
verapamil 240 mg Tablet Extended Release 1 Tablet PO BID (2
times a day).
riboflavin 50 mg Tablet Sig: Eight (8) Tablet PO DAILY
enoxaparin 60 mg/0.6 mL [**Hospital1 **]
Colace
Senna
Bisacodyl
Zofran prn
Compazine prn
Miralax
Vitamin D
MVI
[**Last Name (un) 68419**] and Lomb lubricant eye ointment
Thera tears
Fluticasone nose spray 2 sprays each nostril daily prn
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed for migraine.
2. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. rizatriptan 10 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for migraine.
5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
6. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO BID (2 times a day).
7. riboflavin 50 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for loose stool.
10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
13. fluticasone 50 mcg/actuation Spray, Suspension Sig: [**1-15**]
Sprays Nasal DAILY (Daily).
14. Thera Tears 0.25 % Dropperette Sig: 1-2 Drops Ophthalmic
four times a day as needed for dry eyes.
15. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-15**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
18. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
19. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain/headache.
22. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
23. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
1. Cycle #6 high-dose methotrexate chemotherapy.
2. CNS (brain) lymphoma.
3. Right arm weakness.
4. Subdural hematoma (brain bleed).
5. Hyperglycemia.
6. DVT/PE (deep vein thrombosis and pulmonary embolus; clots in
legs and lungs).
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
You were admitted to the hospital for cycle #6 high-dose
methotrexate for CNS (central nervous system, brain) lymphoma.
Chemotherapy was complicated by migraine headaches,
nausea/vomiting, and after you complained about righ-arm
weakness and headache, MRI of the brain showed a subdural
hematoma (brain bleed). Your blood thinner enoxaparin (Lovenox)
was stopped and the seizure medication levetiracetam (Keppra)
was started.
Neurosurgery Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume these until cleared by your surgeon.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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.
.
MEDICATION CHANGES:
1. Dexamethasone [**2131-3-15**] 1.0 mg every other day
[**2131-3-29**] 0.5 mg every other day
[**2131-4-12**] 0.25 mg every other day
[**2131-4-26**] STOP.
2. Levetiracetam (Keppra) 2x a day.
3. Stop enoxaparin (Lovenox).
Followup Instructions:
You next Methotrexate treatment is scheduled for [**2131-5-3**]. You
should report directly to 11R on [**Hospital Ward Name **] for an admission
that may last about 3 days.
You should call [**Telephone/Fax (1) 1669**] for an appointment with Dr. [**First Name (STitle) **]
in 4 weeks with a CT head.
Completed by:[**2131-4-13**]
|
[
"V12.51",
"V58.69",
"276.8",
"346.90",
"365.9",
"432.1",
"285.3",
"V58.11",
"V12.55",
"375.15",
"273.1",
"790.4",
"564.09",
"200.50",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.7",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
13182, 13327
|
6706, 10216
|
379, 477
|
13603, 13669
|
3998, 3998
|
16017, 16349
|
3023, 3209
|
10997, 13159
|
13348, 13582
|
10242, 10974
|
13693, 15750
|
3224, 3979
|
15770, 15994
|
266, 341
|
505, 1557
|
6341, 6683
|
4014, 6023
|
2534, 2766
|
2782, 3007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,703
| 123,073
|
40349
|
Discharge summary
|
report
|
Admission Date: [**2142-11-5**] Discharge Date: [**2142-11-26**]
Date of Birth: [**2084-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
recent myocardial infarction
Major Surgical or Invasive Procedure:
aortic valve replacement(29mm [**Company 1543**] mosaic porcine) [**2142-11-13**]
coronary artery bypass grafts x 3 (LIMA-LAD,SVG-OM,SVG-PLV)
[**2142-11-13**]
History of Present Illness:
This 58 year old white male presented to [**First Name5 (NamePattern1) 5279**] [**Last Name (NamePattern1) 4117**] on [**11-3**]
with severe shortness of breath and left chest pain after a
couple of weeks of flu like symptoms. he ruled in for
infarction with a Troponin of 6. Catheterization revealed
severe triple vessel disease and a decline of left ventricular
function to 35% from 50% in [**2140**]. He was transferred for
operation.
Past Medical History:
insulin dependent diabetes mellitus
previous coronary PCI
peripheral vascular disease
aortic stenosis
diabetic neuropathy
s/p multiple small embolic infarcts with cognitive deficts
depression
cardiomyopathy
s/p Renal Cadaveric transplant
s/p right carotid endarterectomy
Social History:
Lives with:alone. has brothers and sisters but estranged.
Occupation:retired short order cook- retired after transplant
Tobacco: "a lot" - quit [**2136**]
ETOH: history of ETOH 12 beers per day - quit [**2136**].
Family History:
non-contributory
Physical Exam:
admission:
Pulse:72 Resp: 18 O2 sat: 100%RA
B/P Right: 139/72 Left:
Height: Weight:94.5
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] right CEA scar
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI rigth sternal border
Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds
+
[x]- softly distended with left lower quad scar.
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]- mild PVD changes
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2142-11-26**] 04:40AM BLOOD WBC-11.0 RBC-4.27* Hgb-11.0* Hct-33.4*
MCV-78* MCH-25.9* MCHC-33.0 RDW-15.4 Plt Ct-263
[**2142-11-24**] 10:20AM BLOOD WBC-9.4 RBC-4.40* Hgb-11.3* Hct-35.1*
MCV-80* MCH-25.7* MCHC-32.2 RDW-15.4 Plt Ct-268
[**2142-11-26**] 04:40AM BLOOD Glucose-93 UreaN-24* Creat-1.0 Na-137
K-4.0 Cl-99 HCO3-32 AnGap-10
[**2142-11-24**] 10:20AM BLOOD Glucose-218* UreaN-24* Creat-1.1 Na-139
K-4.2 Cl-99 HCO3-30 AnGap-14
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. An epiaortic scan was
performed. There are simple atheroma in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
6. The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate
(2+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
8. There is a very small pericardial effusion.
9. A small left pleural effusion is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of epinephrine and phenylephrine
1. Prosthetic aortic valve appears well seated with no aortic
insufficiency
2. The RV function is normal
3. The LVEF is 55%, with hypokinesis of the inferoseptal wall
4. 1+ mitral regurgitation persists post-bypass
5. Aortic contours normal post-decannulation
Dr. [**Last Name (STitle) 914**] was notified in person of these results
Brief Hospital Course:
Following transfer the usual preoperative workup was undertaken.
Plavix was stopped and allowed to wash out of patients system.
He had an Enterococcus urinary tract infection, treated with
Ampicillin. On [**11-13**] he went to the Operating Room where
AVR/coronary bypass grafting was performed. Please see operative
report for details in summary he had: Aortic valve replacement
with a 29 mm [**Company 1543**] Mosaic Ultra bioprosthesis, serial
number [**Serial Number 88496**]. Coronary bypass grafting x3 with left
internal mammary artery to left anterior descending coronary;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary; reverse saphenous vein single graft from
aorta to the posterior left coronary artery. Endoscopic left
greater saphenous vein harvesting. His CARDIAC BYPASS TIME was
146 minutes with a
CROSSCLAMP TIME of 111 minutes.
He weaned from bypass on Epinephrine, Propofol and Insulin
infusions. He remained stable, pressors and inotropes were
weaned and he was extubated on POD 3. A Lasix infusion was
begun for gentle diuresis and he progressed well.
He developed a small fluid collection anterior to the sternum in
the lower pole which drained old thin brown fluid. The sternum
was stable and skin intact. Betadine swabbigng,dry dressings and
Vancomycin were begun. With diuresis and vancomycin his BUN and
Creatinine rose slightly. There was no fever or leukocytosis and
antibiotics were changed to Kezol and Lasix stopped.
All tubes lines and drains were removed per cardiac surgery
protocol. On [**11-18**] he was transferred to the floor for further
recovery.
Physical Therapy was consulted. The renal transplant nephrology
service followed him while in the [**Month/Year (2) **].
He made slow progress in his activity level and on POD 13 he was
cleared for transfer to rehabilitation at [**Doctor Last Name **]Rehab.
Sternal drainage had stopped and antibiotics were discontinued.
STOP [**11-23**]
Medications on Admission:
ASA 81, Coreg 25mg daily, palvix 75 daily, cardizem 180 daily,
ergocalciferol 50,000 monthly, HCTZ 25 daily, Novolog 70/30 36
units qam and 46 units qpm, Imdur 30 daily, lisinopril 20 daily,
glucophage 500mg [**Hospital1 **], Niaspan 500mg qhs, pravachol 40mg qhs,
Prograft 1mg [**Hospital1 **], Flomax 0.4mg daily
Plavix - last dose:[**2142-11-5**] 75mg
Discharge Medications:
1. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. niacin 500 mg Tablet Sig: One (1) Capsule, Sustained Release
PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
7. 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*
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x10 days the 200mg QD.
Disp:*40 Tablet(s)* Refills:*2*
11. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-27**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
14. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: 80mg [**Hospital1 **] x 1 week, then 40mg daily until further
instructed.
15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day): 20mEq [**Hospital1 **] x 1 week, then 20mEq daily until further
instructed.
16. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
17. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous twice a day: 30 units with breakfast
and 30 units with dinner.
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: see attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafts
s/p aortic valve replacement
s/p NSTEMI
s/p embolic strokes w/ residual cognitive deficit
peripheral vascular disease
s/p cadaveric renal transplant
insulin dependent diabetes mellitus
peripheral neuropathy
s/p right carotid endarterectomy
aortic stenosis
ischemic cardiomyopathy
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: 2+ bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]on [**2142-12-11**] 3:00
Cardiologist:Dr [**Last Name (STitle) **] [**Name (STitle) **] on [**12-17**] at 3:20pm
Please call to schedule appointments with:
Primary Care: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 88497**] ([**Telephone/Fax (1) 76133**]) in [**4-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2142-11-26**]
|
[
"414.01",
"041.04",
"599.0",
"357.2",
"V42.0",
"410.71",
"V45.85",
"577.0",
"V45.82",
"746.4",
"424.1",
"250.60",
"438.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"38.93",
"35.21",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8938, 8968
|
4298, 6267
|
350, 511
|
9351, 9583
|
2308, 4275
|
10423, 11034
|
1523, 1541
|
6674, 8915
|
8989, 9330
|
6293, 6651
|
9607, 10400
|
1556, 2289
|
282, 312
|
539, 982
|
1004, 1276
|
1292, 1507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,454
| 177,751
|
44602
|
Discharge summary
|
report
|
Admission Date: [**2189-2-9**] Discharge Date: [**2189-2-16**]
Date of Birth: [**2104-8-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Duodenal perforation after ERCP.
Major Surgical or Invasive Procedure:
-[**2189-2-9**] ERCP complicated by duodenal perforation
-[**2189-2-10**] External biliary drain placement by interventional
radiology
History of Present Illness:
84F w/ possible duodenal perforation during ERCP today. Pt w/
complicated medical history including A-fib requiring coumadin,
hypertension and CHF initially presented to [**Hospital 4199**] Hospital ED
three days ago w/ fatigue, diarrhea & hypotension. Noted to be
guiac positive with Hct down to 14 from her baseline 36. Her INR
was supratherapeutic at 16. Anticoagulation was reversed w/ Vit
K, she had a central line placed and was admitted to the ICU
where she received several units of PRBCs and FFP. After
stabilization of her bleeding and blood pressure, she underwent
CT abdomen which demonstrated a mass in the head of her
pancreas. She was seen by Dr. [**First Name (STitle) **] of heme-onc at that time.
She was sent to [**Hospital1 18**] for ERCP and possible stent placement.
During the procedure a 2cm perforation was noted in the
duodenum. The procedure was terminated without sphincterotomy,
an NGT was placed, and surgery urgently consulted.
Past Medical History:
PMH:
- Atrial fibrillation, on coumadin
- CHF
- HTN
- Depression
- Hard of hearing
.
PSH:
- appendectomy
- cholecystectomy
Physical Exam:
Physical Exam on Admission:
97.9 110AF 115/80 18 100%RA
Somnolent, somewhat confused (A&O to self)
Icteric skin, scleral icertus
No cervical, supraclavicular or axial lymphadenopathy
Irreg irreg
CTA bilat
Abd w/ well healed midline surgical scar. Soft. Nontender
throughout. No guarding. No tympanny. No shake tenderness.
Lower extremities edematous w/ brawny skin changes
.
Physical Exam on Discharge:
All vital signs stable
irreg irreg, no m/r/g
CTA bilaterally
Abd soft, non-tender, mildly distended, +BS all 4 quadrants, RUQ
biliary drain in place with bilious output
Pertinent Results:
[**2189-2-9**] 04:26PM BLOOD WBC-6.9 RBC-3.67* Hgb-11.8* Hct-34.1*
MCV-93 MCH-32.0 MCHC-34.5 RDW-18.1* Plt Ct-193
[**2189-2-12**] 01:07AM BLOOD WBC-7.1 RBC-3.32* Hgb-10.6* Hct-31.0*
MCV-93 MCH-32.0 MCHC-34.4 RDW-17.7* Plt Ct-219
[**2189-2-9**] 04:26PM BLOOD Neuts-86.1* Lymphs-7.1* Monos-5.5 Eos-0.9
Baso-0.4
[**2189-2-9**] 04:26PM BLOOD PT-14.0* PTT-32.2 INR(PT)-1.3*
[**2189-2-12**] 01:07AM BLOOD Glucose-64* UreaN-15 Creat-0.5 Na-136
K-4.1 Cl-100 HCO3-25 AnGap-15
[**2189-2-9**] 04:26PM BLOOD ALT-62* AST-91* AlkPhos-480*
TotBili-10.1* DirBili-6.3* IndBili-3.8
[**2189-2-10**] 01:39AM BLOOD ALT-56* AST-65* AlkPhos-465*
TotBili-12.1*
[**2189-2-11**] 02:04AM BLOOD ALT-39 AST-42* LD(LDH)-145 AlkPhos-374*
TotBili-6.8*
[**2189-2-12**] 01:07AM BLOOD ALT-27 AST-22 LD(LDH)-160 AlkPhos-286*
TotBili-4.9*
[**2189-2-10**] 02:25PM BLOOD Type-ART Temp-37 Tidal V-600 FiO2-50
pO2-261* pCO2-35 pH-7.51* calTCO2-29 Base XS-5 Intubat-INTUBATED
Vent-CONTROLLED Comment-ETT
[**2189-2-10**] 03:55PM BLOOD Glucose-73 Lactate-1.3 Na-133 K-3.4
Cl-101
.
[**2189-2-9**] CT a/p with PO/IV contrast:
1. Significant amount of retroperitoneal free air with
discontinuity of the wall of the 2nd part of the duodenum. The
tip of the NG tube lies adjacent to this area of
discontinuation. Findings are consistent with duodenal
perforation.
2. Moderate amount of intra-abdominal ascites.
3. Small bilateral pleural effusions.
4. 4.8 cm pancreatic head mass consistent with neoplasm.
5. Enhancing liver lesion suspicious for metastasis.
6. Intra- and extra-hepatic biliary duct dilation due to
pancreatic neoplasm.
.
[**2189-2-10**] External Biliary Drain placement:
1. Obstruction of the distal common bile duct on the basis of
extrinsic
compression by extraluminal mass. Obstruction was unable to be
crossed by the guidewire.
2. Moderate diffuse intrahepatic biliary ductal dilatation.
3. Incidental demonstration of pneumoretroperitoneum.
4. Successful placement of 8.0 French external biliary drainage
catheter into the common bile duct via the right anterior
intrahepatic segmental duct.
.
[**2189-2-13**] CT a/p with PO and IV contrast:
IMPRESSION:
1. Persistent extensive retroperitoneal free air predominantly
within the
right hemiabdomen; however, with interval decrease to prior. No
extraluminal oral contrast or retroperitoneal collection here.
2. Similar anasarca, ascites and third spacing.
3. Interval increase in bilateral non-hemorrhagic pleural
effusions with
bibasilar atelectasis at the lung bases.
4. Known large pancreatic head mass consistent with neoplasm.
5. Similar enhancing liver lesion concerning for metastasis.
6. No intrahepatic biliary duct dilation; status post external
biliary
drainage catheter into the common bile duct.
7. Similar prominent retroperitoneal lymph nodes.
Brief Hospital Course:
Post her ERCP for pancreatic head mass the patient was
transferred to the TSICU with NGT in place given concern for
duodenal perforation. She was initially emperically begun on
unasyn/fluconazole, subsequently narrowed to unasyn alone. She
was kept NPO with IVF and the NGT in place, with HR control with
IV lopressor and digoxin. CT a/p with NGT and IV contrast
demonstrated massive pneumoperitoneum/RP free air consistent
with duodenal perforation. Her abdomen remained soft during this
time with very mild epigastric discomfort, and she did not
display septic signs. She underwent external biliary drain (in
common bile duct) placement by IR on [**2189-2-11**]. The drain was not
able to be internalized at that time secondary to peri-ampullary
swelling. She returned to IR on [**2189-2-12**] for attempt at
internalization of her biliary drain. However, shortly after
anesthesia induction/intubation, pt's BP decreased along w/ RVR,
treated accordingly by anesthesia. They noted possible inferior
ST wave depressions despite normalization of BP after HR
control. The decision to abort the procedure was made and
patient was reversed and extubated. Formal cardiac rule-out back
in TSICU was negative by clinical exam, EKG and cardiac enzymes.
The family decided not to pursue attempt to internalize drain
the next day. Instead, they requested repeat CT scan, which
showed no active extravasation of contrast from the duodenum.
Her diet was advanced, and on the day of discharge, HD8, she was
tolerating a regular diet. [**2189-2-14**] CDiff returned positive and
she was begun on IV flagyl (in addition to her IV unasyn). On
discharge external biliary catheter was in place, and the family
was instructed to follow up with Dr. [**First Name (STitle) **]. Future discussion
regarding internalization of the drain may be undertaken at that
time. Her home coumadin was restarted (2.5 mg) on HD8, [**2189-2-16**],
and she should have her INR checked on [**2189-2-17**] at rehab. She was
discharged to rehab on [**2189-2-16**], HD8, tolerating a regular diet
with external biliary drain in place, to complete a course of
augmentin given her duodenal perforation, and po flagyl given
her Cdiff + stool. In addition to follow-up with Dr. [**First Name (STitle) **],
follow up appointment was also arranged with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(hematology-oncology) of [**Hospital 4199**] Hospital on discharge (who had
seen her while at [**Last Name (un) 4199**] after her pancreatic mass head was
seen on imaging), and discharge summary was sent to Dr.[**Name (NI) 39123**]
office.
Medications on Admission:
- Metoprolol 100mg [**Hospital1 **]
- Lisinopril 5mg [**Hospital1 **]
- Amlodipine 5mg daily
- Digoxin 0.125mg daily
- Coumadin 2.5mg daily
- Lasix 80mg every other day
- KCl 20mEq PO daily
- Sertraline 100mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for
14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
ERCP complicated by duodenal perforation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for an ERCP procedure to evaluate a mass at
the head of your pancreas. The procedure was complicated by a
perforation of your duodenum, and you were started on IV
antibiotics and underwent a bile-duct drain placement by the
interventional radiologists. The drain was not able to be
internalized because you did not tolerate the anesthesia for
this procedure, and your family elected to hold off on having it
internalized for now. You are being discharged with an external
drain in place, which visiting nurses will help you empty and
care for. You are being discharged on oral antibiotics which you
should continue to take (both for your duodenal perforation and
for a colon infection called "C Diff" which you developed while
in the hospital). Please return to the ED or call Dr.[**Name (NI) 5067**]
office if you experience fevers/chills/nausea/vomiting, have
uncontrollable abdominal pain, notice a change in color in your
drain output, or if the drain becomes dislodged. If you would
like to have the drain internalized in the future you will need
to schedule an appointment through Dr.[**Name (NI) 5067**] office to have
this done (re-attempted) by interventional radiology.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] at [**Hospital 4199**] Hospital of
hematology-oncology to discuss the best next steps going forward
for your pancreatic mass (possibly chemotherapy). His office
number is [**Telephone/Fax (1) 56671**]. An appointment has been scheduled for
you on [**3-5**] at 1:30pm (Level B, [**Hospital 4199**] Hospital)
.
You are scheduled to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
hepatobiliary surgery on Monday [**3-9**] at 3:15 PM. The office
is located in the [**Location (un) 470**] of the [**Hospital Unit Name **] at [**Hospital1 18**] ([**Last Name (NamePattern1) 12939**], [**Location (un) 86**], [**Numeric Identifier 718**]). Please call the office at
[**Telephone/Fax (1) 2998**] if you need to reschedule this appointment.
Completed by:[**2189-2-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
"51.98",
"87.51",
"45.13"
] |
icd9pcs
|
[
[
[]
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8815, 8815
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|
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|
1482, 1607
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,993
| 115,213
|
51473
|
Discharge summary
|
report
|
Admission Date: [**2186-12-14**] Discharge Date: [**2186-12-23**]
Date of Birth: [**2116-4-8**] Sex: M
Service: SURGERY
Allergies:
Vancomycin / Shellfish Derived
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Non-productive cough, lethargy and 13 point drop in Hct, CXR
from PCP showed no acute process.
Major Surgical or Invasive Procedure:
[**2186-12-14**] Endovascular repair of aortic psuedoaneurysm and
placement R renal stent for aortic graft leak.
[**2186-12-16**] Oral exploration and extraction of infected foreign body
and teeth #s 2, 3, 4, 5 and 6.
History of Present Illness:
70 y-o gentleman presents as transfer from [**Hospital1 6687**] for
low HCT. The patient initially presented to his PCP today with [**Name Initial (PRE) **]
new non-productive cough and lethargy. The PCP obtained [**Name Initial (PRE) **] CXR
that showed no acute process. During the patient's workup, the
patient's HCT was found to be 18.1. His baseline is low 30's,
and
the most recent documented HCT before today was 31 in 5/[**2186**].
Even though the patient had no complaints of abdominal pain or
vomiting, an NGT was placed in the patient in [**Hospital1 6687**] - lavage
was guaiac negative. The patient was transferred to [**Hospital1 18**] for
further eval, given his history of recent surgery at this
hospital. On arrival the patient reports no chest pain or
abdominal pain. He has no leg pain and he says he walks around
with a cane without any cramps in his legs. He occasionally
feels pain in his left foot when in bed at nighttime. He denies
any recent fevers or chills. His last BM was yesterday, and the
patient states there was no blood in his stool. Of note, the
patient was admitted to [**Hospital1 18**] in [**2186-2-10**] for melanotic stools -
UGI and colonoscopy obtained at the time were normal. [**Year (4 digits) **]
surgery was consulted for potential aorto-enteric fistula in
this
patient, given his history of aorta repair and his seemingly
sudden drop in HCT. Of note, the patient received 2 units of
pRBCs prior to transfer to [**Hospital1 18**].
Past Medical History:
Hyperlipidemia
HTN
Embolic stroke history, with extended hospitalization and
rehabilitation after bowel surgery [**4-/2185**]
CAD w/ severe 3-vessel disease shown in [**2166**]
AAA - infrarenal 4.8cm s/p repair
PVD
CRI
CHF - reported in prior echo as "depressed EF" without exact
quanitification
Afib s/p ablation [**12-11**]
SDH fall in [**10-16**]
Right fem [**Doctor Last Name **] in situ (93)
s/p Left fem [**Doctor Last Name **] in situ (93)
Vein angioplasty of left femoral artery 01
Hearing impairment
Ischemic bowel s/p SB resection [**4-17**] with MSA stent
Past history EtOH abuse
Social History:
Heavy drinker in past, indicates stopped drinking 1 year ago,
1ppd tobacco for many years until 1 year ago, used to work as a
lawyer (real estate property) and retired in his 50s, now lives
in [**Hospital1 6687**] with wife, who is a school teacher.
Family History:
NC
Physical Exam:
VS T 98.8 P 68 BP 128/48 RR 16 O2 sat 93% on 2 L O2
Gen: NAD, alert and oriented
Heart: RRR, no murmur
Lungs: exp. wheezes b/l, diminished bases
Abd: distended, soft, non-tender, positive bowel sounds
Ext: well perfused b/l
Pulses: DP PT
R Dop palp
L palp palp
Pertinent Results:
[**2186-12-19**] 05:23AM BLOOD
WBC-6.7 RBC-3.21* Hgb-9.3* Hct-27.9* MCV-87 MCH-28.9 MCHC-33.3
RDW-17.5* Plt Ct-94*
[**2186-12-18**] 06:00AM BLOOD
WBC-5.1 RBC-3.07* Hgb-9.4* Hct-26.8* MCV-87 MCH-30.5 MCHC-34.9
RDW-18.2* Plt Ct-88*
[**2186-12-19**] 05:23AM BLOOD
Plt Ct-94*
[**2186-12-19**] 05:23AM BLOOD
Glucose-95 UreaN-26* Creat-1.6* Na-140 K-3.4 Cl-103 HCO3-30
AnGap-10
[**2186-12-19**] 05:23AM BLOOD
Calcium-7.6* Phos-2.3* Mg-1.7
Cardiology:
ECG Study Date of [**2186-12-13**] 5:31:56 PM
Sinus bradycardia. Poor R wave progression. Lateral ST-T wave
changes
suggest myocardial ischemia. Compared to the previous tracing of
[**2186-3-9**]
the lateral T wave inversions are new.
RADIOLOGY:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2186-12-13**] 8:57
PM
Final Report: Comparison is made with a prior study from
[**2186-3-10**].
IMPRESSION:
Adequate position of right IJ and NG tubes.
Mild congestion with increased retrocardiac density which may
reflect
atelectasis or pneumonia. Small left pleural effusion.
CTA PELVIS W&W/O C & RECONS Study Date of [**2186-12-14**] 12:00 AM
IMPRESSION:
1. Interval development of a large amount of intraperitoneal
fluid measuring 10 Hounsfield units. Althouhg this could be
related to cirrhotic liver, differential diagnostic
consideration includes blood tracking into the peirtoneum from
the presumed retroperitoneal fluid (?blood) collection. The low
attenuation of the peritoneal fluid low may be due to patient's
anemia.
2. Low-density fluid collection along the left psoas muscle is
highly
suspicious for a retroperitoneal bleeding.
3. Abdomanial aortic thrombus at the superior aspect of the
graft.
The findings were discussed with Dr. [**Last Name (STitle) 31549**] at the time of
interpretation.
CHEST (PORTABLE AP) Study Date of [**2186-12-14**] 8:24 PM
The patient was intubated in the meantime interval with the ET
tube tip being 6.5 cm above the carina. The right internal
jugular line tip is in distal SVC. The NG tube tip is in the
stomach. There is interval worsening of aeration of the left
lower lung and bilateral increase in pleural effusion. There is
no significant change in perihilar interstitial opacities most
likely representing pulmonary edema since they have been absent
on the study from [**2185-5-31**], and demonstrates fluctuating on
several subsequent radiographs including [**2186-3-10**]. the
appearance on [**2186-12-13**] study suggests acute origin of
the findings rather than chronic interstitial changes.
The aortic graft is noted in the abdomen.
Brief Hospital Course:
[**2186-12-14**] 70 y-o gentleman transfer from [**Hospital1 6687**] for low HCT.
Days prior presented to his PCP today with [**Name Initial (PRE) **] new non-productive
cough and lethargy. Work-up CXR
showed no acute process. HCT was found to be 18.1. His baseline
is low 30's. [**Name Initial (PRE) **]
surgery was consulted for potential aorto-enteric fistula given
his history of aorta repair and his sudden drop in HCT. Patient
received 2 units of pRBCs from OSH prior to transfer to [**Hospital1 18**].
- CT pelvis- showed large amount of intraperitoneal fluid
measuring 10 Hounsfield
units from Leaking of pseudoaneurysm from proximal aortic
graft anastomosis.
- Pre-oped and taken to OR for:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Ultrasound-guided puncture of left brachial artery.
3. Introduction of catheter into aorta.
4. Abdominal aortogram.
5. Proximal cuff extension placement x 2 to previously
placed aortobifemoral bypass graft.
6. Right renal artery stent.
7. Selective renal arteriogram.
8. Percutaneous groin closure of right common femoral
arteriotomy.
- Post-op admitted to CV ICU
- Transfused with 2 units FFP post-op.
- Intubated
- Sedated
- serial HCT
- DVT prophylaxis
[**2186-12-15**] Remains sedate,intubated. Weaned and extubated later.
Nitro drip for BP control.
- Hepatology consult- for elevated LFT's -likely 2nd to liver
cirrhosis- following.
[**2186-12-16**] Serial Hct, transfused with 1 unit PRBC's for Hct 24.8.
Noted to have rash throughout body.
- Started Lasix [**Hospital1 **].
- Started on Cipro for E-coli in urine
- Pain control
- Transferred to [**Hospital Ward Name 121**] 5 VICU
- Oral surgery consulted for infected tooth/upper quadrant
bridge, consented and taken to the OR for eploration and removal
of infected foreign body (upper quadrant bridge) and #'s 2, 3,
4, 5 and 6 teeth and roof fixation.
[**Date range (1) 106728**] VSS. Monitoring Hct-27.9.
- continued to diurese with Lasix
- Floor status, A-line d/c'd, central line kept
- Physical therapy consult, out of bed
- Diet advanced t o as tolerated, aspiration precaution
[**2186-12-19**] No acute events, extra Lasix dose given for respiratory
congestion and diminished breath sounds.
- CXR-Probable no interval change in left pleural effusion and
left lower lobe
atelectasis.
- Electrolytes repleted.
- INR persist to be elevated- Hepatology re-consulted, will
follow.
- Continues on Cipro- urine culture came back with E-coli
sensitive to Cipro.
[**12-20**] - [**12-22**]
[**Hospital 25403**] rehab, coordination of transportation by
ambulance/ferry to [**Hospital1 6687**].
Stable for DC
Medications on Admission:
Keppra 500 mg [**Hospital1 **]
Lamotrigine 50 mg qhs
Lipitor 80 mg qd
Venlafaxine 25 mg [**Hospital1 **]
Lomotil 2.5 mg tid prn
Metoprolol ER 200 mg qd
Plavix 75 mg qd
Mirtazapine 15 mg qd
Trazodone 25 mg prn qhs
Discharge Medications:
1. Levetiracetam 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
2. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Lamotrigine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
4. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
(every 6 hours) as needed.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
10. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Lipitor 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. Venlafaxine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
13. Keppra 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
14. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO at bedtime.
16. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day.
17. Lomotil 2.5-0.025 mg Tablet [**Hospital1 **]: One (1) Tablet PO three
times a day: prn. Tablet(s)
18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily) for 10 days. Tablet(s)
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) NEB IH
Inhalation Q6H (every 6 hours).
21. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
22. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
23. Venlafaxine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) NEB INH Inhalation Q6H (every 6
hours).
25. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
26. Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Primary:
Aortic psuedoaneurysm
aortic graft leak
UTI
Acute on chronic systolic CHF - requiring Lasix
Infected foreign body and teeth #s 2, 3, 4, 5 and 6.
Secondary:
PVD
Hyperlipidemia
HTN
Embolic CVA (after SBR in [**2185**])
CAD
CRI
PMH: SDH ([**2184**]), ischemic colitis
PSH: Aortobifem bypass [**2173**], SB resection ([**Doctor Last Name **]) & SMA Stent
[**2185**], A Fib s/p ablation [**12/2179**], R SFA occlusive disease, L
SFA occlusive disease s/p angioplasty [**2179**]
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Year (4 digits) **] and Endovascular Surgery
Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-12**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-14**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2187-1-18**] 11:45
Completed by:[**2186-12-23**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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11336, 11379
|
5921, 8574
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386, 607
|
11907, 11916
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3336, 5898
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14526, 14711
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3019, 3023
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8837, 11313
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11400, 11886
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8600, 8814
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11940, 13916
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13942, 14503
|
3038, 3317
|
252, 348
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635, 2121
|
2143, 2735
|
2751, 3003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,213
| 121,897
|
53634
|
Discharge summary
|
report
|
Admission Date: [**2190-5-19**] Discharge Date: [**2190-5-27**]
Date of Birth: [**2114-12-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
RML mass; recent hemorrhage after bx; contrast nephropathy
Major Surgical or Invasive Procedure:
rigid bronch + flex bronch + EBUS/TBNA + BAL/Brush/TBBX +
fluoroscopy with on-site cytology
Intubated on [**5-21**]
PICC placement in L arm on [**5-20**] and [**5-25**]
History of Present Illness:
This is a 75yoF with history of CVA, COPD (88 pack-year), DM,
HTN, HLD who initially presented to [**Hospital1 **]-[**Hospital1 **] on [**5-10**] with
shortness of breath, fevers, chills, night sweats and 10lb wt
loss. In [**3-/2190**], she presented fevers, cough and shortness of
breath. CXR at that time found a PNA. She was to be admitted
however she left AMA with PO antibiotics. She then represented
on [**5-10**] with fevers and worsening dyspnea.
While at [**Hospital1 **]-[**Hospital1 **], she had a CT chest which showed a 10cm RML
compressing mass. Pulmonary was consulted and performed a flex
bronchoscopy, which was complicated by bleeding at biopsy
requiring 1 unit of pRBCs and prolonged intubation. She
ultimately extubated on [**5-16**]. Biopsy was ultimately
nondiagnostic. She then underwent a CT-guided biopsy which was
also nondiagnostic. Patient was then transferred to [**Hospital1 18**] for IP
evaluation and rigid bronchoscopy.
Hospitalization was also complicated by acute renal failure [**1-21**]
contrast induced nephropathy and ATN (possibly [**1-21**] hypotension
during bronchoscopy) and Cr peaked to 2.9 on [**5-18**] and trended
downward prior to transfer. Patient also had leukocytosis which
peaked to 20.8 on [**5-13**] and also trended down on transfer.
On transfer on [**5-20**], patient was appeared well although on
transfer to OR, per IP fellow, she appeared clammy. Her vital
signs were stable. She had a right IJ from [**Hospital1 **] that was
removed and replaced with midline.
During procedure, patient was intubated using rigid
bronchoscopy. An EBUS revealed RML mass. Several biospies were
completed and were uncomplicated (with minimal EBL). Frozen
sections unfortunately continued to be nondiagnostic. Upon
withdrawing rigid bronchoscope, 200cc of frank pus was
suctioned, which was thought to be distal to mass. Patient
received Zosyn intra-operatively. When finishing procedure,
noted to have ~50cc of frank bright red blood from LUL and LLL
(unknown source). Epinephrine was injected which resolved bleed.
Patient remained hemodynamically stable and did not require any
blood products. She did receive 1L NS. Patient remained
intubated for airway protection.
On arrival to the MICU on [**5-21**], patient was intubated and
sedation, not following any commands. She was hypotensive on
arrival but improved with 4L bolus of NS and UOP improved to
50cc/hr.
Past Medical History:
Stroke in [**2187**]
Diabetes mellitus, c/b diabetic nephropathy
COPD (untreated)
Hypertension
Hyperlipidemia
Social History:
Lives by herself, manages ADLs independently. No significant
physical activity. Does not cook often, orders out and eats
candy. Smoked 2PPD from [**2132**] to [**2166**]. No EtOH.
Family History:
Does not know biological father
Mother - [**Name (NI) 11964**]
Grandmother - MI
Grandfather - Stroke
[**Name2 (NI) **] biological children
Physical Exam:
Physical exam on admission:
VS: 97.7 134/66 76 18 100/3L
[**5-19**]: I: 340 O: 400
pMN: I: 120 O: 425
HEENT: Anicteric sclera. MMM. Right IJ in place, no erythema
around IV site.
Cor: RRR, no m/r/g
Pulm: Crackles at right base. Moderate air movement.
Abd: Soft, NTND. +BS. Erythematous, macerated skin under pannus.
Ext: Distal lower extremities cool to touch, intact distal
pulsese. No cyanosis or edema. Violaceous 6cm circular patch on
anterior right forearm.
Neuro: Ptosis of L eyelid, mild left facial droop. Poor fine
motor control (difficulty operating TV remote).
Physical exam on discharge:
VS: 98.8 98 138-169/65-86 60-73 18 96-98/2L
Gen: No acute distress. More well-appearing than yesterday.
Seated in chair.
HEENT: Anicteric sclera. MMM.
Cor: RRR, no m/r/g. HS clearer than on prior exams.
Pulm: Breathing comfortably off O2. Lungs are clear to anterior
auscultation.
Abd: Soft, NTND. +BS.
Ext: Edema of upper extremities, R > L. Left edema improving.
Trace pedal edema. Compression stockings in place. WWP, no
cyanosis.
Neuro: Ptosis of L eyelid, mild left facial droop. Alert.
Pertinent Results:
ADMISSION LABS:
-WBC-9.1 RBC-3.76* Hgb-10.2* Hct-32.1* MCV-85 MCH-27.2 MCHC-31.9
RDW-14.9 Plt Ct-297
-Glucose-236* UreaN-69* Creat-2.5* Na-136 K-6.1* Cl-106 HCO3-23
AnGap-13
-Calcium-8.1* Phos-4.7* Mg-2.0
CXR ([**2190-5-20**]): As compared to the previous radiograph, the
patient still has a right internal jugular vein catheter. The
tip of the catheter projects over the low SVC. There is no
evidence of pneumothorax. Bilateral areas of opacities at the
lung bases are atelectatic in nature. The presence of minimal
pleural effusions cannot be excluded. The right lung mass
described on the referring note cannot be unequivocally
identified.
TTE ([**2190-5-24**]): The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) 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 an anterior space which most likely
represents a prominent fat pad. IMPRESSION: Normal global and
regional biventricular systolic function. No significant
valvular pathology.
CXR ([**2190-5-26**]): As compared to the previous radiograph, the
patient has been extubated and the nasogastric tube has been
removed. A left PICC line is in situ. The tip projects over
the right atrium and should be pulled back by approximately 2
cm. There are unchanged relatively extensive right and moderate
left pleural effusions with signs of mild fluid overload as well
as atelectasis at the lung bases. The visible contours of the
cardiac silhouette are constant. There is no evidence of
pneumothorax.
Labs on discharge:
[**2190-5-27**] 04:09AM BLOOD WBC-6.1# RBC-3.56* Hgb-9.7* Hct-30.3*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.8* Plt Ct-142*
[**2190-5-25**] 06:44AM BLOOD PT-13.3* PTT-32.1 INR(PT)-1.2*
[**2190-5-27**] 04:09AM BLOOD Glucose-102* UreaN-30* Creat-1.9* Na-144
K-3.1* Cl-103 HCO3-31 AnGap-13
[**2190-5-25**] 06:44AM BLOOD ALT-17 AST-16 AlkPhos-82 TotBili-0.5
[**2190-5-27**] 04:09AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.5*
[**2190-5-26**] 09:44AM BLOOD CRP-20.4*
Brief Hospital Course:
75 year-old woman with history of CVA in [**2187**], HTN, HLD, DM,
COPD presented with fevers and worsening dyspnea and was found
to have RML mass at OSH transferred for rigid bronchoscopy that
identified purulent mass, without evidence of malignancy,
requiring 4 weeks of antibiotic threapy.
.
ACTIVE ISSUES:
# LUNG MASS: Patient has large compressive RML mass that was
evaluated using rigid bronchoscopy revealed copious purulent
discharge from mass in RML that was concerning for abscess vs.
neoplasm with post-obstructive PNA. Frozen section from [**Hospital1 18**]
bronchoscopy was unrevealing and cultures grew strep anginosis
and viridans strep, pathology and cytology did not identify
malignancy. Patient initally received linezolid and zosyn that
was narrowed to ceftriaxone and flagyl after consultation with
ID. Antibiotics will be continued for at least 4 weeks. Patient
will follow up the Dr. [**Last Name (STitle) 3373**] in the interventional pulmonology
clinic in 4 weeks. Blood cultures from [**2190-5-22**] are pending.
.
# HYPOTENSION: Pt was hypotensive overnight on [**2190-5-20**] after
arrival to MICU, responsive to IV fluid boluses. This was felt
likely transient distributive shock after complicated IP
procedure. Resolved with IV fluids and ongoing antibiotics.
Hypertension medication restarted on transfer to the floor.
.
# HYPERTENSION: Hyperkalemic on day of transfer to floor.
Lisinopril 5mg washeld, replaced with carvedilol 6.25mg [**Hospital1 **]
after transfer from ICU. Tolerating well with BPs
130s-150s/70s-80s on day of discharge.
.
# ACUTE RENAL FAILURE: Baseline Cr 0.6. Peaked to 2.9 at OSH,
felt [**1-21**] CIN vs. ATN. Trended down while in MICU with IV fluid
boluses, but still 2.0 on transfer back to floor. 1.9 on day of
discharge while on carvedilol.
.
# TYPE 2 IDDM: Complicated by neuropathy. Initially hypoglycemic
in MICU so received D5 drip and home glargine was decreased to
10 units qHS. Home gabapentin was held due to renal failure.
Discharged on 10U qHS glargine and insulin sliding scale.
.
# H/O CVA: home ASA initially held given lung bleed during IP
procedure, restarted on [**2190-5-23**].
.
# RASH: Pt noted to have several patches of confluent vesicles
along midline, not respecting dermatomal pattern. She reported
has similar rash along lower back/buttocks almost monthly,
typically pruritic. Reports has had work-up (unclear what this
was) in past which was unrevealing. Rash also noted under
pannus, treated with topical miconazole.
.
# UPPER EXTREMITY EDEMA: More pronounced in RUE vs. LUE, with
effacment of space between knuckles in R hand. Only trace edema
in lower extremities. More pronounced after transfer from ICU.
No evidence of DVT on RUE ultrasound, continues to improve as
she auto-diureses.
.
# HYPERLIPIDEMIA: continued home simvastatin, decreased dose to
40mg from 80mg
.
# CODE STATUS: On admission, patient's code status was DNR/DNI
but okay to intubate for IP procedure. While in the MICU, she
stated "I want to live, even if I need to suffer", and stated
clearly that she would like to switch back to full code.
.
===================================
Transitional issues:
# LOOSE STOOLS: C. difficile PCR pending at time of discharge,
negative at time dc summary was completed
# BLOOD CULTURES from [**2190-5-22**] pending at time of discharge,
negative at time dc summary was completed
Medications on Admission:
Levofloxacin 250mg @ 10AM daily
Magnesium hydroxide 10ml prn
Pantoprazole 40mg po daily
Lispro - 4U TID w/ meals
Glargine - 30 U daily
Dextrose 25ml x1 PRN IV
Glucagon 1mg x1 PRN IM
Miconazole TID PRN
Heparin 5000 U SQ
Gabapentin 600 mg [**Hospital1 **] po
Simvastatin 40mg qpm
Albuterol 2.5mg q4h prn
Atropine sulfate x1 prn
Lidocaine 73.9mg x1 prn
Nitroglycerin q5min prn
ASA 81mg daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Albuterol Inhaler [**3-26**] PUFF IH Q4H:PRN SOB, Wheeze
4. Carvedilol 6.25 mg PO BID
5. CeftriaXONE 1 gm IV Q24H Duration: 4 Weeks
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 4 Weeks
7. Miconazole Powder 2% 1 Appl TP TID:PRN rash
apply under pannus
8. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
Right lung abscess
Secondary diagnoses:
# post-obstructive pneumonia
# ARF on CKD stage III
# DM II
# s/p CVA [**2187**]
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were transferred to [**Hospital1 69**] on
[**2190-5-19**] for evaluation of a lung mass found on a CT scan. A
sample was taken from the mass on [**2190-5-21**]. You required transfer
to the intensive care unit for bleeding in the lungs from the
procedure to take a sample. Your breathing improved and you were
stable for transfer out of the ICU on [**2190-5-23**].
Three samples of the mass and surrouding tissue were taken
during the procedure and sent to pathologists (doctors who are
experts on analyzing tissue samples). Two samples did not show
any evidence of cancer and a third was deemed a poor sample, and
also without any evidence of cancer.
During the procedure, a substantial amount of infected fluid was
drained from the mass. Cultures to grow the bacteria in the
fluid found a number of different bacteria which are typically
found in the mouth. At this time, we do not know the source of
the bacteria. They can be treated with antibiotics, which you
will have to take for four weeks, until your follow-up
appointment with Dr. [**Last Name (STitle) 3373**].
Prior to your transfer, you had a CT-guided biopsy of the lung
mass. After this procedure, a decrease in your kidney function
was noticed. It has continued to improve since your transfer.
Your primary care physician can follow your kidney function
after you leave the hospital.
This change in kidney function required changes in your
medications. We stopped metformin because there is an increased
risk of side effects with lower kidney function. At the time of
your discharge, your kidney function has not yet improved to a
point where metformin is considered safe. In addition,
gabapentin doses must be adjusted when kidney function changes.
Finally, we noticed a change in the amount of potassium in your
blood, which can happen with changed kidney function, but can be
made worse by lisinopril, so changed your high blood pressure
medicine to carvedilol.
While you were in our care, we continued your other home
medications. We gave 30 units of long-acting insulin, and
adjusted your short-acting insulin as needed.
We made the following changes to your medications:
You were admitted to [**Hospital3 **] on:
Novalog sliding scale
Lantus 30U every morning
Metformin 1000mg twice a day
ASA 81mg daily
Simvastatin 80mg daily
Gabapentin 600mg twice a day
Lisinopril 5mg daily
The following changes were made because of changes in your how
your kidneys were working which can change the side effects of
medicines:
1. STOP Lisinopril 5mg daily
2. STOP Metformin 1000mg twice a day
3. STOP Gabapentin 600mg twice a day
The FDA now recommends that patients do not take more than 40mg
of simvastatin:
4. DECREASE Simvastatin to 40mg at night
You were started on antibiotics while in the hospital. You are
currently taking:
5. START Metronidazole 500mg by IV every eight hours for 4 weeks
6. START Ceftriaxone 1gm by IV every twenty-four hours for 4
weeks
We started a new medicine for your high blood pressure:
7. START Carvedilol 6.25mg twice daily
We also started a new inhaler in case you become short of
breath:
8. START albuterol inhaler 4-6 puffs every four hours as needed
for shortness of breath
Finally, we were using a powder to treat a mild fungal infection
of your skin:
9. START Miconazole powder 2% applied three time a day as needed
for rash.
No other changes were made to you medicines.
At this time, you will benefit from rehabilitation with physical
therapy. The interventional pulmonolgy team at [**Hospital1 18**] would like
to follow-up with you in one month about any further steps that
may be required. You will need a CT scan of your lungs prior at
that time. We have scheduled both appointments for you and
included the details below.
It was a pleasure participating in your care at [**Hospital1 18**].
Followup Instructions:
When: THURSDAY [**2190-6-24**] at 9:45 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Campus: EAST Best Parking: Main Garage
****Do not eat or drink anything 3 hours prior to scan***
When: THURSDAY [**2190-6-24**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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362, 532
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,168
| 142,354
|
36149
|
Discharge summary
|
report
|
Admission Date: [**2164-11-11**] Discharge Date: [**2164-11-27**]
Date of Birth: [**2146-7-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Pelvic fracture, splenic laceration, renal laceration, liver
laceration, bilateral radial/ulnar fractures s/p motor vehicle
accident
Major Surgical or Invasive Procedure:
1. Right percutaneous placement of inferior vena cava filter.
2. Open reduction internal fixation posterior component of
T-type acetabular fracture.
3. Open reduction internal fixation of the left distal radius
fracture, 2 parts.
History of Present Illness:
18M transferred from OSH s/p MVC w/tree, unrestrained, self
extricated, ?LOC, air bags deployed. Taken to OSH where he was
intubated electively and was found to have bilateral UE fx's, R
pelvic fx. On tx to [**Hospital1 18**] initial survery revealed +FAST, CT
revealed, Grade 4 splenic lac, grade 2 liver lac, grade 2 renal
lac, B UE and R pelvis fx's
Past Medical History:
None
Social History:
Lives with mother, presently homeless on admission. Has a place
to stay for recovery upon dicharge.
Family History:
Noncontributory
Physical Exam:
T:97.8 HR:157 BP:179/130 RR:18 POX:100 Intubated
Gen: Intubated, collared, sedated
HEENT: Pupils [**3-28**] reactive, L eyebrow laceration
Chest: Equal b/s bilat, + CO2 change
CV: Tachycardic
Abdomen: Soft
Pelvis: stable
MS: Bilat dopplerable pulses UE/LE, gross deformity of L wrist
Pertinent Results:
[**2164-11-11**] 11:19PM HCT-30.8*
[**2164-11-11**] 08:49PM GLUCOSE-138* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-23 ANION GAP-11
[**2164-11-11**] 08:49PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-1.8
[**2164-11-11**] 08:49PM WBC-8.7 RBC-3.96* HGB-11.6* HCT-32.1* MCV-81*
MCH-29.3 MCHC-36.2* RDW-13.4
[**2164-11-11**] 08:49PM PLT COUNT-246
[**2164-11-11**] 02:59PM PT-13.1 PTT-26.7 INR(PT)-1.1
Brief Hospital Course:
Pt admitted to SICU. HD1 traction pin placement with closed
reduction of left wrist by orthopedics. HD2 To OR with
orthopedics and gen [**Doctor First Name **] for ORIF of L hip, R forearm and
placement of IVC filter. HD3 Pt was extubated. HD4 Pt
transferred to hospital floor. HD5 Pt was taken back to the OR
and had remainder of ORIF of L hip completed along with closed
reduction and pinning of L distal radius. HD6 pt was
transitioned to oral medications and began [**Hospital **]
rehabilitation process with physical and occupational therapy.
HD10 surgical incisional wounds noted to be intact with
subcutaneous adipose tissue protruding through portions of the
wound. HD15 Staples removed except ones over posterior pelvis
wound. HD16 Pt progressing well with PT and OT and able to
transfer to wheelchair with appropriate pain relief. HD18 Pt
d/c home.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*6000 mg* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Disp:*90 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg/5 mL Solution Sig: 10-20 mg PO Q3H (every 3
hours) as needed for pain.
Disp:*500 ml* Refills:*0*
4. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right T-type acetabular fracture and left distal radius
fracture.
2. Complex pelvic fracture.
3. Grade 4 splenic laceration.
4. Grade 2 renal laceration.
5. Grade 2 liver laceration.
6. Affect dyscontrol
Discharge Condition:
Good, ambulating with assistance, pain well controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1005**] at [**Telephone/Fax (1) 1228**] to arrange for a
follow up in 2 weeks
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 81982**] to arrange for a
follow up appointment in 2 weeks.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2165-1-15**] 11:45
|
[
"278.00",
"998.32",
"305.20",
"868.03",
"E815.0",
"315.2",
"807.03",
"805.6",
"780.09",
"312.9",
"808.2",
"813.44",
"913.0",
"805.4",
"305.90",
"873.0",
"808.0",
"E878.1",
"300.00",
"865.00",
"864.05",
"916.0",
"307.9",
"860.0",
"807.2",
"822.0",
"813.23",
"311",
"958.4",
"873.42"
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"79.39",
"86.59",
"99.04",
"38.93",
"96.71",
"38.7",
"79.32",
"79.12",
"93.44"
] |
icd9pcs
|
[
[
[]
]
] |
3399, 3405
|
2017, 2886
|
449, 681
|
3656, 3713
|
1564, 1994
|
4793, 5144
|
1225, 1242
|
2941, 3376
|
3426, 3635
|
2912, 2918
|
3737, 4432
|
4447, 4770
|
1257, 1545
|
276, 411
|
709, 1063
|
1085, 1091
|
1107, 1209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,648
| 162,025
|
20684
|
Discharge summary
|
report
|
Admission Date: [**2161-9-27**] Discharge Date: [**2161-11-9**]
Date of Birth: [**2116-7-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
bronchoscopy
Major Surgical or Invasive Procedure:
TIPS revision
Intubation
Bronchoscopy
History of Present Illness:
45 yo male w/ hep C cirrhosis, p/w hematemesis & BRBPR. Pt is
poor historian/confused, but reports coffee ground emesis daily
x 1 mth. Day PTA, increased in frequency, vomited ~1 liter
blood. Also notes intermittent BRBPR x many mths, ?recent
increased frequency. No dizziness/lighheadedness/dyspnea/CP.
Records reveal recent admission [**2081-9-11**] for GIB, following
cocaine/EtOH binge. Following this, Mom kicked him out of
house, & he has been living on street/in shelter, w/
questionable medication compliance. On arrival to ED, tachy to
120s (sinus) BP 130s/60s, satting 99% on RA. Confused. Labs
showed hct 21 (down from 30). Got 2 u PRBCs, cipro 500 IV for
sbp ppx, & ppi. At time of MICU eval, VSS except sinus tach in
110s. ~500 cc uop since arrival, no documented
hematemesis/BRBPR.
Past Medical History:
hep C x 20 yrs ([**2-23**] IVDA), cirrhosis x 3 yrs (?bx), h/o EtOH
hepatitis, portal htn s/p TIPS [**3-26**], grade 2 esophageal varices
& gastric varices (per [**3-26**] egd), ascites, h/o hepatic
hydrothorax, GERD, left inguinal hernia, pulmonary nodule -
coccidioidomycosis dx [**7-2**] (to complete 3 mths fluc), h/o rt IJ
clot
Social History:
SH - previously lived w/ Mom on [**Name2 (NI) **], homeless x ~ 2wks; h/o
heavy EtOH use had quit 2 yrs prior, but binged 2 wks prior; h/o
heroin & cocaine abuse quit 2 yrs prior; recent binge of
cocaine; tobacco - 3 packs per day
Family History:
Mother - hx of stroke
Father - died from getting hit by a drunk driver
Brother - died of problems related to alcohol
Physical Exam:
VS:
HEENT: Intubated and sedated, pupils 2-3mm reactive to light
Heart: S1/S2, rrr, no m/r/g
Lungs: Clear to auscultation, using abdominal muscles for
breathing
Abdomen: Soft, +bs, non-tender, +gynecomastia, +rare spider nevi
on right abdomen, no appreciable hepatosplenomegaly, no shifting
dullness
Ext: 1+pitting edema to shins bilaterally. LLE w/ 4x5 cm area of
erythmea and small .5cm scabbed laceration
Pertinent Results:
[**2161-9-27**] 11:15PM PT-16.7* PTT-30.6 INR(PT)-1.8
[**2161-9-27**] 09:00PM HCT-20.8*
[**2161-9-27**] 01:34PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-9-27**] 01:30PM GLUCOSE-113* UREA N-31* CREAT-0.7 SODIUM-136
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-31* ANION GAP-12
[**2161-9-27**] 01:30PM ALT(SGPT)-26 AST(SGOT)-47* ALK PHOS-71
AMYLASE-21 TOT BILI-2.1*
[**2161-9-27**] 01:30PM WBC-5.7# RBC-2.41*# HGB-7.7*# HCT-21.5*#
MCV-89 MCH-32.1* MCHC-36.0* RDW-16.7*
[**2161-9-27**] 01:30PM PLT COUNT-121*#
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the MICU/[**Hospital Unit Name 153**] with an initial elective
intubation/respiratory support after presenting with AMS and
UGIB.
1. gastrointestinal bleed/Anemia: Upon presentation, the patient
had a stable UPPER GI bleed from presumed varices related to
elevated portal pressures. An EGD was planned, but was delayed
because of patient agitation, combativeness and AMS. Thus, an
elective intubation was pursued to allow EGD evaluation. EGD
revealed Grade I mid-esophageal varices along with bleeding
gastric varices. The patient was stabilized with packed red
blood cells, FFP, platelets. A TIPS revision was pursued - a
patent TIPS was discovered, but a dilation was performed
nevertheless. The patient's bleeding recurred several weeks
after the initial stabilization. Repeated hepatic ultrasounds
with doppler studies revealed patent vasculature and TIPS. He
required further packed red blood cellstransfusions. During his
UPPER GI bleed episodes he was prophylaxed with either
Ciprofloxacin or Zosyn.
On [**11-4**] overnight, pt had approximately 3 L of bloody stool
from rectum with a 7 pt hematocrit drop and mild tachycardia. A
left sided cordus was placed, and the pt was transfused a total
of 5 units of blood and given several L of normal saline. GI was
notified. A orogastric tube lavage was negative, a tagged RBC
scan showed bleeding in the stomach and right side of abdomen.
An US showed his TIPS to be patent. An angiography study was
scheduled for the next day, however, prior to the study the
patient's mother, who was his HCP, decided to make him [**Name (NI) 3225**] since
there was little medical or surgical intervention which could be
offered to him.
2. Respiratory Failure: As mentioned, the patient was electively
intubated to facilitate EGD. However, it was soon discovered
that he was difficult to wean, consistently requiring high PEEP.
This was presumed secondary to a ventilator-associated
pneumonia, underlying hepatopulmonary syndrome, along with AMS.
A tracheostomy tube was placed as he was on mechanical
ventilation for greater than two weeks. By the end of his stay
in the MICU (he was later transferred to the [**Hospital Unit Name 153**] because of
hospital-wide issues with bed space), he was tolerating CPAP. In
regards to his PNA, he had MRSA growing in his sputum and was
treated with Vancomycin (which was changed to Linezolid) along
with Zosyn for ventilator-associated gram negative coverage. He
also had a history of biopsy-positive Coccidiomycosis, which was
initially a concern given his difficulty with weaning and
concerning chest CT (nodular right-sided opacities). However,
after negative BAL washings for Coccidiomycosis and an
evaluation by ID, it was decided that he did not have active
Coccidiomycosis and only needed to complete he previous course
of Fluconazole, which was initiated for a three-week course. Of
note, a urine Histoplasma Ag and Serum Compl Fixation for
Coccidiomycosis were ordered in the MICU.
In the [**Hospital Unit Name 153**], he was tried on a few trach trial and PS which he
would be able to tolerate for a few hours. His CXR's improved
with diuersis. All antibiotics were removed after a total of 14
days. After his GI BLEED, he was kept on AC in order to
comfortably ventilate him. Once his care was changed to comfort,
he was taken off of the ventilator and placed on cool mist and
morphine drip for comfort.
3 AMS. His AMS was considered likely secondary to his hepatic
encephalopathy with a possible contribution from his current
infection. Of note, his NH3 was at 59 late in his course. He
slowly gained cognitive function once Propofol was turned off,
but remained confused and sleepy.
4. Oliguric ARF: After a dose of Amphotericin (when active
Coccidiomycosis was first considered), continuous Vancomycin,
along with chronic hepatorenal disease, he had a few days of
oliguric ARF during the middle of his course. ATN was confirmed
by urine sediment and electrolytes. This resolved with
conservative treatment. A renal U/S was unremarkable for hydro
or blatant chronic disease).
5. HCV Cirrhosis: TIPS was in place and revised as above because
of concern for stenosis. He was continued on Lactulose 30 ml PO
TID, Spironolactone 25 mg PO QD, and Nadolol 20 mg PO BID. He
was placed on ciprofloxacin qWeek for ppx and then changed to
Levaquin prior to being made [**Hospital Unit Name 3225**]. Last US showed increased
ascites. Not a transplant candidate since he was actively using
alcohol and drugs. Liver service followed closely.
6. SI: There was an expression of suicidal ideation during a
brief period in an extubation trial. The pt told his family
that his recent substance binges were suicide attempts. A
psychiatric consult was planned once his mental status had
resolved.
7. Dispo: Plan on admission was for rehabilitation for long
term. However, once his gi bleed continued and he was still in
respiratory failure, his mother made the decision to make him
comfort care. Support services were offered. Pt placed on a
morphine drip for comfort and all therapeutic measures other
than comfort were stopped included NGT. He was called out the
floor on [**11-6**].
Medications on Admission:
home meds (not taking):
spironolactone, folic acid, lactulose, protonix, lasix, atenolol
Discharge Disposition:
Expired
Discharge Diagnosis:
end-stage liver disease
Discharge Condition:
expired
|
[
"578.9",
"070.44",
"789.5",
"303.91",
"584.5",
"518.81",
"780.39",
"291.81",
"572.3",
"511.8",
"114.9",
"276.0",
"305.60",
"263.9",
"305.50",
"456.8",
"482.41",
"571.2",
"280.0",
"453.8",
"507.0",
"V09.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.62",
"96.72",
"38.93",
"33.24",
"96.04",
"39.50",
"99.15",
"31.29",
"39.90",
"38.91",
"99.05",
"00.14",
"45.13",
"99.04",
"34.91",
"99.07",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8317, 8326
|
2969, 8178
|
326, 365
|
8393, 8403
|
2386, 2946
|
1824, 1943
|
8347, 8372
|
8204, 8294
|
1958, 2367
|
274, 288
|
393, 1202
|
1224, 1559
|
1575, 1808
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,776
| 154,016
|
17424+56810
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-6-3**] Discharge Date: [**2185-6-10**]
Service:
CHIEF COMPLAINT: Symptomatic bradycardia.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old male with
a history of coronary artery disease, peripheral vascular
disease, atrial fibrillation and flutter who was recently
discharged from the [**Hospital6 **] in [**Location 1268**] after
undergoing a left femoropopliteal bypass surgery on [**2185-5-16**].
The patient was discharged to rehabilitation. He had
previously been on Lopressor and digoxin. He was started on
amiodarone 400 mg p.o. t.i.d. for atrial fibrillation. On
[**2185-6-2**], the patient was found by his roommate to be
confused, and there was a question of a fall. EMS was
called. On initial examination the patient had a heart rate
in the 20s to 30s with systolic blood pressures in the 80s.
The patient was awake but confused. At an outside hospital,
the patient was intubated, and transcutaneously paced. He
was subsequently started on pressors for hypotension. The
patient was transferred to [**Hospital1 188**] for further care. Here an arterial line was placed,
and pressors were weaned off with a blood pressure of 150/60
with pacing at 80. The patient was able to sustain his
pressure after the pacer was stopped, even though his
intrinsic heart rate was in the 30s. The patient was
admitted to the coronary care unit for close observation
secondary to intubation.
PAST MEDICAL HISTORY: 1. Peripheral vascular disease, status
post left femoropopliteal bypass bypass surgery on [**2185-5-16**].
2. Status post bilateral CEAs. 3. Coronary artery disease,
status post myocardial infarction in [**2175**], coronary artery
bypass grafting surgery in [**2184-8-5**]. 4. Atrial
fibrillation/atrial flutter. 5. Hypertension. 6. Lower back
pain status post lumbar surgery. 7. Spinal stenosis. 8.
Fibrotic granuloma of the left vocal cord. 9.
Hyperlipidemia. 10. Gout. 11. Chronic obstructive pulmonary
disease. 12. Psoriasis. 13. Chronic anemia. 14. Status
post appendectomy. 15. Transitional cell carcinoma. 16.
Right total hip replacement.
MEDICATIONS AT REHABILITATION: 1. Amiodarone 400 mg p.o.
t.i.d. 2. Lopressor 75 mg p.o. b.i.d. 3. Aspirin 325 mg
p.o. q.d. 4. Nebulizers. 5. Ultram 50 mg p.o. q. 6 hours
p.r.n. 6. Coumadin 2 mg p.o. q.d. 7. Multivitamin. 8.
Zantac. 9. Question of digoxin.
ALLERGIES: Allopurinol leads to rash, statins lead to
rhabdomyolysis.
SOCIAL HISTORY: Positive tobacco use, lives with his wife,
[**Name (NI) 1743**] and daughter, [**Name (NI) **].
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Afebrile, pulse in the 30s, blood
pressure 140/55, vent set at AC, tidal volume is 600,
respiratory rate of 14, FIO2 of 80%, PEEP of 5. In general
the patient is an elderly male, intubated and sedated.
HEENT: Pupils are 6 mm, fixed and dilated, absent gag,
absent corneal reflex, oropharynx dry, positive doll's eye.
Cardiovascular: Bradycardic, 2/6 systolic murmur at the
apex. Lungs: Clear to auscultation bilaterally anteriorly.
Abdomen: Soft, nontender, nondistended, with normal active
bowel sounds. Extremities: 2+ lower extremity edema
bilaterally, staples in the right arm and left groin, sutures
in the left foot, status post multiple toe amputations, cool
extremities, nonpalpable lower extremity pulses, otherwise
wounds are clean, dry and intact. Neurological:
Unresponsive, flaccid, reflexes [**2-7**]+ and symmetric, normal
bulk.
LABORATORY DATA: White count 9.1 with 77% neutrophils, 19%
lymphocytes, 3% monocytes, hematocrit 31.8, platelet count
306. Sodium 136, potassium 4.6, chloride 106, bicarbonate
14, BUN 40, creatinine 1.7, glucose 312, calcium 7.4,
magnesium 1.8, phosphorous 5.3. PT 28.3, PTT 44.7, INR 5.3.
CK 47, troponin less than 0.3. Arterial blood gas was 7.24,
36, 178. Urinalysis showed a specific gravity of 1.015,
large blood, 100 protein, trace ketones, leukocyte esterase
and urine nitrite negative.
EKG at the outside hospital showed junctional fascicular
escape rhythm at 64 beats per minute, retrograde PEs, ST
depressions at V2 to V4. In the Emergency Department here
junctional fascicular escape at 36 beats per minute,
retrograde PEs, ST depressions in V3 through V5, right bundle
branch block pattern.
STUDIES: Chest x-ray at the outside hospital showed
cardiomegaly, bilateral fluffy infiltrates with increased
vascular markings.
Transthoracic echocardiogram from [**2185-5-20**] showed an ejection
fraction of 45-50%, mild left ventricular hypertrophy, global
hypokinesis, no focal wall motion abnormalities, [**2-7**]+ mitral
regurgitation, 1+ tricuspid regurgitation.
ASSESSMENT AND PLAN: This is an 81-year-old male with a past
medical history significant for coronary artery disease,
status post myocardial infarction and coronary artery bypass
grafting, peripheral vascular disease, atrial fibrillation
and flutter, who was sent from rehabilitation with mental
status changes, and symptomatic bradycardia with heart rates
in the 20s and hypotension. The patient was intubated,
placed on pressors, transcutaneously paced. Here an arterial
line was placed, pressors were weaned off, pacing was
stopped, patient was able to maintain blood pressures at
140/50 even though he still had an intrinsic junctional
escape rhythm in the 30s.
HOSPITAL COURSE: 1. Coronary artery disease: The patient
ended up ruling in for myocardial infarction, even though his
peak CPK was 109, MB of 16, MB index of 14.7, and troponin I
of 4.1. We believe that this all can be accounted for by the
transcutaneous pacing that he received rather than an actual
new myocardial infarction. There was no obvious ischemia or
myocardial infarction in any particular distribution on EKG.
The patient was eventually placed on a cardiac regimen
including aspirin and Lopressor titrated up to 50 mg p.o.
b.i.d. Given the fact that the patient has a history of
rhabdomyolysis in response to statins, he was not placed on a
statin. Instead, the patient was started on gemfibrozil on
discharge.
2. Rhythm: As already noted, the patient presented with a
junctional fascicular block. We feel that this was
iatrogenic in origin in response to getting an amiodarone
loading dose of 400 mg p.o. t.i.d. for at least one to two
weeks. This was in addition to other nodal blocking agents
that the patient was on including Lopressor and possibly
digoxin even though digoxin was not listed as one of the
rehabilitation medications, but had been taken previously by
the patient. Of note, in addition to transcutaneous pacing,
the patient at one point did receive atropine on the field,
at the same time he was started on pressors including
dopamine and Neo-Synephrine. Even though the patient was
able to maintain his blood pressure without the
transcutaneous pacer, a temporary pacer wire was placed by
the electrophysiologists. However, as all nodal blocking
agents were stopped, the patient converted back to normal
sinus rhythm and did not need the temporary pacer wire.
Eventually, it was felt that the patient was safe enough to
be on Lopressor for his coronary artery needs in addition to
rate control. Of note, the patient has a history of atrial
fibrillation and flutter. He did not exhibit this rhythm
during this hospitalization. The patient was placed on
heparin while hospitalized for atrial fibrillation. However,
it was decided that the patient was too much of a fall risk,
especially given his presentation, and heparin was stopped
and it was decided that it was too risky to continue any
anticoagulation for paroxysmal atrial fibrillation.
3. Pump: The patient has no known history of congestive
heart failure, but does have prior coronary disease. The
patient had an episode of hypoxia on [**2185-6-5**], and was noted
to be volume overloaded on chest x-ray. The patient
responded well to 40 IV of Lasix with good diuresis. An
echocardiogram was performed on [**2185-6-6**]. This showed an
ejection fraction of 30-35%. There was left atrial mild
dilatation, mild symmetric left ventricular hypertrophy.
Left ventricular cavity size was noted to be normal. Left
ventricular systolic function was moderately depressed.
Regional wall motion abnormalities included mid and apical,
anterior, septal and lateral hypokinesis. Right ventricle
was noted to be normal. There was also noted to be 3+ mitral
regurgitation, 2+ tricuspid regurgitation, and mild pulmonary
artery systolic hypertension. Given this ejection fraction,
it was felt the patient would benefit from an ACE inhibitor.
He was initially placed on hydralazine and Isordil for
question of renal insufficiency. Eventually he was converted
to captopril at 25 mg p.o. t.i.d. On discharge, the patient
will be started on lisinopril 10 mg p.o. q.d.
4. Blood pressure: The patient was initially bradycardic and
hypotensive, had to be started on dopamine and
Neo-Synephrine. These were weaned off in the Emergency
Department. The patient was subsequently hypertensive. Beta
blocker and ACE inhibitor were titrated up. The patient will
be discharged on Toprol XL 50 mg p.o. q.d. and lisinopril 10
mg p.o. q.d. On these doses, the patient has sustained
systolic blood pressures of 100 to 120.
5. Neurology: The patient initially presented totally
unresponsive. There was significant concern, given the fact
that this examination included fixed and dilated pupils, lack
of corneal or gag reflex. Initially the patient was thought
to have sustained an anoxic brain injury. Head CT was
performed. There were noted to be chronic microvascular
infarcts. However, there was no evidence of hemorrhage, mass
effect, or blurring of the [**Doctor Last Name 352**] and white matter. Of note,
this head CT was obtained less than 48 hours from the
significant event, so anoxic injury could not really be ruled
out at that point. Over the next several days, the patient
regained his corneal and gag reflexes. He started breathing
over the vent. Once the patient was extubated, he was back
to his baseline neurological status, which appears to be mild
dementia, easily confused at times but also easily
redirected and reoriented. Of note, the patient's pupils at
this point were equal, round and reactive to light and
accommodation. Apparently, the atropine that the patient had
received stuck around in his system for more than the
expected period of time.
Overall the patient did well, but then started developing
confusion overnight, which was thought to be sundowning. The
patient received Ativan and morphine which only made the
situation worse. The patient appeared to be in a delirium.
He was noted to have some difficulty with speech. There were
no focal neurologic signs. The patient had difficulty with
attention, and was quite agitated, trying to get out of bed.
Given the fact that the patient had been on heparin for
atrial fibrillation, there was some concern for a bleed.
Repeat head scan was done on [**2185-6-8**]. This showed no
evidence of hemorrhage. There was prominence of ventricles
and sulci consistent with atrophy. The patient's delirium
was attributed to Ativan and morphine which stay around in
the system given his age. Also, the patient was being
treated for presumed pneumonia at the time. The patient's
mental status slowly improved and continues to improve at
this point. The patient continued to require a sitter while
in house, but Poseys were discontinued without problem.
6. Infectious disease: The patient was noted to be febrile
up to 101.6 on [**2185-6-3**]. Chest x-ray on [**2185-6-3**] showed a
retrocardiac atelectasis/consolidation. The patient was
empirically started on Levofloxacin and Flagyl. E. coli grew
in [**1-12**] blood culture bottles from [**2185-6-3**]. It was noted to
be sensitive to ceftriaxone. The patient was started on a
two-week course of ceftriaxone. Two days later, we received
a report that blood cultures from the outside hospital from
[**2185-6-2**] grew two out of two bottles of MRSA. This
particular organism was not present in any of our blood
culture vials. However, we felt that the patient should
receive a two-week course of vancomycin. The patient's fever
curve resolved and he did not have a white count. He wasn't
bringing up any thick sputum.
7. The patient received a single-lumen PICC line on [**2185-6-9**]
for antibiotics.
8. Urology: The patient was noted to have a bag draining
yellow fluid close to his right femoral artery. There was a
question of a femoral stick penetrating the bladder causing a
fistula. The serous drainage was sampled, and it was noted
to have a creatinine of 3. This is more consistent with
lymph rather than urine. The bag was only draining about 10
cc in 24 hours. At this point it can be watched. There is
no clear source for this serous drainage.
9. Vascular: The patient still has his staples in place.
They should be taken out within two to three days following
discharge per vascular surgery.
10. Fluids, electrolytes and nutrition: Given the patient's
delirium, there was concern that he may be aspirating. A
bedside evaluation was performed and it was ambiguous. At
this point, the patient will receive a video swallowing
study. These results are still pending.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Toprol XL 50 mg p.o. q.d.
2. Lisinopril 5 mg p.o. q.d.
3. Protonix 40 mg p.o. q.d.
4. Albuterol nebulizer, q. 6 p.r.n.
5. Atrovent, one nebulizer, q. 6 p.r.n.
6. Colace 100 mg p.o. b.i.d.
7. Senna 2 tablets p.o. b.i.d.
8. Aspirin 325 mg p.o. q.d.
9. Insulin sliding scale.
10. Gemfibrozil.
11. Vancomycin 1 gram IV q. 24 hours, through [**2185-6-20**].
12. Ceftriaxone 1 gram IV q. 24 hours, through [**2185-6-20**].
DISCHARGE INSTRUCTIONS: The patient is discharged to acute
rehabilitation. The patient will need to follow up with his
primary care physician and cardiologist in addition to his
vascular surgeon.
DISCHARGE DIAGNOSES:
1. Symptomatic bradycardia secondary to amiodarone.
2. Mild congestive heart failure.
3. History of atrial fibrillation/flutter.
4. Coronary artery disease, status post myocardial infarction
and coronary artery bypass grafting.
5. Peripheral vascular disease, status post left
femoropopliteal bypass surgery.
6. Hypertension.
7. Delirium.
8. Pneumonia with positive blood cultures.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2185-6-10**] 07:33
T: [**2185-6-10**] 08:12
JOB#: [**Job Number 48691**]
Name: [**Known lastname **], [**Known firstname 2636**] Unit No: [**Numeric Identifier 8796**]
Admission Date: [**2185-6-3**] Discharge Date: [**2185-6-12**]
Date of Birth: [**2103-12-22**] Sex: M
Service: CCU
ADDENDUM: The patient received a video swallow study which
showed mild aspiration with thin liquids. The patient had
his staples removed. On [**2185-6-10**], he was found to be
hypokalemic down to 3.0 and hypomagnesemic down to 1.9. He
was repleted. On the night prior to being discharged, the
patient had about four episodes of sinus pause during sleep
with a max pause of 1.8 seconds, usually following a run of
APBs. He had no further episodes during wakefulness. The
patient was judged not to need any further evaluation for
pacer at this time. The patient will need to follow-up with
Vascular Surgery regarding inspection of his toe amputations
and sutures.
[**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. [**MD Number(1) 2449**]
Dictated By:[**Name8 (MD) 8797**]
MEDQUIST36
D: [**2185-6-11**] 02:49
T: [**2185-6-11**] 15:01
JOB#: [**Job Number 8798**]
|
[
"427.89",
"286.9",
"785.51",
"428.0",
"790.7",
"507.0",
"584.9",
"293.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.78",
"99.69",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2590, 2608
|
13978, 15834
|
13337, 13758
|
5357, 13282
|
13783, 13957
|
2631, 5339
|
101, 127
|
156, 1437
|
1460, 2459
|
2476, 2573
|
13307, 13314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,846
| 188,344
|
6075
|
Discharge summary
|
report
|
Admission Date: [**2136-8-25**] Discharge Date: [**2136-9-1**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Pain and purulent drainage HD catheter
Major Surgical or Invasive Procedure:
[**2136-8-31**] tunneled external jugular hemodialysis catheter
History of Present Illness:
Pt is a 62 yo F w/ PMH of who presented to ED w/ purulent
drainage noted from HD line (placed [**7-9**]). Pt was at her
dialysis center today for her scheduled HD and was noted to have
purulent drainage at the site and she was sent to the ED. Pt
denies any fever or chills. She reports a one day h/o nausea and
vomiting. Also notes chills last night; denies cough. Felt
poorly all week.
In the [**Name (NI) **], pts vitals: 98.4 80, 127/52, 16, 100%RA. Her cultures
from catheter site from [**8-23**] which grew staph and proteus.
Surgery consulted in ED and plan to pull HD line. Pt was given
a dose of vanco and ceftriaxone (although has pcn allergy and
thus reacted post treatment with hives; given benadryl with
improvement).
Also of note, K was 7.2 on presentation to ED. EKG showed peaked
TW in V2-V3. Of note, pt only got [**1-18**] of her usual HD as
scheduled today. K was treated with 1 amp calcium gluconate,
10U insulin, Kayexalate and 1 amp glucose.
Past Medical History:
- ESRD on HD T, Th, Sat
- DM 2, insulin dependent
- CHF -diastolic heart failure; EF 70%
- Hypercholesterolemia
- BLE DVTs, on warfarin
- OSA refuses CPAP
- OA
- Multiple line infections
--Providencia bacteremia [**2135-12-20**]- treated with 4 weeks aztreonam
--[**2135-12-17**]: Providencia, finished 4wk course of aztreonam
--[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin
and gentamicin
--[**2136-5-17**]; Staph bacteremia tx with vanc- 6 week course abx
- h/o C. Diff
- GERD
- Depression
- Morbid obesity
- osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc
Past surgical history:
- L forearm radial-basilic AV graft, s/p infection, thrombosis
and abandonment ([**12-21**])
- Multiple lines in L upper arm with AV graft
- 1/07 L femoral PermaCath placed
- L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**])
- [**4-23**] Excision of left upper arm infected AV graft; associated
MRSA bacteremia treated with 6 weeks vancomycin.
- Right upper extremity AV fistula creation [**10-23**] s/p revision
- [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring
and IVC filter removed
Social History:
Patient denies a tobacco, alcohol or illicit drug use. She lives
in a nursing home (?[**Hospital3 2558**])
Family History:
Not obtained.
Physical Exam:
Tmax: 35.7 ??????C (96.3 ??????F)
Tcurrent: 35.7 ??????C (96.3 ??????F)
HR: 80 (80 - 81) bpm
BP: 111/44(51) {109/44(51) - 111/53(62)} mmHg
RR: 14 (14 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Physical Examination
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
SEM [**1-22**] heard at base
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: slightly firm, non-tender, no rebound/guarding, not
tympanitic, Bowel sounds present
Extremities: Right: Absent, Left: Absent, Cyanosis, Clubbing
Skin: Warm, Purulence coming from L tunneled HD cath with
surrounding erythema
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, Movement:
Not assessed, Tone: Normal
Pertinent Results:
[**2136-8-25**] 11:24PM POTASSIUM-7.7*
[**2136-8-25**] 08:33PM K+-6.9*
[**2136-8-25**] 06:15PM WBC-6.3 RBC-4.41 HGB-13.7 HCT-44.7 MCV-101*
MCH-31.0 MCHC-30.6* RDW-15.8*
[**2136-8-25**] 06:15PM PLT COUNT-332
[**2136-8-25**] 02:47PM COMMENTS-GREEN TOP
[**2136-8-25**] 02:47PM K+-6.6*
[**2136-8-25**] 02:47PM HGB-15.3 calcHCT-46
[**2136-8-25**] 12:55PM COMMENTS-GREEN TOP
[**2136-8-25**] 12:55PM LACTATE-1.0 K+-6.8*
[**2136-8-25**] 12:50PM GLUCOSE-67* UREA N-55* CREAT-6.8* SODIUM-135
POTASSIUM-7.2* CHLORIDE-92* TOTAL CO2-28 ANION GAP-22*
[**2136-8-25**] 12:50PM estGFR-Using this
[**2136-8-25**] 12:50PM ALT(SGPT)-34 AST(SGOT)-20 LD(LDH)-191 ALK
PHOS-306* TOT BILI-0.4
[**2136-8-25**] 12:50PM LIPASE-35 GGT-60*
[**2136-8-25**] 12:50PM ALBUMIN-4.5 CALCIUM-8.6 PHOSPHATE-8.3*#
MAGNESIUM-2.6
[**2136-8-25**] 12:50PM WBC-6.3 RBC-4.89 HGB-15.2 HCT-50.5* MCV-103*
MCH-31.2 MCHC-30.2* RDW-16.5*
[**2136-8-25**] 12:50PM NEUTS-70.2* LYMPHS-20.6 MONOS-4.0 EOS-4.3*
BASOS-0.8
[**2136-8-25**] 12:50PM PLT COUNT-369
[**2136-8-25**] 12:50PM PT-14.4* PTT-27.8 INR(PT)-1.3*
Brief Hospital Course:
62yo female with h/o ESRD on HD, multiple line infections, dCHF,
DM and bilateral DVTs on coumadin who presented from dialysis
with pus coming from HD site and hyperkalemia. She improved
clinically after pulling the line and Abx treatment.
.
LINE INFECTION (CENTRAL OR ARTERIAL): HD line pulled by surgery
on [**2136-8-25**]. Wound culture from the site grew Proteus mirabilis
and MSSA. She was treated with vancomycin and ceftazidine. Her
vancomycin was dosed per HD protocol with levels. Her
leukocytosis improved on Abx. She is scheduled to complete this
course of antibiotics on [**2136-9-7**].
.
HYPERKALEMIA: Pt admitted with K>7 likely [**2-18**] renal failure.
Because her HD line was pulled she was managed medically with Ca
gluconate, insulin, dextrose, kayexalate x6, and albuterol nebs.
Her ECG was notable for peaked T waves in V2. Her K normalized
on this regimen and a new dialysis line was placed.
.
END STAGE RENAL DISEASE (ESRD): Pt routinely gets HD [**Last Name (LF) **], [**First Name3 (LF) **],
and Sat. She missed HD for 4 days after line was pulled for
infection. During that time she developed sleepiness and
non-cardiac chest pain. These symtpoms improved with dialysis
and were believed to be due to uremia. An ECHO was ordered on
[**2136-8-28**] to check for pericardial effusions [**2-18**] uremia, which did
not find an effusion.
A temporary femoral line placed [**2136-8-27**] and she resumed HD. She
was unable to receive an upper limb tunneled line or central
line [**2-18**] bilateral jugular venous thromboses which were
identified during line attempts. Pt's femoral line was removed
by IR on [**8-31**] and replaced with a permanent L-sided EJ. Pt also
had HD before being discharged and line was working properly.
She was continued on sevelamer and cinalcalcet, and phosphates
were avoided due to her hyperphosphatemia.
.
SLEEP APNEA: Pt desats with apneas at night. She has a known
history of apnea but refuses CPAP. After much encouraging she
agreed to CPAP with sleep. She did begin to accept using CPAP
during hospital course. However, if she refuses CPAP we suggest
1L nasal cannula O2 because higher flows seems to suppress her
respiratory drive.
.
DIABETES MELLITUS (DM), TYPE II: Well controled on her home
insulin regimen.
.
CHEST PAIN: Pt reported chest pain which was reproducible with
palpation of the sternum. Serial ECGs and cardiac enzymes were
WNL. She also vomited once during her chest pain. The DD for her
pain includes uremic pericarditis and gastritis/GERD. She was
started on a PPI and a cardiac ECHO was odered on [**2136-8-28**] which
showed EF >55% No pericardial effusion. Normal global
biventricular systolic function. Technically suboptimal to
exclude focal wall motion abnormality. Mild functional mitral
stenosis from mitral annular calcification.
.
MACROCYTOSIS: Pt with MCV 102, persistently in the 100s this
admission with NL folate and B12 within a month. Etiology could
be uremia, hypothyroidism, or reticulocytosis. TSH returned
normal.
.
DEPRESSION: Continued on home dose of Paxil without incident.
.
HYPOTENSION: Hypotensive on [**2136-8-26**]. Holding BPs well except
during dialysis. She was started on mitodrine to maintain BP on
and off dialysis. Pt historically has low BP.
.
Hx DVT admitted on Coumadin. Pt was found to have bilateral
jugular venous thromboses this admission as well as her history
of bilateral lower limb clots. Coumading was resumed prior to
discharge.
.
[**Date Range 23835**]/HCP: [**Name (NI) **] [**Name (NI) 23081**] ([**Telephone/Fax (1) 23836**], cell ([**Telephone/Fax (1) 23837**]);
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23838**] (cell [**Telephone/Fax (1) 23839**])
.
Code status: Full code
Medications on Admission:
per OMR:
Paxil 20mg
Simvastatin 10mg daily
Sevelamer 1600 TID
ASA 81 mg
colace 100 [**Hospital1 **]
Vit C
Cinacalcet 30mg daily
Insulin- Lantus 10U qhs and Regular SS
Folate 1mg daily
Heparin SC
Albuterol nebs q6 prn
Discharge Medications:
1. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous QHD (each hemodialysis) for 6 days: until [**2136-9-7**].
Disp:*2 Recon Soln(s)* Refills:*0*
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. Vancomycin 1,000 mg Recon Soln Sig: One (1) 1gm Intravenous
QHD for 6 days: until [**2136-9-7**].
Disp:*2 * Refills:*0*
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Ascorbic Acid 500 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. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
11. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for hypotension.
Disp:*180 Tablet(s)* Refills:*0*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous at bedtime.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection once a day.
15. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
18. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Hemodialysis catheter-related infection
End-stage renal disease on hemodialysis
History of deep venous thrombosis
Hyperkalemia
Resolved hypotension
Diabetes mellitus type 2, insulin dependent
Chronic diastolic heart failure
Discharge Condition:
Stable.
Discharge Instructions:
You had a line infection with your hemodialysis line. The line
was removed and you were treated with antibiotics. For your
hemodialysis needs a temporary femoral line was placed (at your
right leg), but for a permanent line interventional radiology
removed the femoral line and placed your permanent line a left
external jugular line (in your neck). You had dialysis through
the line after it was placed and it worked fine. You were
discharged afterwards.
Medication changes:
- you will be given vancomycin 1gm IV with hemodialysis until
[**9-7**]
- and ceftazidine 1gm IV with hemodialysis until [**9-7**]
- also if your blood pressure becomes low midodrine 5mg up to
three times a day
If any of your symptoms return or significantly worsen including
redness or pus around the line, chest pain, shortness of breath.
Return to the ED immediately.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**2-19**] wks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
|
[
"272.0",
"311",
"V58.61",
"996.62",
"327.23",
"428.0",
"276.7",
"250.40",
"428.32",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10725, 10795
|
5018, 8751
|
324, 390
|
11063, 11072
|
3901, 4995
|
11969, 12174
|
2692, 2707
|
9019, 10702
|
10816, 11042
|
8777, 8996
|
11096, 11553
|
2027, 2551
|
2722, 3882
|
11573, 11946
|
246, 286
|
418, 1389
|
1411, 2004
|
2567, 2676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,324
| 145,599
|
28579
|
Discharge summary
|
report
|
Admission Date: [**2191-9-16**] Discharge Date: [**2191-10-3**]
Date of Birth: [**2124-2-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypotension, PEA/VF arrest
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Thoracostomy
History of Present Illness:
HPI: 67M with h/o HTN, hyperlipidemia, and depression presented
to an OSH on [**9-16**] after being found unresponsive at home. He
complained of 1 week of weakness, fatigue, and increased
abdominal pain prior to presentation. On the AM of [**9-16**], he was
found unresponsive by his wife. EMS found him to be bradycardic
without a pulse, and received epinephrine/atropine and was
intubated in the field. At the OSH, ECG showed inferior STE and
he was flown to [**Hospital1 18**] for cath. His cath showed clean
coronaries. He had VF arrest in the cath lab and was shocked
into NSR. CXR showed large R pleural effusion with ?
mediastinal shift, so CT Surgery placed a chest tube, which
drained >1L mucinous fluid. He was started on levophed and
vasopressin for SBP 70s. LVgram showed . Hemodynamics showed
CO 4.12, CI 1.93, elevated R and L-sided filling pressures (RA
14, PCWP 25). He was admitted to the CCU for further
management.
.
In the CCU, his VS on arrival were T 97.8, HR 75, BP 98/30 on
levophed and vasopressin, O2sat 98% on AC 700x12/0/100%.
Cultures were sent including pleural fluid. CT head showed SAH,
Neurosurgery was consulted, recommended MRI/A when stable. CT
torso was performed to look for infectious source. NG with
clots, transfused 1U PRBC, started on Protonix gtt.
Past Medical History:
Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l
Social History:
1. HTN
2. Hyperlipidemia
3. Depression- for past 3y after son passed away
4. Glucose intolerance
5. L eye blindness
Family History:
lives with wife and grandson, worked as mechanic/welder,
currently on disability (family states for obesity?), family
states pt is independent in ADLs however poor hygiene evident on
admission; no EtOH/tob/IVDU per family
Physical Exam:
Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l
Pertinent Results:
[**2191-9-16**] 01:15PM BLOOD WBC-14.6* RBC-3.28* Hgb-9.6* Hct-29.5*
MCV-90 MCH-29.3 MCHC-32.5 RDW-17.5* Plt Ct-434
[**2191-9-16**] 03:37PM BLOOD WBC-25.8* RBC-3.49* Hgb-10.3* Hct-30.8*
MCV-88 MCH-29.6 MCHC-33.5 RDW-17.5* Plt Ct-437
[**2191-9-16**] 03:37PM BLOOD Neuts-83* Bands-6* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-6*
[**2191-9-16**] 03:37PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2191-9-16**] 03:37PM BLOOD PT-14.6* PTT-33.3 INR(PT)-1.3*
[**2191-9-16**] 03:37PM BLOOD Fibrino-463*
[**2191-9-16**] 01:15PM BLOOD Glucose-93 UreaN-50* Creat-1.5* Na-130*
K-3.7 Cl-92* HCO3-29 AnGap-13
[**2191-9-16**] 03:37PM BLOOD Glucose-200* UreaN-91* Creat-2.6*# Na-137
K-5.3* Cl-102 HCO3-25 AnGap-15
[**2191-9-16**] 01:15PM BLOOD ALT-11 CK(CPK)-1183* AlkPhos-29*
Amylase-28 TotBili-0.2
[**2191-9-16**] 03:37PM BLOOD ALT-22 AST-63* LD(LDH)-413* CK(CPK)-2927*
AlkPhos-62 TotBili-0.4
[**2191-9-16**] 01:15PM BLOOD Lipase-34
[**2191-9-16**] 03:37PM BLOOD CK-MB-20* MB Indx-0.7 cTropnT-0.17*
[**2191-9-16**] 03:37PM BLOOD TotProt-4.5* Albumin-2.2* Globuln-2.3
Calcium-6.8* Phos-6.8* Mg-2.2 UricAcd-10.6* Iron-PND
[**2191-9-16**] 01:15PM BLOOD Cortsol-26.6*
[**2191-9-16**] 03:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-9-16**] 02:43PM BLOOD Type-ART Tidal V-700 FiO2-100 pO2-138*
pCO2-53* pH-7.29* calTCO2-27 Base XS--1 AADO2-551 REQ O2-88
[**2191-9-16**] 05:47PM BLOOD Type-ART Temp-36.3 pO2-210* pCO2-49*
pH-7.35 calTCO2-28 Base XS-0
[**2191-9-16**] 12:59PM BLOOD Glucose-162* Lactate-8.6* Na-140 K-4.7
Cl-98*
[**2191-9-16**] 08:19PM BLOOD Lactate-1.5
[**2191-9-16**] 03:55PM BLOOD freeCa-1.05*
[**2191-9-16**] 03:39PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030
[**2191-9-16**] 03:39PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2191-9-16**] 03:39PM URINE Hours-RANDOM Creat-143 Na-30 TotProt-72
Prot/Cr-0.5*
[**2191-9-16**] 03:39PM URINE Osmolal-423
[**2191-9-16**] 03:39PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2191-9-16**] 07:19PM PLEURAL WBC-1222* RBC-[**Numeric Identifier 69195**]* Polys-PND
Lymphs-PND Monos-PND
[**2191-9-16**] SEROLOGY/BLOOD LYME SEROLOGY-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2191-9-16**] PLEURAL FLUID GRAM STAIN-PENDING; FLUID
CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; FUNGAL
CULTURE-PENDING; ACID FAST SMEAR-PENDING; ACID FAST
CULTURE-PENDING
[**2191-9-16**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; ACID FAST
CULTURE-PENDING; ACID FAST SMEAR-PENDING
[**2191-9-16**] URINE URINE CULTURE-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
Brief Hospital Course:
# Shock: Pt had Septic physiology on admission to the CCU, and
the most likely source was felt to be postobstructive pneumonia
and parapneumonic effusion. His CI was high, so his hypotension
was not felt to be due to cardiogenic shock. He was initially
maintained on 3 pressors upon transfer to the MICU service, but
neosynephrine was weaned off quickly. He was given empiric Zosyn
and vancomycin to cover polymicrobial sepsis. Levophed was
gradually weaned the next day, and then vasopressin was stopped.
Levophed had to be restarted for a few hours on [**9-19**] for MAP<60,
but it was weaned off the next day.
.
# Respiratory failure: Pt was intubated during his first PEA
arrest. The R-sided chest tube initially drained a large volume
of mucinous fluid, then drained serosanguinous fluid. The fluid
was grossly exudative with LDH 4000 on a diluted specimen. The
pleural fluid amylase was also elevated, to 3x the serum value.
The Gram stain was negative, and cultures are no growth to date.
His noncontrast chest CT showed a RLL rounded opacity with no
air bronchograms but density consistent with lung parenchyma.
The differential was thought to include atelectasis vs.
postobstructive pneumonia vs. sequestration. He underwent a
bronchoscopy on [**9-18**] with mild secretions and no endobronchial
lesions visualized, and a BAL was sent. His ventilatory
requirements were gradually weaned, however he had trouble
ventilating adequately while on pressure support. CT chest with
contrast showed the RLL opacity was a large mass with
significant surrounding lymphadenopathy and marked pleural
tumor, with possible invasion into the chest wall. Pleural fluid
cytology returned suspicious for adenocarcinoma, and pt was
ultimately diagnosed with stage IIIA lung cancer. Pt's
progressive respiratory failure was treated with BiPAP and nebs,
but he continually removed his BiPAP, leading to significantly
labored breathing and desaturation. A family meeting concluded
that BiPAP should be deferred, and that pt should be made
DNR/DNI with a focus on full comfort measures. Pt ultimately
died of respiratory failure likely due to a combination of COPD,
pneumonia and lung cancer on the morning of [**2191-10-3**].
.
# Altered mental status: She had a subarachnoid and
intracerebral hemorrhage on CT. Neurosurgery was consulted, and
felt that the bleed was likely an effect of reperfusion during
arrest. He had leukocytosis but no fever, and no history of
headache at home, so meningitis was thought to be unlikely and
LP was deferred. Tox screen was negative on admission. He was
able to follow commands and communicate effectively when his
sedation was weaned. Pt maintained a waxing-[**Doctor Last Name 688**] course until
his death on [**2191-10-3**].
.
# ARF: It was thought likely secondary to hypoperfusion/ATN in
the setting of cardiac arrest and shock. His creatinine
gradually improved to normal.
.
# UGIB: His OG tube initially drained clots on admission. He was
felt to have an upper GI bleed in the setting of heparin and
integrilin in the cath lab, and it was self-resolved. Upon
transfer to the MICU, his OG tube was draining a thick white
chylous-appearing fluid. That also resolved spontaneously. His
CT was reviewed by Radiology who stated there was no evidence of
esophageal perforation. He was maintained on an IV PPI [**Hospital1 **], and
his HCT remained stable for the remainder of his course.
.
Pt was maintained on full comfort measures once a family meeting
concluded that he sould be made DNR/DNI w/o further aggressive
management of his progressive respiratory failure. On the
morning of [**2191-10-3**], pt died a peaceful death due to
complications of progressive respiratory failure, likely
secondary to lung cancer, pneumonia, COPD and an expanding
malignant pleural effusion. Pt's family was notified, and they
deferred autopsy.
Medications on Admission:
[**Name (NI) 36173**] (wife held it 1wk ago)
Seroquel (wife held it 1wk ago)
Lisinopril
Crestor
Zyprexa 2.5mg qd (started 2d PTA)
Vicodin prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Lung Cancer
COPD
Pneumonia
Intraparenchymal and subarachnoid hemorrhage
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2191-10-5**]
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21,447
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4666+4667+55595
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Discharge summary
|
report+report+addendum
|
Admission Date: [**2200-5-2**] Discharge Date:
Dictation date [**2200-5-10**]
Date of Birth: [**2158-11-18**] Sex: F
Service: [**Hospital 14843**] Medical Service
CHIEF COMPLAINT: Status post fall, near syncope.
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 19730**] is a 41 year old woman
well as diabetes mellitus Type 1 with a recent admission
between [**4-22**] and [**2200-4-30**] for atrial flutter as well
as multiple medical problems who presented on [**2200-5-2**]
with 1-2 of watery diarrhea, two to three bowel
movements per day and having attempted to make the journey to
her bathroom, was unable to hold her bowels and produced
diarrhea on the floor which she later slipped on injuring her
and her parents called the Emergency Medical Services. The
initial hip films in the Emergency Room being negative for
fracture, the patient was admitted for pain control. The
patient's initial glucose in the Emergency Room was 338, no
insulin was given at that time and the patient missed her
evening dose of lantus the day prior to admission. Her
fingerstick at 5:30 AM the day of admission was greater than
600 and she was given regular insulin 10 units intravenously
as well as NPH 5 units subcutaneously in a 500 cc normal
saline bolus. The patient denied fevers, chills, abdominal
pain, bloody stools, nausea or vomiting. The patient had had
hemodialysis the day of admission and 7 kg were taken off
with post hemodialysis dry weight of 67 kg with an estimated
post hemodialysis weight of 67 kg and a dry weight of 60 kg.
PAST MEDICAL HISTORY: Diabetes mellitus Type 1 since the age
of 23 with a history of diabetic ketoacidosis, end stage
renal disease on hemodialysis for one year, anxiety,
depression, hypertension, upper gastrointestinal bleed with a
recent Medicine Intensive Care Unit admission [**2200-4-14**]
which demonstrated gastritis on an
esophagogastroduodenoscopy, hyperprolactinemia, foot ulcer,
history of Barrett's esophagus and atrial flutter.
ALLERGIES TO MEDICATIONS: Erythromycin.
ACE-I-worsens hyperkalemia
MEDICATIONS ON ADMISSION: Florinef 0.2 mg p.o. q. day,
Atlantis 10 units subcutaneously q.h.s., Humalog sliding
scale, Neurontin 100 mg p.o. t.i.d., PhosLo 4 mg p.o. t.i.d.,
Nephrocaps one p.o. q. day, Nortriptyline 75 mg p.o. q.h.s.,
Protonix 40 mg p.o. b.i.d., Lopressor 100 mg p.o. b.i.d.,
Ativan 1 to 2 mg p.o. q. 6-8 hours prn Reglan 20 mg p.o. q. day.
SOCIAL HISTORY: Lives with her parents, does not use
tobacco, occasionally uses alcohol.
PHYSICAL EXAMINATION: Physical examination at the time of
admission revealed temperature 98.8, blood pressure 215/86 at
the time of admission, decreasing to 110/52, pulse 82,
respirations 15, 94% on room air. In general, alert in no
apparent distress. Dry mucous membranes. Pupils are equal,
round, and reactive to light. Extraocular movements intact.
No lymphadenopathy, crackles were noted at the right base.
There was a regular rate and rhythm with a normal S1 and S2
as well as a II/VI systolic murmur. The abdomen is soft,
nontender with no hepatosplenomegaly, no guarding and no
rebound. Extremities showed no edema. There was tenderness
over the right lateral hip and buttock. Pain with internal
rotation of right hip and pressure against lateral aspect of
pelvis. The back showed no
spinous tenderness. The neurological examination showed the
patient alert and oriented times three. Cranial nerves II
through XII were intact. It was difficult to assess the
lower extremity strength due to the patient's pain.
LABORATORY DATA: Radiologic data - A bilateral film of the
pelvis and hips was performed on [**2200-5-2**] with no fracture
seen, however, it was noted that due to the patient's
demineralization an insufficiency fracture might be difficult
to detect and further imaging was suggested. An magnetic
resonance imaging of the hip on [**2200-5-4**] was read as
follows: Impression - "Insufficiency fractures of the sacral
ala, injection of the ilium and right superior pubic ramus."
Chest x-ray was performed on [**2200-5-3**] and demonstrated the
following impression: "Probable pneumonia in the left lower
lobe. Follow up views suggested." A repeat chest x-ray
performed on [**2200-5-5**] was read as follows: "Mild
improvement in the left lower lobe infiltrate, otherwise no
significant change from prior." Rib films were performed on
[**2200-5-7**] with the following impression: "No fractures or
bone lesions in the available views of the ribs, Perma-Cath
in the right atrium and bibasilar atelectasis increased since
the prior study of [**5-5**]. No pneumothorax."
Laboratory data - Complete blood count at the time of
admission revealed a white count of 12.2, hematocrit of 37.5
with 83.5% neutrophils, 9.5% lymphocytes, 5.1% monocytes,
1.1% eosinophils, 0.8% basophils. Platelet count at the time
of admission was 337. PT was 13.5 with an INR of 1.3, PTT
24.1. Chem-7 at the time of admission was as follows:
Sodium 139, potassium 5.2, chloride 100, bicarbonate 22, BUN
53, creatinine 5.2, glucose 338, creatinine kinase was
repeatedly cycled during this admission, on [**5-2**], [**5-5**], [**5-6**] and all values were noted to be below 15. ALT on [**5-6**] was
34 and AST was 30, alkaline phosphatase was 235, total
bilirubin was 0.2. A troponin on [**5-6**] was 1.0 with a repeat
that evening of 0.6. Calcium at the time of admission was
8.5, phosphate 7.3, magnesium 1.5. Acetones were absent on
[**5-4**] at 5 AM, noted to be large at 12:45 AM on [**5-5**] and
negative on [**5-5**] at 6 AM as well as negative on [**5-6**] at 9
PM. They had been negative on [**5-2**], 2 AM as well. Cortisol
levels were drawn on [**5-6**] at approximately 9 AM and were
after Cosyntropin stimulation, 30 minutes post stimulation
the value was 27, 60 minutes post stimulation the value was
35 for Cortisol with a baseline of 14. Calcium on [**5-6**] was
1.07 and then on repeat 1.12. Blood cultures from [**5-6**] are
pending at the time of this discharge. Blood cultures from
[**5-3**] demonstrated no growth. The mycolytic blood culture
from [**5-7**] is likewise pending. Perineal fluid from [**2200-5-6**] demonstrated no PMNs, no microorganisms, we saw no
growth out of the fluid. Electrocardiogram from [**5-2**] was
read as follows: Sinus rhythm, left ventricular hypertrophy,
nondiagnostic ST-T abnormalities, not changed from prior.
Electrocardiogram from [**5-2**], at 2255 was read as atrial
fibrillation with rapid ventricular response, left axis
deviation and possible left anterior vesicular block. QRS
changes in V3 and V4 probably due to left ventricular
hypertrophy with consistent anterior infarction, left
ventricular hypertrophy nondiagnostic ST-T abnormalities. On
[**5-4**], at 12:26 the electrocardiogram was read as follows,
sinus rhythm, long QTC interval with possible left
ventricular hypertrophy, tall T waves and at 22:47 it was
noted that the P wave after a change was somewhat of pure
antral consistent with ectopic atrial tachycardia, possibly
high junctional tachycardia. These changes were felt to be
nonspecific. Electrocardiogram on [**5-6**] was read as sinus
rhythm, minor nonspecific ST-T segment sagging, since prior
electrocardiogram ST-T abnormalities are nearly resolved. An
electrocardiogram was performed on [**2200-5-5**] with the
following results, ejection fraction of 55 to 60%.
Conclusion was "Left atrium normal, left ventricular wall
thickness normal, left ventricular cavity size normal,
overall left ventricular systolic function normal, mild
septal hypokinesis, right ventricular chamber size and free
wall normal aortic valve leaflets mildly thickened, mitral
valve leaflets are structurally normal and trivial mitral
regurgitation, estimated pulmonary artery systolic pressure
is normal, no pericardial effusion. There is a 2 by 1 cm
mass in the right atrium, at the site of the Porta-Cath which
may present thrombus or vegetation."
HOSPITAL COURSE: The patient was admitted status post fall
complaining of right hip pain as stated above.
Endocrine: The patient had a history of diabetes mellitus
Type 1 since the age of 23 and she has a history of diabetic
ketoacidosis as well. The patient admits to a prior dose of
Lantus prior to admission and fingersticks in the AM at the
time of admission were noted to be quite elevated and the
patient did administer intravenous insulin. The patient's
hyperglycemia rapidly resolved on the day of admission. She
was maintained on frequent fingersticks blood glucoses as
well as a Humalog sliding scale as well as Lantis 10 units
subcutaneously q.h.s. On [**2200-5-4**] at 11:30 PM, the
medical team was called to see the patient for hypotension
and initial tachycardia and the patient's fingerstick blood
glucose was noted to be critically high. The chem-7 was sent
and acetones were large. The patient was begun on an insulin
drip over night which was discontinued by the morning hours
with a repeat chem-7 demonstrating no acetone, noting that
increased anion gap also resolved, although the patient at
baseline presumably secondary to her renal failure has had
widened anion gap. [**Last Name (un) **] was consulted on [**2200-5-5**] and
raised concern that the patient might indeed be septic
contributing to the etiology of diabetic ketoacidosis versus
a cardiac etiology for this problem. The patient was
admitted to the Intensive Care Unit on [**2200-5-5**] for
further management of diabetic ketoacidosis and hypotension
in the setting of end stage renal disease on hemodialysis.
An insulin drip was restarted until the anion gap was noted
to be closing and the patient was ultimately transferred back
to the floor on [**2200-5-7**] with resolved diabetic
ketoacidosis. There was initially some concern in the
Intensive Care Unit for the possibility of hypoadrenalism but
Cosyntropin stimulation test did not support this. The
patient had been transiently taken off of while
insulin drip was applied. This was restarted at the time of
transfer out of the Medicine Intensive Care Unit at 10 units
subcutaneously q.h.s. and the sliding scale for Humalog was
resumed. The Lentis was increased to 12 units subcutaneously
q.h.s. on [**2200-5-8**] for better control of consistently
elevated fingersticks. On [**2200-5-9**] the patient's sliding
scale was changed in accordance with [**Last Name (un) **] recommendations,
again for better diabetic control.
Cardiovascular: The patient had a history of atrial flutter
as well as supraventricular tachycardia which had been
treated with Adenosine in the past. The patient was noted on
[**2200-5-3**], in the evening to have a tachycardia which was
felt possibly to represent atrioventricular nodal reentrant
tachycardia and was given Adenosine 6 mg and 12 mg and
ultimately the patient returned to [**Location 213**] sinus rhythm. She
was continued on beta blocker,
although these were transiently stopped due to hypotension.
The patient was maintained on Telemetry and was transferred
to the Telemetry Floor after this episode of tachycardia. On
the morning of [**2200-5-5**], noting the events of the prior
night, that the patient had been diabetic ketoacidosis with
persistent hypotension and the hypotension had not responded
adequately and with a sustained response of foot ulcer, the
patient was transferred to the Medical Intensive Care Unit.
She was noted to have nonspecific ST-T changes as well as
shortened PR consistent with ectopic atrial focus at the time
of hypotension prior to admission to the Intensive Care Unit.
The patient was noted to be cyanotic and hypotensive at 11:30
PM on [**2200-5-6**] in the Intensive Care Unit and received
chest compressions for what was felt possibly to be pulseless
electrical activity for 30 seconds. The patient was noted to
have had Q wave inversions and QRS widening in the context of
possibly becoming more hypoxic after receiving analgesia in
the form of narcotic analgesics. Transesophageal
echocardiogram was performed as described above and
demonstrated clot adherent to the patient's hemodialysis
catheter within the right atrium. Cardiology Service was
consulted for management of tachycardia. The Cardiology
Service recommended beginning the patient on Amiodarone 400
mg p.o. q. day for one month and then switched over to 200 mg
p.o. q. day. Additionally note that the patient had had a
nuclear stress in [**2200-1-31**] which showed a mild
reversible septal defect and ejection fraction of 61% as well
as an anterior fixed defect which had not been demonstrated
on the first of these, suggesting interval myocardial
infarction. The patient had no further arrhythmias for the
course of her admission and maintained excellent blood
pressures well above 100 whereas the patient had been, at the
time of admission, with blood pressures in the 80 to 90
range. Note as well, the patient was transiently started on
Dopamine for blood pressure support although this was rapidly
discontinued in the Intensive Care Unit.
Orthopedics: The patient was noted to have insufficiency
fractures as noted in the radiology report above.
Orthopedics was consulted and suggested no acute intervention
surgically, instead suggesting physical therapy and
rehabilitation as tolerated. The patient was seen by
physical therapy which was continued for the course of this
admission.Pain control was an issue. Due to transient apnea on
dilaudid drip in ICU we were cautious around narcotic use. She
was givien tylenol and ultram initially with inadequate results.
Codeine was added and titrated up to help get better pain
control.
Renal: The patient continues on hemodialysis and received
hemodialysis multiple times during the course of this
admission. The patient's hemodialysis catheter was noted to
have clot in the right atrium although this was not felt to
be a significant posing risk to her at the current time,
especially since the patient would be placed on
anticoagulation. The patient also had a peritoneal dialysis
catheter in place which was not used during the course of
this admission. She continues to be followed by the Renal
Service.
Infectious diseases: The patient was noted to be febrile on
[**2200-5-4**], spiking a temperature to 102.7. Blood cultures
failed to reveal organism. It was suspected that the patient
might have the pneumonia and the patient was covered with
Levofloxacin 250 mg p.o. q. 4-8 hours which was maintained
for the remainder of the patient's admission. Although
suspicion initially suggested the possibility of infected
hemodialysis or peritoneal dialysis catheter, blood cultures
failed to grow organisms and these catheters were left in
place. Infectious Disease Service was consulted in the
Intensive Care Unit and suggested Vancomycin as well as
Levofloxacin with suggestion to discontinue the Vancomycin if
cultures were negative as well as suggestion to draw fungal
cultures. As noted above, these cultures had not grown
organisms at the time of this discharge summary.
Pain control: The patient was initially maintained on
Morphine for analgesia. Narcotic analgesia was continued in
the Intensive Care Unit, however, the patient was noted to
have an apneic episode felt to possibly be related to
oversedation with narcotic analgesia and the patient upon
transfer to the floor was soon thereafter started on Codeine
as well as Ultram for pain control on which she is continued
at the current moment.[**Name (NI) 19736**] Pt briefly had chest compressions in
ICU for brief episode of unresponsiveness and now has chest wall
pain over sternam that is reproduced with palpation. x-ray neg
for rib fractures however ?sternal fracture or contusion.
Continue narcotics as needed for pain.
Atrila clot at timp of permacath. Discussed with renal team and
IR. The plan is to anticoagualte for 2 weeks with heparin and
coumadin when INR therapeutic, repeat the TTE in 2 weeks, if clot
has decreased in size her line may be removed at that time and/or
anticoagulation d/c'd/
Code status: Full.
DISCHARGE PLAN: The patient will be discharged to a
rehabilitation facility. She will be maintained on Coumadin
3 mg p.o. q. day with her INR being checked q. day with a
goal INR of approximately 2 for a small clot on the patient's
hemodialysis line. The patient will follow up for PTT one
week status post discharge and the patient should be
discharged for an outpatient transesophageal echocardiogram
approximately two weeks from the time of discharge to
reassess the clot in the patient's right atrium. She will be
maintained on Lantus insulin at h.s. as well as Humalog sliding
scale
for control of her diabetes mellitus with fingersticks q.i.d.
as well as diabetic diet. She will participate in physical
therapy at rehabilitation. The patient will be continued on
Amiodarone 400 mg p.o. q. day for one month at which time
Amiodarone should be altered to 200 mg p.o. q. day.
She needs f/u with her cardilogist re: possible cardiac cath as
she had some st segment changes when in her atrial tachycardia.
DISCHARGE DIAGNOSIS:
1. Supraventricular tachycardia
2. Status post diabetic ketoacidosis
3. New insufficiency fractures of the pelvis as described
above.
4, Brittle Type 1 DM
5. Atrial clot on tip of HD catheter
6. ESRD on HD
Please see past medical history for additional diagnoses.
MEDICATIONS ON DISCHARGE:
Coumadin 3 mg p.o. q. day
Nortriptyline 75 mg p.o. q.h.s.
Lorazepam 1 to 2 mg p.o. q. 8 hours prn
Nephrocaps 1 p.o. q. day
Gabapentin 100 mg p.o. t.i.d.
Calcium acetate 4 tablets p.o. t.i.d. with meals
Fludrocortisone acetate .02 mg p.o. q. day
Metoclopramide 5 mg p.o. q.i.d. a.c. h.s.
Colace 100 mg p.o. b.i.d.
Humalog insulin sliding scale (please see current sheet)
Senna 2 p.o. q.h.s.
Amiodarone 400 mg p.o. q. day times one month
Pantoprazole 40 mg p.o. b.i.d.
Tramadol 50 to 100 mg p.o. b.i.d. prn
Codeine 15 mg p.o. q. 4 hours prn pain, hold sedation
Lantus Insulin 12 units subcutaneously q. h.s.
Levofloxacin 250 mg p.o. q. 48 hours time six additional days
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2200-5-9**] 19:02
T: [**2200-5-9**] 20:28
JOB#: [**Job Number 19737**]
Admission Date: [**2200-5-2**] Discharge Date: [**2200-5-15**]
Date of Birth: [**2158-11-18**] Sex: F
Service: [**Doctor Last Name 1181**]
ADDENDUM: This dictation covers the period from [**2200-5-11**] to
[**2200-5-15**].
The patient was continued on amiodarone and monitored on
telemetry, without any further cardiac events. Concerning
discharge summary, it was the opinion of the Renal service
that this clot was unlikely to be clinically significant, and
the patient could be placed on anticoagulation with the hope
that the clot would slowly lyse. The patient was continued
on heparin, which was ultimately changed to Coumadin, with
the heparin being discontinued once the INR rose above 2.0.
The goal INR is 2-2.5 given recent h/o severe GI bleed.
Ultram to better control her hip as well as chest pain from
pelvic insufficiency fracture, and status post chest
compressions respectively.
The patient was sent for hemodialysis on [**2200-5-13**]. On
[**2200-5-14**], the patient was noted to have had a brief episode of
diabetic ketoacidosis overnight, which quickly resolved
without the use of an insulin drip. This was felt likely to
be secondary to the patient not receiving Glargine the night
prior, although this medication had been ordered.
Concerning preparations for the patient's kidney/pancreas
transplant, decision was made to consult Dr. [**Last Name (STitle) **] of the
Cardiology service here in preparation for possible
catheterization should this be necessary prior to evaluation
for transplant. Dr. [**Last Name (STitle) **] suggested evaluation on an
outpatient basis approximately four weeks status post
discharge for question of catheterization.
The patient was again dialyzed on [**2200-5-15**], and remained
stable status post hemodialysis. She is currently awaiting a
rehabilitation bed, and will be discharged once one becomes
available.
DISCHARGE MEDICATIONS: (Please note changes from prior
dictation.) Coumadin 2.5 mg by mouth once daily, Lorazepam 1
to 2 mg by mouth every eight hours as needed, nortriptyline
75 mg by mouth daily at bedtime, Nephro-Caps one by mouth
once daily, gabapentin 100 mg by mouth three times a day,
metoclopramide 5 mg by mouth four times a day before meals
and at bedtime, Colace 100 mg by mouth twice a day, Senna two
by mouth daily at bedtime, Lactulose 30 mg by mouth twice a
day as needed if no bowel movement for greater than 24 hours,
amiodarone 400 mg by mouth once daily until [**6-7**] at which
time this medication is to be changed to 200 mg by mouth once
daily, Protonix 40 mg by mouth twice a day, Tramadol 50 to
100 mg by mouth twice a day as needed for hip pain,
prochlorperazine 10 mg by mouth every eight hours as needed
for nausea, percocet 5/325 one to two by mouth every four to
six hours as needed and hold for sedation, sevelamer 1600 mg
by mouth three times a day, fludrocortisone acetate 0.2 mg by
mouth once daily, Glargine 14 units subcutaneously daily at
bedtime, Humalog sliding scale (please see sheet).
DISCHARGE PLAN: The patient will be discharged to
rehabilitation. She will have finger stick blood glucoses
measured four times a day, and her Humalog should be dosed
with meals. She should had peritoneal dialysis catheter
flushed once a week by an experienced personnel. Her PT, INR
should be measured once daily or every other day, and
Coumadin adjusted as needed with a goal INR of approximately
2.0. The patient should have repeat transthoracic
echocardiography to reassess her right atrial clot on or
about [**2200-5-21**]. The patient should follow up with her primary
care physician within one week of discharge from
rehabilitation facility, and Dr. [**Last Name (STitle) **] of the [**Hospital1 346**] Cardiology service approximately
four weeks status post discharge from the [**Hospital1 346**] for question of catheterization.
The patient should follow up with Dr. [**Last Name (STitle) **] at the [**Hospital **]
Clinic approximately within one week of discharge from the
rehabilitation facility, and the staff of the rehabilitation
facility should feel free to call Dr. [**Last Name (STitle) **] with any
questions regarding the patient's diabetes management. The
patient will be discharged on the [**Doctor Last Name **] of Hearts monitor,
which should be continued for approximately two weeks and
report sent to Dr. [**Last Name (STitle) **] of the [**Hospital1 190**] Cardiology unit, as the patient has been
started on amiodarone during this admission.
CONDITION AT THE TIME OF THIS DICTATION: Stable.
ADDITIONAL DISCHARGE DIAGNOSES:
1. Status post additional episode of diabetic ketoacidosis
with rapid resolution, possibly secondary to lack of Glargine
intended for administration the night prior to episode
[**Name (NI) 19738**] Pt had routine flush of her PD catheter on [**5-15**] which
shoed >300 wbcs with a predominanace of polys meeting criteria
for PERITONITIS. pt had no abdominal
complaints/fever/leukocytosis however antibiotic treatment was
started after cxs were sent wtih Ceftaz 1 gm +1 gm cefazolin via
PD catheter with dwell for 24hours and repeat treatment qd for 1
week. her rehab plans were changed as a result to go to a rehab
that could handle this treatment. repeat fluid counts showed
rising wbc count.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2200-5-15**] 22:17
T: [**2200-5-16**] 00:32
JOB#: [**Job Number **]
Name: [**Known lastname 3197**], [**Known firstname **] Unit No: [**Numeric Identifier 3198**]
Admission Date: [**2200-5-2**] Discharge Date: [**2200-5-17**]
Date of Birth: [**2158-11-18**] Sex: F
Service: [**Doctor Last Name **] M
ADDENDUM:
On [**2200-5-15**], the patient's PD catheter was flushed
revealing a white blood cell count of 300 in the returned
fluid. The patient had no symptoms consistent with
peritonitis, no fever and no abdominal symptoms. A culture
was sent and the patient was started on PDA catheter
antibiotics. This should continue as follows:
1. Ceptaz 1 gram and Cefazolin 1 gram together mixed in 1000
cc. of 2.5% dextrose and instilled inter-peritoneally. The
fluid should dwell for six hours and then be removed. This
should be repeated q. day for an additional five days.
On the day after the antibiotic course is completed, please
send PD fluid for culture and cell count.
The remainder of the patient's course and treatment is
unchanged and is as previously dictated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3258**], M.D. [**MD Number(1) 3259**]
Dictated By:[**Name8 (MD) 292**]
MEDQUIST36
D: [**2200-5-17**] 13:32
T: [**2200-5-17**] 16:58
JOB#: [**Job Number 3260**]
|
[
"805.6",
"250.43",
"E888.9",
"427.32",
"250.13",
"585",
"427.1",
"808.2",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
22944, 25214
|
20278, 21383
|
17089, 17357
|
17383, 18057
|
2099, 2432
|
7987, 16054
|
2546, 7969
|
200, 233
|
262, 1561
|
21400, 22923
|
1584, 2072
|
2449, 2523
|
18082, 20253
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,053
| 182,434
|
12640
|
Discharge summary
|
report
|
Admission Date: [**2135-12-9**] Discharge Date: [**2135-12-14**]
Date of Birth: [**2078-10-28**] Sex: M
Service: UROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 year-old male s/p prostate biopsy [**2135-12-8**] by Dr. [**Last Name (STitle) 3748**]. He
arrived in ED via ambulance and was found to be hypotensive to
SBP in 60s and tachycardic with HR ~120. He was resucitated in
the ED with 4 liters crystalloid and placed on ceftriaxone and
flagyl empirically. Patient does report that he was taking
cipro as prescribed after his biopsy.
Past Medical History:
Hypertension, diabetes
Social History:
He does not smoke tobacco or drink alcohol.
Family History:
Non-contributory
Physical Exam:
On Discharge:
VS: Temp 99.0, HR 90, BP 130/80, RR 17, O2 sat 99% on room air
Gen: NAD, alert and oriented
CV: RRR
Pulm: clear bilaterally
Abd: soft, nontender, nondistended
Pertinent Results:
Admission labs:
[**2135-12-9**] 08:50PM BLOOD WBC-4.8 RBC-4.76 Hgb-13.5* Hct-39.7*
MCV-83 MCH-28.3 MCHC-33.9 RDW-13.3 Plt Ct-185
[**2135-12-9**] 08:50PM BLOOD Neuts-58 Bands-13* Lymphs-17* Monos-2
Eos-0 Baso-1 Atyps-4* Metas-5* Myelos-0
[**2135-12-10**] 02:13AM BLOOD PT-16.3* PTT-30.1 INR(PT)-1.5*
[**2135-12-9**] 08:50PM BLOOD Glucose-240* UreaN-29* Creat-3.1*# Na-142
K-3.1* Cl-102 HCO3-22 AnGap-21*
[**2135-12-9**] 08:50PM BLOOD ALT-15 AST-20 AlkPhos-64 Amylase-110*
TotBili-0.6
[**2135-12-9**] 08:50PM BLOOD Lipase-76*
[**2135-12-9**] 08:50PM BLOOD Albumin-4.4 Calcium-10.4* Phos-1.4*
Mg-1.5*
[**2135-12-9**] 08:48PM BLOOD Lactate-5.8*
Peak WBC:
[**2135-12-12**] 07:50AM BLOOD WBC-13.0* RBC-3.71* Hgb-10.3* Hct-31.3*
MCV-84 MCH-27.8 MCHC-32.9 RDW-13.0 Plt Ct-149*
Discharge labs:
[**2135-12-14**] 04:31AM BLOOD WBC-7.7 RBC-4.07* Hgb-11.1* Hct-34.0*
MCV-84 MCH-27.4 MCHC-32.8 RDW-13.1 Plt Ct-202
[**2135-12-14**] 04:31AM BLOOD Neuts-60.7 Lymphs-27.7 Monos-9.1 Eos-2.1
Baso-0.4
[**2135-12-14**] 04:31AM BLOOD Glucose-282* UreaN-22* Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-24 AnGap-14
[**2135-12-13**] 06:05AM BLOOD ALT-38 AST-85* AlkPhos-66 Amylase-79
TotBili-0.2
[**2135-12-11**] 05:12AM BLOOD Glucose-85 Lactate-1.2
Urine culture: E.coli sensitive to CTX
Blood cultures ([**12-9**]) E. coli sensitive to CTX
Blood cultures ([**12-12**]) no growth to date
Brief Hospital Course:
Mr. [**Known lastname 39048**] was admitted to the ICU on [**2135-12-9**] for septic shock
s/p prostate biopsy on [**2135-12-8**]. His SBP was initially in the
60s so he was aggressively resuscitated with intravenous fluids
in the ED and then in the ICU. He was started on Ceftriaxone
and Flagyl empirically. Urine and blood cultures drawn on
arrival both grew E.coli sensitive to Ceftriaxone, but resistent
to Cipro (the antibiotic Mr. [**Known lastname 39048**] was taking post-biopsy).
He was afebrile and his hemodynamics were stable for 2 days. He
was transferred out of the ICU to the floor on the evening of
[**2135-12-11**]. An ID consult was obtained on [**2135-12-12**]. Repeat blood
cultures were drawn on [**12-12**] and are no growth to date. A PICC
line was placed for longterm IV antibiotics on [**2135-12-13**]. His
WBC count normalized to 7.7. His serum creatinine returned to
his baseline of 1.4 (3.1 on presentation to the ED). He is
discharged in good condition. He will have weekly CBC with
diff, LFT, and BUN/Creatinine. He will continue on the
ceftriaxone until his follow up with Dr. [**Last Name (STitle) 976**] on [**2136-1-10**]. He
still complains of urgency but no dysuria. He was given a
condom catheter at his request so he can return to work. He
will follow up with Dr. [**Last Name (STitle) 3748**] in 2 weeks.
Medications on Admission:
asa 81mg daily, glucophage 850mg [**Hospital1 **], glyburide 10mg [**Hospital1 **], HCTZ
25mg daily, lisinopril 40mg daily, pravastatin 10mg daily
Discharge Medications:
1. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 4 weeks.
Disp:*56 grams* Refills:*0*
5. NS Flush
NS Flush per PICC line protocol
6. Heparin flush
Heparin flush per PICC line protocol
7. Outpatient Lab Work
Please draw CBC with diff, LFTs, and Bun/Creatinine [**Last Name (un) **] on
Mondays and fax the results to Dr. [**Last Name (STitle) 976**] @ ([**Telephone/Fax (1) 1353**]
8. Condom catheter Sig: One (1) catheter once a day.
Disp:*30 catheters* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Septic shock
E. coli sepsis
E. coli UTI
Acute renal failure
Discharge Condition:
Good
Discharge Instructions:
Call your surgeon if you experience:
- fever > 101.5
- chills
- increasing pain not relieved by your medication
- inability to eat or drink
- no urine output
Resume all of your home medications. You will have to take
Ceftriaxone for 4 more weeks until your follow up appointment
with Dr. [**Last Name (STitle) 976**].
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 39049**] in 2 weeks. Call his office at ([**Telephone/Fax (1) 39050**] to schedule your appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**]
Date/Time:[**2136-1-10**] 10:30
|
[
"250.00",
"401.9",
"785.52",
"E878.8",
"038.42",
"998.59",
"041.4",
"E849.9",
"584.9",
"995.92",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4767, 4842
|
2436, 3796
|
283, 290
|
4946, 4953
|
1053, 1053
|
5321, 5639
|
826, 844
|
3993, 4744
|
4863, 4925
|
3822, 3970
|
4977, 5298
|
1840, 2413
|
859, 859
|
873, 1034
|
231, 245
|
318, 703
|
1069, 1824
|
725, 749
|
765, 810
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,903
| 171,296
|
33744
|
Discharge summary
|
report
|
Admission Date: [**2119-2-25**] Discharge Date: [**2119-2-25**]
Date of Birth: [**2073-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
emergency Type A aortic dissection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45 yo male transferred in emergently from [**Hospital **] [**Hospital **] hospital
ER. He presented in their ER 6 hours prior to transfer here. He
was intubated there with noted paraplegia and hypotension.
Past Medical History:
([**First Name8 (NamePattern2) **] [**Hospital1 **] ER record):
CAD
MI
past IVDA
smoker
Social History:
unknown
Family History:
unknown
Physical Exam:
unresponsive, cyanotic, mottled
BP 60 systolic
extremities rigid and cool
fixed and dilated pupils
Pertinent Results:
[**2119-2-25**] 02:48AM BLOOD Type-ART pO2-61* pCO2-67* pH-6.78*
calTCO2-11* Base XS--29 Intubat-INTUBATED Vent-CONTROLLED
[**2119-2-25**] 02:48AM BLOOD Glucose-128* Lactate-6.6* Na-141 K-5.4*
Cl-119*
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2119-2-25**] 3:41 AM
CHEST PORT. LINE PLACEMENT
Reason: ?ET tube correctly positioned
[**Hospital 93**] MEDICAL CONDITION:
45 year old man with aortic dissection
REASON FOR THIS EXAMINATION:
?ET tube correctly positioned
EXAMINATION: AP chest.
INDICATION: Aortic dissection.
Single AP view of the chest was obtained on [**2119-2-25**] at 05:06
hours. No prior films are available for comparison. The patient
is intubated with the tip of the ET tube approximately 5.5 cm
above the carina. A Swan-Ganz catheter has been inserted from
the right side and its tip lies in the main pulmonary artery.
There is almost complete opacification of the left hemithorax.
Bullous changes are seen at both apices. Diffuse haziness seen
in the right hemithorax likely represents layering pleural
effusion. Also, there is increased prominence of the
interstitial markings on the right side.
IMPRESSION:
By history provided, the patient has aortic dissection. As
described, there is almost complete opacification of the left
hemithorax which presumably is a combination of fluid/blood and
atelectasis. Likely layering effusion on the right side.
Interstitial prominence consistent with overload or edema.
Bullous changes at both apices. Please correlate the findings
with any prior imaging, which is not available to us at the time
of this dictation.
DR. [**Known firstname **] [**Last Name (NamePattern1) **]
Approved: SAT [**2119-2-25**] 3:11 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 4508**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78067**] (Complete)
Done [**2119-2-25**] at 3:37:12 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-10-16**]
Age (years): 45 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic dissection. Aortic valve
disease. Coronary artery disease. Hypertension.
ICD-9 Codes: 402.90, 440.0, 441.00, 441.2, 424.1
Test Information
Date/Time: [**2119-2-25**] at 03:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 10% to 15% >= 55%
Aorta - Sinus Level: *4.8 cm <= 3.6 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo
contrast in the body of the LA. Thrombus in the body of the LA.
No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Severe regional LV systolic dysfunction.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta. Simple atheroma in ascending aorta. Mildly
dilated descending aorta. Ascending aortic intimal
flap/dissection.. Descending aorta intimal flap/aortic
dissection.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Moderate (2+) AR.
MITRAL VALVE: Mild (1+) MR.
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. Emergency study. Results were personally reviewed
with the MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
1. The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. A thrombus is
seen in the body of the left atrium. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. There is severe regional
left ventricular systolic dysfunction with anterior and
posterior akinesis
3. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the ascending aorta. The descending thoracic aorta is mildly
dilated. A mobile density is seen in the ascending aorta
consistent with an intimal flap/aortic dissection. The
dissection originates at the level of the LMCA and flow is not
seen in the Left Main. Flow is seen in the RCA. A mobile density
is seen in the descending aorta consistent with an intimal
flap/aortic dissection.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen.
6. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results .
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2119-2-25**] 03:51
?????? [**2113**] CareGroup
Brief Hospital Course:
Taken directly to OR on arrival for possible emergency surgery.
Hypotensive, in shock,on multiple inotropes close to cardiac
arrest. TEE done in OR showed EF 10%, no flow in left main
consistent with LM occlusion, global severe hypokinesia, and
clots in the left atrium. Both lower extremities rigid, severly
acidotic pH in the region of 6 and base excess above -20,
prolonged hypotension during transfer lasting more than a few
hours, unresponsive for about 4 hours. Decision made by Dr.
[**First Name (STitle) **] not to proceed with surgery given the findings on echo
and clinical exam, as well as severe acidosis. Multiple
unsuccessful attempts were made to contact the family. He was
transferred to the CVICU and expired at 6:44 AM on [**2-25**]. Unable
to contact family, and message was left informing them.
Susequently family contact[**Name (NI) **] and informed.
Medications on Admission:
unknown
Discharge Disposition:
Expired
Discharge Diagnosis:
ascending aortic dissection
CAD
MI
Discharge Condition:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2119-4-13**]
|
[
"276.2",
"441.01",
"305.90",
"414.01",
"344.1",
"414.12",
"428.0",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7875, 7884
|
6944, 7817
|
356, 362
|
7962, 8091
|
893, 1240
|
750, 759
|
1277, 1316
|
7905, 7941
|
7843, 7852
|
5284, 6921
|
774, 874
|
282, 318
|
1345, 5235
|
390, 597
|
619, 709
|
725, 734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,103
| 103,563
|
41377
|
Discharge summary
|
report
|
Admission Date: [**2140-3-3**] Discharge Date: [**2140-3-29**]
Date of Birth: [**2088-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Hemodialysis
Removal of hemodialysis catheter
History of Present Illness:
In brief, pt is a 52 year old male with PMH of DM2, obesity,
obstructive sleep apnea, HLD, CAD s/p previous stent at [**Hospital1 3278**]
for possible MI, HTN, and neuropathy who is transferred from
[**Hospital3 **] for further management of rhabdomyolysis with
acute renal failure, severe metabolic acidosis, and
thrombocytopenia.
.
On [**2140-2-29**], at the outside hospital, he underwent an elective
lithotripsy of a right staghorn calculus, during which he was
held in the prone position for 8 hours. He eventually had to
have a percutaneous nephrostomy for stone removal. He had
metabolic acidosis postoperatively and evidence of high lactic
acid, and CK's >15,000 (assay not read higher than this) with
subsequent development of acute renal failure over the next [**12-31**]
days (Cr 0.79-->1.9-->6). He had a pH of 7.18 per anesthesia
records which was treated with a bicarbonate drip. He had an ABG
of 7.4/32/107 on transfer. He was also hyperkalemic to 5.0,
requiring frequent doses of kayaxelate. Of note, he was
hemodynamically stable during his stay without significant
respiratory distress or need for pressors. However, he did have
some runs of Vtach when turned, but responsive to metoprolol. He
was placed on noninvasive ventilation twice during his stay,
once for OSA and otherwise to attempt hyperventilation in
treatment of his metabolic acidosis. He has been oliguric with
dark urine. He also had a PICC line placed [**3-1**]. A nephrology
consult at the OSH thought that he would need hemodialysis, and
he was thus transferred here. His percutaneous nephrostomy tube
eventually dislodged requiring placement of a nephroureteral
stent through existing tract. Drainage was adequate per OSH
report, though the tube was clamped on transfer for unclear
reasons.
.
Course at OSH also c/b thrombocytopenia postoperatively with
platelet counts from 252 preop to 172 immediately postop to 29
morning prior to transfer to 56 after transfusion of 1 unit
platelets. The patient received 1 dose of enoxaparin on [**2140-3-1**].
His platelet was 56 after 1 trasnfusion. Labs on discharge were
significant for an ABG of 7.4/32/107.
.
In the MICU, his renal function has continued to worsen, with
increasing oliguria. Renal has been following, and no urgent
need for HD as of yet. PT has had significant lab abormalities
with AG 20, HCO3 14 today. Pt has been getting IVF and bicarb
per renal recs. Etiology of ARF attributed to rhabdo vs. ATN [**12-30**]
hypotension possibly during surgery, though noted at OSH to be
HD stable with no need for pressors. CK has been improving from
52,000 to 19,000 today. Urology has evaluated given nephrostomy
tube, and recomend keeping tube to gravity. He has also been
noted to have significant transaminitis, which has been
improving, but Tbili rising. Pt has also been hyponatremic.
Pt has also been having leg weakness, left>right since his
surgery at the OSH. Pt states that it hasn't gotten better or
worse. He describes it as a "numbness" but denies tingling. He
was evaluated at the OSH by neurology there, and had considered
CT and spine films, but were not done. Renal has recommended MRI
for possible dissection to explain weakness, LFT abnormalities.
This has not yet been pursued. Pt's thrombocytopenia has been
improving to 70 today. HIT Ab negative. PT has been on
pneumoboots and off heparin since admission. Unclear etiology
thus far.
did not get CT or L-spine films yesterday, exam here with
weakness L>R, but more impressive for decreased sensation rather
than weakness
.
Pt states that he mostly is very tired now. He also has pain in
his mid-lower back that he says has been there since surgery. He
says the numbness and weakness in his left leg as been unchanged
sicne admission. Vital signs prior to transfer were Temp 95.6 HR
78 BP 123/46 HR 78 RR 14 99%RA.
.
.
Review of systems: Positive as above.
Otherwise, denies fever, chills, night sweats. 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
dysuria, frequency, or urgency. Pt is unsure how much if any
urine he is making.
Past Medical History:
-Hypertension
-hyperlipidemia
-chronic kidney disease
-obesity
-OSA - does not tolerate CPAP
-diabetes mellitus type II
-CAD s/p stent placement at [**Hospital1 3278**]
-diverticulitis s/p surgical excision
-neuropathy
-right staghorn calculus
Social History:
- Tobacco: 1 pack per week for 16 years, quit 16 years ago
- Alcohol: none
- Illicits: none
Works as a courier. Married with 2 daughters.
Family History:
adopted without knowledge of family history
Physical Exam:
ADMISSION:
Vitals: 96.2 133/74 81 25 96%2LNC BG 145
General: Obese, Alert, oriented, looks fatigued, but NAD
HEENT: icteric sclera, EOMI, dry MM, oropharynx clear, swelling
an yellowing of left lateral aspect of tongue
Neck: supple, difficult to appreciate JVP given body habitus
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Obes, soft, +BS, non-tender, non-distended
GU: foley in place, minimal urine in bag
Ext: warm, 1+ pitting edema to midshin bilaterally
Neuro: A&Ox3, EOMI, decreased sensation to light touch over left
shin and knee, left foot, pt minimally moving left leg, states
unable to move his left toes, distal strength 5/5 on right
DISCHARGE:
98.7 98.6 130/68 84 18 97%RA
24H 1800 PO / 4850 UOP
8H 380 PO / 1400 UOP
General: Obese, A&Ox3, NAD, eager for discharge
HEENT: EOMI, MMM, L tongue lesion appears well-healing without
drainage, stigmata of recent oozing but no active bleeding;
parotid firm, decreased size, non-erythematous, non-fluctuant,
no interior oozing, no TTP
Neck: supple, difficult to detect JVP 2/2 habitus
Lungs: good BS bilaterally anteriorly and posterolaterally. no
wheeze. no crackles.
CV: Distant sounds [**12-30**] habitus, RRR, nl S1 + S2, no m/r/g
Abdomen: Obese, soft, +BS, no referring pain, some diffuse
abdominal TTP but no r/g, no peritoneal signs. No RUQ pain to
palpation.
Ext: warm, bilat 1+ pitting edema, soft, NT. No asterixis. Faint
BUE tremor, improving.
Neuro: no sensory deficit across abd; [**3-31**] bilat hip and plantar
flexion strength, but unable to dorsiflex or extend L foot > R
foot. UE [**3-31**] bilat.
Pertinent Results:
ADMISSION LABS:
[**2140-3-3**] 09:26PM BLOOD WBC-7.8 RBC-3.43* Hgb-11.8* Hct-30.8*
MCV-90 MCH-34.4* MCHC-38.4* RDW-13.4 Plt Ct-67*
[**2140-3-3**] 09:26PM BLOOD Neuts-81.3* Lymphs-12.2* Monos-5.6
Eos-0.4 Baso-0.5
[**2140-3-4**] 04:01AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2140-3-3**] 09:26PM BLOOD PT-13.3 PTT-23.0 INR(PT)-1.1
[**2140-3-7**] 01:00PM BLOOD Fibrino-1036*
[**2140-3-5**] 01:23AM BLOOD Ret Aut-2.0
[**2140-3-4**] 04:01AM BLOOD Ret Aut-2.3
[**2140-3-3**] 09:26PM BLOOD Glucose-162* UreaN-80* Creat-7.9* Na-131*
K-3.2* Cl-93* HCO3-20* AnGap-21*
[**2140-3-3**] 09:26PM BLOOD ALT-3437* AST-4532* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-196* TotBili-3.4* DirBili-2.7* IndBili-0.7
[**2140-3-4**] 04:01AM BLOOD Lipase-75*
[**2140-3-3**] 09:26PM BLOOD Albumin-2.7* Calcium-6.7* Phos-8.5*
Mg-1.9
[**2140-3-4**] 04:01AM BLOOD Hapto-<5*
[**2140-3-7**] 05:56AM BLOOD Hapto-16*
[**2140-3-8**] 04:28AM BLOOD calTIBC-139* Ferritn-5535* TRF-107*
[**2140-3-8**] 04:28AM BLOOD TSH-3.0
[**2140-3-8**] 04:28AM BLOOD T4-4.4*
[**2140-3-7**] 01:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2140-3-7**] 01:40PM BLOOD HCV Ab-NEGATIVE
[**2140-3-3**] 08:43PM BLOOD Type-ART pO2-79* pCO2-33* pH-7.42
calTCO2-22 Base XS--1
[**2140-3-6**] 08:56PM BLOOD Type-ART pO2-89 pCO2-30* pH-7.25*
calTCO2-14* Base XS--12 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2140-3-3**] 08:43PM BLOOD Lactate-1.4
[**2140-3-6**] 08:56PM BLOOD Glucose-125* Lactate-1.2 Na-126* K-4.1
Cl-98*
[**2140-3-3**] 08:43PM BLOOD Hgb-11.3* calcHCT-34
[**2140-3-3**] 08:43PM BLOOD freeCa-0.89*
.
.
DISCHARGE LABS:
Na 138 | Cl 101 | BUN 75 < Glu 95
K 5.0 | HCO3 27 | Cr 7.1
Ca: 9.5 Mg: 2.0 P: 6.0
WBC 6.3 > Hgb 8.0 / Hct 23.8 < Plt 433
.
STUDIES:
.
Images:
CXR [**2140-3-3**]: The left PICC line tip is at the level of the
cavoatrial junction/proximal right atrium and might be pulled
back for approximately 1 cm to secure its position in the low
SVC/cavoatrial junction. Heart size is normal. Mediastinum is
normal. Lungs are essentially clear except for right basal
opacity most likely representing atelectasis, but infectious
process is another possibility.
.
CXR [**2140-3-5**]:
The left PICC line tip is at the level of cavoatrial
junction/proximal right atrium. Cardiomediastinal silhouette is
stable. The right basal opacity is unchanged. No interval
development of interstitial edema or new consolidations has been
demonstrated.
Overall, no significant change noted since the prior study.
Continued attention to the right lower lung is recommended to
exclude the possibility of developing infectious process in this
location.
.
CTAP [**2140-3-5**]:
IMPRESSION:
1. No retroperitoneal hematoma.
2. Heterogeneously fatty liver.
3. Moderately distended gallbladder.
4. Large bowel dilatation extending to what appears to be a
surgical site within the deep pelvis, though evaluation of
surgical anatomy is limited without oral contrast or surgical
operative notes. Decompressed bowel distal to this anastomotic
site is suggestive of a partial or early large bowel
obstruction.
5. Bilateral perinephric stranding with well-positioned
right-sided
nephroureteral stent. Residual calculi noted in the right
kidney, largest measuring 1.1 cm.
6. Nonobstructing small bowel herniation through left abdominal
wall likely related to prior surgery.
7. Significant soft tissue stranding, likely representing
post-surgical change, is noted in the left-sided subcutaneous
tissue overlying the abdomen.
.
RUQ U/S [**2140-3-6**]:
IMPRESSION: Limited examination; however, no overt hepatic
venous or portal venous thrombus is seen. Normal directional
flow is demonstrated.
.
EKG [**2140-3-9**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Slight non-specific T wave changes. Consider
electrolyte abnormality. The poor R wave progression may be a
normal variant but consider prior anterior wall infarction. No
previous tracing available for comparison.
.
CXR [**2140-3-10**]: NG tube tip is out of view below the diaphragm.
Right IJ catheter tip remains in the right atrium. Left PICC tip
is in the mid SVC. There are low lung volumes. There is no
pneumothorax or large pleural effusions. Aside from bibasilar
atelectasis, the lungs are clear.
.
RUQ U/S [**2140-3-13**]: : Study limited by technique. The liver appears
echogenic, compatible with known history of cirrhosis. Trace
perihepatic fluid is noted. Portal vein appears patent. The
common bile duct measures 0.4 cm. The gallbladder appears normal
without evidence of gallstones. The limited visualization of the
head and body of the pancreas appears unremarkable. The tail is
not clearly visualized.
IMPRESSION:
1. Limited examination with echogenic liver, consistent with
known cirrhosis. Trace perihepatic fluid.
2. Partially visualized pancreas appears unremarkable.
.
EKG [**2140-3-14**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Non-specific ST-T wave abnormalities. Compared to
the previous tracing of [**2140-3-9**] no diagnostic change.
.
Renal U/S [**2140-3-15**]: The right kidney measures 14.0 cm. The left
kidney measures 14.5 cm. There is no hydronephrosis,
hydroureter, or evidence of residual renal calculi. The right
percutaneous nephrostomy tube is vaguely evident. Small amount
of perihepatic ascites is noted, but there is no perirenal
fluid. The bladder is not visualized, secondary to patient's
body habitus and bowel gas obscuration.
IMPRESSION: No hydroureteronephrosis. No residual renal stone
noted. Small perihepatic ascites.
.
MRI Thoracolumbar [**2140-3-16**]:
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the thoracic spine were acquired.
FINDINGS: In the mid thoracic region at T7-8 a central disc
herniation identified moderately narrowing the spinal canal
indenting the spinal cord. At T8-9 there is a small central
disc herniation seen with mild narrowing of the spinal canal and
indentation on the spinal cord. Mild degenerative changes are
seen at other levels. There is no evidence of abnormal signal in
the thoracic spinal cord. In the visualized lower cervical
region at C7-T1 level there is a disc herniation or protrusion
identified on sagittal images which narrows the spinal canal and
indents the spinal cord. There is suspicion for increased signal
within the spinal cord at this level.
IMPRESSION:
1. Spinal canal narrowing in the lower cervical upper thoracic
region with indentation on the spinal cord by disc protrusion
seen on the sagittal images. Increased signal is also suspected
in the spinal cord at this level on the sagittal images. A
focussed study of the cervical spine would be helpful for
further assessment.
2. Disc protrusions at T7-8 and T8-9 levels indenting the spinal
cord with moderate spinal stenosis at T7-8 and mild spinal
stenosis at T8-9 levels. No abnormal signal in the thoracic
spinal cord. 3. Subtle increased signal within the posterior
muscles on the right side in the thoracic region could be due to
edema.
.
LUMBAR SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the lumbar spine acquired.
FINDINGS: From T12-L1 to L3-4 no abnormalities are seen. At L4-5
disc bulging and a disc protrusion seen in the midline extending
to the left with moderate narrowing of the left subarticular
recess. At L5-S1 level no abnormalities are seen. Increased
signal is seen in both erector spinae muscles in the lumbar
region which could indicate edema. Soft tissue edema is also
seen in the subcutaneous fat in the lumbar region. Diffuse
decreased signal is visualized in the bony structures which
could be secondary to anemia or renal dysfunction. Clinical
correlation recommended.
IMPRESSION: Small disc protrusion at L4-5 level with moderate
narrowing of the left subarticular recess. No intraspinal fluid
collection or thecal sac compression. Increased signal within
the erector spinae muscles and soft tissues could indicate
edema.
.
Renal U/S [**2140-3-19**]: Transabdominal son[**Name (NI) 493**] images are limited
by body habitus but demonstrate normal-appearing kidneys without
hydronephrosis or stones. The left kidney measures 14.1 cm. The
right kidney measures 13.8 cm.
IMPRESSION: Normal renal ultrasound.
.
MICRO:
URINE CULTURE (Final [**2140-3-5**]): NO GROWTH.
MRSA SCREEN (Final [**2140-3-6**]): No MRSA isolated.
Blood Culture, Routine (Final [**2140-3-14**]): NO GROWTH.
URINE CULTURE (Final [**2140-3-10**]): YEAST. >100,000
ORGANISMS/ML.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final 04/13-15/11):
feces negative x3
URINE CULTURE (Final [**2140-3-11**]): NO GROWTH
LEFT PICC CATHETER TIP (Final [**2140-3-13**]): No significant
growth.
WOUND CULTURE (Final [**2140-3-15**]):
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH. PAN-SENSITIVE
URINE CULTURE (Final [**2140-3-18**]): YEAST. 10,000-100,000
ORGANISMS/ML.
URINE CULTURE (Final [**2140-3-22**]): NO GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-3-22**]): Feces
negative
OVA + PARASITES (Final [**2140-3-25**]): NO OVA AND PARASITES SEEN.
Brief Hospital Course:
Mr [**Known lastname 1968**] is a 52yo M with h/o HTN, HLD, CAD, DM2, and right
staghorn calculus who developed a likely rhadomyolysis-induced
acute renal failure following operative removal of his
nephrolith at [**Hospital3 **], transferred here with
nephroureteral stent. His hospital course at [**Hospital1 18**] was
complicated by worsening renal failure, thrombocytopenia and
transaminitis. He was transferred to the MICU for altered mental
status in setting of renal failure and needing to initiate
hemodialysis. He was called out from the MICU [**3-12**]. He was on
intermittent hemodialysis, but his renal function improved and
he has not needed hemodialysis since [**3-18**]. The hemodialysis
catheter was pulled [**3-24**]. Additionally, he has had left leg
weakness and numbness since the surgery at [**Hospital3 **]. He
has had no evidence of retroperitoneal bleed, but MRI showed
stenosis and disc herniation that may explain some of the pain
and sensory level findings. He may also have a lumbar plexopathy
from extended prone positioning or cord infarct due to
intraoperative ischemia from positioning. He was also treated
for parotitis. Below is a summary of each of his medical issues
in further detail.
.
*) RIGHT STAGHORN CALCULUS S/P OPERATIVE RETRIEVAL:
Laser lithotripsy was unsuccessful and pt had right percutaneous
nephrostomy and retrieval with later right percutaneous
nephroureteral stent placement after dislodged perc tube. [**3-15**]
renal ultrasound showed no residual stones and no hydronephrosis
bilaterally. Perc nephroureteral stent clamped [**3-17**] AM, UOP not
decreased, [**3-18**] subsequent renal ultrasound with no
hydronephrosis. However, urology recommends leaving tube open to
gravity/bag drainage until patient is seen in followup with his
urologist. Per urology, stent may be in place for 2-3 months
without problems. [**Name (NI) **] has been on allopurinol every other day for
stones, and has had pain control with PO oxycodone. Pain may
have a neuropathic component as below.
.
*) ACUTE KIDNEY INJURY with ANION GAP METABOLIC ACIDOSIS,
causing TOXIC METABOLIC ENCEPHALOPATHY:
Likely due to rhabdomyolysis after prolonged surgery while on
statin and gemfibrozil, causing acute tubular necrosis. Urine
sediment with not many muddy brown casts. His BUN/Cr continued
to rise despite downtrend in CK's initially, and despite much IV
resuscitation. He became increasingly oliguric and IV fluids
were discontinued. This all led to profound anion gap metabolic
acidosis and uremia causing a toxic metabolic encephalopathy. He
was transferred to the MICU and hemodialysis was initiated; the
AMGA and encephalopathy improved. In the workup for HD, his PPD
was negative; hepatitis panel was done and he received HBV
vaccine [**3-22**]. He received intermittent hemodialysis and his
renal function continued to improve. He made progressively more
urine and his BUN/Cr began to trend down spontaneously. He was
last dialyzed on [**2140-3-18**] and the dialysis catheter was removed
[**2140-3-25**]. At the time of discharge he had 5 consecutive days of
downward-trending BUN/Cr. He failed Foley removal twice and was
unable to urinate, so his Foley catheter remains in place. He
will continue on sevelamer until his followup with nephrology as
an outpatient. He will require daily Chem-10 to monitor renal
function and phosphorus.
.
*) DIARRHEA:
Patient has had multiple watery bowel movements since admission.
Negative c.diff [**3-11**], [**3-22**]. Flexiseal placed on admission,
discontinued [**3-21**]. His stool consistency and frequency has been
improving on loperamide prn.
.
*) LOWER EXTREMITY NUMBNESS/WEAKNESS and GENERALIZED PAIN
DIFFUSELY:
He has baseline neuropathy but notes numbness and weakness of
the lower extremity L>R since his surgery. Possible peripheral
nerve damage due to positioning at time of surgery but op notes
are unrevealing. He had no evidence of compartment syndrome or
retroperitoneal bleed either clinically or radiologically. Per
the neurology team, these symptoms are most likely due to cord
infarct/injury vs lumbar plexopathy L>R from surgical
positioning. He is is likely without risk of further injury and
is likely to improve slowly with neuropathic pain meds and
mobilization. MRI showed stenosis and disc herniation; however,
patient is largely asymptomatic from it and is without back
pain. Spine consultants recommended no surgical intervention
given that MRI findings are not likely to be clinically
significant. His pain was controlled on oxycodone and
gabapentin, renally dosed. Physical therapy followed him while
inpatient and he underwent EMG on [**3-28**] prior to discharge. He
will require aggressive physical and occupational therapy while
at rehab. He will need to follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of
neurology 1-2 weeks after he is discharged from rehab.
.
*) PAROTITIS/TONGUE LACERATION:
He presented with a left-sided tongue laceration, presumably
from biting the tongue during surgery. This was stable and
well-healing although [**3-26**] it had a small, self-limited episode
of bleeding. It has not continued to bleed. For parotitis
diagnosed [**3-12**] he was started on Vancomycin and Unasyn, which
was narrowed to Unasyn and then Augmentin given cultures
negative for MRSA. He received a total of 10 days of
antibiotics. He is to continue warm packs as needed and [**Doctor Last Name **]
wedges three times daily with all meals to stimulate salivary
flow to the left parotid gland.
.
*) ANEMIA:
He has a normocytic anemia. His hematocrit was stable at ~30 for
several days since admission, and then following his onset of
renal failure it drifted downward and stabilized at 22-24 since
[**2140-3-13**]. He has had no evidence of bleeding and it is felt that
the anemia is most likely dilutional given volume overload from
acute renal failure; he is now autodiuresing.
.
*) RHABDOMYOLYSIS:
Initial elevated creatinine kinases to 52,000 (now normalized),
oliguria, dark urine, and acute renal failure were consistent
with acute rhabdomyolysis, possibly due to extended prone
position in the setting of morbid obesity while taking statin
and gemfibrozil. CK's were elevated on admission and trended to
normal. His statin and gemfibrozil continue to be held until his
renal failure completely resolves.
.
*) TROPONIN ELEVATION:
The patient complained of chest pressure [**3-14**] AM; it was in fact
epigastric abdominal pain at his prior baseline, no chest
pressure or pain. His troponin was borderline but his baseline
was unknown. His ECG was unchanged. His troponins were trended
and were overall stable, with a mild rise acceptable in the
setting of acute renal failure, rhabdo, and severe metabolic
derangement. He had no further chest pain so troponins were not
rechecked.
.
*) THROMBOCYTOPENIA:
He had a rather precipitous platelet drop at [**Hospital3 **]
from a pre-op 252 to a nadir of 29 prior to a platelet
transfusion at [**Hospital3 **]. HIT antibody came back negative.
Etiology of thrombocytopenia is still unclear; platelets trended
upward and have normalized since [**2140-3-8**].
.
*) ELEVATED TRANSAMINASES:
Most likely due to shock liver in setting of hypotension at
[**Hospital3 **]; continued to trend down and have normalized
since [**2140-3-19**]. His lipase was also elevated but trended down as
well.
.
*) DIABETES MELLITUS TYPE II:
His home metformin was held while he was inpatient; he was
placed on a lispro insulin sliding scale with evening glargine
dosing increased to 12 units at discharge. His blood sugars were
acceptable on this regimen.
.
*) HYPERTENSION:
His home metoprolol tartrate (50mg [**Hospital1 **]) was increased to TID on
[**2140-3-26**] given upward-trending BPs. This was transitioned to
metoprolol succinate 150mg daily upon discharge.
.
*) CORONARY ARTERY DISEASE/HYPERLIPIDEMIA:
He is s/p stent at [**Hospital1 3278**] for possible MI. He is not on aspirin
at home so this was started [**3-15**]. He was continued on home
metoprolol. His statin/gemfibrozil were held due to rhabdo and
may be restarted once his renal failure resolves.
.
*) OBSTRUCTIVE SLEEP APNEA:
Patient has not tolerated CPAP previously. O2 sats were normal
even at night.
.
*) Prophylaxis: pneumoboots and ASA
*) CONSULTS WHILE INPATIENT: Nephrology, Neurology, Spine,
Nutrition, PT, Social [**Name (NI) **]
*) Communication: Patient, wife [**Name (NI) 5321**] [**Telephone/Fax (1) 90071**]
TRANSITION OF CARE:
- Patient is full code
- Patient has EMG study results pending from [**2140-3-28**]; he will
follow up with neurology 1-2 weeks after discharge from rehab
(appointment will need to be scheduled)
- Patient will follow up with urology for nephroureteral stent
removal within 1-2 weeks after discharge from rehab (appointment
will need to be scheduled)
- Patient will follow up with nephrology on [**2140-5-11**] (appointment
scheduled with Dr. [**Last Name (STitle) 118**]/Dr. [**Last Name (STitle) **] per discharge planning)
- Patient will require weekly CBC for monitoring of anemia and
daily chem-10 until creatinine, phosphate stable
Medications on Admission:
Home meds:
gabapentin 100mg cap TID
gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
toprol XL 100mg daily
pravastatin 80mg qhs
.
On transfer from OSH:
Metoprolol 50mg PO BID
Sodium bicarb at 3 oz/L of IV D5W infusing at 150cc/hr
Insulin at 10U qHS plus sliding scale insulin
hydromorphine 0.5-1mg IV q3hrs PRN pain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: Two (2)
Subcutaneous ASDIR (AS DIRECTED): 2 units for FS of > 150,
increase by 2 units for every 50 over 150.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for for mouth pain: swish and
spit.
9. Outpatient Lab Work
Daily Chem 10.
Weekly CBC
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stool.
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime: Or according to your doctor's
recommendation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Acute Kidney failure
Acute tubular necrosis
Rhabdomyolysis
.
Secondary:
Parotitis
Spinal stenosis
Disc herniation
Neuropathic pain
Left leg weakness
Type 2 diabetes
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 1968**],
It was a pleasure to care for you at [**Hospital1 827**]. You were hospitalized with acute renal failure
caused by rhabdomyolysis following your surgery from an outside
hospital. You were initiated on hemodialysis with slow recovery
of your kidney function and have not needed dialysis since [**3-18**]. Certain medications were stopped due to this issue. Please
follow up as indicated for restarting these. You were evaluated
by Renal and Urology specialists regarding the
nephroureterostomy stent you have in place. We tried twice to
remove your bladder catheter and both times you were unable to
void. To avoid damage to your bladder we have left the catheter
in place.
You briefly received tube feeds while hospitalized but were able
to tolerate a regular diet eventually. You had a rectal tube for
diarrhea, and this was eventually removed. There was no noted
infection in your stool.
You have completed a course of antibiotics for an infection in
your left parotid gland. You should continue to have [**Doctor Last Name **]
wedges with all meals to stimulate saliva flow.
You were evaluated by Neurology and Spine specialists regarding
left leg weakness and numbness and pain on your abdominal skin.
Although an MRI showed some herniation and stenosis of your
spine, it was determined that surgery was not necessary, and
that these findings do not necessarily correlate with your
symptoms. Your neuropathic pain improved with Neurontin, and
your weakness is improving with physical therapy and
mobilization. You had a nerve conduction study prior to
discharge and these results can be followed up as an outpatient.
Your medications were changed in the following ways:
STARTED baby aspirin for history of cardiovascular disease
STARTED allopurinol every other day - ask your primary care
physician how long to continue this
STARTED insulin sliding scale - follow up with your primary care
physician about blood sugar control
STARTED insulin glargine (Lantus) before bedtime
STARTED nephrocaps
STARTED sevelamer carbonate
STARTED heparin shots - while you are unable to get out of bed
STARTED lidocaine swish and spit for Parotitis
INCREASED metoprolol from 100mg to 150mg daily
INCREASED gabapentin - follow up dosing based on renal function
STOPPED gemfibrozil - follow up with physician about when to
restart
STOPPED metformin - follow up with physician about when to
restart
STOPPED pravastatin - follow up with physician about when to
restart
CHANGED percocet to oxycodone - attempt to wean yourself off
this medication
Continue the rest of your medications as prescribed.
Do not drive or operate heavy machinery while taking narcotics
or Neurontin (gabapentin).
You will need to follow up with your primary physician to follow
up your hospitalizations and medications.
You will need to follow up with your urologist to determine when
your nephroureterostomy stent should be removed.
You will need to follow up with the neurologist within 1-2 weeks
of being discharged from rehab.
Followup Instructions:
See your primary care physician within one week to follow up
your hospitalizations.
Follow up with your urologist within 1-2 weeks of being
discharged from rehab. If you wish to transfer your urologic
care to [**Hospital1 18**], you may call ([**Telephone/Fax (1) 8791**] to schedule this
appointment with Dr [**Last Name (STitle) 3748**] instead. If you are going to transfer
care to Dr [**Last Name (STitle) 3748**] please bring your [**Hospital3 **] urologic
records with you.
Follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of neurology within 1-2 weeks of
being discharged from rehab. Please call ([**Telephone/Fax (1) 5088**] to
schedule this appointment.
You are to continue with daily lab draws to monitor your kidney
function and weekly lab draws to monitor your blood count.
Department: WEST [**Hospital 2002**] CLINIC (NEPHROLOGY)
When: WEDNESDAY [**2140-5-11**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] (with Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2140-3-29**]
|
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"728.88",
"873.64",
"V45.82",
"357.2",
"276.1",
"414.01",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
27079, 27151
|
16099, 25229
|
323, 371
|
27389, 27389
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6829, 6829
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5036, 5081
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|
264, 285
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399, 4230
|
6845, 8487
|
27404, 27541
|
4618, 4864
|
4880, 5020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,150
| 112,212
|
44073
|
Discharge summary
|
report
|
Admission Date: [**2189-11-18**] Discharge Date: [**2189-12-3**]
Date of Birth: [**2112-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
-Central Line placement (Right internal jugular) in ICU-removed
at discharge
-[**2189-11-30**] Uncomplicated placement of a percutaneous GJ tube with
tip in jejunum. The T-fasteners will fall out on their own in
approximately six weeks. The tube should be changed
approximately every 3 months.
History of Present Illness:
Mr. [**Known lastname 42086**] is a 77M with a PMH s/f ogilvies syndrome with
frequent admissions for abdominal pain/distention, who was sent
to the emergency department when he complained of lower
abdominal pain at an outpatient ophthalmology appointment.
.
The patient is a difficult historian secondary to expressive
aphasia, but he is able to tell me that he has right upper
quadrant pain with associated nausea, and no vomiting. His last
bowel movement was in the emergency department. He also reports
three weeks of cough, denies sore throat, but does report
chills. Otherwise his review of systems is negative.
.
In the emergency department presenting vital signs were T=99.4,
BP=167/72, HR=93, RR=20, O2sat=99%RA. Per ED resident, his
abdominal examination was benign. Laboratory data was wnl,
though a lactate was not drawn. A CT of the abdomen showed
unchanged sigmoid dilation, consistent with his known Ogilvies
syndrome, with moderate fecal loading. A Surgical consultation
was obtained, and they assessed him to have no signs of ischemia
at this time. They recommended admission to medicine for serial
abdominal exams, rectal tube decompression, and GI consultation
for possible colonoscopic decompression. Of note, his CT showed
"concern for aspiration vs. pneumonia at lung bases". He was
given 750mg of levofloxacin.
Past Medical History:
#. Ogilvies Syndrome- Has frequent admissions for abdominal
distention, with dilated colon on imaging, which resolves with
rectal tube decompression.
#. Chronic aspiration (Per PCP)
#. CVA complicated by expressive aphagia, dysphagia
#. Coronary artery disease, s/p CABG in [**2154**], mild systolic
regional hypokinesis with EF 55%
#. HTN
#. Hyperlipidemia
#. GERD
#. History of pancreatitis
#. Type 2 diabetes c/b gastroparesis
#. Anemia
#. Atrial fibrillation on coumadin
Social History:
Living at [**Hospital3 1186**] nursing home since stroke in [**2183**], wife
passed away 5 years ago, no tobacco or ETOH use. Is on
aspiration precautions with honey thick liquids.
Family History:
Non-contributory
Physical Exam:
Exam on admission [**2189-11-18**]:
T=97.6, BP=138/65, HR=89, RR=20, O2=93%RA
GENERAL: Elderly male in NAD, non-toxic appearing
HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.
Neck Supple
CARDIAC: Irregular rhythm, normal rate, no murmurs
LUNGS: Crackles at the right base, overall, good air movement
ABDOMEN: On inspection, his abdomen is distended. High pitched
bowel sounds. Soft, tympanitic. Tenderness to deep palpation
diffusely, no rebound or guarding.
EXTREMITIES: No edema or calf pain
SKIN: No rashes/lesions, ecchymoses.
Exam on discharge [**2189-12-3**]:
T 98.5 BP 145/72 HR 78 O2 95-97%RA
GENERAL: Elderly male in NAD, lying in bed, alert
HEENT: MMM. OP clear. Neck Supple
CARDIAC: Irregular rhythm, normal rate, unable to appreciate
murmurs due to upper airway sounds
LUNGS: Poor effort, difficult to assess given upper airway
sounds, clear at apices, coarse breath sounds at bases laterally
ABDOMEN: soft, mildly distended, non-tender, +BS, no rebound or
guarding.
EXTREMITIES: warm, R hand with 1+ edema, R foot with 2+ edema, L
foot with trace edema
SKIN: Well healed coccyx sore without signs of infection
Pertinent Results:
Labs on admission [**2189-11-18**]:
WBC-7.1 RBC-3.59* Hgb-10.4*# Hct-32.1* MCV-89 MCH-28.8 MCHC-32.3
RDW-16.6* Plt Ct-283
Neuts-77.2* Lymphs-13.9* Monos-5.7 Eos-2.9 Baso-0.3
PT-28.2* INR(PT)-2.8*
Glucose-118* UreaN-32* Creat-1.0 Na-142 K-6.5* Cl-115* HCO3-21*
AnGap-13
Labs on discharge [**2189-12-3**]:
WBC-5.5 RBC-3.23* Hgb-9.2* Hct-28.8* MCV-89 MCH-28.3 MCHC-31.8
RDW-16.9* Plt Ct-254
PT-26.8* PTT-42.2* INR(PT)-2.6*
Glucose-92 UreaN-9 Creat-0.6 Na-140 K-3.7 Cl-112* HCO3-26
AnGap-6*
Calcium-7.9* Phos-2.3* Mg-1.8
Iron studies:
calTIBC-134* VitB12-1305* Folate-16.7 Ferritn-248 TRF-103*
Thyroid studies:
TSH 6.3
Free T4 0.98
.
MICRO:
[**2189-11-18**], [**2189-11-22**] Urine culture: negative
[**2189-11-19**], [**2189-11-22**] Blood cultures: negative
[**11-20**] MRSA screen: negative
[**11-20**] and [**11-22**] c diff: negative
[**2189-11-22**] sputum culture:
STAPH AUREUS COAG +.- MODERATE GROWTH.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING:
[**11-18**] CXR: No acute pneumonia.
[**11-18**] CT Abd/pelvis:
1. Unchanged, massively dilated sigmoid colon, with smooth taper
and a
fluid-filled rectum, compatible with pseudoobstruction ([**Last Name (un) **]
syndrome).
2. Unchanged marked fecal loading in the proximal colon.
3. Interval resolution of bilateral pleural effusions. Chronic
bibasilar
consolidations, suggestive of chronic aspiration.
[**11-20**] TTE:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the mid to distal anterior
septum and distal anterior wall. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Compared with the
prior study (images reviewed) of [**2189-8-17**], the findings are
similar.
[**11-20**] CT abd/pelvis:
1. Mildly dilated sigmoid and rectum without evidence of
obstructions; findings consistent with pseudoobstruction.
2. Stable bilateral consolidation at the lung bases, may
represent chronic aspirations
[**11-21**] Right UE ultrasound:
Right axillary vein could not be assessed due to arm
contracture. Right internal jugular, subclavian and brachial
veins patent, without evidence of thrombus.
[**11-22**] KUB:
Interval improvement in gaseous distention of bowel.
[**11-22**] CXR:
Limited study demonstrating streaky density at the right base
most consistent with subsegmental atelectasis.
[**2189-11-29**] KUB: In comparison with the study of [**11-22**], there is
some increase in the generalized dilatation of the colon with a
substantial amount of fecal material within it. The findings are
consistent with the clinical impression of colonic ileus.
Nasogastric tube extends to the upper stomach. Total hip
arthroplasties are again seen.
Brief Hospital Course:
Mr. [**Known lastname 42086**] is a 77M with a PMH s/f Ogilvies Syndrome, who
presents with abdominal pain
.
#. Abdominal pain/Ogilvies Syndrome: Distention and abdominal
pain were consistent with prior episodes of Ogilvies. Initial
exam and CT were not concerning for an acute intra-abdominal
catastrophe. Rectal tube was placed, and bowel regimen given.
He continued to have profuse watery stools. Shortly after
admission he had two episodes of vomitting guaic-positive
material. He also developed a fever to 100.8. In the context
of these changes, abdominal pain worsened over the first
hospital day, although abdominal exam remained benign. Repeat
KUB demonstrated increased distention and possible volvulus.
Immediately after this was discovered he was briefly
hypotensive, as below. He was given levofloxacin and
metronidazole empirically. Surgery was consulted and
recommended serial exams and noncontrast CT abdomen when stable
to evaluate further volvulus which was negative. Antibiotics
were discontinued, and pt's obstruction improved with rectal
tube, which was stopped. Tube feeds were given via NGT until
[**2189-11-29**], when he had more distention again attributed to mild
obstruction with KUB results as above. His fibersource tube
feeds were held. His abdominal distention again improved and
no-fiber tube feeds were initiated to decrease work for colon.
TSH slightly elevated but Free T4 normal suggesting
hypothyroidism not a major etiology in his Ogilvies.
.
# Hypotension: After blood pressures ranging 130-160 all day
morning of admission, patient was found on routine vital signs
check to have blood pressure 58/40 several hours after he had
complained of worsening abdominal pain. His mental status
remained at baseline during the episode, and telemetry
demonstrated sinus tachycardia. He was bolused with IVNS, and
pressure rebounded to systolic 100 within 30 minutes. This was
thought to be secondary to an intra-abdominal process vs a
primary cardiac event, as below.
.
# Demand ischemia: During and immediately after hypotensive
episode, Mr. [**Known lastname 42086**] complained of new [**10-3**] substernal chest
pain. EKG demonstrated new precordial TWI similar to EKG during
recent NSTEMI [**8-2**]. Chest pain responded partially to SL nitro
and morphine. Troponin was elevated above recent values, but CK
was normal. EKG changes partially normalized with return of
blood pressure, and the changes were thought to be most likely
representative of demand ischemia. However, he continued to
complain of chest pain. He was transferred to the intensive care
unit for futher management and improved with sublingual
nitroglycerin. As he was therapeutic on Coumadin, a heparin
drip was not started. Home CAD regimen including ACEI, beta
[**Last Name (LF) 7005**], [**First Name3 (LF) **], Imdur, simvastatin were continued. Chest pain
resolved without recurrence during remainder of hospitalization.
Echo [**2189-11-20**] unchanged from [**2189-8-17**].
.
# Chronic aspiration / nutrition: Pt was evaluated by speech and
swallow multiple times. At times, he was able to tolerate some
PO and at others, he demonstrated frequent aspiration. With poor
nutrition, NGT was placed for tube feeds. After discussion with
family, pt had G-J tube placed by IR on [**2189-11-30**] as above.
No-fiber tube feeds were initiated, which pt tolerated well. He
refused final speech and swallow evaluation prior to discharge
and remained NPO at discharge. He should be evaluated by speech
and swallow at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] if he would like to eat for
pleasure. If he remains NPO, oral care should be performed every
4 hours.
.
# Anemia - pt had continued low hematocrit. Iron studies as
above. Guaiac negative. He required 2 blood transfusions during
his hospitalizations. Hct 28.8 at discharge. continue workup as
outpatient.
.
# Pneumonia: Sputum grew Staph aureus coag positive. Pt started
on vancomycin changed to bactrim after sensitivities returned
for total 7 day course.
.
#. Hypertension: For his chronic hypertension, ACEI and BB were
initially continued but stopped after episode of hypotension.
.
#. GERD: Omeprazole changed to lansoprazole after placement of
PEG.
.
#. Type 2 diabetes c/b gastroparesis: Pt developed hypoglycemia
on NPH while NPO. His NPH was stopped and he was continued on
Humalog ISS. He was discharged on humalog insulin sliding scale.
He will need outpatient adjustment of his insulin regimen as
nutrition improves with tube feeds.
.
#. Atrial fibrillation: The patient was in NSR or sinus
tachycardia throughout his stay. INR became supratherapeutic
with poor nutrition, likely secondary to vitamin K deficiency.
His warfarin was held and he was maintained on heparin drip once
INR decreased until PEG placement. Home beta [**Last Name (NamePattern1) 7005**] was
continued. He was re-initiated on coumadin titrated to INR goal
[**1-27**].
.
# Communication:
[**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] SW ([**Doctor First Name **]): [**Telephone/Fax (1) 94608**]
Son [**Name (NI) **] (HCP): [**Telephone/Fax (1) 94609**] (work/attorney for Ride);
[**Telephone/Fax (1) 94610**] (cell); [**Company 94611**]
Medications on Admission:
-Aspiration precautions
-Honey thick liquids
-Prednisolone 1% eye drops 1gtt right eye [**Hospital1 **]
-Neomycin/polymyxin ointment to right eye daily
-Aspirin 325 mg daily
-Multivitamin
-Lisinopril 20 mg daily
-Omeprazole 20 mg daily
-Metoprolol Tartrate 25 mg [**Hospital1 **]
-Isosorbide Dinitrate 10 mg TID
-Mirtazapine 30 mg qhs
-Warfarin 2 mg daily
-Furosemide 20 mg daily
-KCl 40MEQ daily
-Simvastatin 40mg daily
-Novolin N 5 Subcutaneous QAM/QHS.
-Polyethylene Glycol 3350 17 gram Powder one packet daily
-Fleet enema, daily prn if ducolax does not produce bm
-Bisacodyl suppository daily as needed for BM/24hrs
-MOM, if no BM in 3 days
-Calcium/ Vitamin D
-Nitro prn
Discharge Medications:
1. Aspiration Precautions
2. Prednisolone Acetate 1 % Drops, Suspension [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Neomycin-Bacitracin-Polymyxin Ointment [**Hospital1 **]: One (1) Appl
Ophthalmic DAILY (Daily).
4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
6. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): Hold for SPB<100 or HR<60.
9. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): Hold for SBP<120.
10. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
11. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: Hold
for SBP<100.
12. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Two (2) PO once a
day.
13. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Miralax 17 gram/dose Powder [**Last Name (STitle) **]: One (1) packet PO once a
day.
15. Fleet Enema 19-7 gram/118 mL Enema [**Last Name (STitle) **]: One (1) enema Rectal
once a day as needed for If Dulcolax does not produce bowel
movement: Please give if dulcolax does not produce bowel
movement.
16. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) suppository Rectal
once a day as needed for for 1 BM / 24 hours: Please give as
needed for 1 BM / 24 hours.
17. Milk of Magnesia 400 mg/5 mL Suspension [**Last Name (STitle) **]: [**5-3**] mL PO As
directed as needed for if not BM in 3 days: Please give if pt
has not had Bowel movement in 3 days.
18. Nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Year (2) **]: One (1) tablet
Sublingual as directed as needed for chest pain: 1 tablet every
5 minutes x3 tablets as needed for chest pain.
19. Calcium 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a
day.
20. Vitamin D 400 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
21. Warfarin 2 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
22. Humalog 100 unit/mL Solution [**Month/Year (2) **]: as directed as directed
Subcutaneous As directed: Per Humalog Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1188**] house
Discharge Diagnosis:
PRIMARY:
Ogilvies Syndrome
Chronic aspiration
Staph aureus pneumonia
SECONDARY:
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Sometimes alert and interactive vs
somtimes lethargic but arousable
Activity Status:Bedbound vs Out of Bed with assistance to chair
or wheelchair
SaO2 97% RA, tolerating tube feeds, having bowel movements, PEG
site without erythema or induration
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
distention. Your blood pressure dropped and you developed chest
pain, which was concerning for a heart attack. You were closely
monitored in the intensive care unit, and your pain resolved.
Your abdominal fullness improved with decompression. A PEG tube
was placed for feeding given your chronic aspiration. You were
treated for a pneumonia.
The following changes were made to your medications:
1. STOP Omeprazole
2. START Lansoprazole 30mg daily as it can go through the PEG
3. CONTINUE your home bowel regimen
4. CONTINUE Warfarin 2mg daily and it will be titrated to INR
goal [**1-27**]
5. STOP Novolin (NPH) 5 units in the morning and at night
6. START finger sticks QID (4 times a day) and use the Humalog
sliding scale for insulin. Once you reach a steady state on your
tube feeds, your doctor can adjust your insulin regimen.
Avoid lactulose or high fiber foods in your diet.
Followup Instructions:
Please call Dr.[**Name (NI) 51133**] office at [**Telephone/Fax (1) 608**] to be seen
within 2 weeks of discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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icd9cm
|
[
[
[]
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] |
[
"44.32",
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icd9pcs
|
[
[
[]
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15740, 15798
|
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2734, 3879
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275, 291
|
652, 1987
|
15969, 16262
|
2009, 2485
|
2501, 2684
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,692
| 116,133
|
19351
|
Discharge summary
|
report
|
Admission Date: [**2186-7-1**] Discharge Date: [**2186-7-2**]
Date of Birth: [**2130-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2186-7-1**] CVL placement
History of Present Illness:
Mr. [**Known lastname 52653**] is a 55 yo M with end-stage sarcoid on 3LNC at
baseline, transferred from Radius with shortness of breath,
tachypnea, hypoxia and fevers. According to reports from Radius
has has been hypoxic for several days with O2 sats 91-92% on
100% NRB with desaturation to 86% with minimal exertion, patient
refusing to come to hospital.
.
In the ED T99.2 BP 145/84 RR 20-30 HR 92-140 96% on 100%NRB. He
was noted to be significantly hypoxic and tachypnic and was
intubated due to concern for increasing work of breathing. He
was given 2.5LNS, levofloxacin 750mg IV, cefepime 2g IV x1,
decadron 10mg IV x1 and versed 2mg IV x1.
Past Medical History:
1. Hepatitis C, diagnosed as part of the lung transplant workup
at the [**Hospital1 756**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in GI. He
is hepatitis B core surface antibody positive and surface
antigen
negative. In addition, he has hepatitis C antibody plus type 2b
with a viral load in [**8-/2185**], of 5.5 million. He had grade 2
fibrosis on [**2184-4-28**]. He is not thought to be a candidate
currently for interferon treatment given his sarcoidosis. He has
transaminitis.
2. Sarcoidosis. He is followed by Dr. [**Last Name (STitle) 2168**]. The patient has
been obtaining PFTs from Dr. [**Last Name (STitle) **], and he is currently on
azathioprine and prednisone with prophylaxis Bactrim.
3. Sleep apnea.
4. Erectile dysfunction.
5. Emotional lability and anxiety.
6. Status post mandible fracture [**8-20**].
7. Status post multiple rib and clavicle fractures over the past
year secondary to fall.
8. Spinal stenosis: diagnosed on MRI and is followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**], [**First Name3 (LF) **] orthopedic physician at the [**Hospital1 18**]. The diagnosis was
established as part of a workup for progressive lower leg
weakness, which led to multiple falls and currently an inability
to ambulate.
9. Shingles in [**12/2184**] on the right side of the face with
residual neuropathic pain.
Social History:
Has been living in a rehab facility since recent admission in
[**2186-4-13**]. Previously lived in an apartment in [**Location (un) 1459**] with his
27 yo daughter who is s/p traumatic brain injury in a motor
vehicle accident. Has another daughter from whom he is
estranged. Recently divorced from his wife of 33 years who he
says did "not want to take care of him." Patient is a former
food salesman, selling restaurant supplies to pizzerias. Has
been unemployed for about a year, no longer on unemployment.
Recently obtained some disability benefits. Reports a 10 pack
year smoking history, but quit 20 years ago. Reports no history
of ethanol use or IV drug use. Pt had previous admission in
which he was on high doses of methadone and benzodiazepenes that
were verified by PCP to be prescribed by an outpatient physician
to treat his pain from spinal stenosis; pt believed to withdraw
from both on previous admissions.
Family History:
Noncontributory of pulmonary disease.
Physical Exam:
Physical Exam (per Dr. [**First Name8 (NamePattern2) 4311**] [**Last Name (NamePattern1) 4312**])
Vitals: T97.6 BP 93/68 HR 100-115 RR 24 99% on CMV 100% TV 500
RR 20 PEEP 10
Gen - sedated, intubated, non responding to verbal or physical
stimulation
HEENT: NC AT, intubated, NG tube in place, pupils 2mm equal and
reactive to light
CV- distant heart sounds unable to appreciate murmur
Lungs - coarse vented breath sounds, crackles bilaterally,
expiratory wheezing
Abd - multiple scattered bruises diffusely over abdomen, soft,
ND, no apparent guarding, BS +
Ext: somewhat cachectic lower extremities, 2+ pitting edema,
right foot warm to palpation, left foot cool, DP's by doppler
Pertinent Results:
On admission [**2186-7-1**]:
Na 142 K4.7 Cl 102 HCO 33 BUN 29 creat 0.5 Gluc 93
CK 29 MB - Trop <0.01
AST 100 ALT 102 AP 317
WBC 13.2 HCT 32.1 PLT 307 29% bands
UA: leuk neg, mod blood, nitr neg, [**2-15**] granular casts, [**11-2**]
hyaline casts
.
[**2186-7-1**] EKG:sinus tachycardia at 125bpm, normal axis, normal
intervals, poor baseline, no apparent ST segment or T wave
changes. Compared with [**2186-4-7**] sinus tachycardia is new
otherwise no clear change.
.
Micro:
[**3-1**] Blood Cx: pending
.
Imaging:
[**2186-7-1**] CXR: (prelim dictation) extensive pulm fibrosis and
emphysema unchanged, no effusion, no PTX, ETT terminates 4.5cm
above carina, RIJ at cavo-atrial junction, OG tube in esophagus.
Otherwise no acute cardiopulmonary changes.
.
[**2186-4-8**] CTA chest:
1. Small PE of segmental/subsegmental right upper lobe branch.
This was communicated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 24949**] with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3766**] by telephone in the AM on [**2186-4-10**].
2. New minimally displaced fracture of the lateral right ninth
rib. Multiple additional bilateral healing rib fractures.
3. Healing left distal clavicle fracture.
3. Resolution of right upper lobe pneumonia.
4. Chronic severe pulmonary fibrosis in the setting of
sarcoidosis.
.
[**2185-11-8**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-10-6**],
right ventricular systolic function now appears depressed.
Brief Hospital Course:
SIRS/Sepsis: Patient met SIRS criteria based on tachycardia and
bandemia of 29%. Most likely cause is PNA given underlying
severe sarcoidosis, other consideration is infected midline
which has been in place for unclear duration of time. Vancomycin
IV was started to cover for possible line infection. Meropenem
was started to provide coverage for resistant pseudomonas seen
on recent sputum culture. Patient's urinalysis was
unremarkable. Urine cultures were obtained. PICC line was
discontinued on arrival to ICU. Patient had central line placed
in ED. IVF fluids were administered to maintain CVP 8-10. With
progressive hypoxia patient became hypotensive requiring
norepinephrine and phenylephrine to maintain MAP > 65 on his
second day of admission. Additional fluid boluses had no effect
on hypotension and tachycardia. Pressors were discontinued only
after the family made the decision to make him CMO.
Hypoxic respiratory failure: In the setting of fever and recent
pseudomonas-positive sputum culture, pneumonia superimposed on
underlying sarcoidosis is most likely etiology. No clear
infiltrate on CXR although difficult to interpret in the setting
of already severe pulmonary fibrosis. Sputum and blood culture
were obtained. Due to his increased susceptibility patient was
treated empirically with vancomycin and meropenem for possible
PNA, with levoquin added for double PSA coverage and atypical
coverage. He was also covered empirically for PJP, although he
had been on bactrim prophylaxis, and ETT PCP DFA was ordered.
Patient also received frequent nebulizer therapies. Patient was
intubated on arrival to ED and became progressively more hypoxic
during his admission. Pt ultimately required maximum ventilator
settings to keep his SpO2 above 80%. Multiple blood gases
obtained illustrated his further deterioration. Patient was
given trial of pressure controlled ventilation, volume
controlled ventilation and APRV at varying levels of PEEP, but
all failed to improve oxygen saturations. Pt was then placed in
prone position so as to improve O2 sats, with no effect.
Patient's daughter was present and the status of patient was
discussed. She informed other family members who then met at
the hospital for a family meeting. Family meeting was conducted
with physicians and nurses present. They were in acceptance of
pts deteriorating state and at that point did not want any
resuscitative measures. Patient was started on comfort measures
and remained ventilated.
.
End stage sarcodiosis: Patient has severe sarcoidosis at
baseline; is currently on high dose steroids. Pt was continued
on high dose steroids, and PCP prophylaxis with bactrim until
the decision was made to take comfort measures only. Pt was
kept on mechanical ventilation.
.
Chronic pain/spinal stenosis: home medications (ms contin and
percocet) were held. Pt was sedated with fentanyl/midazolam.
.
Communication: daughter [**Name (NI) **] [**Last Name (NamePattern1) 52655**] is HCP
H:[**Telephone/Fax (1) 52656**] c: [**Telephone/Fax (1) 52657**]
.
Code status - On presentation to the [**Name (NI) **] pt was full code. After
discussion of the patient's status with his daughter/HCP the
decision was made to declare him DNR. Once other family members
were notified of his health status and given the opportunity to
come to the hospital the decision was made to offer Comfort
Measures Only and withdrawal all supportive care.
Medications on Admission:
-Albuterol Sulfate 2.5 mg/3 mL neb q4 hours and q7 hours prn
-Atrovent Nebs Q4Hours and Q 7 hours prn
-Solu-medrol 60mg IV Q6hrs
-Novalog sliding scale QACHS
-mucomyst 10% 3ML INH QID
-Clonazepam 1 mg PO TID prn
-NPH insulin [**Hospital1 **] (unclear dosing had been on 12QAM and 6QPM
during last admit)
-Nexium 40mg daily
-dulcolax 10mg pr qday prn
-colace 100mg po bid
-milk of magnesia 30ML daily
-MS Contin 45mg [**Hospital1 **]
-percocet 1-2 tabs TID prn
-zocor 20mg daily
-heparin SQ 5000mg TID
-Azathioprine 150 mg PO DAILY
-cymbalta 90mg po daily
-ASA 325mg daily
-Sennakot 1 [**Hospital1 **]
-Bactrim DS 1 tab QMWF
-trazodone 25mg qhs prn
-vitamin b1 100mg daily
-risperdal 1mg [**Hospital1 **]
-haldol 1mg po BID prn
-lactulose 30mg po tid prn
-saline nasal spray 2 sprays each nostril QID
-Mirtazapine 15 mg PO HS
-roxanol 10mg po q3hrs prn
-fleet enema pr daily prn
-MTV daily
-primaxin IV 250mg Q6 hours
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Sarcoidosis, pneumonia, hypoxic respiratory failure
Discharge Condition:
expired
Discharge Instructions:
Patient has expired
Followup Instructions:
none
|
[
"135",
"V54.19",
"517.8",
"070.30",
"416.8",
"V85.22",
"607.84",
"724.00",
"995.92",
"458.9",
"300.00",
"733.00",
"327.23",
"515",
"V66.7",
"518.81",
"038.9",
"486",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"89.62",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10910, 10919
|
6478, 9913
|
322, 352
|
11024, 11034
|
4179, 6455
|
11102, 11110
|
3423, 3462
|
10881, 10887
|
10940, 11003
|
9939, 10858
|
11058, 11079
|
3477, 4160
|
275, 284
|
380, 1032
|
1054, 2467
|
2483, 3407
|
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