subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
15,193
| 193,337
|
20772
|
Discharge summary
|
report
|
Admission Date: [**2137-5-14**] Discharge Date: [**2137-5-20**]
Date of Birth: [**2061-1-25**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
who was an unrestrained driver in a low speed motor vehicle
accident with minimal car damage, who was found unresponsive
at the scene with a GCS of 8. He was hemodynamically stable
on transfer. He was purported to have a crush injury parked
car.
PAST MEDICAL HISTORY: Significant for hypertension, lower
extremity edema, BPH, and arthritis.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Nadolol 80 mg by mouth every day.
2. Lisinopril 10 mg by mouth every day.
3. Lasix 20 mg by mouth every day.
INITIAL PHYSICAL EXAM: Vital signs: Temperature was 99.8
degrees, heart rate 56-65, blood pressure 240/110, and O2
saturation of 100%. Exam, the patient opened eyes to pain.
No verbal response with right extremity flexion to pain with
a GCS of 6. HEENT: He was normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. TMs clear.
Midface stable. Trachea midline. Lungs: Clear to
auscultation bilaterally. Heart: Regular rate and rhythm.
Abdomen: Soft. Extremities: With ankle edema and intact
peripheral pulses. Back: No deformities. Rectal: Normal
tone, guaiac negative. Neuro: No movement on the left side.
INITIAL LABORATORY DATA: White blood cell count 9.3,
hematocrit 43.7, platelets 302, PT 12.5, PTT 22.8, INR 1.0,
fibrinogen 352, lactate 1.5, amylase 75, sodium 140,
potassium 3.9, chloride 102, bicarb 29, BUN 15, creatinine
0.6, and glucose 140. UA was negative. Urine tox negative.
Serum tox negative. ABG with re-intubation was 7.35 pH,
bicarb 33, PO2 166, base excess of plus 4.
RADIOGRAPHIC STUDIES: Chest x-ray, elevated diaphragms with
perihilar haziness and question wide mediastinum. Pelvis, no
fracture. CT of head, right thalamic intraparenchymal bleed
with subarachnoid hemorrhage into the lateral ventricles. CT
of C-spine, deformity of C5 consistent with old injury. CT
of the chest, small basilar consolidation versus atelectasis.
CT of the abdomen, no solid organ injury.
BRIEF HOSPITAL COURSE: The patient was seen and evaluated in
the Trauma Bay. As stated above, he was unresponsive with a
GCS of 6 and was intubated in the Trauma Bay for airway
protection. He was started on propofol drip and given
hydralazine, which resulted in some trend towards
normalization of his blood pressure. He was taken to the CT
scanner where the above mentioned findings were seen. Given
this, an emergent neurosurgical consultation was obtained
with recommendations for admission to the intensive care unit
with blood pressure control. He was loaded with Dilantin in
the trauma bay as well. Over the course of the night, he did
become bradycardic to the 30s with a drop in his blood
pressure, which responded to IV atropine. He had a central
line placed with the CVP of around 11, 12, and he was given
IV fluid for resuscitation. He had a repeat head CT the
following day, which showed no significant change in the
amount of bleeding due to the fact that this was thought to
be a pre-existing hypertensive intrathalamic bleed, which
subsequently caused his motor vehicle accident. A CTA was
ordered at the request of Neurosurgery. However, due to
difficulty in timing his bolus, this was unable to be done,
and he had an MRI/MRA of his neck and circle of [**Location (un) 431**]. He
additionally had an MRI of his C-spine as well. These showed
no aneurysms or AVMs and a stenosis at the origin of his
right internal carotid artery. His MRI of the cervical spine
was without prevertebral soft tissue swelling or other
indicators of cervical trauma, so his C-spine was clear on
that basis. He continued to have a minimal response. He did
start moving his left side, however, he would only localize
the pain to his upper extremities. He subsequently had 2
additional head CTs, which showed no interval change. Over
the course of the weekend, the patient's exam did not
significantly change. He was started on tube feeds and
advanced to goal. He was given Lasix for diuresis and his
vent was weaned down to pressure support. Family meeting was
convened on [**5-20**], and the decision was made that because the
patient's prognosis was extremely poor and it was unlikely
that he would ever return to even close degree of premorbid
functioning that they would withdraw care and make him
comfort measures only. Of note, in the days before this, he
did begin to spike temperatures. He was pan cultured with no
significant growth. He had also been started on Cipro for a
mucosal thickening of his maxillary sinus. He also not only
did not improve, but had some diminished movement of his left
side. After discussion with the family, consensus was made
and he was made comfort measures only. He subsequently
expired in the ensuing hours. The case was referred to the
medical examiner, who did not accept the case, and an autopsy
was declined by the family.
DISCHARGE DIAGNOSIS: Intracranial hemorrhage secondary to
hypertensive stroke in the right thalamus with
intraventricular bleed.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2137-5-20**] 19:48:34
T: [**2137-5-21**] 12:56:06
Job#: [**Job Number 36623**]
|
[
"427.89",
"V66.7",
"E812.0",
"401.9",
"342.90",
"780.09",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2225, 5091
|
5113, 5494
|
636, 758
|
567, 615
|
774, 2201
|
165, 446
|
469, 543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,414
| 104,313
|
28666+57604
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-7-30**] Discharge Date: [**2165-8-16**]
Date of Birth: [**2098-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
66yo male found to have Asc Ao aneurysm by CT done for workup of
several month complaint of cough.
Direct admit to operating room after preop evaluation in CT [**Doctor First Name **]
clinic
Major Surgical or Invasive Procedure:
s/p Ascending aortic hemiarch replacement(32mm
Gelweave)/AVR(27mm CE Magna pericardial) [**2165-7-30**]
History of Present Illness:
found to have ascendin aortic aneurysm by chest CT done to w/u
complaint of cough x several months. History of previous
Aorto-bifem bypass graft
Past Medical History:
2+AI,6.4 cm Aortic aneurysm
hypertention
^cholesterol
Mitral valve prolapse
Basal cell skin CA
L hernia repair
Aorto-bifem graft-[**2162**]
Elbow ORIF
Social History:
Maintenance worker part time
Married lives with wife
[**Name (NI) 1139**]: 40 pack years, currently 6 cigarettes/day
Alcohol: 1 drink/month
Family History:
Father deceased at 62 "blood clot"
Brother deceased at 62 myocardial infarction
Physical Exam:
Pre operative:
Vitals: Blood pressure 176/80, Heart Rate 64, Weight 184 pounds
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, well healed
scar
Ext: well perfused, no edema, no varicosities
Pulses: +2 dorsal pedal, +1 posterior tibial, +2 radial
Neuro: nonfocal
Skin: well healed basal cell scars left anterior chest wall
Discharge:
VS: T98.4 HR79SR BP110/60 RR18 Sat95%RA
Gen: NAD
Neuro: A+O, nonfocal exam
Pulm: CTA
CV: RRR, Sternum stable, incision CDI
Abdm: soft, NT/ND/NABS
Ext warm and well perfused, no edema
Pertinent Results:
[**2165-7-30**] 01:15PM WBC-19.9* RBC-3.75* HGB-12.0* HCT-33.8*
MCV-90 MCH-32.0 MCHC-35.6* RDW-13.5
[**2165-7-30**] 01:15PM PLT COUNT-226
[**2165-7-30**] 12:09PM GLUCOSE-134* NA+-140 K+-5.2
[**2165-8-12**] 05:30AM BLOOD WBC-15.2* RBC-3.68* Hgb-11.5* Hct-33.7*
MCV-92 MCH-31.1 MCHC-34.0 RDW-13.8 Plt Ct-627*
[**2165-8-11**] 09:54PM BLOOD PT-17.3* PTT-61.2* INR(PT)-1.6*
[**2165-8-12**] 05:30AM BLOOD Glucose-71 UreaN-14 Creat-0.9 Na-141
K-4.8 Cl-104 HCO3-27 AnGap-15
Brief Hospital Course:
Mr [**Known lastname 1637**] was a direct admission to the operating room for
Aortic aneurysm repair on [**7-30**]. At that time he had an Ascending
Aorta and Hemiarch replacement with #32 Gelweave graft and
Aorticvalve replacement with #27 CE magna pericardial tissue
valve. His bypass time was 140 minutes and crossclamp was 87
minutes with circulatory arrest of 8 minutes. PLease see
operating room report for full details.
He tolerated the operation and was transferred from the OR to
cardiac surgery intensive care on Epinephrine, Neosynephrine and
Propofol infusions. The patient was hemodynamically stable once
in the ICU and the Epinephrine was weaned off. He was slow to
wake and therefore was not extubated until the morning after
surgery. Additional he was noted to have right sided hemiparesis
for which Neurology was consulted. The patient also suffered
episodes of intermittent confusion most exagerated during the
nightime hours.
HE also ahd intermittent episode of post-op Atrial fibrillation
that was not well controlled with beta blockers and he was
started on Amiodarone as well as Heparin and Coumadin. He stayed
in the ICU to monitor his hemodynamic/pulmonary and neurologic
status until POD 8 at which time he was transferred to the step
down floor for continuing post-op care. Once on the floor the
patients post-op course was largely uneventful. He continued to
make slow progress in his physical therapy, he was slowly
anticoagulated and continued to have intermittent episodes of
atrial fibrillation but was generally in sinus rhythm, and he
only had rare episodes of disorientation that were easily
corrected with reminders.
On POD 12 it was decided that the patient was stable and ready
to be discharged to rehabilitation at [**Hospital 69348**] Rehabilitation
Center.
Medications on Admission:
Diltiazem 420 QD
Pravachol 20 QD
Amoxicillin PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then 200mg QD.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
9. Warfarin 1 mg Tablet Sig: 1-10 mg PO DAILY (Daily): Adjust
dose QD to
Target INR 2.0-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Asc Ao and Hemiarch replacement(#32Gelweave)AVR(#27 CE Magna
pericardial)
cva, post-op Afib
PMH: HTN,^chol,MVP,Aorto-Fem BPG, L hernia repair, ORIF elbow,
removal Basal cell CA
Discharge Condition:
Good.
Discharge Instructions:
Keep wounds clean and dry. ok to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Make an appointment with Dr. [**Name (NI) 23019**] 1-2 weeks after d/c
from rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2165-8-12**] Name: [**Known lastname 5990**],[**Known firstname 3206**] F Unit No: [**Numeric Identifier 11828**]
Admission Date: [**2165-7-30**] Discharge Date: [**2165-8-16**]
Date of Birth: [**2098-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Mr. [**Known lastname **] did not receive a rehab bed placement until Thursday
[**8-15**]. He also remained for an elevated WBC and treatment of a
UTI. Therapy was adjusted based on culture sensitivities.
Discharged to rehab on POD # 16. Coumadin dose today only is
3mg. Target INR is 2.0 - 2.5.
Pertinent Results:
[**2165-8-15**] 05:50AM BLOOD WBC-15.1* RBC-3.93* Hgb-12.2* Hct-35.5*
MCV-90 MCH-31.0 MCHC-34.3 RDW-14.0 Plt Ct-604*
[**2165-8-15**] 05:50AM BLOOD Plt Ct-604*
[**2165-8-15**] 05:50AM BLOOD PT-26.4* PTT-40.9* INR(PT)-2.7*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 2 days then 200mg QD.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Warfarin 1 mg Tablet Sig: 1-10 mg PO DAILY (Daily): Adjust
dose QD to
Target INR 2.0-2.5
Dose today only [**8-15**] is 3 mg.
9. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 7 days: complete course on [**8-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2165-8-15**]
|
[
"424.1",
"305.1",
"443.9",
"401.9",
"434.11",
"V10.83",
"599.0",
"997.02",
"041.10",
"427.31",
"438.20",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.21",
"38.45",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7870, 8076
|
2442, 4240
|
513, 619
|
5509, 5517
|
6614, 6836
|
5719, 6595
|
1142, 1223
|
6859, 7847
|
5305, 5488
|
4266, 4316
|
5541, 5696
|
1238, 1927
|
283, 475
|
647, 793
|
815, 968
|
984, 1126
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,878
| 104,617
|
23536
|
Discharge summary
|
report
|
Admission Date: [**2148-7-8**] Discharge Date: [**2148-7-15**]
Service: SURGERY
Allergies:
Penicillins / Optiray 350 / Lactose
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p fall with multiple right sided rib fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **] yo male s/p fall. Patient attempted to sit into
chair and fell backwards onto coffee table. no LOC.
Past Medical History:
Parkinson's disease
DM2 c/b neuropathy on neurontin
diplopia x one year, horizontal, no clear etiology per patient,
followed by ophtho
HTN
Migraines
s/p MI [**57**] yrs ago
s/p cataract [**Doctor First Name **] bilat
s/p laminectomy in [**2089**]
Social History:
Recent move to [**Location (un) 86**] from NY 10 days ago. lives with wife in
senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no
etoh, no drugs, has 2 sons
Family History:
Father with strokes, no seizures, no parkinsons, sons are
healthy
Brief Hospital Course:
[**Age over 90 **] y.o. male with multiple right sided rib fracture after fall
on [**7-8**]. He was admitted to the surgery service and taken to the
regular floor and because of his age, poor pain control and
multiple rib fractures he was transferred to Trauma SICU. Acute
Pain Service was consulted and an epidural catheter was placed
for better pain control; oral analgesics were eventually
introduced and his pain is currently under much better control.
He has required nasal oxygen since admission with saturations in
low 90's. He is on scheduled nebulizer treatments as well and
using the incentive spirometer much more effectively pulling
volumes of ~1200-[**Numeric Identifier 20476**] cc's.
He was seen by Neurology at the request of his family due to his
tremors. A head CT was recommended which showed no evidence of
acute intracranial abnormalities or interval change. He was
continued on his home meds which include carbidopa/levodopa,
Aricept/namenda; following his discharge from rehab he should
follow up with his PCP and primary movement disorder specialist
for any adjustments of his meds.
With regards to his PMH he has known chronic kidney disease and
appears to have a baseline creatinine around 2.5. His home
medications for his type II DM were continued.
He has a recent community acquired pneumonia (completed
Levaquin) and UTI treated with Bactrim which has been stopped.
He was evaluated by Physical therapy and is being recommended
for acute level rehab after his hospitalization.
Medications on Admission:
aricept, nameda, glipizide, neurontin, allopurinol, simvistatin,
lisinopril, amlodipine, atenolol, mirtazapine,
carbidopa-levadopa
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Amlodipine 5 mg Tablet Sig: 1 [**12-23**] Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
15. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
18. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to chest wall over rib fracture sites .
20. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
24. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
25. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
s/p Fall
Right rib fractures [**6-30**]
Urinary tract infection
Secondary diagnosis:
Pneumonia (resolving was being treated for this prior to his
fall)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized following a fall where you broke many ribs
on your right side. These injuries did not require any
operations; an epidural catheter was placed to deliver pain
medication to help with managing the discomfort associated with
rib fractures. Once your pain was better controlledthe catheter
was removed and you were started on oral pain medications. It is
important that you continue to do your breathing exercises and
use the spirometer t least 10x every hour you're awake.
You were also seen by Neurology while here in the hospital per
request of your family due to your tremors, there were no major
recommendations other than some minor adjustments of your
Parkinson medication which they have deferred to your primary
movment disorder specialist.
Followup Instructions:
Follow up in [**1-24**] weeks in [**Hospital 2536**] clinic for your rib fractures;
call [**Telephone/Fax (1) 600**] for an appointment. You will need an end
expiratory chest xray for this appointment.
Follow up with your primary providers after discharge from
rehab.
Completed by:[**2148-7-15**]
|
[
"346.90",
"357.2",
"860.4",
"585.9",
"403.90",
"250.60",
"348.30",
"E885.9",
"332.0",
"368.2",
"584.9",
"276.7",
"599.0",
"807.05",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
4893, 4959
|
1018, 2531
|
289, 295
|
5155, 5155
|
6123, 6422
|
927, 995
|
2712, 4870
|
4980, 5045
|
2557, 2689
|
5330, 6100
|
201, 251
|
323, 457
|
5066, 5134
|
5170, 5306
|
479, 727
|
743, 911
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,626
| 124,380
|
19569
|
Discharge summary
|
report
|
Admission Date: [**2165-8-8**] Discharge Date: [**2165-8-11**]
Date of Birth: [**2096-2-13**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
pericardial effusion
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
69 y/o M PMH: malignant mesothelioma (T3,N1, stage III). dx'd
[**2-13**] s/p extrapleural pneumonectomy, resection of his diaphragm,
resection of the pericardium, and reconstruction with [**Doctor Last Name 4726**]-Tex
graft, and lymph node dissection [**5-14**] and chemo
(Cisplantin/Alimta)1 wk ago. P/W: large pericardial effusion.
HPI: Screening chest CT [**2165-8-2**] revealing a large pericardial
effusion measuring 3.4cm in thickness which was new compared to
CT scan [**2165-6-14**]. He has had dyspnea on exertion and at rest for
last week. No evidence of clinical tamponade: pulsus 8-10 mm hg,
no elevation in JVP, normotensive. Echo yesterday confirmed
large effusion, 1.5-2cm circumferential; + respiratory variation
in inflow, brief RA invagination, no RV collapse. CT surgery saw
pt for window & are suggesting pericariocentesis, feel likely
post-op rather than malignant. Pericardiocentesis was performed
and 320-350 cc of thin red fluid was withdrawn. No hemodynamic
evidence of cardiac tamponade was observed CO6.69, CI 3.61,
PCWmean 4, RAmean 6, PA 13/10 mean 12, RV 30/5, SVC 71%, Ao 98%.
Pt tolerated the procedure well. Post-pericardiocentesis ECHO
showed resolution of effusion. Pt was transferred to the CCU
for observation.
Past Medical History:
--malignant mesothelioma [**2165-5-31**] extrapleural pneumonectomy,
resection of his diaphragm, resection of the pericardium, and
reconstruction with [**Doctor Last Name 4726**]-Tex graft, and lymph node dissection.
--hypercholesterolemia
--GERD
--diverticulosis
--s/p bilateral knee surgery
Social History:
Pt was a shipyard worker and had exposure to asbestos. He lives
with his wife. Smoked 5 ppd until age 29. 3 whiskey drinks per
day. Never drugs.
Family History:
son died at 23 y/o of unclear heart condition. son died at 26
y/o of skin related cancer. father died of MI in 60s. mother
died of MI in 80s.
Physical Exam:
[**2165-8-9**] T:98 BP:153/94 HR:90 RR:20 O2sat:100% 3L
[**2165-8-10**] T:98 BP:123/61 HR:87 RR:22 O2sat:100% 3L
HEENT: no JVD, no elevation of JVP (~7), EOMI, PERRL, MMM, no
lymphadenopathy
CV: RRR, NL S1/S2, no M/R/G, pulsus [**8-20**]
PULMO: CTAB
ABD: BS+, NT, ND, firm to palpation of RUQ
EXT: warm, no C/C/E, 2+ DP, palp PT
NEURO: AxOx3, no neuro deficits
I/Os 1.2/1 = +200cc, 70/550 = +500cc
drain = 250cc yesterday, 50cc o/n
Pertinent Results:
[**2165-3-20**] PATHOLOGY: Tumor cells are positive for Keratin
cocktail, Calretinin and Keratin 7 and negative for Keratin 20,
TTF1, LeuM1 and CEA suggesting a mesothelial origin.
[**2165-4-11**] PFTs: Actual Pred %Pred Actual %Pred %chg
FVC 2.93 3.95 74
FEV1 2.17 2.69 81
MMF 1.63 2.55 64
FEV1/FVC 74 68 109
Mechanics: The FVC is mildly reduced, the FEV1 is within normal
limits and
the FEV1/FVC ratio is elevated.
Flow-Volume Loop: Reduced volume excursion.
Volumes: The TLC is mildly reduced while the FRC, RV and
RV/TLC ratio are
within normal limits.
DLCO: Mildly reduced.
Impression: Mild restrictive ventilatory defect
[**2165-4-11**] ECHO: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal.
[**2165-5-31**] PATHOLOGY:
I. (Pleura) (A):Fragment of fibrous tissue with malignant
and mesothelioma.
II. (Right lung and pleura, pneumonectomy and pleural
resection) (B-AC):
1) Diffuse malignant mesothelioma, epithelioid type (papillary
pattern).
2) Tumor focally invading into lung parenchyma and soft tissue
of chest wall, and is focally within less than 1 mm of the black
inked resection margin. The tumor invades within 1.0 mm of the
diaphragm muscle.
3) Bronchial and vascular resection margins are free of tumor.
4) Lymphangiovascular tumor invasion present.
5) Thirteen hilar lymph nodes with no malignancy identified
(0/13).
6) Polarizable foreign material and foreign body giant cell
reaction present in multiple foci within the pleura.
7). Uninvolved lung parenchyma show mild emphysematous changes.
[**2165-8-9**] ECHO:
1. The left atrium is mildly dilated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No color doppler was performed across
the mitral valve to assess for the presence of AI.
5.The mitral valve leaflets are mildly thickened. No color
doppler performed across the aortic valve to assess for the
presence of MR.
6.There is a moderate to large sized circumferential pericardial
effusion. There is no pericardial thickening. No right
ventricular diastolic collapse is seen. However, there is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
[**2165-8-9**] PERICARDIOCENTESIS:
1. Drainage of pericardial fluid. No evidence of tamponade.
2. Normal left and right sided filling pressures.
3. Preserved cardiac index.
[**2165-8-9**] ECHO POST-drainage:
1. The left atrium is normal in size.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade
[**2165-8-8**] CXR: Patient s/p right pneumonectomy with large amount
of
fluid occupying the right hemithorax. Small amount of air is
seen loculated
within the right upper hemithorax. The left lung appears grossly
clear. The
cardiac size is difficult to assess, but appears to be unchanged
since the
prior study. Pulmonary vascularity is normal. No left effusion
is identified.
No pneumothorax is seen on the left side.
IMPRESSION:
1) Cardiac size is difficult to assess, however, appears
relatively unchanged
since the prior study.
2) S/P right pneumonectomy with right hydropneumothorax.
[**2165-8-8**] 04:10PM PT-12.3 PTT-24.2 INR(PT)-1.0
[**2165-8-8**] 04:10PM PLT COUNT-201
[**2165-8-8**] 04:10PM NEUTS-62.7 LYMPHS-25.9 MONOS-8.5 EOS-2.3
BASOS-0.5
[**2165-8-8**] 04:10PM WBC-4.6 RBC-4.10* HGB-10.2* HCT-32.1* MCV-78*
[**2165-8-8**] 04:10PM cTropnT-<0.01
[**2165-8-8**] 04:10PM CK(CPK)-23*
[**2165-8-8**] 04:10PM GLUCOSE-99 UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-31* ANION GAP-17
[**2165-8-8**] 04:44PM K+-3.6
[**2165-8-9**] WBC4, Hct29.6, Plt141, Na136, K4.1, Cl97, Co232, BUN13,
Cr0.9, Gluc109, Mg1.6
[**2165-8-9**] PERICARDIAL FLUID
WBC2700 RBC01 Hct8 Fl2 Polys82 Lymphs14 Monos2 Other2 Glucose90
LD(LDH)3010 Amylase18 Albumin2.7 No PMNs No organisms
Brief Hospital Course:
69 y/o M w/ malignant mesothelioma s/p pleurodsesis, right
pneumonectomy, on chemo who p/w large pericardial effusion
likely secondary to surgical procedure vs. chemotherapy vs.
mesothelioma vs. idiopathic, unlikely due to TB, bacterial,
viral, collagen vascular disease, trauma, uremia.
Pericardial effusion:
--The patient was not clearly in tamponade. A
pericardiocentesis was performed and over 400 cc of fluid was
drained. A repeat echo showed minimal pericardial effusion and
drain was pulled after being in place for 24 hours. His
pericardial fluid was negative for malignant cells but did
contain numerous lymphocytes, red blood cells, macrophages and
rare reactive mesothelial cells. He was instructed to obtain a
follow up echo as an outpatient within one week of his
discharge.
MESOTHELIOMA:
--The patient was maintained on folic acid during his admission
and his complete blood count remained stable throughout the
admission.
Medications on Admission:
prilosec
lipitor
MVI
ASA
Discharge Medications:
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO QD
Folic Acid 1 mg PO QD
Multivitamins 1 CAP PO QD
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion status post pericardiocentesis
Mesothelioma status post pneumonectomy and chemotherapy
Hypercholesterolemia
Discharge Condition:
Stable and improved
Discharge Instructions:
Call your doctor or report to the Emergency Room immediately if
you experience sudden onset shortness of breath. Call your
doctor if you experience chest pain or palpitations.
Followup Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 10085**] in 1 week for
an echo. Follow up with your oncologist as per your plan prior
to admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"163.9",
"424.0",
"E878.6",
"997.1",
"423.9",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8508, 8514
|
7367, 8307
|
312, 332
|
8687, 8708
|
2742, 7344
|
8933, 9278
|
2115, 2261
|
8382, 8485
|
8535, 8666
|
8333, 8359
|
8732, 8910
|
2276, 2723
|
252, 274
|
360, 1617
|
1639, 1933
|
1949, 2099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,894
| 170,918
|
31809
|
Discharge summary
|
report
|
Admission Date: [**2177-10-2**] Discharge Date: [**2177-10-30**]
Date of Birth: [**2120-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Epigastric discomfort and lethargy
Major Surgical or Invasive Procedure:
[**2177-10-6**] Five Vessel Coronary Artery Bypass Grafting(LIMA to
LAD, with vein grafts to first diagonal, second diagonal, obtuse
marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring),
with Insertion of an IABP.
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old male who presented to OSH in mid
[**Month (only) 359**] with shortness of breath, gastric discomfort and
fatigue. He ruled in for a ST elevation MI. Subsequent cardiac
catheterization revealed severe three vessel coronary artery
disease and an LVEF of 36%. Echocardiogram at that time was
notable for an LVEF of 40% with inferior wall akinesis and
moderate mitral regurgitation. Patient was declined for surgery
at [**Hospital3 2005**](secondary to poor distal targets) and
eventually transferred to the [**Hospital1 18**] for further evaluation and
treatment.
Past Medical History:
Ischemic Cardiomyopathy, Coronary Artery Disease with inferior
wall ST Elevation MI on [**2177-9-30**], Mitral Regurgitation,
Hypertension, Type II Diabetes Mellitus(poorly controlled),
Hyperlipidemia
Social History:
Denies tobacco and ETOH. He lives alone. He is a truck driver.
Family History:
Denies family history of premature coronary artery disease.
Physical Exam:
Admission
HR 74 SR BP 126/62 RR 20 Sat 96% on 4L
Neuro Arousable, follows commands with encouragement. MAE,
strength 5/5 t/o. PERRL.
CV RRR no M.R.G
Lungs wheezes, crackles
Abdomen soft/NT
Extrem 1+ edema, warm 2+ pulses t/o
no carotid bruits
Discharge
T 99.6 HR 76SR BP104/60 RR22 O2sat 96%RA
Neuro: Awake, moves rt side to command, left dense hemiparesis
CV: RRR, sternum stable
Pulm: course rhonchi
Abdm: soft, NT/+BS
Ext: left LE 3+ edema, Rt LE no edema
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2177-10-30**] 02:29AM 8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0*
281
Source: Line-CVL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2177-10-30**] 02:29AM 281
Source: Line-CVL
[**2177-10-30**] 02:29AM 20.5*1 65.6* 1.9*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2177-10-30**] 02:29AM 150* 25* 1.2 137 3.8 99 30 12
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2177-10-29**] 1:30 PM
CHEST (PORTABLE AP)
Reason: dobhoff placement
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with s/p CABG
REASON FOR THIS EXAMINATION:
dobhoff placement
CHEST, SINGLE AP FILM
History of CABG.
Status post CABG. Distal end of feeding tube overlies body of
stomach. There is cardiomegaly and a left pleural effusion with
associated atelectasis in the visualized left lower lung. No
pneumothorax. The left subclavian CV line has tip located over
the proximal SVC.
IMPRESSION: No definite pneumothorax. Left pleural effusion and
associated atelectasis in left lower lobe, overall appearances
being essentially unchanged since prior study of [**2177-10-28**].
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
[**2177-10-2**] 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4
MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273
[**2177-10-2**] 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4*
[**2177-10-2**] 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133
K-4.7 Cl-94* HCO3-27 AnGap-17
[**2177-10-2**] 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531*
AlkPhos-325* Amylase-35 TotBili-0.6
[**2177-10-2**] 10:30PM BLOOD Albumin-3.3* Mg-2.5
[**2177-10-2**] 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49*
calTCO2-28 Base XS-4
[**2177-10-2**] 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1
Cl-94*
[**2177-10-5**] 08:58PM BLOOD %HbA1c-12.4*
[**2177-10-3**] Non Contrast Head CT Scan:
There is no evidence of intracranial hemorrhage, mass effect, or
shift of normally midline structures. [**Doctor Last Name **]-white matter
differentiation is preserved. The ventricles are normal in size
and symmetric. There is no evidence of acute major vascular
territorial infarction. There are moderate cavernous carotid
calcifications. There is complete opacification of the right
maxillary sinus. The remaining paranasal sinuses and mastoid air
cells are clear.
[**2177-10-6**] Intraoperative TEE:
PRE-BYPASS:
Pt requiring dobutamine infusion at 7.5
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild to moderate global left ventricular hypokinesis
(LVEF = 35-40 %), with basal to mid inferior and
inferior-lateral akinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.].
3. Right ventricular chamber size is normal. There is mild to
moderate global right ventricular free wall hypokinesis.
4. There are simple atheroma in the ascending aorta. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Trace aortic regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen, with noted centrally
directed regurgitant jet. The mitral regurgitation vena
contracta is >=0.7cm.
7.The tricuspid valve leaflets are mildly thickened; there is
mild to moderate ([**12-17**]+) tricuspid regurgitation.
POST-BYPASS:
Pt removed from cardiopulmonary bypass on vasopression,
milrinone, epinephrine and norephinephrine infusions and
placement of intra-aortic balloon pump.
1. Pt s/p mitral valve annuloplasty. There is no mitral
regurgitation.
2. Biventricular function is improved. Right ventricular is
normal sized and function has improved from moderate to mild
dysfunction. Left ventricular function remains globally
depressed; basal to mid inferior walls remain akinetic; there is
improvement of anterior wall function.
3. Aortic contours are intact post-decannulation. There is an
intra-aortic balloon noted in the proper position.
[**2177-10-15**] Transthoracic ECHO:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
akinesis of the inferior and inferolateral walls. The remaining
segments contract normally (LVEF = 35-40 %). 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. No mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is a
very small pericardial effusion most prominent around the right
atrium.
[**2177-10-16**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated native 3 vessel coronary artery disease. The LMCA
had
diffuse mild disease. The LAD was occluded in the mid vessel.
The LCX
was occluded proximally. The RCA was occluded proximally. The
SVG-PDA
was patent with slow flow into a small PDA. The SVG-D1 was
patent as was
SVG-D2, both with slow flow into small distal vessels. The
SVG-OM was
patent with slow flow as well. The LIMA-LAD was patent. The LAD
beyond
the LIMA was diffusely small with slow flow.
2. Limited resting hemodynamics were performed. The systemic
arterial pressures were borderline low measuring 86/63mmHg.
[**2177-10-20**] Non contrast Head CT Scan:
There is no sign for the presence of an intracranial hemorrhage.
There is a question of a 1cm area of low density seen within the
region of the right uncus, which did not appear to be present on
the prior CT scan. If real, this finding could represent an area
of developing infarction. No other definite interval changes are
appreciated. There is no hydrocephalus or shift of normally
midline structures.
[**2177-10-21**] MRA Brain:
Multiple areas of restricted diffusion bilaterally including
also the right cerebellar hemisphere as described above, areas
of subacute ischemic changes extending from the posterior limb
of the right internal capsule to the right, hippocampal area.
These [**Month/Day/Year 4493**] are suggestive of subacute infarcts likely from
an embolic source involving multiple vascular territories.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service. He
remained pain free on intravenous Heparin and Nitroglycerin. He
was initially evaluated by the Neurology service for an altered
mental status, experiencing periods of unresponiveness,
confusion and agitation/delirium. A head CT scan was
unremarkable and his altered mental status was attributed
metabolic encephalopathy. There was no evidence of stroke. Over
the next several days from a cardiac standpoint, he gradually
developed cardiogenic shock and required inotropic support.
Given his critical condition, he was urgently brought to the
operating room on [**10-6**] where Dr. [**Last Name (STitle) 1290**] performed
coronary artery bypass grafting and mitral valve repair. Given
his low ejection fraction, an IABP was placed prior to weaning
from cardiopulmonary bypass. For additional surgical details,
please see seperate dictated operative note. Following the
operation, he was brought to the CVICU in critical condition.
His postoperative course will now be broken down into systems:
CARDIAC: Initially required multiple inotropes for poor
hemodynamics. Started on Amiodarone on postoperative day two for
atrial and ventricular arrhythmias. The IABP was slowly weaned
and eventually removed on postoperative day four without
complication. He remained pressor dependent at that time.
Cardioversion was performed on postoperative day six for
episodes of atrial fibrillation associated with a decrease in
SVO2. By postoperative seven, all inotropic support was weaned.
Despite Amiodarone, he continued to experience atrial and
ventricular arrhythmias. He went on to develop an episode of
sustained ventricular fibrillation/torsades on postoperative day
eight for which successfull defibrillation was performed.
Amiodarone was discontinued and switched to Lidocaine. A calcium
channel blocker was concomitantly initiated. The EP/cardiology
services were consulted and recommended EPS with potential VT
ablation. To rule out ischemia as the cause for ventricular
tachycardia, cardiac catheterization was performed on [**10-16**] which showed patent grafts. Given ventricular arrhythmias,
he was eventually started on Mexiletine.
PULMONARY: Given critical condition, required prolonged
mechanical ventilation. Eventually extubated on postoperative
day nine. He was electively re-intubated for cardiac
catheterization on [**10-16**], and re-extubated later that
night. Unfortunatly, he went on to develop acute respiratory
failure later that night and required reintubation. Bronchoscopy
was performed on [**10-17**] which found patent airways without
evidence of mucous plugs and only minimal scant secretions. A
left sided chest tube was placed for pleural effusion. The
effusion improved and the chest tube as removed.
NEURO: Given his critical condition, had a prolonged period of
sedation. Following his initial extubation, he awoke
neurologically intact. Following his second re-extubation on
postoperative day 14, he was noted to have new onset left
hemiparesis and left sided neglect. Neurology was consulted
while head CT scans and MR [**First Name (Titles) 654**] [**Last Name (Titles) 4493**] consistent with
embolic stroke(see result section). Heparin and coumadin were
started.
RENAL: Developed oliguric acute renal failure. Creatinine peaked
to 2.9 on postoperative day eight. The renal service was
consulted and attributed his renal insufficiency to pre-renal
etiology. Renal function gradually improved and he responded
nicely to diuretics.
ENDOCRINE: Initially maintained on Insulin drip. Transitioned to
lantus insulin.
HEME: Mild postoperative anemia and was intermittently
transfused to maintain hematocrit near 30%.
ID: Remained afebrile with no evidence of infection.
GI: Bedside swallow on [**10-22**] recommended continuing NPO/tube
feeding as he was not consistently awake enough to safely
attempt anything by mouth. Tolerating tube feedings.
Skin: A hematoma formed at an ex-chest tube site on his left
flank and began bleeding with anticoagulation. It was sutured on
[**10-26**] and subsequently improved.
Medications on Admission:
Intravenous Nitroglycerin
Docusate Sodium 100 [**Hospital1 **]
Metoprolol 75 [**Hospital1 **]
Pantoprazole 40 qd
Aspirin 325 qd
Lisinopril 2.5 qd
Simvastatin 40 qd
Glargine 20 units qhs
RISS
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Two
(2) Puff Inhalation Q4H (every 4 hours).
4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
6. Carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day). Tablet(s)
7. Mexiletine 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q8H (every
8 hours).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
11. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: One (1)
Inhalation Q4H (every 4 hours) as needed.
13. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Day (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
15. Warfarin 1 mg Tablet [**Month/Day (2) **]: as directed Tablet PO DAILY
(Daily): target INR 2-2.5
Pt to receive 7.5mg on [**10-30**].
16. Lisinopril 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
17. Furosemide 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location 12243**] Senior Care - [**Hospital1 189**]
Discharge Diagnosis:
- Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction,
Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock
- s/p Urgent CABG and Mitral Valve Repair on IABP
- Postoperative Stroke
- Postoperative Acute Respiratory Failure
- Postoperative Acute Renal Failure
- Postoperative Atrial Fibrillation/Flutter
- Postoperative Ventricular Tachycardia
- Postoperative Bradycardia
- Postoperative Anemia
- Postoperative Pleural Effusion
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus
Discharge Condition:
Stable.
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4-5 weeks, please call for appt
Cardiology clinic-Dr [**Last Name (STitle) **] (EP) in [**2-16**] weeks, please call
for appt
Completed by:[**2177-10-30**]
|
[
"997.1",
"997.5",
"285.1",
"410.21",
"427.31",
"428.0",
"998.11",
"272.4",
"401.9",
"511.9",
"342.80",
"785.51",
"997.3",
"434.11",
"427.41",
"348.31",
"414.01",
"518.5",
"584.9",
"276.1",
"428.20",
"427.89",
"424.0",
"250.00",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"88.57",
"99.61",
"96.72",
"36.14",
"39.61",
"89.68",
"38.93",
"34.71",
"39.64",
"99.04",
"36.15",
"99.62",
"33.23",
"35.12",
"37.22",
"37.61",
"96.6",
"88.56",
"96.71",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
14849, 14930
|
8619, 12740
|
356, 583
|
15481, 15491
|
2095, 2640
|
1536, 1597
|
12981, 14826
|
2677, 2707
|
14951, 15460
|
12766, 12958
|
15515, 15766
|
15817, 16007
|
1612, 2076
|
282, 318
|
2736, 8596
|
611, 1216
|
1238, 1440
|
1456, 1520
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,184
| 155,853
|
6353
|
Discharge summary
|
report
|
Admission Date: [**2141-2-9**] Discharge Date: [**2141-2-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Right-sided weakness, altered consciousness
Major Surgical or Invasive Procedure:
Thrombolysis with tPA
IR-guided PEG tube placement
History of Present Illness:
[**Age over 90 **] year-old man with history of hypertension, dyslipidemia,
critical aortic stenosis (reportedly non-surgical), benign
prostatic hypertrophy, recent left lower lobe pneumonia with
bilateral effusions, and reportedly with a brain tumor with a
right-sided craniotomy in the past, who presents after an
episode
of altered mental status, facial droop, and right-sided
weakness.
The patient, who is reportedly alert, oriented, and independent
at baseline, was reportedly in his usual state of health until
1:30 pm, when he reportedly emerged from the bathroom at his
rehabilitation facility (where he was recovering from pneumonia)
and vomited. He became "increasingly unresponsive." Vitals on
the scene included blood pressure of 140/60, heart rate of 59,
and an SaO2 of 94% on room air. Per EMS, pupils were reportedly
unequal, smaller on the right, and reactive. He had impaired
arousal. He was "aphasic," with right facial droop. He was
rushed to [**Hospital3 **], where a code stroke was called at 3:13
pm;
Neurology was at bedside within two minutes. NIHSS was 22.
Review of Systems:
Unable to provide at this time.
Past Medical History:
-Hypertension, dyslipidemia, critical aortic stenosis
(reportedly
non-surgical), benign prostatic hypertrophy, recent left lower
lobe pneumonia with bilateral effusions, reportedly with a brain
tumor with a right-sided craniotomy in the past
Social History:
Living at [**Hospital3 **] after recent pneumonia. He is a
widower who was reportedly independent of ADLs. He reportedly
does not smoke or drink.
Family History:
Unknown at this time
Physical Exam:
Vitals: T 98.8 F BP 138/58 P 76 RR 25 SaO2 94 3LNC
General: elderly man, somnolent
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: irregular rhythm, no MMRG
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present
Ext: warm, no edema, pedal pulses appreciated, wrapping at right
knee
Skin: red petechial-type lesions on feet
Neurologic Examination:
Mental Status:
Somnolent but arousable to touch, unable to relay history or
follow commands, mute. Appears to be neglecting right space.
Cranial Nerves:
Fundoscopy technically limited; Reduced blink to threat on the
right. Pupils equally reactive to light, 2.5 to 1.5 mm on the
left and 2 to 1.5 mm on the right. Leftward gaze deviation,
does
not cross midline on Dolls. Reduced corneal response on the
right with right facial droop.
Sensorimotor:
Flaccid on the right side, tone appears preserved on left. On
the
left, he is able to hold his arm and leg anti-gravity, but they
drift downward in less than 2 seconds.
Reflexes:
Hyporeflexic throughout, areflexic at the ankles. Toes were
upgoing bilaterally.
Coordination and gait could not be performed.
Pertinent Results:
Admission labs:
[**2141-2-10**] 02:24AM BLOOD WBC-11.8* RBC-3.05* Hgb-9.4* Hct-28.6*
MCV-94 MCH-30.8 MCHC-32.9 RDW-15.3 Plt Ct-266
[**2141-2-9**] 03:50PM BLOOD WBC-12.3* RBC-3.32* Hgb-10.6* Hct-31.5*
MCV-95 MCH-32.0 MCHC-33.7 RDW-15.4 Plt Ct-277
[**2141-2-10**] 02:24AM BLOOD PT-17.7* PTT-34.6 INR(PT)-1.6*
[**2141-2-9**] 03:50PM BLOOD PT-15.0* PTT-28.7 INR(PT)-1.3*
[**2141-2-10**] 02:24AM BLOOD Glucose-145* UreaN-46* Creat-1.8* Na-139
K-4.1 Cl-115* HCO3-15* AnGap-13
[**2141-2-9**] 03:50PM BLOOD Glucose-153* UreaN-48* Creat-2.2* Na-136
K-5.2* Cl-108 HCO3-16* AnGap-17
[**2141-2-10**] 02:24AM BLOOD CK(CPK)-24*
[**2141-2-9**] 03:50PM BLOOD AST-18 LD(LDH)-266* CK(CPK)-31*
AlkPhos-152* TotBili-0.4
[**2141-2-10**] 02:24AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2141-2-9**] 03:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2141-2-10**] 02:24AM BLOOD Calcium-7.0* Phos-4.5 Mg-1.5* Cholest-PND
[**2141-2-9**] 03:50PM BLOOD Albumin-3.3*
[**2141-2-9**] 05:23PM BLOOD %HbA1c-6.3*
[**2141-2-9**] 03:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2141-2-9**] 03:44PM BLOOD Lactate-1.8
CT Perf Head/Neck [**2141-2-9**]:
1. CT of the head demonstrates encephalomalacia from prior right
frontal
infarct. There is an area of left frontal lobe, corresponding to
the anterior division of the left MCA, consistent with acute
infarct. There is also a dense MCA sign seen in the left MCA. 2.
Perfusion study demonstrates a large area of increased MTT and
decreased blood flow involving the left MCA distribution. There
is a small area of reduced cerebral blood volume in the anterior
portion of the left MCA istribution, corresponding to a small
ischemic core with a larger surrounding
ischemic penumbra.Normal cervical carotid and vertebral
arteries. There is no significant occlusion or stenosis. Abrupt
cutoff demonstrated in the left MCA, distal M1/proximal M2.
Bilateral pleural effusions
.
CXR [**2141-2-9**]:
IMPRESSION:
1. Findings compatible with mild-to-moderate pulmonary edema
with bilateral
pleural effusions, mild-to-moderate in extent.
2. Bibasilar opacities, which may represent atelectasis, but
aspiration or
pneumonia is not excluded.
MRA Brain [**2141-2-9**]: Acute infarction of the anterior division of
the left middle cerebral artery. Multiple small intraparenchymal
foci of hemorrhage within the infarcted region. Chronic right
frontal infarct. MRA demonstrates normal intracranial
circulation and circle of [**Location (un) 431**],
with apparent reperfusion of the previously occluded M2 segment
of the left MCA.
NCHCT [**2141-2-10**]:Continued evolution of anterior division of the
left MCA infarction. Multiple hyperdense foci within the
infarcted region, consistent with small intraparenchymal
hemorrhages. Mild mass effect resulting in approximately 3 mm
rightward shift of normally midline structures.
.
CXR [**2141-2-10**]:The distal tip of Dobbhoff tube projects in expected
location of the stomach. The heart size is moderately enlarged,
aorta is very tortuous. Moderate left and small right pleural
effusions have improved. Bibasilar atelectasis appears
unchanged. Pneumonia in the lung bases cannot be excluded. No
pneumothorax is detected.
.
TTE [**2141-2-10**]:
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 60-70%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is a moderate sized pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade
.
LENI's [**2141-2-11**]: No DVT in either leg. Left [**Hospital Ward Name 4675**] cyst.
.
NCHCT [**2141-2-11**]: Interval increase in parenchymal hemorrhage within
the left MCA infarct territory, now spanning a region of 5.2 x
3.3 cm. Associated increase in edema with mild increase in
subfalcine rightward herniation, now measuring 5 mm. New
hyperdense focus in the right anterior frontal cortex could
represent tiny site of hemorrhage, without mass effect or edema.
Alternatively, this could be artifactual. Stable right frontal
infarct. NOTE ADDED AT ATTENDING REVIEW: The right frontal
finding appears to be an artifact, rather than a focus of
hemorrhage.
.
Renal U/S [**2141-2-12**]: No hydronephrosis. Bilateral renal parenchymal
thinning and increased echogenicity, compatible with chronic
medical renal disease.
Left pleural effusion.
.
G tube placement [**2141-2-15**]: Uncomplicated placement of a 14 French
[**Doctor Last Name 9835**] transgastric jejunal feeding tube with tip positioned in
the jejunum.
.
Brief Hospital Course:
This [**Age over 90 **] yo M presented with sx of dense R hemiplegia and global
aphasia as outlined in the HPI. He received tPA in the ER here
as he was within the time window and risks/benefits d/w family.
He was found with new AF in the ER on tele. His subsequent MRI
showed a new moderate sized infarct in his left anterior
temporal lobe. The following day, he had significant improvement
in his motor function (able to move RUE and RLE anti-gravity)
but remained globally aphasic. He failed his S/S eval and a NGT
was placed. His TTE showed ongoing mod to severe AS, but no
atheroma, thrombus, or PFO. A repeat NCHCT post-tPA showed a
small area of hemorrhage within the new left infarct. It was
felt that starting ASA 325 mg daily was acceptable, but while
the team felt coumadin was indicated, the start date was delayed
for 2 weeks to allow his bleeding to organize. He was
transferred to the floor.
.
On the floor he had an episode of hypoxia, tachycardia throught
related to an aspiration event. He was transferred to MICU for
persistent hypoxia and started on Vancomycin and Unasyn. His
oxygenation improved and MRSA swab was negative therefore his
antibiotics were changed to Augmentin to complete a 10 day
course. He was transferred back to general medical floor.
.
On the floor, he continued to be globally aphasic but with
anti-gravity motor function in RUE and RLE. After family
discussions, it was decided to place a G-J tube for long term
feeding and medication administration. A repeat head CT showed
evolution of stroke, but without new areas of hemorrhage.
Neurology recommended starting anti-coagulation for atrial
fibrillation on [**2141-2-24**]. His atrial fibrillation was
well-controlled with metoprolol. Given his recent stroke, blood
pressure was tightly controlled with target systolics 100-140's.
On day prior to discharge, BP's were elevated to 140-170's and
lisinopril was started for better control. On [**2141-2-15**], patient
noted to have swelling of right upper extremity, an IV had been
placed in this location the previous day. An ultrasound showed
no evidence of blood clot and swelling was resolving. A family
discussion on [**2-16**] with Internal Medicine, Neurology, Social
work, Speech Therapy and Physical Therapy attending communicated
the overall very guarded prognosis with this patient with
limited life expectancy and unclear chances of any functional
recovery. He is not expected to recover speech function but may
recover some motor function if he is able to participate in
rehabiliation. He is discharged to rehab for continued
rehabilitation with hopes that his possibility of recovery will
become more apparent over the next several weeks.
Medications on Admission:
-Norvasc 10 daily
-Lasix 20 mg daily
-Prilosec 20 daily
-Ocuvite tablet [**Hospital1 **]
-Sorbitol daily
-Senna daily
-As needed acetaminophen, artificial tears, Dulcolax
Was previously on a statin, which was discontinued for
"polypharmacy."
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) Inhalation q2H PRN () as needed for wheezing.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-9**]
Drops Ophthalmic PRN (as needed).
9. Olanzapine 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day
as needed for agitation.
10. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO TID (3
times a day).
11. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Last Name (STitle) **]: Ten (10) mL (500mg) PO BID (2 times a day)
for 6 days: Until [**2141-2-22**].
14. Lisinopril 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
15. Morphine Sulfate 0.5 mg IV Q4H:PRN air hunger
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute MCA cardiovascular infarct
Aspiration pneumonia
Atrial fibrillation
Hypertension
Aortic stenosis
Discharge Condition:
Hemodyamically stable and afebrile. Guarded prognosis
Discharge Instructions:
You were admitted from [**Hospital 100**] rehab and found to have a stroke.
You were treated with an IV medication to break up the blood
clot that caused the stroke. You also had an episode of
difficulty breathing that was thought to be due to an aspiration
event. A feeding tube was placed for nutrition and medication.
Followup Instructions:
Please follow up as directed by your physicians at [**Hospital 100**] rehab.
Completed by:[**2141-2-17**]
|
[
"427.1",
"784.3",
"272.4",
"423.9",
"342.90",
"424.1",
"799.02",
"585.9",
"434.91",
"276.2",
"584.9",
"600.00",
"276.0",
"403.90",
"507.0",
"286.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"96.6",
"46.32"
] |
icd9pcs
|
[
[
[]
]
] |
13190, 13256
|
8534, 11230
|
305, 358
|
13403, 13459
|
3260, 3260
|
13829, 13937
|
1979, 2002
|
11523, 13167
|
13277, 13382
|
11256, 11500
|
13483, 13806
|
2017, 2453
|
1496, 1530
|
222, 267
|
386, 1477
|
2632, 3241
|
3276, 8511
|
2492, 2616
|
2477, 2477
|
1552, 1796
|
1812, 1963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,118
| 114,016
|
40685
|
Discharge summary
|
report
|
Admission Date: [**2126-5-16**] Discharge Date: [**2126-6-9**]
Date of Birth: [**2057-6-9**] Sex: M
Service: MEDICINE
Allergies:
Potassium Aminobenzoate / lisinopril
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure, "found down"
Major Surgical or Invasive Procedure:
Intubation
Central line placement
Tracheostomy
Interventional pulmonary cauderization of trachea site bleed
Bilateral pleural pigtail catheter placement
History of Present Illness:
68M with history of ETOH abuse, afib on coumadin who was
transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where he presented after
being being found down by a neighbor with altered mental status
and with blood at his oropharynx. On arrival to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital, he was hypothermic with rectal temp of 93. He was
given Octreotide and Protonix given concern for UGIB, 1 unit
pRBC, 2 FFP, Vit K, 1 pRBC, Zosyn for lung infiltrates on CT
chest and a banana bag. He was noted to have a CK of >3000 and
was transferred to [**Hospital1 18**] for futher care.
.
Upon arrival to [**Hospital1 18**] ED, vitals were T= 96.4 HR=97 BP= 93/69
RR= 24. On arrival here, he was continued on protonix and
octreotide gtts and vancomycin was added to his abx coverage. An
NG lavage was negative. Stool was brown and OB +. A bedside US
showed, GB sludge and he went for a RUQ which showed sludge but
not acute cholecystitis. He was started on IVF for rhabdo.
.
On arrival, he denies pain. History was limited as his mouth was
caked with dried blood. He states that he slipped and fell and
bit his lip and that is how the blood got in his mouth. He
denies hematemesis, melena or hematochezia. He also denies any
abdominal pain. He drinks 2-3 beers per day and [**1-31**] glasses of
wine (self reported, not confirmed). He states that his hands
have been purple in the past and that he has been told he has
Raynauds.
.
Review of systems:
(+) Per HPI
(-) Denies cough, shortness of breath. Denies chest pain. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
afib
? (Raynauds Disease)
Social History:
positive for ETOH as in HPI
Family History:
Noncontributory
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
***
Pertinent Results:
Admission labs:
===============
[**2126-5-16**] 12:10AM BLOOD WBC-21.1* RBC-3.49* Hgb-12.0* Hct-35.5*
MCV-102* MCH-34.3* MCHC-33.7 RDW-15.0 Plt Ct-270
[**2126-5-16**] 12:10AM BLOOD Neuts-95* Bands-1 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2126-5-16**] 12:10AM BLOOD PT-20.2* PTT-29.6 INR(PT)-1.8*
[**2126-5-16**] 12:10AM BLOOD Glucose-87 UreaN-21* Creat-0.7 Na-127*
K-4.8 Cl-87* HCO3-26 AnGap-19
[**2126-5-16**] 12:10AM BLOOD ALT-103* AST-300* CK(CPK)-2610*
AlkPhos-276* TotBili-3.5*
[**2126-5-16**] 12:10AM BLOOD Albumin-2.4* Calcium-7.4* Phos-5.6*
Mg-1.6
.
Discharge labs:
===============
.
Imaging:
========
[**5-16**] Liver u/s:
1. Fatty liver. Other forms of more serious liver disease such
as hepatic fibrosis/cirrhosis cannot be excluded on this study.
2. Gallbladder sludge, without acute cholecystitis.
.
[**5-16**] CXR: Right hilar enlargement should be further evaluated
with
conventional PA and lateral films, when feasible.
.
[**5-17**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
The ascending aorta is mildly dilated. The aortic valve is not
well seen. Aortic stenosis is present (likely minimal or mild
but not quantified). No aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
[**5-18**] LENI: Thrombosis of the right posterior tibialis vein (calf
vein).
.
[**5-20**] TTE: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated with borderline normal
free wall function. There is abnormal septal motion/position.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
[**5-23**] U/S:
1. Gallbladder sludge with slight wall thickening and slightly
decreased
distention. These findings are nonspecific in the setting low
albumin and
there is no definite evidence for cholecystitis. A HIDA should
be performed if clinical concern for cholecystitis warrants.
2. Prominent CBD, but no intrahepatic biliary ductal dilatation
and no change from [**5-15**].
3. Bilateral pleural effusions and trace ascites.
4. Echogenic liver which may be due to fatty infiltration,
although other
forms of liver disease such as cirrhosis or fibrosis are not
excluded.
.
[**5-24**] HIDA:
Normal study, specifically with no evidence of cholecystitis
.
[**5-25**] CXR:
An endotracheal tube, right subclavian central venous line, and
nasogastric tube are in unchanged position. There is no
pneumothorax. The cardiac silhouette is stably enlarged. There
is moderate pulmonary edema which is not significantly changed.
There is persistent retrocardiac opacity, as well as bibasilar
opacities, greater on the left, likely representing a
combination of pleural effusion, atelectasis and/or pneumonia.
Overall, the appearance is unchanged.
.
Brief Hospital Course:
68 yo found down who presented from OSH with elevated CK,
leukocytosis, bandemia, hypothermia, and hypotension. Pt also
with ecchymosis, impaired wound healing. Patient had extende
MICU course with respiratory failure, severe volume overload,
ventilator acquired pseudomonal pneumonia.
.
# Hypoxemic Respiratory Failure: Patient was intubated on [**5-17**].
Etiolgy of respiratory failure likely multifactorial - secondary
to aspiration pneumonia, pulmonary edema, and possible pulmonary
embolism (although this was not confirmed initially as patient
was not stable for CT scan). Patient was intubated and remained
intubated until [**6-3**] when a tracheostomy was placed. Patient
was treated with ARDS protocol with low tidal volumes and high
PEEP. Patient was treated initially for aspiration pneumonia
with unasyn and then pseudomonal ventilator acquired pneumonia
with cefepime.
Several days in to admission patient was +26L - severe volume
overload felt to be contributing to symptoms. Patient was
diuresed with lasix gtt which was supplemented with diuril,
metolazone, and acetolazomide. Diuresis was difficult because
of potassium wasting and metabolic alkalosis, as well as
hypotension. He was treated for his aspiration pneumonia with
cefepime. Sputum cultures grew two strains of pseudomonas and
klebsiella. Blood cultures grew pseudomonas sensitive to
meropenem, so he was switched to meropenem for total 14 day
course, Day 1 = [**5-30**]. On [**5-28**], he self extubated himself;
however, needed to be reintubated later that evening for severe
hypoxia. [**6-3**] a tracheostomy and PEG tube were placed
Sputum cultures from [**6-7**] grew a new strain of pseudomonas, now
resistant to meropenem and susceptable to ciprofloxacin. ID was
reconsulted and recommended that the full 14 course of meropenem
be completed on [**6-13**], while starting a 7 day course of
ciprofloxacin, Day 1 = Evening of [**6-9**].
.
Work should continue towards weaning off the ventilator to a
trach mask as tolerated while at rehab.
#Plural Effusions. Patient had repeated accumulation of
pulmonary effusions. [**6-3**] a pig-tail was placed in the right
lung. [**6-8**] a pig tail was placed on the left. Both sides were
draining significant amounts of fluid (600cc to 1 liter daily)
at the time of discharge. They were in place, and when they
drain less that 200 cc per day, they can be removed. These chest
tubes are draining on water seal. These can be removed in
Rehabilitation Facilty and he should not require change in his
anticoagulation, or an appointment can be made with [**Hospital1 18**]
Interventional Pulmonology service for chest tube removal.
#Hemoptysis. On [**6-4**], following tracheotomy tube placement,
patient began to have bloody ET tube secretions. Persistent
submassive hemoptysis prompted evaluation by Interventional
Pulmonology service, and required OR procedure to cauderize an
area of bleeding at the trach tube site. After this procedure
on [**6-8**], bloody secretions cecreased substantially.
.
# Pulmonary emboli: On admission, lower extremity ultrasound
showed R posterior tibial DVT. In the setting of refractory
hypotension, a CTA chest was done [**5-30**] showing bilateral
segmental and subsegmental pulmonary emboli without evidence for
right heart strain. The patient was started on a heparin IV
continuous infusion. He was started on warfarin; however, due to
blood clot around trach site, this was held. Coumadin should be
restarted at the rehab facility and patient will be continued on
heparin gtt until INR > 2 for 24 hours.
.
# Hypotension: Patient with likely low blood pressures at
baseline (may have underlying cirrhosis). Patient required
pressors to maintain blood pressure following intubation. Likely
multifactorial in setting of sepsis, as patient with pneumonia
versus cardiogenic shock. No evidence of ACS. He required
maximum doses of 4 pressors shortly after intubation which were
weaned down over time. TTE was done and did not [**Location (un) 381**] EF.
During admission patient had blackening of finger tips on right
side associated with neo use. Vascular surgery was consulted and
recommended stopping neo. Patient's blood pressure was
maintained with dopamine. Patient was treated for pneumonia and
with a heparin gtt for possible PE. Patient remained dependent
on pressors, which were switched to vasopressin and
phenylephrine by [**5-30**]. Pressors were stopped [**5-31**] and the patient
was able to maintain his blood pressures.
.
# Volume overload: Patient with anasarca on exam, pulmonary
edema on CXR. Patient was diuresed with heparin gtt, diuril,
metolazone, and acetazolamdie. Diuresis was difficult because
of persistent hypokalemia and metabolic alkalosis. At the time
of discharge, lasix dose was 60 mg IV once a day, and can be
uptitrated as needed. Patient also has element of extreme
hypoalbuminemia, with a recent albumin of 1.4. Patient's
nutritional status will hopefully improve with tube feeds.
.
# Thrombocytopenia / coagulopathy: Patient had thrombocytopenia
and elevation of INR. It was likely secondary to sepsis.
Work-up for HIT and DIC was negative. Coags improved throughout
admission and DIC work-up unrevealing. Likely in setting of
liver disease and malnutrition (albumin 1.4) and infection.
.
# Metabolic alkalosis: Patient with pH elevations > 7.55 in the
setting of diuresis. Improved with KCl and acetazolamide.
.
# Atrial fibrillation with RVR: Patient with hx of a fib on
Coumadin. Patient with atrial fibrillation with RVR during ICU
course. Was loaded with IV amiodarone while on levophed. When
levophed was weaned patient was restarted on home dose of
sotalol. His EKG's were monitored after each of the first 4
sotalol doses, with his QTC remaining under 500. Patient was
anticoagulated on heparin gtt and will be transitioned to
coumadin as above.
.
# Transaminitis: Persistently elevated throughout admission.
Patient had RUQ ultrasound that showed fatty liver, could not
exclude cirrhosis. Patient's alk phos was more elevated during
admission and he underwent repeat RUQ ultrasound that did not
show stone. Patient had normal HIDA.
.
# Altered Mental Status: Patient's initial presentation was
likely due to ingestion vs aspiraton pneumonia prior to
admission. Patient reportedly had similar episodes prior of
being "found down" in setting of EtOH use. Has now resolved,
patient responsive, following commands, awake, and alert. He
does have intermittent bouts of agitation and hallucination. He
was started on seroquel 25 mg qhs for sleep-wake cycle
normalization.
Medications on Admission:
lasix 40 daily
diltiazem 240 daily
digoxin 0.125 daily
coumadin
sotalol 80 [**Hospital1 **]
lorazepam 0.5mg HS prn
omeprazole 40 daily
celexa 20 daily
norco (10/325) tid prn
ms contin 30mg [**Hospital1 **]
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral
Solution Sig: 1000-1500 units Intravenous Per sliding scale:
check PTT per facility protocol, titrate to goal PTT 60-80.
Continue until INR >2 for >24 hours.
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
11. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for PAIN.
12. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
13. meropenem 1 gram Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours: LAST DAY = THROUGH [**6-13**].
14. furosemide Sig: Sixty (60) mg Intravenous once a day.
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Pt
call, INR should be titrated to between [**1-31**].
16. Outpatient Lab Work
Please check INR Q72 hous and titrate warfarin dose to goal INR
[**1-31**]
17. Outpatient Lab Work
Please check chem 7 twice weekly and replete lytes as needed
18. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days: Please continue until [**2126-6-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Ventilator-associated, pseudomonal pneumonia
Recurrent pleural effusions
Respiratory failure
Sepsis
Bilateral Subsegmental Pulmonary emboli
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted after being found unresponsive. You were
extremely sick, requiring high-level intensive care unit care.
You required long-term ventilatory support, so a tracheostomy
and PEG tube were placed. You had fluid accumulating in your
lungs, so drains were placed that continue to drain fluid. You
are going to a rehabilitation facility that is comprehensive
enough to care for you. At the time of discharge, you remained
delirious. Your mental status will hopefully improve over the
coming weeks.
.
We made the following changes to your medications:
- STOPPED PO Lasix
- STARTED Famotidine
- STOPPED Omeprazole
- STOPPED Diltiazem
- STOPPED MS Contin
- STARTED Quetiapine
- STOPPED Hydrocodone-Acetaminophen
- STOPPED Lorazepam
- STARTED Miconazole powder
- STARTED Docusate
- STARTED Aspirin
- STARTED Oxycodone liquid
- STARTED Meropenem
- STARTED IV Lasix 60 mg once a day
- STARTED IV heparin drip
Followup Instructions:
Test for consideration post-discharge: Modified Acid-Fast stain
for Nocardia
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"785.52",
"286.7",
"728.88",
"263.9",
"348.31",
"276.0",
"511.9",
"507.0",
"305.01",
"287.5",
"V58.61",
"041.3",
"995.92",
"041.7",
"V02.59",
"733.13",
"997.31",
"276.3",
"427.31",
"276.8",
"514",
"873.64",
"518.81",
"E888.9",
"038.9",
"276.69",
"573.9",
"E879.8",
"453.42",
"998.11",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.04",
"33.21",
"33.24",
"31.1",
"96.72",
"96.6",
"34.04",
"34.91",
"31.5"
] |
icd9pcs
|
[
[
[]
]
] |
14850, 14950
|
6223, 12404
|
329, 484
|
15134, 15134
|
2915, 2915
|
16206, 16412
|
2365, 2382
|
13087, 14827
|
14971, 15113
|
12856, 13064
|
15268, 15800
|
3510, 6200
|
2397, 2397
|
2891, 2896
|
15829, 16183
|
2028, 2255
|
256, 291
|
512, 2009
|
2931, 3494
|
2411, 2877
|
15149, 15244
|
2277, 2304
|
2320, 2349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,077
| 123,493
|
28044
|
Discharge summary
|
report
|
Admission Date: [**2185-8-28**] Discharge Date: [**2185-9-3**]
Date of Birth: [**2130-5-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
57 yo s/p fall with c1 fracture and concussion.
Major Surgical or Invasive Procedure:
None on this admission.
History of Present Illness:
55yo male s/p fall down stairs. +LOC, +ETOH.
Past Medical History:
depression, anxiety disorder
Physical Exam:
Confused, in pain
NC/AT PERRLA EMOI
TTP neck
RRR
CTA B
S/NT/ND
Warm no edema
Pertinent Results:
[**2185-8-28**] 05:00AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2185-8-28**] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2185-8-28**] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2185-8-28**] 05:00AM PT-13.5* PTT-24.1 INR(PT)-1.2*
[**2185-8-28**] 05:00AM WBC-15.1* RBC-3.96* HGB-13.7* HCT-38.7*
MCV-98 MCH-34.6* MCHC-35.4* RDW-12.8
[**2185-8-28**] 05:00AM PLT COUNT-195
[**2185-8-28**] 05:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-8-28**] 05:17AM GLUCOSE-106* LACTATE-2.9* NA+-140 K+-6.3*
CL--102 TCO2-23
[**2185-8-28**] 05:00AM AMYLASE-86
Brief Hospital Course:
55yo male s/p fall down stairs. +LOC, +ETOH.
Admittted to ICU. Doing well HD#2 AAOx3. Ready from a medical
stand point for D/C. HD3 PM became disoriented. Received 100
mg Haldol and 20 mg Ativan. Pt agitated and keept trying to
remove his collar. Psyche at bedside. HD#5 AAOX2 transfer to
floor. Metabolic w/u negative for cause of psychosis. Did well
on floor stopped requiring a sitter and cleared by PT and OT to
go home with family supervision.
Medications on Admission:
Trazadone, Xanax, Effexor
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**11-29**]
Tablets PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
C1 fracture and occipital fracture.
Discharge Condition:
Good.
Discharge Instructions:
****You must wear your c-collar AT ALL TIMES for the next 12
weeks.*****
.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please arrange a follow-up appointment with Dr [**Last Name (STitle) 548**]. You must
call ([**Telephone/Fax (1) 88**]. One appointment must be arranged for [**3-3**]
weeks, at which time you must get plain films (AP and lateral)
of the C-spine. The second appointment is in 12 weeks, at which
time you will need a CT of your c-spine with reconstruction.
Please let the secretary know of these films when you call to
make an appointment. ***You must wear your c-collar AT ALL TIMES
for the next 12 weeks.***
Completed by:[**2185-9-3**]
|
[
"311",
"305.00",
"805.01",
"V45.3",
"293.0",
"E880.9",
"716.90",
"801.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2234, 2253
|
1375, 1834
|
361, 387
|
2333, 2341
|
627, 1352
|
3382, 3920
|
1910, 2211
|
2274, 2312
|
1860, 1887
|
2365, 3359
|
530, 608
|
274, 323
|
415, 462
|
485, 515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,194
| 115,597
|
33992
|
Discharge summary
|
report
|
Admission Date: [**2115-5-1**] Discharge Date: [**2115-5-17**]
Date of Birth: [**2066-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Neck, jaw and chest pain
Major Surgical or Invasive Procedure:
[**5-1**] Ascending Aorta and Hemiarch Replacement with 28mm Gelweave
Graft, Resuspension of Aortic Valve
History of Present Illness:
48 y/o male who presented to OSH c/o left-sided neck and jaw
pain, along with chest pain. Underwent a CTA which showed a Type
A ascending aortic dissection. Was then transferred to [**Hospital1 18**] for
surgical management.
Past Medical History:
Hypertension, Hemorrhoids, Ankylosing Spondylitis, Subarachnoid
Hemrrhage (Rupture of cerebral aneurysm) s/p Craniotomy and
clipping with VP shunt, Occasional Migraines, Hydrocephalus,
Right Renal Cell Carcinoma
Social History:
Denies tobacco or ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 66 20 85/40 6'2" 163.5#
Gen: NAD
Skin: Unremarkable
HEENT: EOMI, PERRL
Neck: Supple, FROM, shunt noted right neck
Chest: CTAB
Heart: RRR
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, decreased pulse rt. arm
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**5-1**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the
left atrial appendage. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is markedly dilated
There are three aortic valve leaflets. Moderate (2+) aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion. A large aneurysm of the ascending aorta
is present with a dissection flap and entry point visible just
above the STJ. The STJ is effaced. Epi-aortic done to view arch.
Wire introduced into right femoral artery seen in descending
aorta.
Post- Bypass: Patient is not paced, on norepinephrine infusion.
Procedure was an ascending aorta replacement and hemi-arch. Good
biventricular systolic fxn. Trace MR. AI is now 1 - 2+.
Descending aorta is intact.
[**5-2**] CTA of Head/Neck: 1. Unchanged CT of the head with no acute
intracranial process demonstrated. 2. Density abutting the
brachiocephalic artery represents either a false luminal
thrombosis or postoperative hematoma compressing the vessel,
although the vessel distal to this is patent and opacified.
[**5-2**] EEG: This is an abnormal portable EEG due to dimunition of
voltages broadly over the right side suggestive either of a
structural or destructive process of the cortical and
subcortical structures on the right versus material interposed
between the skull and cortex on the right side. In addition,
there were intermittent bursts of mixed frequency slowing noted
in the left anterior quadrant suggestive of an underlying area
of subcortical dysfunction in that region as well. Transient
sharp discharges were noted in the right frontal region but
appeared most likely artifactual in nature given their narrow
morphology and atypical field. On video, there was no clinical
correlate for these. The background was disorganized and
consisted mainly of a low voltage fast activity which may
reflect medication effects from concomitant benzodiazepine
administration. If clinically warranted, consideration could be
given for a period of extended monitoring to further
characterize the abnormalities noted above.
[**5-6**] MRA of Head/Neack: 1) Multiple tiny scattered infarcts in
both cerebral hemispheres, suggesting a central source of
emboli. 2) Patent major intracranial arteries. 3) Very limited
but grossly normal MRA of the neck, which excludes the origins
of the carotid and vertebral arteries. [**5-7**] Abd X-ray: Single
supine radiograph, which is limited by motion is presented for
review. Upper abdomen is excluded from the field of view. Air
and stool are present throughout the colon. Small bowel is not
dilated. The liver appears to be enlarged. The evaluation for
free intraperitoneal air is limited by technique, however, there
is no supine evidence of free air.
[**5-10**] CT of Spine: Alignment is within normal limits. No fracture
is demonstrated. Multilevel degenerative changes are seen. There
has been a recent median sternotomy.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 13551**] was transferred from OSH with
a Type A Aortic Dissection. He was emergently taken to the
operating room where he underwent an Ascending Aorta and
Hemiarch Replacement with Aortic Valve Resuspension. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Later that night he was weaned from sedation and he
was noted to have no left arm movement and onset of rhythmic
movement of the right arm (epilepsia partialis continue per
neuro). Neurology and Stroke service were consulted on the
morning of post-op day one. He was started on Dilantin with
continuous EEG monitoring. CT of the head was negative for
stroke. Both services continued to follow pt. throughout
hospital course. He required post-op [**Known lastname **] transfusions for low
HCT. He remained intubated over the next several days d/t lack
of purposeful movements and not following commands. Chest tubes
and epicardial pacing wires were removed per protocol. On
post-op day five he underwent a head MRA which revealed multiple
tiny scattered infarcts in both cerebral hemispheres, suggesting
a central source of emboli. On post-op day six he was again
weaned from sedation. Neurologically he was more alert and
following commands with weaker right side along with tremors. He
was then successfully extubated without incident. On post-op day
seven he appeared stable and was transferred to the telemetry
floor for further medical care. In the morning of post-op day
eight he was found unresponsive and hypotensive (BP 50/30's w/
HR in 60's). This episode was felt related to hypotension d/t
pt. recently receiving increased dose of beta blocker. Received
appropriate treatment with increase in responsiveness and was
transferred to the CVICU for closer monitoring. He was
eventually found to be septic and was started on antibiotics. On
post-op day nine he underwent CT of spine to evaluate for
vertebral fracture d/t his h/o ankylosing spondylitis and
current extremity weakness. Study was negative for fracture
which reassured weakness not d/t cord compromise. Over the next
several days patient became increasingly confused and
delusional. He required a patient observer and was appropriately
treated with Haldol, along with psychiatry consult. On post-op
day twelve he was transferred back to the telemetry floor for
further care. His haldol was weaned. By post-op day 16 he was
ready to be transferred to rehab.
Medications on Admission:
Lisinopril , Iron, Percocet prn, Fentanyl patch
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
2. LeVETiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
bag Intravenous Q 12H (Every 12 Hours).
Disp:*60 bag* Refills:*0*
12. Outpatient Lab Work
weekly CBC/diff, BUN/cre, ESR, CRP, and vancomycin trough faxed
to [**Doctor First Name **] at infectious diseases ([**Telephone/Fax (1) 16411**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Type A Aortic Dissection s/p Ascending Aorta and Hemiarch
Replacement
Post-op Seizures
PMH: Hypertension, Hemorrhoids, Ankylosing Spondylitis,
Subarachnoid Hemrrhage (Rupture of cerebral aneurysm) s/p
Craniotomy and clipping with VP shunt, Occasional Migraines,
Hydrocephalus, Right Renal Cell Carcinoma
Discharge Condition:
stable/good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 78487**] in 2 weeks.
Cardiologist in 2 weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (infectious diseases) in [**1-2**] weeks. Call
([**Telephone/Fax (1) 6732**] to make an appointment. Fax weekly CBC/diff,
BUN/cre, ESR, CRP and vacomycin trough to [**Doctor First Name **] at Infectious
Diseases ([**Telephone/Fax (1) 16411**].
Obtain CTA of chest in 2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2115-5-17**]
|
[
"345.70",
"424.1",
"790.7",
"E942.6",
"293.0",
"997.02",
"285.9",
"441.01",
"720.0",
"401.9",
"V45.2",
"458.29",
"997.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"01.02",
"38.45",
"89.60",
"39.61",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8334, 8479
|
4237, 6766
|
301, 408
|
8826, 8839
|
1254, 4214
|
9174, 9759
|
958, 976
|
6864, 8311
|
8500, 8805
|
6792, 6841
|
8863, 9151
|
991, 1235
|
237, 263
|
436, 662
|
684, 897
|
913, 942
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,442
| 125,815
|
23662
|
Discharge summary
|
report
|
Admission Date: [**2121-4-30**] Discharge Date: [**2121-5-6**]
Date of Birth: [**2082-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
38 y/o female w/ worsining SOB requiring trach tube s/p
prolonged intubation s/p burn/trauma [**Date range (1) 60506**].
Referral from [**Location (un) 36413**] [**State 2690**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 60507**]
resection and reconstruction
Major Surgical or Invasive Procedure:
s/p [**Last Name (Titles) 60507**] resection & primary reconstruction [**4-30**]
Past Medical History:
suicide attempt -> burn (38% BSA) [**2-4**], s/p skin grafts,w/
intubation of 45 days, s/p trach for [**Month/Year (2) 60507**] stenosis, s/p CCY,
s/p L hand tendon release ([**4-15**])
Social History:
Lives w/ husband and 3 children ( age 21, 19 and 8 months) in
[**Location (un) **] [**State 2690**].
Marriage counsoling and psychiatric care provided s/p suicide
attempt.
Physical Exam:
General- healthy appearing female in running suit, sitting in
NAD w/ tracheostomy in place.
HEENT- PERRLA, ears, wnl-good light reflex, pharynx w/o erythema
or exudate
Neck- trach tube in place #4, no adenopathy, skin graft present.
Mobility-good flexion extension.
Resp- Clear bilat
CV- RRR, no R. M, G
ABD- + BS, NT, ND.
EXT-LE , no edema, UE as below
Mus/ Skel- L hand- in ace wrap- recent tendon release of L 5th
digit.
Skin- graft sites at torso and neck, graft source sites at upper
thighs. Grafts intact. No erythema, or drainage. Burn scar site
at hands and UE bilat.
Brief Hospital Course:
38 y/o female admitted SDA [**4-30**] for [**Month/Year (2) 60507**] resection and
primary reconstruction on [**2121-4-30**].
Intraoperative course uncomplicated, pt estubated in OR and
transferred to TSICU in stable condition
POD#1- Stable overnight, w/o respiratory distress, pain control
w/ morphine PCA.
Incision dsg D&I, guardian stitch form chin to chest intact. Pt
OOB to chair w/o event. Pt transferred to floor in afternoon.
Activity precautions taken for limited neck movement.
POD#2- Stable overnight, afebrile. Some c/o itching on morphine,
resolved w/ benedryl. Advancing activity w/ neck movement
precaution, guardian stitch in place, dsg D&I.
POD#[**4-5**] progressing well. Guardian stitch removed on POD#4.
POD#5 every other staple removed. Pt bronched and d/c'd to hotel
w/ transition to home in [**State 2690**] after f/u on thursday [**2121-5-8**] w/
Dr. [**Last Name (STitle) **] and bronch on monday [**2121-5-12**].
Medications on Admission:
ciprofloxacin for total 10 day course
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
2. Docusate Sodium 60 mg/15 mL Syrup Sig: 15ml ml PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
-> burn (38% BSA) [**2-4**], s/p skin grafts, s/p trach, s/p CCY, s/p
L hand tendon release ([**4-15**])
Discharge Condition:
good
Discharge Instructions:
Take all medications as prior to hospitalization.
Do not drive while taking percocet for pain.
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience fever,
chills, shortness of breath, chest pain, difficulty swallowing,
or productive cough.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Thursday [**2121-5-8**] at
10:30 am in [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**], [**Hospital1 18**]- [**Hospital Ward Name **]. 45 minutes before Dr.[**Doctor Last Name 4738**] appointment-- go to
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **] RADIOLOGY Dept, for Chest
XRAY.
You have a follow up appointment for a bronchoscopy in the
Interventional Pulmonology suite on [**Hospital Ward Name **] 2 [**Hospital Ward Name **] on Monday
[**2121-5-12**]-please call for time [**Telephone/Fax (1) 170**]
Completed by:[**2121-6-23**]
|
[
"070.70",
"519.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
"33.22",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
3008, 3014
|
1755, 2695
|
659, 742
|
3163, 3169
|
3494, 4134
|
2783, 2985
|
3035, 3142
|
2721, 2760
|
3193, 3471
|
1155, 1732
|
281, 621
|
764, 951
|
967, 1140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,492
| 118,470
|
48516
|
Discharge summary
|
report
|
Admission Date: [**2117-6-26**] Discharge Date: [**2117-7-30**]
Date of Birth: [**2038-9-24**] Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Declining mental status
Major Surgical or Invasive Procedure:
PICC line placement *2
Arterial Line placement
Dialysis Catheter Placement-Tunneled Line *2 and Temporary
Catheter *1
Central Venous Line Placement
Bronchoscopy
History of Present Illness:
78 year old woman with history of multiple medical problems
including type 2 diabetes mellitus, hypertension, obstructive
sleep apnea s/p trach placement, and breast cancer being
transferred from [**Hospital 100**] Rehab MACU for further evaluation. For
the past 3 weeks, she has been progressively weak, somnalent,
and hypercapnic. She had orginally ventilated just overnight,
but has been on 24 hour ventillation for these 3 weeks. She
continues to have CHF on CXRs.
At [**Hospital 100**] Rehab, she was noted to have progressive delerium. She
was reportedly independent in the months prior to admission, but
now is persistantly somnilent arousing to minimal stimili.
She has had a persistant c-diff infection requireing a rectal
tube, and from which she has developed malnutrition with
albumins in the 1.5-2 range. She was initially on TPN, but later
had an NG placed. She is now on elemental feeds, with a plateau
in her albumin. She has been found to be anasarcic [**1-25**]
malnutrition with skin breakdown.
She also developed progressive renal failure, with a creatine
rising to mid 2s.
Paliatitive care has been involved at HebReb, but her sister
[**Name (NI) 102110**], who is HCP, continues to want everything done. She
requested that her sister be transferred to the hospital to see
if there's anything else that can be done for her.
Currently she is minimally responsive.
Review of systems: unable to obtain.
Past Medical History:
1. Hypertension
2. Diabetes Mellitus
3. Breast Cancer
- Infiltrating ductal carcinoma
4. Obstructive Sleep Apnea
- s/p tracheostomy [**2089**]
5. Osteoarthritis
6. s/p multiple falls
7. Congestive Heart Failure
8. Atrial Flutter
9. Atrial Septal Defect
10. Mitral Regurgitation
11. Cor Pulmonale
12. s/p Stroke
13. Obesity
14. Spinal Stenosis
15. Lower GI bleed
Social History:
Normally lives at home, but has been at rehab since last
hospitalization. Denies alcohol, drug or current tobacco use.
Per her sister, she is a former smoker, but unclear what her
pack year smoking history is.
Family History:
Diabetes mellitus.
Physical Exam:
Exam on Admission:
Vitals: T 97.1 HR: 80 BP: 109/63 Sat 97 on AC 450/12/45/5
Gen: anasarcic, somnilent, understands that she is at [**Hospital1 18**]
HEENT: trach in place
CV: RR, NL rate. quiet heart sounds.
LUNGS: intubated, bilateral anterior breath sounds
ABD: Obese, distended, tender to palpation.
EXT: No edema. 2+ DP pulses BL
SKIN: palm breakdown, decubetous ulcers on back
NEURO: minimal response to stimuli, twitching of her foot.
Exam on Discharge:
Vitals: T: 97.1 HR: BP: 117/48 rr: 19 sP02: 94% on CPAP,
pressure support: [**11-30**].
Gen: Anasarcic, alert, able to mouth responses to questions.
HEENT: trach in place
CV: RR, NL rate. quiet heart sounds.
LUNGS: intubated, coarse bilateral anterior breath sounds
ABD: Obese, distended, non tender to palpitation, bowel sounds.
EXT: No edema. 2+ DP pulses BL
NEURO: responds to stimuli, moves all extremities.
Pertinent Results:
Labs on Admission: [**2117-6-26**]
WBC-9.2 RBC-2.86* Hgb-8.0* Hct-26.7* MCV-93 RDW-18.7* Plt Ct-239
Neuts-85.3* Bands-0 Lymphs-11.0* Monos-3.3 Eos-0.2 Baso-0.1
PT-17.9* PTT-33.7 INR(PT)-1.6*
Glucose-134* UreaN-85* Creat-1.9* Na-145 K-5.1 Cl-105 HCO3-32
AnGap-13
ALT-32 AST-66* LD(LDH)-274* AlkPhos-114 TotBili-0.2
proBNP-[**Numeric Identifier **]*
TotProt-5.8* Albumin-2.4* Globuln-3.4
Lactate-1.1
Type-ART Rates-[**11-24**] Tidal V-450 PEEP-5 FiO2-50 pO2-67* pCO2-59*
pH-7.35 calTCO2-34* Base XS-4
Other Labs:
[**2117-7-10**] WBC-18.0* RBC-2.35* Hgb-6.9* Hct-22.4* MCV-95 RDW-23.1*
Plt Ct-221
[**2117-6-27**] 06:57PM BLOOD CK-MB-10 MB Indx-8.8* cTropnT-0.62*
[**2117-6-28**] 03:45AM BLOOD CK-MB-NotDone cTropnT-0.61*
[**2117-6-28**] 11:47AM BLOOD CK-MB-NotDone cTropnT-0.76*
[**2117-7-1**] calTIBC-191* Ferritn-178* TRF-147*
[**2117-7-9**] Hapto-<20*
[**2117-6-26**] TSH-2.6
[**2117-7-21**] Cortsol-23.0*
Labs on Discharge:
[**2117-7-30**] 03:16AM BLOOD WBC-9.8 RBC-3.01* Hgb-8.8* Hct-29.5*
MCV-98 MCH-29.2 MCHC-29.8* RDW-18.4* Plt Ct-230
[**2117-7-30**] 03:16AM BLOOD PT-15.2* PTT-32.3 INR(PT)-1.3*
[**2117-7-30**] 03:16AM BLOOD Glucose-121* UreaN-16 Creat-2.0* Na-138
K-4.1 Cl-101 HCO3-30 AnGap-11
[**2117-7-30**] 03:16AM BLOOD ALT-19 AST-28 LD(LDH)-325* AlkPhos-109
TotBili-0.7
[**2117-7-30**] 03:16AM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.3* Mg-1.7
[**2117-7-30**] 03:40AM BLOOD Type-ART pO2-68* pCO2-54* pH-7.38
calTCO2-33* Base XS-4
_________________________________________________________
CITROBACTER KOSERI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
PIPERACILLIN---------- 16 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2117-6-26**] Endotracheal sputum culture
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S <=1 S
CEFTAZIDIME----------- 2 S 2 S
CIPROFLOXACIN---------<=0.25 S 0.5 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
[**2117-7-14**]: Joint aspirate: FLUID CULTURE (Final [**2117-7-17**]): NO
GROWTH.
Urine culture [**2117-7-24**], [**2117-7-21**], [**2117-7-4**], [**2117-7-5**], [**2117-7-6**]
[**2117-7-8**]
[**2117-7-20**]: colonization with alpha streptoccocus and
lactobacillus.
[**2117-7-30**]: MRSA screen: No MRSA isolated.
Blood cultures on [**2117-6-26**], [**2117-7-4**], [**2117-7-5**], [**2117-7-6**], [**2117-7-8**],
[**2117-7-10**]: no growth
Blood cultures: [**2117-7-18**], [**2117-7-21**], [**2117-7-23**]: no growth
Respiratory culture ([**2117-7-24**]): no growth, fungal culture:
preliminarily no fungus.
Sputum cultures: [**2117-6-26**], [**2117-6-29**], [**2117-7-4**], [**2117-7-8**], [**2117-7-8**],
[**2117-7-13**],: contamination with oral secretions only.
Other Studies:
[**2117-6-26**] EKG: Sinus rhythm. Prolonged P-R interval. Right-bundle
branch block. Non-specific repolarization abnormalities.
Generalized low voltage.
Compared to the previous tracing of [**2117-4-16**] voltage has
decreased and
P-R interval has prolonged somewhat.
[**2117-6-26**] CXR: Tracheostomy is present in the midline. Orogastric
tube courses below the diaphragm, but the tip is not seen. Heart
is massively enlarged. Mediastinum is prominent. Central
pulmonary vasculature is also prominent consistent with mild
congestive failure. There are small bilateral pleural effusions
as well as bibasilar atelectasis. There is very little change in
the appearance of the chest since the prior study.
[**2117-7-22**] CT chest/abd/pelvis w/: 1. Left lower lobe atelectasis.
2. Cardiomegaly. 3. Right adrenal nodule not meeting CT criteria
for adenoma. MRI would be useful to further characterize. 4.
Anterior wall hernia without bowel strangulation. 5.
Diverticulosis without evidence of diverticulitis. 6. Distended
gallbladder, stable from prior exam.
7. No discrete masses, fluid collections, or evidence of abscess
formation.
[**2117-7-21**] Echo: Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated with mild global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. There is
abnormal septal motion/position. 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. The tricuspid valve leaflets are
mildly thickened. The tricuspid valve leaflets fail to fully
coapt. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
[**2117-7-14**] L wrist x-ray: Possible non-displaced fracture of distal
radius.
[**2117-6-26**] CT head: No acute intracranial pathological process.
Stable chronic
changes from prior infarcts. Small hyperdensity is seen anterior
to the left side of the pons may represent a small meningioma
and is unchanged since [**2117-3-24**].
Brief Hospital Course:
78 year old female with multiple medical problems including
obstructive sleep apnea requiring tracheostomy, diastolic
congestive heart failure, atrial fibrillation, chronic
clostridium difficile infection presents from LTAC with
worsening mental status and failure to improve.
ALTERED MENTAL STATUS: Progressive worsening mental status has
been a slow process and likely related to infection. Neuro exam
was non-focal, but CT was performed that showed no acute
process. Urine from [**2117-6-26**] was positive for Citrobacter and
Klebsiella. She was treated with a course of ciprofloxacin for
UTI. From [**Date range (1) 58392**] patient's mental status was briefly much
improved so that she could remember events, and indicate that
she was not in pain. Patient status waxed and waned over
subsequent days with a disturbed sleep/wake cycle suggest
underlying delirium liked related to prolonged hospitalization
and ventilator dependence.
RESPIRATORY FAILURE: Patient with severe obstructive apnea and
obesity hypoventilation. She has been tracheostomy dependent
since [**2087**]. Respiratory failure was felt to be due to anasarca
and volume overload from diastolic failure complicated by known
pulmonary hypertension. Patient was 100+ lbs above her dry
weight; CVVH was initiated after minimal diuresis effect of
lasix gtt and zaroxyln. The patient had hypotension on CVVH and
various pressors were needed to continue to remove volume.
Eventually CVVH was stopped after removing around 70kg from the
patient. She did well on this CVVH holiday and was able to be
trach masked. The patient tired on trach mask and needed to be
placed back on ventilator. Patient, as below, was transitioned
to HD. She will continue to work on ventilator weaning at
[**Hospital1 **].
ACUTE BLOOD LOSS ANEMIA and ANEMIA OF CHRONIC DISEASE: The
patient has had several sites of minor bleeding, including her
trach site, vagina, and GI tract. A bronchoscopy was done and no
active bleeding was noticed. A CT of the neck was done and it
ruled out erosion of the innominate artery. It was also felt
that her nutritional status, longstanding chronic illnesses and
need for frequent phlebotomy was the reason for her persistently
low hematocrit. She recieved at total of 10 units of packed red
blood cells during her month long stay in the hospital. We
monitored her hematocrit. She will continue to need her
hematocrit monitored with a goal hematocrit of greater than 27.
LEUKOCYTOSIS/INFECTION: The patient's urinary tract infection
was treated with ciprofloxacin. The patient has a history of
Pseudomonas in her sputum, so she was not started on any
antibiotics for her [**6-26**], [**6-29**] sputums given the low suspicion for
pneumonia at the time her culture was postive. She was treated
with PO vanc for any recurrence of clostridium difficile
throughout her hospital stay. She will continue on PO vanc for
14 days after her last dose of any other antibiotics. On [**2117-7-21**]
when she became hypotensive she was pan cultured and started on
Vanc, Cefepime, Cipro, Micafungin. When the only positive
culture were urine cultures persitently growing yeast ([**Female First Name (un) **]
albicans), her vancomycin, cefepime and ciprofloxacin were
discontinued. Patient was treated with a 8 day course of
micafungin.
CLOSTRIDIUM DIFFICILE INFECTION: Patient has had severe
malnutrition from longstanding clostridium difficile infection
that has perisisted despite PO Vancomycin. ID was consulted for
recurrent clostridium difficile. They recommended 14 days of PO
vanc after her last dose of antibiotics. She was clostridium
difficile negative during her MICU stay. On discharge she was on
day [**5-6**] of her PO vancomycin course.
DIASTOLIC HEART FAILURE: Volume overloaded on admission and was
continued on CVVH as needed until patient is stable enough to
tolerate HD.
HYPOTENSION: The patient was initially on levophed and dopamine
but had significant ectopy so was switched to neosynephrine to
maintain MAPS >60. When her CVVH was stopped, she was able to
weanned off her pressors. However, on [**2117-7-21**] when she had
hypotension neosynephrine was temporarily restarted. She was
quickly weaned off, but had another episode of hypotension on
[**2117-7-23**] and pressures were restarted. She was weaned off as of
am [**7-24**].
ACUTE ON CHRONIC RENAL FAILURE: Creatinine on admission 1.9. Was
1.1-2.2 since [**Month (only) 547**], prior had been around 1.3. Patient was on
CVVH with and without pressors during her hospital course. It
was felt that she developed ATN during several repeat episodes
of hypotension resulting in likely long term need for
hemodialysis. However, On [**2117-7-21**] the patient became
hypothermic, hypotensive and pressors were restarted. Patient
was treated empirically with antibiotics, but no pathogen was
found other than yeast in her urine. She was started on
midodrine and treated with micafungin. CVVH was restarted once
her pressures stabalized. She had a tunneled line placed on
[**2117-7-26**]. Patient was then transitioned to HD and tolerated it
well without a need for pressors. Patient will continue with HD
at [**Hospital1 **]. It is felt that she will not recover enough renal
function to be able to stop hemodialysis.
H/O BREAST CANCER: Was on arimidex, but this was held [**1-25**]
medication effect with ischemic heart disease.
Type 2 Diabetes Mellitus: Patient was treated with standing and
sliding scale insulin with good blood glucose control.
GERD: Stable on H2 blocker.
Hyperlipidemia: Stable on simvastatin
Stage II sacral decubitus: Patient was treated according to
wound consult and the ulcer was healed.
The patient was FULL CODE during this hospitalization
Medications on Admission:
Acetaminophen 1000 mg PO TID
Nystatin Cream 1 Appl TP [**Hospital1 **]
Acetylcysteine 20% 3-5 mL NEB [**Hospital1 **]
Omeprazole 20 mg PO DAILY
Albuterol-Ipratropium 6 PUFF IH Q6H
Ondansetron 4 mg IV Q8H:PRN nausea
Arimidex *NF* 1 mg Oral daily
Racepinephrine 0.5 mL IH Q4H:PRN shortness of breath
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
Vancomycin Oral Liquid 250 mg PO Q8H
Lidocaine 5% Patch 1 PTCH TD QD 12 hours on, 12 off
Warfarin 2 mg PO DAILY
Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical every twelve (12)
hours: 12 hours on, 12 hours off, to right knee.
4. 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*
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 * Refills:*2*
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): for constipation, please hold for loose stools.
Disp:*60 * Refills:*0*
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for when off vent.
Disp:*1 * Refills:*0*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for off vent.
Disp:*1 * Refills:*0*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
Disp:*1 * Refills:*0*
11. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*90 * Refills:*2*
13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty Nine (29)
units Subcutaneous once a day: given at 8AM.
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous every six (6) hours.
16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days.
17. Normal Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection
every four (4) hours as needed for line flush per care protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
1. Altered Mental Status
2. Urinary Tract Infection
3. Acute on Chronic Renal Failure, Hemodialysis Dependent
4. Delirium
5. Acute Blood Loss Anemia
6. Anemia of Chronic Disease
7. Chronic Clostridium Difficile Infection
8. [**Female First Name (un) 564**] Albicans Funguria
9. Acute on Chronic Diastolic Heart Failure
10. Type 2 Diabetes Mellitus
11. Stage II Decubitus Ulcer
Secondary
Gastroesophageal Reflux Disease
Hyperlipidemia
Obstructive Sleep Apnea
Atrial flutter
Discharge Condition:
fair, with tracheostomy tube, and requiring ventilation.
Discharge Instructions:
Ms. [**Known lastname **] was admitted to the hospital from [**Hospital 100**] Rehab because
of progressive hypercapnia with declining mental status. This
was likely due to an infection and she was treated for a UTI.
She was found to be volume overloaded and in renal failure, was
started on dialysis, initially CVVH to prevent low blood
pressures, and is now able to tolerate hemodialysis without
dropping her blood pressures. She required intubation with
mechanical ventilation. She now only requires pressure support
and weaning from ventilator support can be continued at [**Hospital1 **].
She also developed progressive renal failure. She had known
persistent c-diff infection, for which she was treated with oral
vancomycin. Because of this infection, she requires supplemental
nutrition and is now receiving elemental tube feeds via a Doboff
tube. She was anemic due to bleeding and her malnutrition, which
has now improved with blood transfusions, iron and cessation of
bleeding. Continued hematocrit monitoring will be needed, with
goal above 27.
The following changes were made to her medications:
New:
Vancomycin PO DAY [**5-6**]
Atorvastatin 80 mg daily to help protect your heart
Chlorhexidine mouthwash to help prevent pneumonia
Epogen to help support your red blood cells
Docusate Sodium to help prevent and treat constipation
Your insulin was adjusted to help control your blood sugars.
Your omeprazole was changed to famotidine.
You were treated with oral vancomycin due to your history of
chronic clostridium difficile infection.
You were started on midodrine to help with your blood pressure.
You were started on subcutaneous heparin to help with prevent
blood clots.
Discontinued:
Your omeprazole was changed to famotidine.
Your warfarin was stopped due to recurrent episodes of bleeding.
Your should discuss with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 19824**] and
benefits of restarting this medication.
Your arimidex was stopped due to the cardiovascular side
effects.
Your acetylcysteine was stopped as you are on other medications
for your breathing.
Your zofran was stopped and you have not endorsed any nausea.
Your morphine was stopped and you have had not complaints of
pain.
Followup Instructions:
Please follow up with PCP [**Name (NI) 102111**] at [**Hospital1 5595**] at [**Telephone/Fax (1) 102112**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2117-9-3**] 2:40
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2117-9-9**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2040**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2117-9-9**] 9:20
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"285.1",
"038.9",
"995.92",
"E878.3",
"518.84",
"280.9",
"278.01",
"273.8",
"786.3",
"327.23",
"428.0",
"427.32",
"578.1",
"424.0",
"707.22",
"250.40",
"585.6",
"997.31",
"584.9",
"428.33",
"261",
"530.81",
"519.09",
"416.8",
"785.52",
"403.91",
"599.0",
"V58.67",
"719.03",
"008.45",
"782.3",
"707.03",
"293.0",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"39.95",
"86.07",
"38.95",
"33.21",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17906, 17989
|
9542, 9828
|
298, 461
|
18516, 18575
|
3473, 3478
|
20867, 21531
|
2542, 2562
|
15837, 17883
|
18010, 18495
|
15291, 15814
|
18599, 20844
|
2577, 2582
|
1894, 1913
|
235, 260
|
4401, 9283
|
489, 1875
|
3039, 3454
|
9292, 9519
|
3492, 3973
|
9843, 15265
|
1935, 2299
|
2315, 2526
|
3985, 4381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,629
| 147,433
|
20447
|
Discharge summary
|
report
|
Admission Date: [**2119-11-8**] Discharge Date: [**2119-11-13**]
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Tegretol / Dilantin / Heparin Agents /
Benzodiazepines
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
decannulation of trach
Major Surgical or Invasive Procedure:
[**2119-11-9**]: Rigid bronchoscopy with yellow Dumon tracheoscope and
bronchoscope. Flexible bronchoscopy.
Silicone Y-stent revision and replacement.
Tracheostomy stoma revision. Tracheostomy tube placement
percutaneously.
[**2119-11-8**]: Flexible bronchoscopy with therapeutic aspiration.
Tracheostomy tube change.
History of Present Illness:
Mr. [**Known lastname 34384**] is a 84 year old male with severe TBM and tracheal
stenosis.
Patient was trached after a stroke in [**2115**]. Multiple airway
procedures including t-tube in [**2115**] (removed for GT), y stent x3
for severe TBM and tracheal stent for SGS (removed
2/2migration). Current trach has been in approx 2 yrs. Patient
washospitalized in [**4-1**] for LLL PNA and had a longer y stent
placed. More recently, in [**2119-6-25**] he underwent GT ablation in
the LMS
with revision of Y stent and trach. He was discharged to home
with trach mask and vent at night with nursing care. According
to home health nurse, patient uses vent at night approx 5
nights/wk and cool mist via trach 2 nights per week. He has not
problems on nights he does not use the vent. He has also been
episodically capped for >12 hours without difficulty. He has
been getting TFs but will occasionally eating a snack by mouth
without overt evidence of aspiration.
Past Medical History:
1) Tracheomalacia, status post stent x 2 with failure secondary
to stent migration. Status post trach revision [**3-28**]. Status
post T-tube removal on [**2115-6-26**].
2) Status post stroke in [**2109**] with TIA; right upper extremity
weakness resulting.
3) Hypertension.
4) Seizure disorder.
5) History of MRSA.
6) Hemorrhoids.
7) Arthritis.
8) Depression.
9) History of CHF.
10) CRI
Social History:
Married and lives at home with wife with nursing care. Remote hx
of smoking, duration unknown. Rare Etoh.
Family History:
NC
Pertinent Results:
[**2119-11-10**] WBC-12.7* RBC-3.49* Hgb-11.2* Hct-32.4* Plt Ct-226
[**2119-11-9**] WBC-11.0 RBC-4.20* Hgb-13.4* Hct-39.1* Plt Ct-225
[**2119-11-10**] Glucose-180* UreaN-38* Creat-1.4* Na-140 K-3.7 Cl-102
HCO3-31
[**2119-11-9**] Glucose-119* UreaN-35* Creat-1.3* Na-141 K-4.3 Cl-101
HCO3-30
[**2119-11-9**] URINE URINE CULTURE (Pending):
CXR: [**2119-11-9**] FINDINGS: AP single view of the chest has been
obtained with patient in sitting semi-upright position. A
tracheal cannula is now in place. There is no pneumothorax, but
plate atelectases are present on both bases, slightly more on
the left than the right. The pulmonary vasculature is not
congested, and no new infiltrates are identified.
Brief Hospital Course:
Mr. [**Known lastname 34384**] was admitted to the floor on [**2119-11-8**] the
Tracheostomy tube change. Initially he did well immediate
postoperatively but as the evening approached he was unable to
clear his secretions. He was transferred to the SICU for
further managment. On [**2119-11-9**] he was taken back to the
operating room and underwent Rigid bronchoscopy,Flexible
bronchoscopy, Silicone Y-stent revision and replacement,
Tracheostomy stoma revision, Tracheostomy tube placement
percutaneously (8.0 Portex cuffed). He tolerated the procedure
well and was taken back to the SICU for further monitor and
management. He was seen by Speech and swallow for a bedside
swallowing evaluation which was deferred d/t secretion
management issues. Recommendation was for pt to follow up as an
outpt. He was on CPAP overnight and progressed to trach mask
with oxygen saturations in the high 90's. He had decreased UOP
administered a small fluid bolus with good results. His Urine
was positive and cipro was started empirically pending urine cx.
A bladder scan showed >300cc of urine. He continued to do well
and was transferred to the floor on [**2119-11-10**].
Pt was unable to handle his secretions and was re-admitted to
the ICU for pul tiolet. He stabilized and was d/c'd to home on
[**11-13**] w/ 24hr private VNA care as prior to admission.
Medications on Admission:
Reglan 5 qid, scopolamine 1.5 tp q72h, KCL (dose unknown) qday,
Lactinex tid
phenobarb 97.2 qhs, hctz 12.5 qday, omeprazole 20, bicarb
10cc/day
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Phenobarbital 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig:
Twenty (20) ML PO BID (2 times a day) for 8 days.
Disp:*320 ML(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO TID (3 times a day).
13. sodium bicarb
10cc via feeding tube w/ omeprazole
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 15054**] [**Hospital 107**] Home Health &Hospice
Discharge Diagnosis:
1. Trachebronchomalacia status post stent x 2 with failure
secondary to stent migration. Status post trach revision [**3-28**].
Status post T-tube removal on [**2115-6-26**].
2. Hemorrhagic stroke
3. HTN
4. seizure disorder
5. MRSA PNA
6. hemrrhoids
7. arthritis
8. depression
9. CHF
10. CRI
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 10084**] if develops difficulty
breathing or issues concerning the trach.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as directed
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54770**] [**Telephone/Fax (1) 54771**]
Call ([**Telephone/Fax (1) 25326**] - [**Doctor First Name 1785**] to schedule a video swallow study.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2119-11-15**]
|
[
"585.9",
"530.81",
"403.90",
"V44.1",
"716.90",
"V55.0",
"519.19",
"345.90",
"519.02",
"599.0",
"311",
"455.0",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"97.37",
"96.05",
"97.23",
"33.24",
"31.41",
"33.22",
"31.74"
] |
icd9pcs
|
[
[
[]
]
] |
5707, 5799
|
2928, 4283
|
306, 632
|
6135, 6144
|
2202, 2905
|
6329, 6729
|
2179, 2183
|
4478, 5684
|
5820, 6114
|
4309, 4455
|
6168, 6306
|
243, 268
|
660, 1627
|
1649, 2039
|
2055, 2163
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,188
| 162,549
|
2082
|
Discharge summary
|
report
|
Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-30**]
Service: [**Hospital Unit Name 196**]
Allergies:
Neurontin / Topamax / Aldactone / Dicloxacillin / Amiodarone
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Elective Ultrafiltration
Major Surgical or Invasive Procedure:
Ultrafiltration by CHF solutions
History of Present Illness:
Pt is a 84 year old Russian speaking male with hx CAD s/p CABG
'[**37**] and re-do '[**51**] (LIMA --> LAD; SVG -->OM1; SVG -->PDA),
ischemic DCM with EF 25%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], and chronic AF now
s/p atrio-ventricular junctional ablation with BiV-pacemaker who
now presents for elective admission for ultrafiltration for
volume overload secondary to CHF. The pt has a history of
recalcitrant NYHA stage 4 CHF with numerous protracted previous
hospital courses requiring lasix drips, nesiritide and
intubations. He currently has [**1-27**] pillow orthopnea, denies CP
or anginal equivalents, and notes indolent bilateral lower
extremity swelling.
Past Medical History:
1. CAD status post CABG in [**2137**].
2. Status post MI x2.
3. CHF, dilated ischemic cardiomyopathy with
systolic/diastolic heart failure, EF 30 percent, 1 plus
AR, 2 plus TR, 2 plus MR in [**10-28**].
4. Paroxysmal atrial fibrillation.
5. Low back pain status post laminectomy/fusion.
6. Peripheral neuropathy.
7. Chronic renal insufficiency.
8. Benign prostatic hypertrophy.
9. Dementia
10. DM
11. Depression
Social History:
Patient lives with wife. [**Name (NI) **] and daughter are very involved in
medical care. Denies tobacco or EtOHuse.
Family History:
non-contributory
Physical Exam:
97.3 82 96/52 18 98% RA
Gen: NAD, good spirits, alert gentleman
Heent: EOMI, PEERL, MMM
Neck: 7-9 cm JVP, brisk carotid upstrokes,
Heart: regular rate, increased S2, 1/6 SEM
Lungs: clear, no wheezes or rales
Abd: soft, nt/nd. NABS
Ext: 1+ bilateral lower extremity edema with overlying
erythematous, warm skin
Neuro: non-focal, difficult to assess [**1-26**] language barrier
Pertinent Results:
[**2161-10-12**] 03:57PM WBC-6.3 RBC-3.45* HGB-8.8* HCT-28.1* MCV-81*
MCH-25.6* MCHC-31.5 RDW-20.5*
[**2161-10-12**] 03:57PM NEUTS-76.6* LYMPHS-12.5* MONOS-8.1 EOS-2.5
BASOS-0.3
[**2161-10-12**] 03:57PM PLT COUNT-194
[**2161-10-12**] 03:57PM PT-16.1* PTT-32.2 INR(PT)-1.6
.
[**2161-10-12**] 03:57PM GLUCOSE-114* UREA N-56* CREAT-2.9* SODIUM-134
POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
[**2161-10-12**] 03:57PM TOT PROT-6.9 ALBUMIN-3.2* GLOBULIN-3.7
CALCIUM-8.4 PHOSPHATE-4.9*# MAGNESIUM-2.6
.
[**2161-10-12**] 03:58PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2161-10-12**] 03:58PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2161-10-12**] 03:58PM URINE RBC-[**11-14**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
[**2161-10-12**] 03:58PM URINE OSMOLAL-360
[**2161-10-12**] 03:58PM URINE HOURS-RANDOM UREA N-629 CREAT-59
SODIUM-LESS THAN
.
[**2161-10-18**] 04:18AM BLOOD ESR-55*
[**2161-10-18**] 04:18AM BLOOD CRP-27.76*
[**2161-10-13**] 04:00AM BLOOD Hapto-69
.
[**10-12**] CXR: The heart is enlarged consistent with cardiomegaly.
There is a left chest wall biventricular pacemaker with the
leads in good position on this single projection. There is
interval placement of a right IJ central line with the tip in
the right atrium. If the position desired is the SVC, recommend
pulling back approximately 4 cm. There is no evidence of
pneumothorax. There is perihilar haziness and bilateral small
pleural effusions, findings consistent with CHF. The patient is
status post median sternotomy and CABG. The aorta is tortuous.
.
IMPRESSION:
1. Interval placement of right IJ central line with the tip in
the right atrium.
2. Findings consistent with congestive heart failure and
pulmonary edema.
3. Bilateral pleural effusions.
.
[**2161-10-17**]: CT Abdomen/pelvis:
IMPRESSION:
1. Moderate bilateral pleural effusions.
2. No bowel wall thickening or abscess is detected.
3. Colon diffusely distended with air and stool.
4. Cholelithiasis.
.
[**2161-10-17**]: portable abominal x-ray
FINDINGS: There is gaseous distention of the entire colon. There
is gas and feces visualized in the right and the left colon and
the rectum. There are no evidence of mechanical obstruction of
the small or large bowel. On the upright film there is no
evidence of free intraperitoneal air.
.
IMPRESSION: Gaseous distention of the colon. No evidence of
bowel obstruction. No evidence of free air.
.
[**2161-10-19**]: left upper extremity ultrasound
UNILATERAL UPPER EXTREMITY VENOUS ULTRASOUND, LEFT: Both [**Doctor Last Name 352**]
scale and color Doppler ultrasound was used for this evaluation.
There is normal compressibility of the left cephalic, basilic,
paired brachial, axillary, and jugular veins. There is normal
respiratory variation in the left jugular, subclavian, axillary,
paired brachial, basilic, and cephalic veins. No intraluminal
filling defect identified. No deep venous thrombosis.
.
IMPRESSION: No deep venous thrombosis.
.
[**2161-10-19**] TTE:
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
.
Conclusions:
1. The left atrium is dilated.
2. The left ventricular cavity is mildly dilated. There is
severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is
severely depressed.
3. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
5. Moderate to severe [3+] tricuspid regurgitation is seen.
There is severe
pulmonary artery systolic hypertension.
6. No evidence of endocarditis seen..
7. Compared with the findings of the prior report (tape
unavailable for
review) of [**2161-9-17**], the mitral regurgitation is less.
.
[**10-21**] chest ultrasound:
REASON FOR THIS EXAMINATION:
? abscess/infected pacer pocket
INDICATION: Pacer, septic.
Limited ultrasound of the chest wall was performed around the
pacer demonstrating no fluid collections. No evidence of
abscess.
.
[**10-24**] Left wrist x-ray
There is mild diffuse osteopenia. There is severe narrowing of
the radiocarpal joint with essentially complete loss of the
joint space. There is a large relatively well circumscribed (15
mm) lucency in the subchondral portion of the distal radius,
abutting the distal radioulnar joint. There is moderate
degenerative narrowing of the first CMC joint. There is also
slight narrowing of the triscaphe joint. There is ill-definition
of the distal corner of the scaphoid radially -- ? subtle
erosion. Incidental note is made of an ossicle adjacent to the
ulnar styloid. There is diffuse soft tissue edema with faint
vascular calcification.
.
IMPRESSION:
1. Soft tissue edema about the wrist.
2. Marked degenerative narrowing of the radiocarpal joint and to
a lesser extent the first CMC joint.
3. Subchondral lucency in the distal radius medially. Because it
is relatively well circumscribed, this most likely represents a
large degenerative subchondral cyst (geode).
4. Faint chondrocalcinosis over triangular fibrocartilage. This
can be seen in CPPD, hyperparathyroidism, or hemochromatosis.
5. Ill-definition of the scaphoid -- this is not well seen on
the oblique view and may be an artifact due to a small spur.
6. Otherwise, no findings specific for osteomyelitis.
.
[**2161-10-25**] CXR:
Since the previous radiograph, the patient has been intubated
with endotracheal tube terminating at the thoracic inlet level.
A right subclavian vascular catheter has been placed and has an
unusual midline location with respect to the mediastinum. A
nasogastric tube courses below the diaphragm.
No pneumothorax is identified.
The cardiac silhouette is enlarged. Pulmonary vascularity is
within normal limits for supine technique. No definite areas of
consolidation are observed in either lung. There is subcutaneous
emphysema in the right chest wall.
.
IMPRESSION:
1) Unusual midline position of central venous catheter. This
appears much more medial than anticipated for the superior vena
cava, and an arterial location should be considered. This
finding has been communicated with the clinical service caring
for the patient on the morning of [**2161-10-26**] when the
radiograph was available for interpretation.
2) Nasogastric tube in satisfactory position.
.
Left wrist, tenosynovium: ([**2161-10-25**]; pathology specimen)
Granulation tissue with acute and chronic inflammation and
fibrinopurulent exudate.
.
[**2161-10-26**] CXR:
FINDINGS: There has been interval removal of the right sided
subclavian catheter. No evidence of mediastinal hematoma, and
hematoma at catheter placement site cannot be assessed by chest
x-ray. The tip of of the endotracheal tube remains 5 cm above
the carina. Enteric tube remains present. Pace maker and leads
remain unchanged. Sternotomy sutures are intact.
The extreme left costophrenic angle has been coned from this
study. Cardiac and mediastinal silhouettes remain stable. No
evidence of mediastinal hematoma. No evidence of pneumothorax or
pneumonia. Note is made of a slight haziness of the right lower
lung fields, which has been seen on prior examinations. It is
unclear whether this represents a small pleural effusion or
minimal atelectasis.
.
IMPRESSION:
Interval removal of right subclavian catheter. No other
significant change.
.
[**2161-10-26**] TEE:
IMPRESSION: Mildly thickened mitral, aortic and tricuspid valves
but without
discrete vegetation. Mild aortic regurgitation. Moderate mitral
regurgitation.
Moderate tricuspid regurgitation. No vegetations identified.
.
Brief Hospital Course:
1. Dilated Cardiomyopathy: Pt was admitted for elective
ultrafiltration with CHF solutions with the goal of rapid
removal of volume and restoration of euvolemia. He was
obviously volume overloaded on admission, and his MAP's were in
the low 70's. Mr.[**Known lastname 11300**] was maintained on his [**Hospital 3782**] medical
regimen, minus the beta-blocker and ace-inhibitor for the chance
of hypotension during ultrafiltration. He was placed on a
heparin drip to prevent clotting of the ultrafiltration machine.
He diuresed 12L using ultrafiltration. During ultrafiltration,
his pressures transiently dropped and he did require low-levels
of dopamine (3-5mic/kg/min) for this problem. Interestingly,
the pt's creatinine decreased from admission level of 2.7 down
to 1.8 on [**2161-10-16**] (likely from increased renal perfusion from
improvement of his Frank-Starling equilibrium and better forward
flow). After discontinuation of ultrafiltration, diuresis was
continued with IV lasix. Low dose ACE and beta-blocker were
re-started. While pt was septic with MRSA bacteremia, ACE,
beta-blocker were held. Lasix transiently discontinued but for
the most part continued for further diuresis, as pt was volume
overloaded. Pt continued to diurese well. His creatinine
decreased steadily down to normal and stabilized around 1.2. on
[**10-24**], pt was found to be hypernatremic with sodium of 150. Pt
was found to have a free water deficit of 4.5 liters. He was
started on D5W and continued on this for a few days with
resolution of hypernatremia. D5W was discontinued. At this
point, pt appeared to be intravascularly depleted, but with
total body volume overload. Pt was restarted on diuresis to help
mobilize fluid. It was noted at pt's albumin was 1.9.
.
2. CAD: From a CAD standpoint, pt remained stable. He was
chest pain free and had no ischemic changes on EKG throughout
this hospitalization. Pt was maintained on asprin, and a statin.
His BB and ACE-inhibitor was held during ultrafiltration and
briefly re-started after the discontinuation of ultrafiltration.
Beta-blocker and ACE were held while patient was septic with
MRSA bacteremia. Statin was held when pt was started on
Daptomycin for treatment of MRSA bacteremia. Low-dose ACE and
beta-blocker were restarted after pt recovered from sepsis. Pt
was discharged on Lisinopril 5mg and Toprol XL 12.5mg qd. These
medications should be titrated up to his home dosages of
Lisinopril 5mg and Toprol XL 25mg qd. In addition, Lipitor 20mg
qd should be restarted after he completes his course of
Daptomycin on [**10-31**].
.
3. Rhythm: Pt does have chronic AF, but he is s/p AV junction
ablation and BiV pacemaker placement [**8-29**] (last
hospitalization). His pacemaker was working correctly and
mainly revealed a paced rhythms at 80bpm with a non-specific
intraventricular delay pattern on surface EKG. His coumadin was
held during this hospitalization and he was maintained on
heparin. Anticoagulation was discontinued on [**10-17**] after an
extensive discussion with the family who stated that they felt
that the pt was at great risk of falls (per family, pt has
several recent falls at home) and they did not wish for him to
be anticoagulated. They were explained the increased risk of
stroke off anticoagulation. EP interrogated the pt's pacer and
found that the pt had an underlying AV nodal rhythm. The pacer
was stopped. Pt had an underlying rhythm which was at a rate of
90-110 in atrial fibrillation. They recommended removal of the
pacer since the pt didn't appear to need it. After extensive
discussion between the EP and ID services, it was decided not to
remove the pacemaker, since it appeared that the source of
persistent infection was the septic left wrist joint. Prior to
discharge, the pacer was restarted.
.
4. Infection: During the beginning of the hospital course, pt
had an enterococcal UTI which was treated with Levoquin. Pt was
also noted to have bilateral warm, erythematous, painful lower
extremities worrisome for cellulitis complicating chronic venous
insufficiency. He was treated for this with clindamycin from
[**Date range (1) 11301**] and these symptoms subsequently resolved. On
[**2161-10-17**] (24 hours after central line removal), pt spiked a
temperature of 101.4. He was pancultured. CXR was negative for
pneumonia. Pt complained of abdominal pain and an abdominal CT
was obtained to look for an acute abdominal process. CT
Abd/pelvis was negative and only found dilated loops of large
bowel with lots of stool, but no obstruction or air-fluid
levels. On [**2161-10-18**], pt had [**3-29**] positive blood cultures for gram
positive cocci. He was started on empiric antibiotics of
vancomycin, levo, flagyl. At the time, pt had several possible
sources of infection including recent central line, UTI, sacral
ulcer, GI tract, endocarditis, pacemaker infection, hardware for
spinal fusion. The central line was most likely the portal of
entry of the bacteria. Pt was provided supportive care and daily
blood cultures were drawn. From [**Date range (1) 4359**], the pt grew out
13/14 positive blood cultures, all with coag positive staph
aureus, which was found to be high grade MRSA bacteremia. On
[**10-18**], pt's left upper extremity was noted to be swollen; this
was thought to be secondary to IV infiltration. An ultrasound of
the Left upper extremity was found to be negative for DVT.
Infectious disease was [**Month/Year (2) 4221**] on [**10-19**] who agreed with vanco
and stated that vanco levels needed to be dosed daily using
vanco trough levels, with goal trough level of 15-20. A TEE on
[**10-19**] showed no evidence of endocarditis. On [**10-20**], pt was found
unresponsive and rigoring; BP 89/50 and ABG 7.48, pCO2 28, pO2
190. Antihypertensives and diurestics were held during this
time. On [**2161-10-20**], pt was started on Daptomycin; daily CK levels
were checked and statin was discontinued. On [**2161-10-21**],
ultrasound of the pacer pocket was negative for abscess or
infection. EP interrogated the pt's pacer and found that the pt
had an underlying AV nodal rhythm. They recommended removal of
the pacer since the pt didn't appear to need it. Pt appeared to
be improving clinically and remained afebrile. However, he
continued to grow out new positive blood cultures from [**10-23**],
[**10-24**]. On [**10-24**], it was noted that pt's left and hand and wrist
looked warm with an area of fluctuance on the dorsum of the hand
and decreasd range of motion of the wrist along with severe
pain. Ortho was [**Month/Year (2) 4221**]. Left hand films showed possible
erosion of scaphoid bone. They performed a bedside tap of the
wrist joint and removed 1cc of purulent fluid and diagnosed left
septic wrist joint. On [**10-25**], the pt was taken to the OR for
wash out of the left wrist joint. They performed open irrigation
and debridement of the radiocarpal joint, radioulnar joint,
extensor sheaths, and extensive tenosynovium. The patient was
electively intubated for the I&D and started on pressors during
the procedure. The pt was left intubated and extubated for
planned pacer removal on [**10-26**]. On [**10-25**], pt was noted to have
lesions on his right buttocks suggestive of zoster and was
started on acyclovir. TEE was performed on [**10-26**] and was negative
for endocarditis. After extensive discussion between the EP and
ID services, it was decided not to remove the pacemaker, since
it appeared that the source of persistent infection was the
septic left wrist joint. It was also felt that the pacemaker
leads were most likely endothelialized by this point and
unlikely to be infected. Pt was successfully extubated and
weaned off pressors. On [**10-27**], a sample from the suspected zoster
lesions were diagnosed as Herpes Simplex virus type 2. Acyclovir
was discontinued. In total, pt has had 20/36 blood cultures
positive for MRSA, the last positive set was from [**10-25**] which is
the date of the left wrist I&D. He has received
a 14 day course of Vanco and 11 day course of dapto. ID
recommended giving a total of 4 weeks of vanco from [**10-25**]; pt's
last day of vanco should be [**11-21**]. However, he should
follow-up with [**Hospital **] clinic prior to discontinuing vanco. Pt should
receive one week of Daptomycin from [**10-25**], last day is [**10-31**]. Pt should follow-up with Dr. [**Last Name (STitle) 6173**] in [**Hospital **] clinic
([**Telephone/Fax (1) 457**])
.
5. Renal Failure: Pt had an elevated Cr of 2.7 on admission.
He diuresed 900 cc after foley placement, and conitnued to
diurese likely from post-obstructive diuresis. His Cr decreased
to 1.8 on discharge, close to his baseline of 1.5-1.7. This
improvement in GFR is likely due to a combination of both
post-renal and pre-renal azotemia. The improvement is due to
decompression of obstruction and improved forward flow,
respectively. Pt continued to diurese well during his infection
both on and off diuretics. Pt creatinine progressively decreased
and stabilized around 1.2.
.
5. GI: Pt was noted to be contipated on [**2161-10-17**]. He was started
on an aggressive bowel regimen which included Senna, lactulose,
bisacodyl, Docusate, and daily saline enemas. From that point
on, the goal was for daily bowel movements.
.
6. Pulm: Pt was briefly intubated and easily extubated
perioperative during after the left septic wrist I&D.
.
7. BPH: The pt diuresed 900cc cloudy urine when a foley was
placed on admission. He has severe BPH and he was maintained on
his outpt regimen for this issue. He did have a Pseudomonal UTI
and likely he experienced a post-obstructive diuresis from this.
He was emperically treated with levaquin since his previous
Pseudomonal UTI was pan-sensitive, including levaquin. Foley
was removed when pt was transferred to the floor, where he got
[**Hospital1 **] straight caths. Foley was replaced when pt returned to the
CCU with sepsis.
.
8. Access: On [**2161-10-25**], a right subclavian central line was
attempted. CXR found the line to be located in the subclavian
artery. The line was removed. Vascular surgery was [**Date Range 4221**] who
felt that the patient appeared stable post-procedure without
further complications. Femoral venous access was obtained. On
day of discharge, a PICC line was placed by IR and the femoral
line was removed.
Medications on Admission:
tamsulosin 0.4mg po daily
donepazil 10mg po dialy
coumadin 5mg po daily
finestaride 5mg po dialy
toprol XL 25 mg po daily
tiagabine 12mg po nightly
oxycodone sustained release 10 mg po BID
lipitor 20 mg po dialy
asprin 81 mg daily
lisinopril 5mg po dialy
toresmide 80 mg po dialy
Discharge Medications:
1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD ().
4. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
5. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
6. Tiagabine HCl 4 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 15 ml PO
BID (2 times a day).
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed.
13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Morphine Sulfate 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H
(every 4 hours) as needed for pain.
18. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 2 days: 400 mg QD not 500
mg.
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) 1000 mg
Intravenous Q24H (every 24 hours) for 4 weeks: goal level
15-20- check daily troughs.
20. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: please give [**12-26**] tab
Qd and titrate up as tolerated.
21. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
NYHA Class 4 heart failure- EF 20% secondary to ischemia
cardiomyopathy
MRSA septicemia
Left wrist septic joint- MRSA
CRI
BPH
hypercholesterolemia
CAD s/p MI x 2, s/p CABG
Discharge Condition:
Improved and stable on cardiac meds
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2161-11-9**] 1:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1113**] Date/Time:[**2161-11-11**] 9:45
Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 5446**] [**Hospital 1947**] CLINIC Where: CC-2
[**Hospital 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2161-11-25**] 3:40
Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] [**Telephone/Fax (1) 3512**] Follow-up appointment
should be in 1 month
Infectious Disease clinic will contact patient about appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6173**] in [**12-26**] weeks.
Device Clinic- [**12-7**] at 3 pm, [**Hospital Ward Name 23**] 7
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**12-7**] at 3:30 pm- [**Hospital Ward Name 23**] 7
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"041.7",
"428.0",
"599.0",
"727.05",
"425.4",
"459.81",
"038.11",
"V53.31",
"054.9",
"427.31",
"276.0",
"V09.0",
"428.43",
"564.00",
"711.03",
"584.9",
"458.29",
"996.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.78",
"96.71",
"88.72",
"81.91",
"83.39",
"96.6",
"96.04",
"38.93",
"80.83",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
22494, 22573
|
9772, 20112
|
315, 349
|
22789, 22826
|
2116, 5972
|
22996, 24248
|
1658, 1677
|
20442, 22471
|
22594, 22768
|
20138, 20419
|
22850, 22973
|
1692, 2097
|
251, 277
|
6001, 9749
|
377, 1072
|
1094, 1508
|
1524, 1642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,176
| 120,995
|
49244
|
Discharge summary
|
report
|
Admission Date: [**2180-12-26**] Discharge Date: [**2181-1-3**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
gentleman with a history of rheumatic heart disease and known
severe mitral stenosis with chronic atrial fibrillation,
previously determined left ventricular ejection fraction of
50%.
The patient presented to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
with four to five days of worsening dyspnea on exertion. The
patient states that he is experiencing extreme dyspnea with
minimal exertion. The patient also complains of paroxysmal
nocturnal dyspnea and orthopnea.
In the Emergency Room, the patient was found to be in
congestive heart failure, and was treated with intravenous
Lasix. The patient was admitted to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for evaluation and treatment of his severe
mitral stenosis and congestive heart failure.
PAST MEDICAL HISTORY: 1. History of seizure disorder. 2.
History of rheumatic fever with rheumatic heart disease. 3.
Status post squamous cell carcinoma of the neck. 4. History
of chronic obstructive pulmonary disease. 5. History of
chronic atrial fibrillation since [**2176**] with multiple failed
cardioversions. 6. Chronic renal insufficiency with a
baseline creatinine of 1.5 to 1.8.
MEDICATIONS ON ADMISSION: Lasix 40 mg p.o.q.a.m. and 60 mg
p.o.q.p.m., trandolapril 4 mg p.o.q.d., verapamil 240 mg
p.o.q.d., digoxin 0.1 mg p.o.q.d., Fosamax 30 mg p.o.q. week,
Tums one p.o.t.i.d., and Flonase one spray right nostril q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a former smoker, quit 20
years ago, and uses alcohol rarely. The patient lives alone.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a pulse of 90, atrial fibrillation, blood
pressure 122/69, respiratory rate 21 and oxygen saturation
95% on one liter nasal cannula. General: Patient noted to
be short of breath with conversation, however, he was in no
acute distress. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, pupils equal, round, and reactive
to light and accommodation, extraocular movements intact,
moist mucous membranes, oropharynx clear. Neck: Positive 13
cm jugular venous distention, carotids without bruit. Chest:
Crackles one-third of the way up bilaterally.
Cardiovascular: Irregularly irregular with a II/VI diastolic
murmur, loudest at left lower sternal border with a right
ventricular heave. Abdomen: Soft, nontender, nondistended,
positive bowel sounds, no hepatosplenomegaly, positive
hepatojugular reflux. Extremities: No clubbing or cyanosis,
1+ nonpitting edema, positive right groin bruit. Neurologic
examination: Alert and oriented times three, cranial nerves
II through XII grossly intact, sensation intact.
LABORATORY DATA: White blood cell count was 7.1, hematocrit
41.3, platelet count 183,000, prothrombin time 19.5, partial
thromboplastin time 36.2, INR 2.6, sodium 140, potassium 4.6,
chloride 102, bicarbonate 29, BUN 32, creatinine 1.8, blood
sugar 193, and digoxin level less than 0.3. Chest x-ray
showed bilateral pleural effusions, cardiomegaly, no
congestive heart failure. Electrocardiogram showed low
voltage in limb leads, atrial fibrillation, no ST-T wave
changes.
HOSPITAL COURSE: The patient was admitted to the cardiology
service. He was given vitamin K and fresh frozen plasma to
decrease his INR as well as Lasix to treat his congestive
heart failure.
On [**2180-12-27**], the patient underwent a transthoracic
echocardiogram to evaluate his valvular disease. This showed
a moderately dilated left ventricle with overall normal left
ventricular systolic function, 1+ aortic regurgitation,
moderate mitral stenosis with 2+ mitral regurgitation,
moderate to severe tricuspid regurgitation, normal pulmonary
artery pressures, no pericardial effusion.
The patient was taken to the cardiac catheterization
laboratory on that same day. Catheterization revealed no
significant coronary artery disease, elevated left
ventricular end-diastolic pressure of 18, pulmonary capillary
wedge pressure of 24, mitral valve area 1.2 cm2, mean mitral
gradient 11 mm of mercury, and left ventricular ejection
fraction of 45%.
The patient was taken to the Operating Room on [**2180-12-29**] with Dr. [**Last Name (STitle) **] for a mitral valve replacement with a
#29 St. [**Male First Name (un) 1525**] mechanical valve. The patient was transferred
to the Intensive Care Unit on a dobutamine infusion in stable
condition.
Transesophageal echocardiogram was performed in the Operating
Room, which showed a left ventricular ejection fraction of
50%, mild global right ventricular systolic dysfunction,
moderate tricuspid regurgitation, trace mitral regurgitation
which is considered normal for the prosthesis. Please see
the operative note for further details.
In the Intensive Care Unit, the patient had rapid atrial
fibrillation and was started on amiodarone for rate control.
The patient required a Neo-Synephrine infusion to maintain
adequate blood pressure. Dobutamine was weaned off, with
adequate cardiac index. The patient was weaned the next day
from mechanical ventilation on his first postoperative night.
On postoperative day number one, the patient was started on
Coumadin for anticoagulation of his mitral valve. The
Neo-Synephrine drip was weaned to off. The patient was
started on Lopressor. The patient's hematocrit in the
Intensive Care Unit on postoperative day number one was found
to be 23 and no treatment was given at that time as the
patient was hemodynamically stable.
The patient was transferred out of the Intensive Care Unit on
postoperative day number two. On postoperative day number
three, the patient was started on a heparin infusion, as he
was still subtherapeutic for anticoagulation of his mitral
valve. The patient continued to be in atrial fibrillation
with a controlled ventricular response.
The patient's pacing wires were removed on postoperative day
number three. The patient began ambulating with the aid of
physical therapy. On postoperative day number four, it was
noted that the patient's creatinine was elevated to 1.9. His
hematocrit was 23.9. It was discussed with Dr. [**Last Name (STitle) **] and
the decision was made to transfuse one unit of packed red
blood cells.
The patient continued on a heparin infusion for
anticoagulation because his prothrombin time and INR were
subtherapeutic on his Coumadin dosing. The patient was
cleared for discharge to a rehabilitation facility on
postoperative day number five.
CONDITION AT DISCHARGE: The patient's maximum temperature is
97.6, pulse 99, atrial fibrillation, blood pressure 98/50,
respiratory rate 14 and oxygen saturation 94% on two liters
nasal cannula. The patient is awake, alert and oriented
times three without complaints. Cardiovascular: Irregularly
irregular without rub or murmur, sharp valve click.
Pulmonary: Breath sounds clear bilaterally. Abdomen: Soft,
nontender, nondistended, positive bowel sounds. The patient
is tolerating a regular diet. His sternal incision is intact
with staples, there is no erythema or drainage. The sternum
is stable, without click. Laboratory data are pending.
DISCHARGE DIAGNOSES:
1. Status post mechanical mitral valve replacement.
2. Chronic atrial fibrillation.
3. History of seizure disorder.
4. Status post squamous cell carcinoma of the neck.
5. Chronic obstructive pulmonary disease.
6. Chronic renal insufficiency.
DISCHARGE MEDICATIONS:
1. Fosamax 30 mg p.o.q. week.
2. Tums one p.o.t.i.d.
3. Metoprolol 25 mg p.o.b.i.d.
4. Lasix 40 mg p.o.q.a.m. and 60 mg p.o.q.p.m.
5. Potassium chloride 20 mEq p.o.q.d.
6. Colace 100 mg p.o.b.i.d.
7. Protonix 40 mg p.o.q.d.
8. Flonase one spray right nostril q.d.
9. Heparin infusion at 1,050 units/hour, to be continued
until patient's INR is greater than 2, at which time the
heparin infusion can be stopped.
10. Tylenol 650 mg p.o./p.r.q.4-6h.p.r.n.
11. Coumadin 10 mg on [**2181-1-3**]; patient has to have a PT/INR
checked on [**2181-1-4**] and Coumadin dose is to be adjusted for
an INR of 3 to 3.5; upon discharge from rehabilitation,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone [**Telephone/Fax (1) 7728**], is to be
contact[**Name (NI) **] and he will manage the patient's Coumadin
dosing.
DISCHARGE INSTRUCTIONS: Staples on the sternal incision are
to be removed on [**2181-1-11**] if the patient is still at
rehabilitation. If the patient is discharged from
rehabilitation prior to that, please call [**Telephone/Fax (1) 103221**] for an
appointment to have staples removed.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) **] in three to four weeks; please call his office on
discharge from rehabilitation for an appointment. The
patient is to follow up with Dr. [**Last Name (STitle) **] upon discharge from
rehabilitation, as well as for monitoring of Coumadin.
DISCHARGE STATUS: The patient is cleared for discharge to a
rehabilitation facility in stable condition.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2181-1-3**] 08:40
T: [**2181-1-3**] 09:14
JOB#: [**Job Number 103222**]
|
[
"593.9",
"428.0",
"496",
"396.1",
"397.0",
"429.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.72",
"39.61",
"88.53",
"35.24",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
7466, 7715
|
7738, 8612
|
1504, 1773
|
3497, 6800
|
8637, 9614
|
1916, 3479
|
6815, 7445
|
137, 1078
|
1101, 1477
|
1790, 1893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,091
| 165,797
|
35290
|
Discharge summary
|
report
|
Admission Date: [**2141-1-31**] Discharge Date: [**2141-2-2**]
Date of Birth: [**2086-12-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He
had been in unusal state of health at baseline resp status
(using 4L NC at rest and 6L NC with exertion) when 3 days PTA,
he hugged his cousin who has rats for pets and also the heat
came up from the basement of his house. He feels that with these
two events, he breathing became acutely worse and is concerned
for allergen exposure. He denies any sick contacts, fevers,
chills, worsening [**First Name3 (LF) **]/productive [**First Name3 (LF) **], rhinorrhea. He did
receive flu and pneumovax.
He has had a recent admissions in [**11-16**]/09 with progressive
DOE. CT revealed increased ground glass opacity in LL
superimposed on pulmonary fibrosis with elevated eosinophils
peripherally (12%). A BAL was also positive for eosinophils. He
was started on high dose steroids (prednisone 60mg) [**2139-12-24**] with
plan for close outpatient follow up for eosinophilic lung
disease. He was discharged on [**12-27**] on 2-3L NC. He then
represented to [**Hospital1 18**] on [**12-1**] for spontaneous
pneumomediastinum of unclear etiology.
On day of admission, Pt called pulmonologist (Dr. [**First Name (STitle) **] c/o
worsening shortness of breath since Saturday [**1-28**]. Yesterday he
was at pulmonary rehab and desaturated to the 70s on 6L with
minimal exertion, and he is currently on 4L NC at rest. No sick
contacts recently and [**Name2 (NI) **] has not changed. He was asked to go
to ED given concern for either acute exacerbation of underlying
IPF vs superimposed infection vs pneumothorax.
In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC.
Patient was given levoquin X 1 and was sent to floor. Of note,
by transfer to ICU, his sats in ED were near baseline at 96% 4L
NC.
On the floor, he reports feeling comfortable. He denies any
complaints except that with exertion he has noticed left sided
chest pain, that does not radiate to jaw or arm. He also notes
occasional palpitations (rapid, regular) which have been lasting
up to 1 hour ocuring more frequently. He denied PND, worsening
orthopnea, LE swelling.
Past Medical History:
Pectus excavatum
Idiopathic pulmonary fibrosis
Hypertension
Social History:
Currently not working but previously worked as a painter as well
as sandblasting for 4 yrs during the [**2111**] (wore respirator but
beard prevented tight seal). Occasionally travels overseas to
[**Country 2045**] and [**Country 14635**] but states not a/w Sx. No known asbestos
exposure. Smoked for 19 yrs but quit 19yrs ago. No EtOH use for
20 years.
Family History:
Brother died of rare, agressive form of pulmonary fibrosis at VA
in CT. Brother did work with him briefly as a painter.
Physical Exam:
Vitals - T: 98.2 BP: 144/90 HR: 90 RR: 20 02 sat: 93% on 4 L
GENERAL: Middle-aged male sitting in bed in NAD
HEENT: OP clear, no LAD
CARDIAC: RRR, no MRG, no JVD
LUNG: Patient breathing comfortably. Insipratory crackles
throughout his lungs.
ABDOMEN: + BS, soft NTND
EXT: No edema, clubbing present. 2 + DP.
NEURO: Alert and appropriate. 5/5 strength in his upper and
lower extremitis. Sensation to light touch intact.
DERM: No rashes
Pertinent Results:
[**2141-1-31**] 10:32PM BLOOD WBC-12.5* RBC-4.86 Hgb-13.6* Hct-41.4
MCV-85 MCH-27.9 MCHC-32.8 RDW-13.8 Plt Ct-403
[**2141-1-31**] 10:32PM BLOOD Neuts-68.0 Lymphs-20.9 Monos-5.0 Eos-5.6*
Baso-0.4
[**2141-1-31**] 10:32PM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-139
K-3.8 Cl-98 HCO3-32 AnGap-13
[**2141-2-1**] 04:47AM BLOOD Glucose-99 UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-101 HCO3-31 AnGap-11
[**2141-1-31**] 10:32PM BLOOD CK(CPK)-36*
[**2141-2-1**] 04:47AM BLOOD CK(CPK)-35*
[**2141-1-31**] 10:32PM BLOOD cTropnT-<0.01
[**2141-2-1**] 04:47AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-2-1**] 04:47AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3 Cholest-PND
[**2141-1-31**] 10:40PM BLOOD Lactate-1.1
Labs on day of discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2141-2-2**] 05:30AM 14.3*# 4.78 13.3* 40.3 84 27.8 33.0 13.6
416
ADDED DIFF [**2-2**] 8:20AM
DIFFERENTIAL Neuts Lymphs Monos Eos Baso
[**2141-2-2**] 05:30AM 77.6* 11.2* 5.6 5.1* 0.5
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-2-2**] 05:30AM 89 10 0.8 139 4.1 99 30 14
BNP 53
HEMATOLOGIC D-Dimer
[**2141-2-1**] 12:40PM 184
CXR ([**1-31**]):
FINDINGS: Lung volumes are markedly diminished. There are
extensive fibrotic changes at the lung bases, grossly stable
from the prior exam. Less traumatic opacifications are noted in
the more cephalad lungs. Grossly, there is no superimposed acute
process that can be identified when comparing to multiple remote
studies. The mediastinum is grossly unremarkable and stable. No
definite effusion or pneumothorax is noted.
IMPRESSION: Extensive baseline disease with fibrotic changes at
the lung
bases and scattered mostly peripheral opacities in the upper
lungs. No
definite superimposed process identified.
CT Chest noncontrast ([**2-1**]):
FINDINGS: Previously reported pneumomediastinum has resolved.
Widespread
interstitial lung disease is largely unchanged compared to the
recent study except for a few minimal areas of progression with
similar morphology and distribution to the previous examination.
There are no new superimposed findings to suggest an active
pulmonary infection.
Enlarged mediastinal lymph nodes are again demonstrated and are
likely
hyperplastic in the setting of diffuse lung disease. The main
pulmonary
artery remains enlarged. The heart size is normal.
Exam was not tailored to evaluate the subdiaphragmatic region,
and only a
small portion of the abdomen is included on the study, but no
concerning
abnormalities are evident on this limited assessment.
Skeletal structures demonstrate no suspicious lytic or blastic
skeletal
lesions.
IMPRESSION:
1. Slight progression of widespread interstitial pulmonary
fibrosis, likely due to acute exacerbation of IPF as reported on
the earlier CT of [**2140-11-21**].
2. Resolution of pneumomediastinum.
Brief Hospital Course:
54 yo male with progressive IPF undergoing transplant evaluation
at [**Hospital1 112**] admitted with worsening hypoxia and dyspnea on exertion,
found to have progression of IPF on chest CT.
# IFP: The patient was admitted with worsening dyspnea and
hypoxia on exertion. He spent one night in the MICU for
monitoring and was weaned back down to his baseline oxygen of 4
L/min at rest and 6 L/min on exertion. A D-dimer was within
normal limits, making PE unlikely, and he appeared euvolemic
with no history of heart failure and a normal BNP. Pulmonary
was consulted and recommended a CT scan. CT scan on [**2-1**] showed
progression of his IPF, likely accounting for his symptoms of
worsening DOE and his increased hypoxia with exertion. His
providers at [**Hospital1 112**] were [**Name (NI) 653**], and transfer was arranged to
pursue a 3-day in-patient transplant evaluation. He was also
continued on his home regimen of NAC TID.
# Chest pain: The patient reports chest discomfort when short of
breath occasionally, however he has been experiencing this
stablely for a long time. Was ruled out for MI and EKG without
ischemic changes. Per his outpatient pulmonary fellow (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]), he will undergo a right heart cath as part of
transplant work-up, so she will request that he undergo a left
heart cath at that time to evaluate for cardiac disease.
# CODE: Full code
Medications on Admission:
Acetylcysteine 600 mg TID
Acetaminophen 500 mg PRN
Calcium 500 mg TID
Vitamin D 400 [**Hospital1 **]
Discharge Medications:
1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Progressive interstitial pulmonary fibrosis
Discharge Condition:
Stable, satting in the mid 90's on 3 L NC.
Discharge Instructions:
You were admitted to the hospital with worsening shortness of
breath on exertion. You underwent a chest CT which showed
progression of your lung disease. You will be transferred to
[**Hospital6 1708**] to undergo evaluation for lung
transplantation.
You were started on a medication called pantoprazole which you
will need to taken 40 mg daily. Otherwise no changes were made
to your medications.
Followup Instructions:
You will undergo lung transplantation workup at [**Hospital1 3372**]. You will need to follow up with your primary
pulmonologist after the inpatient workup.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2141-2-2**]
|
[
"401.9",
"515",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8572, 8587
|
6405, 7847
|
292, 298
|
8674, 8719
|
3497, 6382
|
9168, 9479
|
2897, 3019
|
7999, 8549
|
8608, 8653
|
7873, 7976
|
8743, 9145
|
3034, 3478
|
233, 254
|
326, 2426
|
2448, 2509
|
2525, 2881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,820
| 125,172
|
5828
|
Discharge summary
|
report
|
Admission Date: [**2171-10-25**] Discharge Date: [**2171-11-6**]
Service: MEDICINE
Allergies:
Indomethacin / Ace Inhibitors / Anti-Inflam/Antiarth Agents
Misc. Classf / Ambien
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Pulmonary Intubation x2
History of Present Illness:
Mr [**Known lastname 23099**] is a [**Age over 90 **] year-old man with a history of severe CAD s/p
CABG x 2 and multiple PCIs, dCHF, DM, and CKD who presents with
respiratory failure. The patient is intubated and cannot provide
history; his wife is at bedside.
He was recently discharged from rehab on [**2171-10-18**] after a two
week recent ([**2171-9-7**]) admission at [**Hospital1 18**] for decompensated
heart failure complicated by ARF in the setting of bumex
diuresis. He was doing well at rehab for the past one week at
home until this morning when he woke up with shortness of
breath. He saw his cardiologist three days prior to arrival and
he was noted to be in stable health. Baseline weight was
reported as 129 lb. He had no CP, fevers, myalgias, nausea, or
vomitting.
He called EMS and on arrival, he was noted to be in significant
respiratory distress, using accessory muscles to breath. No
vital signs are recorded in the EMS notes but his respiratory
distress was worsening and he did not respond to ambu bagging.
He was intubated in the field. Nitro paste was also applied and
he was given lasix 80 iv x 1.
In the emergency department, VS were 96.9 135/64 68 and he was
satting 100% on AC 500 x 18, peep 5, fio2 40%. His CXR was
consistent with acute heart failure. His gas showed 7.35/55/414
on the above settings. He was also empirically treated for
consern of PNA with vanc, levo, and zosyn. His ECG did not show
signs of ischemia and he was also given [**Hospital1 **]. The nitro paste
was removed for SBPs in the 100s. During his stay in the ED he
put out 500 cc of urine. He is being admitted to CCU for
further management.
On review of systems, as discussed with patient wife, the
patient had complained of some lower extremity edema but no
chest pain, myalgias, joint pains, cough, hemoptysis, black
stools or red stools, fevers, chills or rigors.
Past Medical History:
- Severe CAD: CABG [**2146**] and [**2156**] with LIMA --> LAD, SVG to
posterior L ventricular branch. Multiple PCI/stents with last
[**11-2**]: native 3VD, multiple SVG->LPL stenoses, patent LIMA->LAD,
Stent to mid, prox, ostial SVG (to LPL)
- Moderate mitral regurgitation
- Chronic diastolic congestive heart failure, TTE from [**9-6**]
with EF 55% with regional systolic dysfunction
- Hyperlipidemia
- Diabetes
- Hypertension
- History of ischemic bowel disease and subsequent urgent right
hemicolectomy subsequent to his last coronary intervention.
- Chronic anemia, on Epo.
- TIA
- GERD
- h/o UGI bleed (no NSAIDs aside from [**Month/Year (2) **])
- Glaucoma
- Carotid stenosis: 60-69% stenosis of the bilateral internal
carotid arteries.
- Myelodysplastic Syndrome s/p BMB in [**2167**], followed by Dr.
[**Last Name (STitle) 2539**]
- Chronic Renal Failure baseline Cr. 1.2-1.4
- Gout
Social History:
Lives with wife has some help that comes in several times a
week. Has 3 children, one son is a retired OB/GYN. Never smoked
cigarettes and rarely smoked cigars, none recently Denies
alcohol consumption. Patient was in the Navy. Retired
businessman.
Family History:
Family hx of CAD
Physical Exam:
GENERAL: intubated, sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD to jaw
LUNGS: Bibasilar rales no wheezing.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
ADMISSION LABS [**2171-10-25**]:
[**2171-10-25**] 08:25AM WBC-7.9 Hgb-10.1* Hct-31.7* Plt Ct-171
[**2171-10-25**] 01:09PM Neuts-82.5* Lymphs-11.0* Monos-5.6 Eos-0.7
Baso-0.2
[**2171-10-25**] 08:25AM PT-12.7 PTT-22.4 INR(PT)-1.1
[**2171-10-25**] 08:25AM Fibrino-410*
[**2171-10-25**] 01:09PM Glucose-196* UreaN-36* Creat-1.3* Na-138 K-3.5
Cl-103 HCO3-27 AnGap-12
[**2171-10-25**] 08:25AM CK(CPK)-43
[**2171-10-25**] 08:25AM Lipase-17
[**2171-10-25**] 08:25AM cTropnT-0.02*
[**2171-10-25**] 08:25AM CK-MB-NotDone proBNP-3420*
[**2171-10-25**] 08:46AM Type-ART Tidal V-500 FiO2-100 pO2-414* pCO2-55*
pH-7.33* calTCO2-30 Base XS-1 AADO2-249 REQ O2-49 -ASSIST/CON
[**2171-10-25**] 08:35AM Glucose-184* Lactate-1.2 Na-139 K-4.2 Cl-100
calHCO3-27
CE TREND:
[**2171-10-25**] 08:25AM CK(CPK)-43
[**2171-10-25**] 04:09PM CK(CPK)-34*
[**2171-10-26**] 06:41AM CK(CPK)-27*
[**2171-10-27**] 12:26AM CK(CPK)-205*
[**2171-10-27**] 06:31AM CK(CPK)-228*
[**2171-10-27**] 03:02PM CK(CPK)-189*
[**2171-10-28**] 03:57AM CK(CPK)-116
[**2171-10-25**] 08:25AM CK-MB-NotDone cTropnT-0.02*
[**2171-10-25**] 04:09PM CK-MB-NotDone cTropnT-<0.01
[**2171-10-26**] 06:41AM CK-MB-NotDone cTropnT-0.03*
[**2171-10-27**] 12:26AM CK-MB-23* MB Indx-11.2* cTropnT-0.76*
[**2171-10-27**] 06:31AM CK-MB-29* MB Indx-12.7* cTropnT-0.97*
[**2171-10-27**] 03:02PM CK-MB-23* MB Indx-12.2*
[**2171-10-28**] 03:57AM CK-MB-11* MB Indx-9.5* cTropnT-0.86*
OTHER PERTINENT LABS:
[**2171-10-26**] 06:41AM ALT-12 AST-15 AlkPhos-73 TotBili-0.3
[**2171-11-1**] 02:08AM ALT-11 AST-18 AlkPhos-64
[**2171-10-25**] 01:09PM TSH-3.7
[**2171-11-1**] 02:08AM TSH-3.2
[**2171-11-1**] 02:08AM T4-5.5
UA:
[**2171-10-25**] 08:35AM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2171-10-25**] 08:35AM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO:
RESPIRATORY CULTURE (Final [**2171-11-2**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci
.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2171-10-25**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2171-10-25**]):
Negative for Influenza B.
BCx - negative x2
[**Last Name (un) **] Legionella - negative
UCx - negative
IMAGING:
[**2171-10-25**] ECHO:
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 inferior and inferolateral hypokinesis. Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2171-9-2**],
the degree of aortic stenosis has increased. The prior echo did
not mention the presence of aortic stenosis, which was an error.
[**2171-10-25**] CXR:
1. Status post intubation with endotracheal tube terminating 2.2
cm above the carina.
2. Nasogastric tube suboptimally located, terminating within the
distal
esophagus; recommend advancement.
3. Patchy opacities extending from the hila to the lung
periphery
bilaterally, right greater than left, suggests asymmetric
pulmonary edema or an infectious process. Small right pleural
effusion.
[**2171-10-31**] Cardiac Cath:
COMMENTS:
1. Coronary angiography in this right dominant system was not
performed
given the patients known totally occluded LCx and RCA.
2. Arterial conduit angiography revealed the LIMA to be widely
patent.
The SVG-LPL had diffuse disease with patent stents and normal
flow.
3. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP 15 mmHg and PCWP 17 mmHg. There was
moderate
pulmonary artery systolic hypertension with PASP 44 mmHg. The
cardiac
index was preserved at 3.6 L/min/m2. The systemic vascular
resistance
was mildly low at 684 dynes-sec/cm5. The pulmonary vascular
resistance
was mildly elevated at 204 dynes-sec/cm5. There was mild
systemic
arterial systolic hypotension with SBP 95 mmHg.
FINAL DIAGNOSIS:
1. Patent LIMA to LAD.
2. Patent SVG-LPL.
3. Elevated filling pressures.
[**2171-11-1**] CXR:
ET tube tip is 4.4 cm above the carina and lies against the left
lateral wall of the trachea. There has been minimally improved
moderate pulmonary edema. The lungs are better expanded. Left
lower lobe retrocardiac opacity is persistent. Pleural effusions
are larger on the left side. Cardiomediastinal contours are
unchanged. There is no pneumothorax.
DISCHARGE LABS [**2171-11-6**]:
[**2171-11-6**] 07:20AM WBC-6.5 Hgb-9.8* Hct-31.6* Plt Ct-243
[**2171-11-6**] 07:20AM Glucose-119* UreaN-64* Creat-1.9* Na-138 K-4.1
Cl-97 HCO3-34* AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 23099**] is a [**Age over 90 **] year old man with a history of severe CAD s/p
CABG x 2 and multiple PCIs, dCHF, DM, and CKD who presented with
shorness of breath and respiratory distress. He was intubated
twice during the hospitalization for pulmonary edema.
# Acute on Chronic diastolic CHF: Currently appears euvolemic
with no pedal edema or crackles but labs note pt is
intravscularly dry. Exacerbation consistant with increased Na
load before admission and with likely ischemia during hospital
stay. Cardiac catheterization did not show any lesions amenable
to intervention. Imdur was increased to prevent ischemic
episodes and Norvasc was started to replace nifedipine. Bumex
was continued at 2mg daily and Coreg at 50 mg [**Hospital1 **], same as
before admission. Weight at discharge was 131 pounds and should
be considered dry weight. Pt was able to ambulate without O2 and
SOB. Extensive teaching done with pt and daughter about CHF
prevention and monitoring. Daughter has met with a nutritionist
and VNA is in place to continue to monitor closely. Pt has been
referred to CHF specialists and will see them next week. TEDS
stockings were given to mobilize peripheral edema.
# CAD s/p CABGx2 and multiple stents, currently on medical
management: cardiac catheterization with no lesions amenable to
intervention. Likely experiencing microvascular ischemia leading
to repeat episodes of pulmonary edema. HR at goal, Imdur
increased and CCB changed as noted above. Pt will continue on
[**Hospital1 **], clopidogrel, and atorvastatin. He has NTG SL that he uses
at home for "back pain" his anginal equivalent.
# HTN: Currently controlled. Home regimen includes BB and CCB.
# Acute on Chronic kidney injury: creatinine inc today to 1.9
after brisk diuresis, very likely pre-renal. Renal status is a
limiting factor to further aggressive diuresis. Will continue
Bumex as outpt, check lytes on Friday with results to Dr. [**First Name (STitle) 437**].
# MDS/ Chronic Normocytic Anemia: Patient has known chronic
anemia at baseline thought [**12-31**] myelodysplasia. Followed by Heme
as outpatient. On Epo injections 20K at home and will continue
after discharge.
# Diabetes type 2: hyperglycemia improved with lantus dose and
regular insulin sliding scale. No change made to home regimen.
Medications on Admission:
1. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
4. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **]
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
6. Latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime.
7. Nifedipine 30 mg Tablet Sustained Release Sig: (1) Tablet PO
BID
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Epogen 20,000 unit/2 mL Solution Sig: 1 Injection once a
week.
16. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime prn
17. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO BID
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
21. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
22. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
23. Aspirin 81 mg Tablet, Delayed Release (E.C.) 1 tab PO DAILY
24. XIBROM 0.09 % Drops Sig: One (1) gtt Ophthalmic twice a day.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet 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) Tablet,
Sublingual Sublingual PRN (as needed) as needed for CP: take up
to 3 tablets 5 minutes apart. Call Dr. [**First Name (STitle) **] if you have chest
pain. .
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
10. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
12. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Isosorbide Mononitrate 120 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*
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Lantus 100 unit/mL Solution Sig: as directed per sliding
scale units Subcutaneous at bedtime.
17. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
18. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
19. Outpatient Lab Work
please check Chem 7 on [**11-7**] and call results to Dr. [**First Name (STitle) 437**] or
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 62**].
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Coronary Artery disease
Acute on Chronic Kidney disease
Acute on chronic Diastolic congestive Heart failure
Diabetes Mellitus
Myelodysplastic syndrome
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 had 2 episodes of congestive heart failure that required you
be treated with a ventilator to breathe. You were given
diuretics and we adjusted your medicines as described below. You
had a cardiac catheterization to see if there were any blockages
in your coronary arteries that could be treated, there were not.
You kidneys did not work very well after the catheterization but
are stable. You will get your kidney function checked again on
Friday.
.
Medication changes:
1. Increase the Imdur to 120 mg daily
2. Stop taking Nifedipine
3. Start taking Norvasc to prevent chest pain.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. in 1 day or 6 pounds in 3 days.
You have an appt to get your Epogen shot on Monday.
Followup Instructions:
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14973**] Phone: [**Telephone/Fax (1) 133**] Date/Time: Wednesday
[**11-13**] at 10:45
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: please keep any
regularly scheduled appts.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2171-11-11**] 11:00
.
Hematology: Epogen injection
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2171-11-11**] 12:30
|
[
"403.90",
"250.00",
"238.75",
"518.81",
"433.30",
"428.33",
"V45.82",
"285.9",
"414.02",
"V12.54",
"416.8",
"530.81",
"585.9",
"433.10",
"414.01",
"414.2",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.57",
"96.04",
"96.71",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14921, 14964
|
9162, 11487
|
310, 360
|
15159, 15159
|
4000, 5409
|
16120, 16805
|
3476, 3494
|
13041, 14898
|
14985, 15138
|
11513, 13018
|
8500, 9139
|
15336, 15790
|
3509, 3981
|
15810, 16097
|
251, 272
|
388, 2277
|
5431, 8483
|
15173, 15312
|
2299, 3194
|
3210, 3460
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,849
| 122,692
|
49483+49484
|
Discharge summary
|
report+report
|
Admission Date: [**2140-2-5**] Discharge Date: [**2140-2-7**]
Date of Birth: [**2090-7-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
gentleman with class IVb pulmonary artery hypertension
(secondary to scleroderma) and also with congestive heart
failure with diastolic dysfunction (last ejection fraction
was 55%) who was admitted to the hospital for a cardiac
catheterization and titration of his Flolan for worsening
shortness of breath over the past week despite an increase in
his Flolan dose as an outpatient.
The cardiac catheterization showed elevated pulmonary artery
pressures of 69/12. His wedge was 27. There was no evidence
of effusion. He had normal right-sided and left-sided
filling pressures. This increase in his pulmonary
hypertension had increased since his last catheterization.
His cardiac output was preserved at 5.52; which was slightly
reduced since his previous cardiac catheterization.
His recent outpatient workup for this worsening shortness of
breath had included a computed tomography scan of his lungs
which showed that he had an increasing right pleural
effusion. An echocardiogram showed no changed from previous,
and there had been a question of dietary indiscretion.
Recently, his outpatient diuretic regimen had been increased.
On admission, his creatinine was 2.
REVIEW OF SYSTEMS: Review of systems revealed no fevers or
chills. No chest pain. Shortness of breath as noted above.
PAST MEDICAL HISTORY:
1. Scleroderma.
2. Pulmonary hypertension on Flolan since [**2139-5-21**].
3. He also has a history of pleural effusion on the right.
4. History of hypocalcemia.
5. History of chest wall cellulitis.
6. Gastroesophageal reflux disease.
7. History of Staphylococcus aureus bacteremia.
8. Status post turbinectomy.
9. Status post venous stripping.
10. Hypertension.
11. History of neck pain; question migraines.
12. History of low back pain.
MEDICATIONS ON DISCHARGE:
1. Flolan 21 ng/kg/min.
2. Bumex 4 mg by mouth twice per day.
3. Aldactone 25 mg by mouth once per day.
4. Zaroxolyn 2.5 mg three times per week.
5. Protonix 40 mg by mouth once per day.
6. Ativan.
7. Vicodin.
8. Nasal cannula oxygen 4 liters.
9. Diltiazem 300 mg by mouth once per day.
10. Coumadin 1 mg by mouth at hour of sleep.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient lives in [**Location (un) **]. He is
disabled. He lives with his sister. [**Name (NI) **] history of alcohol,
tobacco, or drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 96.8
degrees Fahrenheit, his heart rate was 70, his respiratory
rate was 12, his blood pressure was 92/42, and his oxygen
saturations were 90% on 4 liters. In general, the patient
was in no apparent distress. He was plethoric. He was alert
and oriented times three. Head, eyes, ears, nose, and throat
examination revealed the pupils were equal, round, and
reactive to light and accommodation. The mucous membranes
were moist. There was no thrush. There were
telangiectasias. Neck examination revealed he had a
Swan-Ganz catheter in place. Respiratory examination
revealed the patient had decreased breath sounds at the right
base. There were no rhonchi and no wheezes. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. He did have a loud P2.
There were no murmurs, rubs, or gallops. The abdomen was
soft, nontender, and nondistended. Extremity examination
revealed he had blisters on his shins. He had dusky legs.
Mild sclerodactyly. No clubbing, cyanosis, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed his white blood cell count was 15.1, his
hematocrit was 36.8, and his platelets were 273. His
Chemistry-7 was significant for a sodium of 129 and a
creatinine of 2.1 (up from his baseline of 1.7). His
arterial blood gas was 7.44/46/123.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Medical Intensive Care Unit. His
hospital course by issue/system was as follows.
1. PULMONARY ARTERY HYPERTENSION ISSUES: The patient with
pulmonary artery hypertension causing increasing shortness of
breath.
The patient was admitted for Flolan titration and sildenafil
therapy. The patient's Flolan initially was left at 21
ng/kg/min and sildenafil was added at 25 mg three times per
day. The Swan-Ganz catheter was used to monitor his
pulmonary artery pressures. His pulmonary artery pressures
initially decreased by about 10% with the doses of
sildenafil; however, over the following days there was not
significant improvement in his pulmonary artery pressures
with this dose.
On [**2-6**], his Flolan dose was titrated up to 29
ng/kg/min; however, due to a headache, nausea, and vomiting
his dose had to be titrated down to 25 ng/kg/min. On [**2-7**], it was titrated down to 23 ng/kg/min as it appeared that
he was having side effects, but no change in his pulmonary
artery pressures.
With regard to the sildenafil, he began experiencing
headaches. Therefore, the decision was made to continue the
sildenafil q.8h. as needed; however, holding for headaches
and systolic blood pressures of less than 90.
If the patient persistently has shortness of breath, they may
do a thoracentesis and remove some of the fluid from the
right lung.
2. CARDIOVASCULAR ISSUES/CONGESTIVE HEART FAILURE: The
patient with an ejection fraction of 55%. On admission, his
diuretics were held until his systolic blood pressure
improved. The patient was placed on a low-sodium diet with a
fluid restriction.
On [**2-6**], he restarted his Bumex and Aldactone at his
home doses. He appeared to be volume overloaded on the
evening of [**2-6**], so he was given some as-needed Lasix.
He was to restart his Zaroxolyn on Monday, and it will be at
a decreased dose. It will be Zaroxolyn 2.5 mg every Monday
and Thursday only. They will continue to measure
ins-and-outs and daily weights on the floor.
3. RENAL FAILURE ISSUES: It appeared that the renal failure
had been in the setting of over diuresis as an outpatient.
It improved over the course of his hospital stay. This will
continue to be followed.
4. HYPONATREMIA ISSUES: Again, the hyponatremia was likely
secondary to outpatient diuresis. This improved over the
course of his hospital stay. On discharge from the Intensive
Care Unit, his sodium was 132.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
kept on a low-sodium/cardiac diet as noted above.
6. ACCESS ISSUES: The patient's Swan-Ganz catheter was
pulled prior to leaving the Intensive Care Unit.
NOTE: The rest of this dictation will be done upon discharge
from the hospital.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2140-2-7**] 13:04
T: [**2140-2-7**] 14:16
JOB#: [**Job Number 103540**]
cc:[**Last Name (NamePattern1) **] Admission Date: [**2140-2-4**] Discharge Date: [**2140-2-12**]
Date of Birth: [**2090-7-7**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old male with
past medical history of scleroderma (limited systemic sclerosis -
CREST syndrome) and NYHA Class IIIB-IV pulmonary hypertension, on
Flolan since [**2139-5-21**], CHF thought to be secondary to
diastolic dysfunction versus related to pulmonary hypertension,
who presented on [**2140-2-4**] status post right heart catheterization
after reporting a several week history of increasing shortness of
breath and dyspnea with exertion.
Patient had been stable on outpatient regimen of Flolan 75 cc per
24 hours, Bumex, aldactone, Zaroxolyn, and IV Lasix boluses since
last discharged in [**2139-11-21**]. However, for the past two
weeks, he has noted increasing dyspnea. He had attempted to self
titrate his Flolan at home without relief. In response to his
symptoms, he underwent echocardiogram as an outpatient.
Echocardiogram on [**2140-2-2**] demonstrated mildly dilated left
atrium, left ventricular ejection fraction greater than 55%. The
right ventricle was moderately dilated with moderate global right
ventricular free wall hypokinesis. There is abnormal septal
motion in position consistent with right ventricular pressure,
volume overload, 1+ tricuspid regurgitation was noted. There was
severe pulmonary artery systolic hypertension. There was
also moderate sized pericardial effusion, which was
circumferential, but with no signs of tamponade other than
brief right atrial collapse.
He was referred into the hospital by his primary pulmonologist
for right heart catheterization, and titration of his Flolan.
Right heart catheterization showed a mean pulmonary capillary
wedge pressure of 8 (earlier measurements raised possibility of
PCW = 27, but Dr. [**Last Name (STitle) 911**] reviewed tracings and felt PCW = 8 more
accurate), mean right atrial pressure of 5, pulmonary artery
pressure of 69/12, right ventricle pressure of 68/4.
Demonstrated normal right and left sided filling pressures.
Cardiac output was relatively preserved at 5.52 liters per
minute. Pulmonary vascular resistance was increased at 421.
Pulmonary artery systolic hypertension was increased compared
with prior catheterizations when he had been on higher Flolan
doses.
Status post right heart catheterization, he was transferred
to the Medical Intensive Care Unit for further monitoring as
well as titration of his Flolan. While in the Medical
Intensive Care Unit, the Swan-Ganz catheter remained in place for
continuous monitoring. He had a trial of sildenafil 25 mg
p.o. t.i.d. which demonstrated a drop in his pulmonary artery
pressure of approximately 10%, demonstrated increased cardiac
output, and a slight drop in his systolic blood pressure.
However, he had difficulty tolerating the sildenafil
secondary to severe headache. Also while in the Medical
Intensive Care Unit, his Flolan was titrated up to a dose of
23 ng/kg/minute.
PAST MEDICAL HISTORY:
1. Scleroderma with CREST syndrome diagnosed approximately 20
years ago due to sclerodactyly. Associated pulmonary
hypertension, on Flolan since [**2139-5-21**]. Pulmonary
function tests in [**2140-1-29**] showed worsening
restrictive function with FEV1 of 1.68 liters, FVC of 42%
predicted, elevated FEV1/FVC ratio at 118% predicted, total
lung capacity 49% predicted, residual volume 60% predicted,
and DLCO of 28% predicted.
2. History of right pleural effusions status post
thoracentesis in [**2139-12-21**], which revealed a mildly
exudative fluid with an increased total protein and increased
LDH with lymphocyte predominance. Cytology and flow
cytometry demonstrated no evidence of malignancy or lymphoma.
3. History of pneumonia.
4. History of hypokalemia.
5. History of chest wall cellulitis.
6. GERD.
7. History of Staphylococcus aureus bacteremia.
8. Status post turbinectomy.
9. Status post venous stripping.
10. Hypertension.
11. Congestive heart failure diagnosed in [**2139-11-21**].
Echocardiogram in [**2140-2-2**] with mildly dilated LA, left
ventricular ejection fraction greater than 55%, right
ventricle moderately dilated with moderate global right
ventricular free wall hypokinesis. There is abnormal septal
motion and position consistent with right ventricle pressure
and volume overload. One plus tricuspid regurgitation.
Severe pulmonary artery systolic hypertension. A moderate
sized pericardial effusion, circumferential, with no signs of
tamponade, but brief right atrial collapse.
12. History of neck pain, perhaps with migraine component.
13. History of low back pain.
14. Status post Hickman catheter re-placement on [**9-23**].
MEDICATIONS PRIOR TO ADMISSION:
1. Flolan at 21 ng/kg/minute.
2. Bumex 4 mg p.o. b.i.d.
3. Aldactone 25 mg p.o. q.d.
4. Zaroxolyn 2.5 mg p.o. 3x a week on Mon/Wed/Fri.
5. Protonix 40 mg p.o. q.d.
6. Ativan prn.
7. Vicodin prn.
8. Oxygen continuous 4 liters nasal cannula.
9. Diltiazem 300 mg p.o. q.d.
10. Coumadin 1 mg p.o. q.d.
11. Digoxin 0.125 mg po qd
ALLERGIES: Patient reports no known drug allergies.
SOCIAL HISTORY: Patient lives in [**Location (un) **] with his
sister. [**Name (NI) **] is unemployed on disability. He denies alcohol,
tobacco, or IV drug use.
FAMILY HISTORY: No family history of scleroderma or CREST
syndrome or any cardiopulmonary disease.
PHYSICAL EXAMINATION ON TRANSFER: Vital signs showed him to
be afebrile, blood pressure 104/62, heart rate 68,
respiratory rate 18, and oxygen saturation 97% on 4 liters
nasal cannula O2. General appearance: Well-developed,
well-nourished white male, breathing easy, comfortable in no
acute distress. HEENT: Masked facies. Head and neck with
plethora. Pupils are equal, round, and reactive to light.
Mucous membranes moist. No oral thrush noted. Neck:
Supple, no masses or lymphadenopathy. Jugular venous
pressure at 8-10 of H2O at 45 degrees. Lungs: Decreased breath
sounds at right base with dullness to percussion. Otherwise
clear to auscultation bilaterally with no rhonchi, rales, or
wheezes. Cardiac: Regular rate and rhythm. Normal S1 with a
very loud split fixed S2. No murmurs, rubs, or gallops.
Abdomen: Firm, mildly distended, nontender, positive normoactive
bowel sounds. Extremities: No clubbing, cyanosis, or edema.
Sclerodactyly livedo on palms. Dark discoloration of anterior
tibial skin bilaterally. Some evidence of autoamputation of the
distal fingertips.
PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES:
Laboratories on transfer showed complete blood cell count
with WBC 9.5, hematocrit 30.7, platelets 196. Serum
chemistries demonstrate sodium 132, potassium 4.1, chloride
92, bicarbonate 35, BUN 23, creatinine 1.2, glucose 108,
calcium 9.1, phosphorus 4.4, magnesium 1.7.
Chest x-ray showed paracentral increase in densities, but
bilateral effusions consistent with pulmonary edema.
Chest CT from [**2140-2-2**] demonstrated diffuse central lobular
ground-glass opacities with smoothly thickened septal lines.
There was band-like areas of probable atelectasis at the
bases bilaterally. There were moderate sized right pleural
effusions, which had increased in size compared with previous
studies. There was prominence of the pulmonary artery.
There were minimal reticular opacities at the extreme left
base.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Dyspnea: Patient's dyspnea was felt to be secondary to
worsening pulmonary hypertension. While he was in the
Medical Intensive Care Unit, he had his Flolan dose titrated
up to 23 ng/kg/minute. He also underwent a trial of
sildenafil for nitric oxide mediated dilatory effects,
however, this resulted in severe headache and patient was
unable to tolerate sildenafil.
After he failed his trial of sildenafil, we attempted to
titrate up his Flolan dose while on the floor. However, he
did not tolerate the increased Flolan dose secondary to
dizziness, headache, and nausea. He also underwent
esophageal balloon studies under the hypothesis that perhaps
some component of his dyspnea was due to chest wall
restriction secondary to scleroderma. However, his
esophageal balloon studies showed relatively normal elastic
recoil of the chest wall and slightly increased recoil of
the lung consistent with interstitial edema/effusion or perhaps
early inflammatory/fibrotic changes from scleroderma.
It was postulated as well that perhaps some component of the
patient's dyspnea was secondary to his history of right
ventricular CHF. Therefore, he was diuresed aggressively
while on the floor with Lasix intravenous, Bumex, metolazone,
spironolactone. He continued to be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
of the Advanced Heart Failure Clinic, and she and her staff
made recommendations as to changes to the medications
diuretic regimen in order to increase his subjective sense of
breathing improvement.
It was noted also that the patient had not been using the
recommended ice packs while using his Flolan at home. These
ice packs help increase the efficacy and half-life of Flolan.
He was educated aggressively on the need to use the ice packs
with his Flolan in order to enhance his breathing. Patient
had been tried on Bosentan in the past. Per the patient, he
felt no subjective improvement with Bosentan alone. It is
postulated that perhaps, Flolan and Bosentan together would
provide subjective improvement in his dyspnea. He will
likely try this regimen as an outpatient.
Additionally, it was noted that the patient's diltiazem had
been discontinued while he was in the Medical Care Intensive
Care Unit. It was discontinued in hopes that perhaps ACE
inhibitor would be more appropriate in providing afterload
reduction in light of his history of congestive heart
failure. However, after discussion with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
Dr. [**Last Name (STitle) **], diltiazem was reinitiated and ACE inhibitor was
held. He will likely restart an ACE inhibitor as an
outpatient.
Finally, the patient underwent a repeat chest CT scan in
order ascertain whether the ground-glass opacities
demonstrated on his [**2140-2-2**] CT scan were indicated of
congestive heart failure or whether there was a secondary
process, possibly alveolitis, going on as well. Initial read
of the chest CT demonstrated persistent ground-glass
opacities. Further followup will be required to determine if
this due to residual interstitial edema or early alveolitis.
2. Right ventricular congestive heart failure: Patient had a
recent echocardiogram, which demonstrated preserved ejection
fraction. It is unclear whether the mechanism of his CHF was
due to diastolic dysfunction alone or perhaps mediated by
severe pulmonary hypertension. Initially, he was continued
on his outpatient regimen of Zaroxolyn 2.5 mg 3x a week,
Bumex, aldactone with Lasix added on an as needed basis for
continued diuresis.
He was followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the Advanced Heart
Failure Clinic, who made recommendations as to the changes in
his regimen. He was noted to have a right sided pleural
effusion on his CT scan. He therefore was evaluated by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] of the Interventional Pulmonary service,
who did a bedside ultrasound of the patient's effusion, and
found it to be a small subpulmonic effusion not amenable to
therapeutic thoracentesis.
In addition, to his aggressive diuretic regimen, he was
maintained on a low sodium diet with daily weights and I's
and O's recorded. He diuresed well during this admission
with a several kg weight loss. This corresponded with a
subjective improvement in his breathing. The patient was
educated on the importance of the low sodium diet and the
importance of maintaining it while as an outpatient.
Additionally, a family member brought in his home scale for
calibration compared to the hospital scale. Of note, the
patient's home scale was 3 pounds lighter than the hospital
scale. His discharge instructions were to modify to account
for this difference. As an outpatient, he will be maintained
on Bumex 4 mg p.o. b.i.d., spironolactone 25 mg p.o. q.d. as
well as metolazone sliding scale based on his weights. He
was instructed to weigh himself daily and follow the sliding
scale accordingly.
3. Acute renal failure: Upon admission, the patient had a
slight bump in his creatinine most likely secondary to
prerenal versus diuretic-induced causes. He had no evidence
of urinary sediment to suggest sclerodermal renal crisis.
His creatinine improved with fluid hydration while in the
Intensive Care Unit. It remained relatively stable during
continued diuresis on the floor.
4. Fluids, electrolytes, and nutrition: Patient was
maintained on a low sodium diet. His electrolytes were
followed serially and repleted as needed. His potassium was
monitored closely in light of his history of hypokalemia, it
was repleted aggressively.
5. Code status: The patient is full code.
6. Access: The patient has a right internal jugular
Permacath.
7. Disposition: Patient was discharged to home once his
dyspnea had improved. Of note, his weight on day of
discharge on hospital scale was 69.5 kg, which is within his
baseline range.
DISCHARGE CONDITION: Stable. Afebrile. Hemodynamically
stable. Dyspnea stable. Tolerating oral intake without
nausea or vomiting. Ambulating independently. Weight at
69.5 kg.
DISCHARGE STATUS: Patient was discharged to home with
services.
DISCHARGE DIAGNOSES:
1. Severe pulmonary hypertension.
2. Scleroderma/calcinosis cutis, Raynaud phenomenon,
esophageal motility disorder, sclerodactyly, and
telangiectasia syndrome.
3. Congestive heart failure with diastolic dysfunction.
4. History of right pleural effusion.
5. History of hypokalemia.
6. History of pneumonia.
7. History of chest wall cellulitis.
8. Gastroesophageal reflux disease.
9. History of Staphylococcus aureus bacteremia.
10. Status post turbinectomy.
11. Status post venous stripping.
12. Hypertension.
13. History of neck pain perhaps with migraine component.
14. History of low back pain.
15. Status post Hickman catheter placement in [**2139-11-21**].
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Flolan 23 ng/kg/minute continuous intravenous infusion.
3. Oxygen continuous 4 liters nasal cannula.
4. Bumex 4 mg p.o. b.i.d.
5. Spironolactone 25 mg p.o. q.d.
6. Potassium chloride 80 mEq p.o. b.i.d. Patient is also
instructed to take an additional 40 mEq of potassium on days
that he takes Zaroxolyn.
7. Diltiazem 300 mg p.o. q.d.
8. Fluoxetine 20 mg p.o. q.d.
9. Coumadin 1 mg p.o. q.d.
10. Ativan 0.5 mg one tablet p.o. q.4-6h. as needed for
anxiety.
11. Loperamide 2 mg [**1-22**] capsules p.o. q.i.d. as needed for
loose stools.
12. Vicodin 1-2 tablets p.o. q.4-6h. as needed for pain.
13. Metolazone 2.5 mg tablets via sliding scale. Patient's
baseline weight should be less than 153 pounds, however, this
is based on the hospital scale. Patient brought in his home
scale, and the home and hospital scales were calibrated
appropriately. He is to dose metolazone as follows based on
his weight on his home scale: If his weight is less than 150
pounds, he should not take any metolazone. If his weight is
between 150-153 pounds, he should take metolazone 2.5 mg p.o.
q.d. If his weight is greater than 153 pounds, he is to call
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **], and notify him of his increased
weight and likely increased fluid retention.
FOLLOW-UP PLANS: Patient had the following appointments
scheduled:
1. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2140-2-19**] at 9 a.m. in the [**Hospital Ward Name 23**]
Clinical Center.
2. Pulmonary function testing on [**2140-2-19**] at 8:45 a.m. in the
[**Hospital Ward Name 23**] Clinical Center.
3. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2140-3-3**] at 10 a.m. in the [**Hospital Ward Name 23**]
Clinical Cardiac Services Center.
DISCHARGE INSTRUCTIONS: In addition, he was instructed to
weigh himself every morning. If his weight was less than 150
pounds, he was not to take metolazone. If his weight was
between 150-153 pounds, he was to take one metolazone tablet
2.5 mg p.o. q.d. If his weight was greater than 153 pounds,
he was to call Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. He was instructed
to adhere to the 2-gram sodium diet as well as a 1500 cc a
day fluid restriction. He was educated on the use of ice
packs as instructed with his Flolan in order to increase his
efficacy. He is also instructed to call Drs. [**Last Name (STitle) **],
[**Name5 (PTitle) **], [**Name5 (PTitle) **] [**Doctor Last Name **] if he experienced any worsening shortness of
breath, chest pain, dizziness, lightheadedness, fainting,
fevers, chills, or any other worrisome symptoms.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2691**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2140-2-15**] 10:26
T: [**2140-2-15**] 10:53
JOB#: [**Job Number 103541**]
cc:[**First Name8 (NamePattern2) 103542**]
|
[
"517.2",
"428.30",
"428.0",
"401.9",
"416.8",
"276.1",
"276.3",
"710.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"89.64",
"89.67"
] |
icd9pcs
|
[
[
[]
]
] |
20575, 20802
|
12502, 14553
|
20823, 21486
|
21509, 22828
|
1988, 2377
|
23361, 24556
|
14581, 20553
|
11940, 12320
|
4132, 7321
|
22846, 23336
|
1376, 1478
|
7350, 10218
|
10240, 11908
|
12337, 12485
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,011
| 128,179
|
33015+57829
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-2-1**] Discharge Date: [**2175-2-21**]
Date of Birth: [**2112-1-20**] Sex: F
Service: SURGERY
Allergies:
Amiodarone / Mobic
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
s/p ERCP w/pancreatic stent and sphincterotomy.
.
PTC [**2175-2-6**]
.
Successful removal of the previously placed plastic pancreatic
stent.
History of Present Illness:
63 year old female who is a transfer from [**Hospital3 **] hospital
for suspected perforation after ERCP. Patient initially
presented
to [**Hospital3 **] hospital on [**1-31**] for a scheduled ERCP with
pancreatic stent placement and sphincterotomy for repeated
episodes of pancreatitis. Procedure was complicated by
persistent
bleeding after the sphincterotomy which treated with epinephrine
and bicapped with a 10 French bicap. Post procedure the patient
was admitted for abdominal pain during which the pain became
more
severe. The pain was described as sharp, constant and diffuse
with no allieviating or exacerbating factors. A CT scan revealed
retroperitoneal gas, likely bleeding perforation related to ERCP
with no demonstration of active leak. The patient was then
placed
on IVF had an NGT placed and was started on IV antibiotics. The
patient was transferred to [**Hospital1 18**] for further management and care
Past Medical History:
Recurrent pancreatitis, hx of afib, s/p pacemaker
implantation, hx diabetes mellitus, HTN, depression, hx CAD s/p
ACS in [**6-20**], s/p PCI [**5-20**], hx of renal artery stenosis, s/p
renal
PTA and stenting, right leg claudication, s/p R femoral artery
embolization, dyslipidemia
Social History:
Patient is retired school teacher and lives with her
husband. She [**Name2 (NI) 25190**] 3 times a week
Family History:
Father died of heart disease at 56 and mother died of
dementia at 76. No history of cancer
Physical Exam:
VS - T97.9 P76 BP132/68 RR18 O2sat 98%RA
PE - Gen - alert and oriented, no acute distress
CV - regular rate and rhythm, no murmurs, gallops or rubs
Pulm - clear to ascultation bilaterally
GI - Abdomen is firm, nontender to deep palpation, no
palpable masses, non distended
Ext - no clubbing, cyanosis or edema
Pertinent Results:
[**2175-2-2**] 05:30AM BLOOD WBC-9.0 RBC-3.59* Hgb-11.1* Hct-33.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-14.2 Plt Ct-166
[**2175-2-2**] 05:30AM BLOOD PT-14.6* PTT-29.4 INR(PT)-1.3*
[**2175-2-2**] 05:30AM BLOOD Glucose-107* UreaN-19 Creat-0.9 Na-143
K-3.3 Cl-107 HCO3-28 AnGap-11
[**2175-2-2**] 05:30AM BLOOD ALT-88* AST-74* LD(LDH)-187 AlkPhos-171*
Amylase-1037* TotBili-1.0
[**2175-2-2**] 05:30AM BLOOD Lipase-582*
[**2175-2-2**] 05:30AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.6* Mg-1.7
[**2175-2-2**] 09:39AM BLOOD Lactate-1.1
[**2175-2-2**] 05:30AM BLOOD Digoxin-1.6
[**2175-2-17**] 04:50AM BLOOD WBC-7.5 RBC-2.97* Hgb-9.3* Hct-28.2*
MCV-95 MCH-31.4 MCHC-33.1 RDW-15.8* Plt Ct-473*
[**2175-2-17**] 04:50AM BLOOD PT-13.1 PTT-37.9* INR(PT)-1.1
[**2175-2-19**] 12:25PM BLOOD Glucose-166* UreaN-22* Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-30 AnGap-11
[**2175-2-20**] 04:04AM BLOOD ALT-60* AST-59* AlkPhos-256* Amylase-409*
TotBili-1.1
[**2175-2-13**] 04:59AM BLOOD ALT-39 AST-38 AlkPhos-173* Amylase-235*
TotBili-1.6*
[**2175-2-20**] 04:04AM BLOOD Lipase-624*
[**2175-2-13**] 04:59AM BLOOD Lipase-198*
[**2175-2-4**] 04:00PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2175-2-4**] 09:40AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2175-2-19**] 12:25PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
[**2175-2-2**] 05:30AM BLOOD Digoxin-1.6
[**2175-2-4**] 10:49PM BLOOD Phenyto-10.1
.
ERCP [**2-17**]:
1. A previously placed plastic stent placed in the pancreatic
duct was found in the major papilla
2. There was surrounding edema in the major papilla.
3. Successful removal of the previously placed plastic
pancreatic stent
[**2-1**]: CT Abd(OSH) - retroperitoneal gas due to perforation, no
active leak, [**Year (2 digits) **]
[**2-4**]: CT Abd - Interval decrease in pneumoperitoneum with free
air seen around the porta hepatis, pancreatic head and
retroperitoneum. No peripancreatic fluid collections. Mild
intrahepatic biliary dilatation and CBD dilatation measuring up
to 9 mm in diameter. 1.6 x 1.3cm hypodense lesion in the L
kidney likely angiomyolipoma.
[**2-7**] PTC: Nondilated intrahepatic ducts with contrast passing
freely into the duodenum. No leakage or filling defects were
detected in the ducts. 6.7 French external [**Last Name (un) 12170**] catheter
placed from the R hepatic lobe, w/tip in CBD.
[**2-14**] CT: Interval resolution of free intra-abdominal air. No
fluid collection. Interval placement of PCT internal-external
biliary catheter, with associated [**Month/Day (4) **]. Small b/l pleural
effusions with basilar atelectasis. Hypoenhancement of upper &
interpolar aspects of R kidney, likely from impaired arterial
supply.
Weight
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] for further care
Neuro: The patient received IV morphine while NPO with good
result for occasional abdominal pain.
CV: The patient was put on metoprolol IV for blood pressure and
heart rate control. She was closely monitored. Her acute on
chronic heart failure was closely monitored; please see below.
Pulm: Incentive spirometry and ambulation were encouraged.
GI: The patient was made NPO on admission with an NGT.
She was stable and comfortable. On the morning of HD 3, she was
having increased abdominal pain, but did not look septic or have
peritoneal signs.
A CT was performed and showed b/l pleural effusions, perihepatic
edema, intrahepatic biliary dilatation, gastric dilatation, no
collections or free fluid in abdomen, no [**Last Name (LF) **], [**First Name3 (LF) **] free
fluid in pelvis, decreased retroperitoneal free air.
The NGT was removed on HD 3; following removal, the patient had
intermittent nose bleeds for which she received AFrin with good
result. That evening, the patient had one bout of emesis of
about 200cc clotted blood. The patient had complained of
continued nausea and epigastric pain at that time, and a
hematocrit and cardiac enzymes were monitored, which at that
time were stable. The following day, Saturday [**2-5**], the
patient continued to have episodes of hematemesis; and NGT was
placed, and the patient required multiple (~4 u prbcs, and FFP)
transfusions for a GI hemorrhage. The patient was transferred
to the ICU for constant monitoring and serial hematocrits. The
patient's hematocrit stabilized by [**2-7**]. Throughout this
episode, however, the patient's total bilirubin rose to 8.8,
with an elevated direct bilirubin as well (4.3). On [**2-7**], GI
was consulted for a possible ERCP, however they felt that this
was not the best option as the patient would have significant
edema and probable clot present. Instead, the patient was taken
for a PTC; for details please see report. As the patient
would be NPO for an indeterminant period of time, the patient
was started on TPN, and her electrolytes were routinely
monitored.
On [**2-9**], the patient's NGT was removed, and the patient's diet
was advanced to sips. When appropriate, the patient's diet was
advanced, and her TPN was tapered down to nothing; she tolerated
the diet well.
The PTC drain was capped, but she did not tolerate this as she
had a rise in her LFT's, Tbili, Amylase and Lipase.
The drain was uncapped and she was doing well. Please replace
drain output 1/2cc/cc with LR.
GU: She received IVF when appropriate, and her urine output was
routinely recorded. When the patient appeared to be fluid
overloaded, with pulmonary congestion and shortness of breath,
she received Lasix, and was eventually transitioned to her home
Lasix dose which she had not been receiving throughout her
hospitalization.
Endo: The patient was put on an insulin sliding scale
Heme: The patient's hematocrit was followed routinely, and she
was transfused when appropriate.
ID: The patient was continued on IV antibiotics for 10 days.
Proph: Ms. [**Known lastname **] was put on subcutaneous heparin with
pneumoboots throughout her stay.
On discharge, the patient was doing well, vital signs stable,
afebrile, tolerating a regular diet, ambulating, voiding, and
pain well controlled.
Medications on Admission:
Atenolol 50qam/100qpm, Warfarin ([**4-19**], afib), Crestor 40',
Dilantin 100'', Digoxin 0.25', SSI, Lasix 40', Lexapro 10',
Lisinopril 40', Norvasc 5'', Potassium, Protonix 40'', Zetia
10', Vitamins
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
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 Q12H (every 12 hours).
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
14. Insulin Lispro 100 unit/mL Solution Sig: As directed
Subcutaneous ASDIR (AS DIRECTED).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Place Nursing Center
Discharge Diagnosis:
Recurrent pancreatitis
Perforation s/p ERCP w/pancreatic stent and sphincterotomy.
GI hemorrhage
Discharge Condition:
Good
Tolerating a diet
PTC draining
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
* No heavy lifting >10 lbs for 6 weeks.
* Continue to eat several small meals throughout the day.
Advance your PO diet as tolerated.
* Continue with PTC drain care.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**3-19**] weeks. Call to schedule.
.
Please follow-up with Dr. [**Last Name (STitle) **] on [**2174-3-3**] on 8:30am. Call
[**Telephone/Fax (1) 1231**] with questions or concerns.
.
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2175-3-21**] 12:40
Completed by:[**2175-2-21**] Name: [**Known lastname 1974**],[**Known firstname 12502**] Unit No: [**Numeric Identifier 12503**]
Admission Date: [**2175-2-1**] Discharge Date: [**2175-2-21**]
Date of Birth: [**2112-1-20**] Sex: F
Service: SURGERY
Allergies:
Amiodarone / Mobic
Attending:[**First Name3 (LF) 2083**]
Addendum:
Of note, the patient was on Digoxin for Diastolic heart failure
with an EF of 60%. Post-operatively, she was treated with lasix
for acute on chronic heart failure and fluid overload. She
responded appropriately and was discharged on her home dose of
digoxin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1540**] Place Nursing Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2175-2-21**]
|
[
"998.11",
"577.0",
"250.00",
"428.0",
"414.01",
"V45.82",
"998.2",
"E878.8",
"440.1",
"428.33",
"427.31",
"V45.01",
"486",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"99.07",
"97.56",
"99.15",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
12418, 12643
|
4945, 8291
|
292, 435
|
10062, 10100
|
2301, 4922
|
11354, 12395
|
1831, 1924
|
8541, 9828
|
9941, 10041
|
8317, 8518
|
10124, 11331
|
1939, 2282
|
237, 254
|
463, 1387
|
1409, 1693
|
1709, 1815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,933
| 125,026
|
53626
|
Discharge summary
|
report
|
Admission Date: [**2172-12-17**] Discharge Date: [**2172-12-23**]
Date of Birth: [**2104-7-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with a history of paroxysmal atrial fibrillation, status
post failed cardioversion with Procainamide, Amiodarone and
DC cardioversion, now on chronic anticoagulation,
hypertension, probable coronary artery disease with prior
admission for a rectus sheath hematoma, now presenting with
2-4 weeks of increased dyspnea on exertion, increased
orthopnea and increased lower extremity edema. The patient
reports he is typically able to walk 1?????? to 2 miles per day
without dyspnea. For the past month he has had decreased
exercise tolerance secondary to fatigue and dyspnea. He
reports orthopnea times approximately one month. No history
of paroxysmal nocturnal dyspnea. He does admit to a dry
cough, no fevers, chills or sweats, no chest pain with the
exception of some upper chest tightness associated with his
dyspnea. Symptoms on admission today are brought on by the
slightest exertion including bending over to tie his shoes.
He also describes one week of watery black diarrhea. No
abdominal pain, no emesis, occasional nausea. The patient
has had poor po intake earlier in the week secondary to
nausea. No hematemesis, no bright red blood per rectum, no
melena. He has a daughter with diarrheal symptoms
approximately one week ago. The patient was seen in the
clinic today and noted to have brown stool with bright red
blood on rectal exam. His hematocrit was found to be 24.7
with INR of 7.7. He had no symptoms at rest. He was
admitted one year ago for similar symptoms and found to be
dyspneic on exertion with a low hematocrit attributed to
demand ischemia. At that time the patient had an upper and
lower endoscopy which were negative with exception of some
diverticula noted in the large bowel. The patient had no
prior history of bright red blood per rectum, melena or
hematemesis. As noted above, ultrasound on that prior
admission revealed a large rectus sheath hematoma.
PAST MEDICAL HISTORY: 1) History of paroxysmal atrial
fibrillation, hypertension, probable coronary artery disease
with a mibi in [**11-24**] which showed a mild reversible inferior
defect. 2) History of chronic low back pain. 3) History of
external hemorrhoids. 4) History of a rectus sheath hematoma
in the setting of anemia requiring blood transfusion. 5)
History of bright red blood per rectum in [**2171-12-26**] with
a negative EGD, negative colonoscopy and cardiac risk factors
include hypertension and age. 6) History of iron deficiency
anemia, previously on iron supplementation.
MEDICATIONS: On admission, Toprol 50 mg po bid, Verapamil
180 mg po bid, Coumadin 2.5 mg po q d, Motrin 20 mg po q d,
Temazepam 15-45 mg q h.s. prn.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father with diabetes, no history of coronary
artery disease or hypertension.
SOCIAL HISTORY: Patient married with three children, no
tobacco. He drinks approximately one drink per month.
PHYSICAL EXAMINATION: Temperature 97.2, pulse 80, blood
pressure 132/82, respiratory rate 20, pulse 98% on room air.
General appearance, patient awake, alert, oriented times
three, no acute distress. HEENT: Pupils are equal, round,
and reactive to light and accommodation, extraocular
movements intact, moist mucus membranes, sclera anicteric.
Neck, no jugulovenous distension at 45 degrees, supple.
Cardiovascular, irregularly irregular, normal rate, no
murmurs. Lungs with decreased breath sounds at the left
base, trace crackles at the right base. Abdomen soft with
some mild periumbilical tenderness to palpation with active
bowel sounds, no rebound or guarding, no palpable masses, no
CVA tenderness. Rectal exam, brown stool with bright red
blood per PCP. [**Name Initial (NameIs) **], 1+ pitting edema to the mid
calf, 2+ pedal pulses.
LABORATORY DATA: On admission, white blood count 11.7,
hematocrit 24.7 from a baseline of 40 two weeks ago.
Differential, 87% neutrophils, 0% bands, 8% lymphocytes, 3%
monocytes, sodium 139, potassium 4.1, chloride 104, CO2 25,
BUN 28, creatinine 1.0, glucose 157, INR 7.7, ESR 37, uric
acid 3.7. CKs were negative times three. ALT was 69,
alkaline phosphatase 72, [**Doctor First Name **] which was ordered at outpatient
office was positive with a titer of greater than 1:1280 with
a diffuse pattern. As noted above, prior EGD and colonoscopy
had been negative with the exception of some diverticulosis
of the sigmoid and descending colon as well as some grade 3
mixed thrombosed hemorrhoids.
HOSPITAL COURSE:
1. Cardiovascular: Patient with a history of coronary
artery disease. In the setting of his anemia with likely
congestive heart failure, the patient was noted to have some
diffuse ischemic changes on EKG. He subsequently ruled out
for myocardial infarction. He had no chest pain complaints
during this admission. His blood pressure medications were
initially held in the setting of his GI bleed and then
reintroduced. The patient also with evidence of congestive
heart failure, thought to be likely due to demand ischemia.
The patient's dyspnea symptomatically improved after
correction of his hematocrit. Even after aggressive
transfusion for GI bleeding, however, the patient remained
dyspneic on exertion with mild desaturation with ambulation.
He was noted to have persistent bilateral pleural effusions
right greater than left. Please see pulmonary section below.
The patient's atrial fibrillation was rate controlled with
usual dose of Lopressor. The patient was started on a low
dose of Lasix at the time of discharge.
2. GI: The patient presented with one week of black
diarrhea and noted to have bright red blood per rectum on
digital rectal exam by PCP on the day of admission. He
presented with an elevated INR and a low hematocrit. On the
night of admission the patient had a large bloody bowel
movement. He was transfused two units overnight but his
hematocrit did not increase. He became progressively more
tachycardic and uncomfortable. He was subsequently
transferred to the Medical Intensive Care Unit where he was
transfused an additional 4 units of packed red blood cells.
He was also transfused three units of FFP and given three
doses of Vitamin K for elevated INR. A tagged red blood cell
scan was negative. Surgery was consulted. The patient was
not scoped on this hospitalization as his bleeding had
resolved and there was no obvious source on tagged RBC scan.
It was thought that the likely source of his bleeding was
colonic diverticula in the setting of an elevated INR. CT
scan of the abdomen showed no retroperitoneal hematoma.
3. Pulmonary: Patient noted to have some congestive heart
failure as well as bilateral pleural effusions, worse over
baseline on admission. The patient did symptomatically
improve after some diuresis but had a persistent left
moderately sized pleural effusion. On the day prior to
discharge the pleural effusion was tapped and 600 cc of
yellow serous fluid removed. Fluid analysis was as follows:
Gram stain with no polys, no organisms. Pleural fluid
analysis did reveal 9 white blood cells, 8,675 red blood
cells, total protein 3.3, glucose 146, LDH 166, PH 7.47,
cytology, [**Doctor First Name **] and rheumatoid factor were pending at the time
of discharge. Pleural serum LDH ratio was noted to be 0.55
and pleural serum protein ratio was also noted to be 0.55,
the latter consistent with an exudative effusion. The most
likely explanation for this was her Procainamide induced
lupus causing pleuritis. The patient had also been noted to
have evidence of a non hemodynamically significant
pericardial effusion on echocardiogram and chest CT also
supported this diagnosis. An antihistone antibody which is
generally consistent with lupus in the setting of
Procainamide was also pending at the time of discharge. The
patient was noted to spike several high fevers after
returning to the floor following his MICU course. His white
blood cell also jumped from a normal range to approximately
25 in this setting. The concern initially was that his
pleural effusion might represent infectious etiology or be
parapneumonic in etiology. Sputum gram stain and culture
were sent. Chest x-ray could not rule out an underlying
pneumonia although patient had minimal respiratory symptoms.
He had a dry cough with good O2 saturations on room air. The
patient was noted to have a urinalysis consistent with a
urinary tract infection and was treated with po Levaquin.
The day following initiation of antibiotics and tapping of
the pleural effusion, the patient was afebrile with a
resolving white blood count.
4. Infectious Disease: As noted above, the patient was
treated for a urinary tract infection with Levaquin. Based
on pleural analysis, it did not appear that the effusion was
infectious in etiology. Culture was still pending at the
time of discharge, however.
5. GI: The patient was noted to have mild elevations in his
transaminases. This was thought to perhaps be consistent
with possible auto immune hepatitis given that the patient
also had a positive [**Doctor First Name **]. Hepatitis panel was negative
although HCV antibody was equivocal and should be followed up
at the time of discharge. SPEP was also sent as this can be
seen in the setting of auto immune hepatitis.
As noted above, patient with a GI bleed significant enough to
drop his hematocrit by approximately [**9-7**] points. No
obvious bleeding at the time of discharge. His hematocrit
had been stable for several days at the time of discharge.
The patient's hepatitis C serology should be reexamined at
the time of discharge and his transaminases rechecked in
several weeks. Patient is scheduled for a follow-up
appointment with Dr. [**First Name (STitle) **] from gastroenterology.
6. GU: The patient had had a PSA level drawn by his
outpatient physician and this was noted to be elevated. This
should be followed up as an outpatient as well.
7. Hematological: The patient presented with an elevated
INR on Coumadin. He received several doses of Vitamin K.
His INR was corrected and he ultimately was restarted on his
Coumadin at prior dose. He should receive close follow-up
for effective monitoring of his INR.
DISCHARGE DIAGNOSIS:
1. Hypertension.
2. Coronary artery disease.
3. Paroxysmal atrial fibrillation.
4. Elevated INR.
5. GI bleeding.
6. Left pleural effusion, possibly secondary to Procainamide
induced lupus.
7. Elevated PSA.
8. Elevated transaminases.
9. Equivocal hepatitis C virus antibody.
DISCHARGE MEDICATIONS: Verapamil 180 mg po bid, Iron Sulfate
325 mg po tid, Lopressor 50 mg po bid, Levaquin 500 mg po q d
times five days, Protonix 40 mg po q d, Lasix 20 mg po q d,
Temazepam prn, Coumadin 2.5 mg po q h.s., Folate 1 mg po q d.
The patient is told to avoid all Aspirin and Motrin products.
FOLLOW-UP:
1. The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 141**].
2. Patient to follow-up with gastroenterologist, Dr. [**First Name (STitle) **] on
[**1-18**] at 1:20 p.m. in the [**Hospital Ward Name 23**] Bldg, [**Location (un) 436**].
[**Last Name (LF) **],[**First Name3 (LF) **] R. M.D. [**MD Number(1) 144**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2172-12-25**] 19:18
T: [**2172-12-25**] 20:10
JOB#: [**Job Number 44679**]
|
[
"578.9",
"790.92",
"427.31",
"428.0",
"710.0",
"511.9",
"285.1",
"790.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2900, 2978
|
10691, 11547
|
10383, 10667
|
4658, 10362
|
3114, 4641
|
161, 2098
|
2121, 2883
|
2995, 3091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,585
| 149,038
|
43823
|
Discharge summary
|
report
|
Admission Date: [**2143-9-15**] Discharge Date: [**2143-9-27**]
Date of Birth: [**2063-1-6**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Amoxicillin
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 80 yo female h/o HTN, osteoporosis, and emphysema who
presents with progressive weight loss, early satiety, hoarseness
and pedal edema. Weight loss was unintentional, documented from
113->97 lbs in about one year. Along with this, she has lost
strength, balance, and energy. No fever/chills/NS. She has also
had early satiety which she describes as wanting to eat a meal,
but stopping short [**2-21**] feeling that it will come up. Yesterday,
for example, she only had a little bit of chicken noodle soup
for dinner. The hoarseness has also been progressing over the
last year, with associated production of white "foam" that she
has been coughing up more frequently with no blood or distinct
colors other than white. Of note, no difficulty swallowing, no
constipation/diarrhea, no melena/BRBPR. She had a recent E. coli
UTI [**2143-8-28**] with hematuria which was treated with Bactrim for 3
days and resolved with f/u UA with no RBCs. Finally, she has
also had gradually increasing pedal edema over the past few
weeks. She has no chest pain, but has dyspnea after walking ~1
block that is stable. ROS otherwise negative except for urinary
stress incontinence that she has had for years which is stable.
Past Medical History:
(1) Hypertension.
(2) Osteoporosis.
(3) Emphysema.
(4) Osteoarthritis.
(5) Ectopic pregnancy.
(6) Uterine prolapse.
(7) Hyperlipidemia. Her triglycerides were elevated in [**2142**].
(8) Gastroesophageal reflux disease and heartburn. An upper GI
in [**2140**] showed hiatal hernia. An EGD in [**2141**] showed moderate
gastritis.
(9) Colonic polyps. A colonoscopy in [**2142**] showed a polyp.
(10) Claudication.
(11) Urinary stress incontinence.
(12) Coronary artery disease. An echo in [**2140**] showed trace MR.
(13) Status post appendectomy.
Social History:
The patient is retired, lives in [**Location (un) 5481**] retirement home in
[**Location (un) 2624**], MA. She quit smoking in [**2137**] after heavy smoking for 20
years. She does not drink. She is a widow with 3 children,
youngest lives close by in [**Location (un) 3786**], MA.
Family History:
There is no family history of colorectal cancer.
Physical Exam:
PE: T 98.3 BP 134/88 HR 100 R 20 95% O2 Sats RA
Gen: Frail, pleasant woman in NAD, hoarse
HEENT: Clear OP, MMM, when speaking has hoarse, gurgly voice,
occasionally bringing up white frothy sputum.
NECK: Supple, No LAD
CV: RR, NL rate. NL S1, S2. III/VI holosystolic murmur best
heard over the apex, radiating to axilla.
LUNGS: Bilateral coarse breath sounds with kyphoscoliotic spine
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout with good effort.
Normal coordination. Gait guarded, but stable with cane, stooped
[**2-21**] kyphoscoliosis
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
Admit WBC 7.9, hgb 11, plt 247.
.
Na 139, K 4.1, Cl 102, bicarb 30, BUN 24, Cr 0.8
.
SPEP: no monoclonal spike. hypogammaglobulinemic at IgG 461* IgA
55* IgM 57 .
Admission CXR: severe cardiomegaly; kyphoscoliosis
.
STUDIES:
.
Laryngoscopy: no vocal cord paralysis, no mass, presbylaryngis
and signs of pharyngeal/laryngeal reflux.
.
CT torso: [**2143-9-18**]:
1. Right apical 2-cm mass, consistent with appearance of
carcinoma.
2. Bilateral pleural effusions, with adjacent atelectasis in
both lower lobes.
3. Small left liver lobe as well as dilated intrahepatic bile
ducts.
4. 37 x 29 mm nonenhancing structure in the left liver lobe, not
present on the MR study of [**2143-4-20**]. The differential
diagnosis includes hematoma and pseudocyst.
5. Free pelvic fluid.
.
[**9-16**] eccho: There is a large pericardial effusion. The effusion
appears circumferential. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology.
.
CXR [**9-18**]: Mild pulmonary edema has improved. Left lower lobe
atelectasis and small left pleural effusion have worsened.
A small collection of pleural air at the base of the right lung
is stable. No pneumothorax is seen elsewhere.
.
Echo [**9-18**]: There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is a small
to moderate sized pericardial effusion most prominent
inferolateral to the left ventricle, but also circumferential.
There is no 2D echocardiographic evidence for tamponade
physiology.
.
[**9-20**] Echo: still with resolution of effusion
.
[**9-20**] PPD negative
.
EKG: NSR @ 93, borderline RAD, nl intervals, low voltages, no
ischemic changes.
.
RUE US: patient with IVC sluggish flow, pre- compression state.
.
[**9-24**] Gastric emptying study: delayed at 1hr; nl at 2.5 hrs
Brief Hospital Course:
Ms [**Known lastname 1104**] is an 80 yo F with h/o HTN and COPD who presented with
failure to thrive, hoarseness, and peripheral edema. She had
recently had a negative malignancy work-up including mammogram,
colonoscopy, EGD, pap smear, and CT chest abdomen and pelvis
within the preceding 6 months. She was initially admitted to
facilitate further workup for these problems with plans for a
laryngoscopy, gastric emptying study, and ecchocardiogram.
.
# Hoarseness - Laryngoscopy revealed presbylaryngis (failure of
the vocal cords to completely collapse) and inflammation
suggestive of pharyngeal/laryngeal reflux without any evidence
for cancer or vocal cord paralysis. She was started on [**Hospital1 **] PPI
treatment with some improvement in her voice. She should
receive vocal therapy on dishcarge.
.
# Pericardial effusion - patient was found to have new murmur
initially and on subsequently Echo she was found to have a large
circumferential pericardial effusion with tamponade physiology.
She was clinically stable on the floor with 8-10 pulsus pardoxus
and cardiology service was consulted. The effusion was likely
deemed to be chronic since she was tolerating it without
hemodynamic instability. It was decided that she would benifit
from fluid drainage for symptomatic relief, and also to
facilitate workup for the cause of her effusion and FTT. She
was transferred to the CCU and underwent pericardiocentesis in
the cath lab with 450cc drained. Opening pressure was 15,
pericardium was thickened. CO 3.14, CI 2.32, mean RA 11, mean
PCW 12. The procedure was complicated by hypotension, which
responded to atropine. This was attributed to the drainage of
500cc of bloody fluid, suspected from a venous structure, likely
the azygous or splenic vein. Post-procedure echo confirmed
evacuation of fluid. She was then transferred to the CCU for
further care and monitoring. The pericardial drain was
discontinued and she transfered from CCU back to the floor.
Repeat eccho the next day on [**9-20**] continued to show no
reaccumulation of fluid. She continued to remain
hemodynamically stable on the floor and was monitored on
telemetry without evidence of tachycardia. She has not had
clinical evidence of fluid reaccumulation, however this is very
likely to recurr and she should be seen by cardiology within a
month (Dr.[**Name (NI) 94146**] saw her at [**Hospital1 18**])
.
With regard to the etiology of her pericardial effusion clinical
suspicion was very high for malignancy, especially considering
her extensive smoking history. A chest CT revealed a 2cm
spiculated RUL lung mass. Additionally pericardial fluid was +
for CEA+ malignant-appearing cells. Otherwise, her PPD was
negative, ESR nl, she had no uremia.
.
# Right Apical Mass: CT this admission showed 2cm right apical
mass concerning for malignancy. She has a h/o smoking and
otherwise negative malignancy work up (including colonoscopy,
EGD, pap, mammogram, and CT abdomen/pelvis). Pericardial fluid
showed malignant appearing cells that were strongly + for CEA
and considered most consistent with adenocarcinoma. The overall
clinical picture is most concerning for NSCLC. Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 3274**], a lung cancer specialist consulted and agreed with
this assessment. With this assumption she would be considered
an unresectable lung cancer and Dr. [**Last Name (STitle) 3274**] agreed that she
would likely not be a chemotherapy candidate because of her very
poor performance status. Nonetheless we had been pursuing a
tissue diagnosis. Gastroenterology service considered
trans-esophageal biopsy of the mass it was decided that she was
too high risk especially in light of potential pneumothorax.
Interventional pulmonology felt they would not be able to
technically perform a bronchoscopic biopsy. Interventional
radiology was willing to perform the procedure next week but
cited an approximate 30% risk of pneumothorax with 5-10% risk of
needing a chest tube. Ultimately patient decided to contemplate
the biopsy further and wished to be have addressed as an
outpatient, leaning towards not proceeding with the biopsy.
.
# Anemia: ms. [**Known lastname 1104**] was admitted with a normocytic anemia.
Iron studies, B12, folate unrevealing. She had a crit drop with
the bleeding from her pericardiocentesis which stabilized over
one day. She was none-theless transfused 2 U pRBCs on [**9-20**] with
appropriate rise in hematocrit and has demonstrated stability
since.
.
# Ms [**Known lastname 1104**] developed right arm swelling in the setting of IV
placement. Doppler did not reveal obvious clot but there was
suggestion of sluggish flow in her R internal jugular vein which
was further evaluated by an MRI. Unfortunately the patient only
tolerated [**3-23**] of the exam. The official [**Location (un) 1131**] of the study is
pending upon discharge but will be followed up by PCP.
.
# Constipation: has many prn meds.
.
# Weight loss/Early Satiety: Most likely related to malignancy.
Her pre-albumin was low-normal and her albumin was normal on
admission. Gastric emptying study revealed delayed emptying and
she was started on tid reglan which she tolerated. Nutrition
consulted and she was given nutritional suppluments. Her
appetite has somewhat improved but will need to be monitored.
.
# Hypoxia: Ms. [**Known lastname 1104**] developed hypoxia in the CCU which was
felt to be partly COPD + heart failure, no signs of infection.
CXR revealed pulmonary edema and bilateral pleural effusions.
This improved with diuresis (lasix 20 IV) and with afterload
reduction with lisinopril 10. [**9-26**] CXR was improved and she is
being discharged on room air. Patient may also have underlying
restrictive lung component due to kyphoscoliosis that may be
further diagnosed as outpatient but may not change further
managment.
.
# HTN: had been on lisinopril as outpt, was held for decreased
BP in CCU. She was restarted on lisionpril 5 on [**9-24**] which was
increased to lisinopril 10. She is normotensive on discharge
.
# COPD: Stable inhouse. She received albuterol/ipratropium nebs
prn.
.
# GERD: Pt stopped taking PPI at home as she felt it wasn't
helping. She now has gastritis and evidence of laryngeal
pharyngeal reflux. She was therefore started on protonix 40mg
po bid with some improvement insymptoms
.
# PPx: Ms [**Known lastname 1104**] received SQ heparin. PPI. Bowel regimen. PT
consulted and has been working with patient.
.
# Contact: Pt and son [**First Name8 (NamePattern2) **] [**Name (NI) 1104**]). Family mtg held [**9-19**] in
CCU to discuss CT findings. home: [**Telephone/Fax (1) 94147**], work:
[**Telephone/Fax (1) 94148**], would like to be called with updates; PCP: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 4033**] ([**Telephone/Fax (1) 94149**] (pager)
Medications on Admission:
Fosamax, stopped >1 month ago
Protonix, stopped 1 month ago, felt like it wasn't working
Ditropan, recently changed to unknown med one week ago
Lisinopril unknown dose
Citracal tid
Glucosamine [**Hospital1 **]
ASA 81 mg qd
Vit E qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] [**Hospital1 1501**]
Discharge Diagnosis:
1. Malignant pericardial effusion with tamponade
2. Malignancy, unspecified
3. Presbylaryngis, laryngeal/pharyngeal reflux
4. Emphysema
5. Hypertension
6. Urinary incontinence
Discharge Condition:
Fair, Afebrile, Vital signs stable.
Discharge Instructions:
Please continue to take all medications as prescribed. We have
started you on 1 new medication called Reglan or metaclopramide
to help with your appetite and digestion. We are started you on
a medicien called protonix to take for your hoarse voice. You
should take this twice per day.
As you know, you had fluid drained from around your heart. This
fluid might reaccumulate in the future and you may need to be
seen by a cardiologist about this. Symptoms of this would be
worsening shortness of breath, leg swelling, or worsening
weakness or light headedness. Please seek medical attention if
you have any of these symptoms. You should also seek medical
care if you have fever over 100.4, worsening swelling of your
arm, [**Last Name (un) 2043**] pain, or for any other concerns
Followup Instructions:
Please follow up with your primary care physician within the
next 1-2 weeks.
.
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2143-10-25**] 10:00. [**Hospital1 18**] cardiology
|
[
"401.9",
"492.8",
"423.9",
"420.0",
"458.29",
"162.3",
"V15.82",
"447.1",
"788.30",
"478.79",
"272.4",
"285.1",
"596.8",
"783.7",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
13424, 13496
|
5251, 12098
|
305, 311
|
13722, 13760
|
3276, 5228
|
14595, 14885
|
2439, 2489
|
12381, 13401
|
13517, 13701
|
12124, 12358
|
13784, 14572
|
2504, 3257
|
248, 267
|
339, 1554
|
1576, 2125
|
2141, 2423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,062
| 137,099
|
21095
|
Discharge summary
|
report
|
Admission Date: [**2184-4-1**] Discharge Date: [**2184-4-13**]
Date of Birth: [**2145-2-3**] Sex: M
Service: Trauma Surgery
ADMISSION DIAGNOSIS: Status post motorcycle accident.
DISCHARGE DIAGNOSES:
1. C7 burst fracture with spinal cord compression with lower
extremity paresthesias requiring steroids.
2. T4 through T6 compression fractures.
3. Postoperative ileus.
4. Postoperative delirium requiring Intensive Care Unit
monitoring.
5. Left lower extremity weakness requiring AFO brace.
PROCEDURES DURING ADMISSION:
1. Anterior vertebrectomy of C7 with fusion of C6 to T1 and
anterior cage placement at C7 with anterior instrumentation
autograft on [**2184-4-6**].
2. Posterior fusion from C6 to T9 with posterior
instrumentation from C6 to T1 and T2 to T9 with multiple
thoracic laminectomies, autograft and open treatment of C7,
T4 and T5 fractures on [**2184-4-7**].
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
gentleman who was involved in a low-speed motorcycle crash.
The patient was helmeted and did not have any loss of
consciousness. He did have an .................... on the
front of his head, and he initially complained of mild
numbness and tingling of his bilateral lower extremities
which improved upon admission to the Trauma Bay.
On admission to the Emergency Room, the patient complained of
minimal left lower extremity numbness with some chest
tightness and "lung pain." The patient denied abdominal pain
or shortness of breath.
PAST MEDICAL HISTORY: Attention deficit hyperactivity
disorder.
MEDICATIONS ON ADMISSION: ?Dexatrim?
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies tobacco. Occasional ethanol use.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient was afebrile, his heart rate was 69, his blood
pressure was 164/63, and he was saturating 100% on room air.
His [**Location (un) 2611**] Coma Scale was 14. The extraocular movements
were intact. The pupils were equal, round, and reactive to
light and accommodation bilaterally. The tympanic membranes
were clear. The neck was stabilized in a cervical collar
with an area of tenderness in the lower aspect of his neck.
His back was tender around the C5 area. The lungs were
clear. The heart was regular. There was no crepitus over
his chest. The abdomen was soft, nontender, and
nondistended. The pelvis was stable. On extremity
examination, his lower extremities did have mild weakness in
his left lower extremity; however, his right lower extremity
was [**4-7**]. The patient did have a positive subtle Hoffmann
sign bilaterally with 1+ clonus in his gait. He had slight
decreased sensation in his left lower extremity in the T5 to
T10 dermatomes.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
hematocrit was 44.9. His ethanol level was 163.
PERTINENT RADIOLOGY/IMAGING: The patient's chest x-ray was
negative.
The pelvis x-ray was negative.
The head computed tomography was negative.
A computed tomography of the cervical spine revealed a C7
fracture with cord impingement.
A computed tomography of the chest showed a rib fracture on
the right.
A magnetic resonance imaging of his spine showed T4 through
B6 compression fractures with no significant spinal stenosis
as well as a C7 fracture with burst (as previously noted).
SUMMARY OF HOSPITAL COURSE: The patient was admitted on
[**2184-4-1**] to the Trauma Service. The patient was placed
in the Intensive Care Unit for every 1-hour neurologic checks
given his C7 burst fracture with spinal cord compression.
The patient was placed on methylprednisolone per protocol for
48 hours. His lower extremity paresthesias did improve. The
patient did have somewhat of an ileus during his original
admission. The patient did not tolerate tube feedings, and
his nasogastric tube was placed to low wall suction with
moderately high output.
On [**2184-4-6**] the patient was taken to the operating room by
the Spine Service. The patient underwent an anterior
vertebrectomy of C7 with a fusion of C6 to T1 as well as an
anterior cage placement of C7 and anterior instrumentation
and autograft. The patient tolerated the procedure well.
However, postoperatively, the patient was not moving his left
leg at all. He was placed on a Solu-Medrol drip per
protocol. On the evening of [**4-6**], although the patient was
intubated his sedation was decreased and he was noted to be
moving his left lower extremity slightly.
On [**2184-4-7**] the patient was taken to the operating room
for a posterior approach. The patient underwent a posterior
fusion from C6 to T9 and a posterior instrumentation from C6
to T1 and T2 to T9 with multiple thoracic laminectomies and
autograft and open treatment of his C7, T4, and T4 fractures.
The patient tolerated the procedure well. He remained
intubated.
On the morning following the procedure, the patient was
extubated. The patient was quite delirious. He was treated
with Ativan as well as Haldol. It was thought that possibly
his delirium was secondary to Reglan, and this was
discontinued. His delirium did improve.
The patient was transferred to the floor. Otherwise, his
hospital course was essentially uneventful. The patient did
have some continued weakness in his left lower extremity with
4/5 strength in his quadriceps, 3/5 strength in his tibialis
anterior, [**2-6**] in his extensor hallucis longus, and [**3-8**] in his
hamstring flexors. The patient was fitted with a AFO brace
for his left lower extremity. The patient was placed on
adequate pain control.
DISCHARGE DISPOSITION/CONDITION: On [**2184-4-13**], given the
fact that the patient was doing well, he was discharged to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Tylenol.
2. Dulcolax.
3. Colace.
4. Lopressor.
5. Dilaudid 2 mg to 8 mg by mouth q.3-4h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in the office in
approximately one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2184-4-12**] 17:33
T: [**2184-4-12**] 18:03
JOB#: [**Job Number 55987**]
|
[
"782.0",
"E878.8",
"997.4",
"805.07",
"729.89",
"E819.2",
"560.1",
"806.20",
"807.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.05",
"77.79",
"81.02",
"96.71",
"84.51",
"81.63",
"81.03",
"03.09",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
222, 904
|
5766, 5875
|
1594, 1644
|
5909, 6347
|
3364, 5740
|
167, 201
|
933, 1500
|
1524, 1567
|
1661, 3334
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,102
| 109,175
|
6519
|
Discharge summary
|
report
|
Admission Date: [**2113-2-28**] Discharge Date: [**2113-3-9**]
Date of Birth: [**2041-4-26**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Methotrexate / Aspirin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
minimally invasive esophagectomy with gastric pull-up
History of Present Illness:
Mr. [**Known lastname 25006**] is a 71 yo M who had an EGD done in [**10-10**] for
abdominal pain with weight loss. This demonstrated an esophageal
mass. Biopsy demonstrated poorly differentiated adenocarcinoma.
T3 lesion on EUS. He completed neoadjuvant chemoradiation
therapy and now presents for definitive surgery with a minimally
invasive esophagectomy with gastric pull-up in cooperation with
Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] of Thoracic Surgery.
Past Medical History:
PMH: Esophageal cancer, poorly differentiated adenocarcinoma,
EUS showing T3 lesion, s/p neoadjuvant chemoradiotherapy,
Hypertension, Hyperlipidemia, Rheumatoid arthritis, Hemorrhoids,
GERD
PSH: hemorrhoidectomy, laparoscopic cholecystectomy,
rhinoplasty, and tooth extraction
Social History:
He lives in [**Location (un) **] and worked as a property manager but was
just laid off. He has a significant other - [**Name (NI) 16883**] - who has
been helping to take care of him. He was formerly a heavy
drinker, however, cut back in the last 10 years or so,
now drinks two to three drinks a night, although less recently.
He smoked three packs a day for 30 years but quit 35 years ago.
No illicits.
Family History:
Family History:
- Mother: uterine cancer in her 70s
- Father: CAD, colon cancer in his 50s
- Brother with multiple dystrophy
- Brother: prostate cancer.
Physical Exam:
At surgical consultation:
On physical examination, he is a well-developed gentleman. Head,
eyes, ears, nose, and throat are normal. He has dentures. The
neck is supple, without mass, nodes, or thyromegaly. Chest is
clear to percussion and auscultation. Heart sounds are regular
without murmurs or gallops. The abdomen is soft without
tenderness, mass, or organomegaly. There are well-healed
laparoscopic scars. Extremities are without cyanosis, clubbing,
or edema. He is neurologically intact.
Pertinent Results:
PET Scan [**2112-11-7**]: 1. Marked FDG-avidity at the gastroesophageal
junction, compatible with known carcinoma. 2. No metastatic
disease identified.
Barium esophagogram [**2113-3-6**]: 1. No leak at the site of
anastomosis.
2. Pneumoperitoneum, which is expected post-surgically,
unchanged from [**2113-3-5**].
Brief Hospital Course:
Mr. [**Known lastname 25006**] [**Last Name (Titles) 1834**] minimally invasive esophagectomy with
gastric pull-up on [**2113-2-28**] and was admitted to the General
Surgery service. Immediately after the surgery, he was taken,
after being extubated, to the Surgical ICU for close monitoring.
Overall, he had a smooth hospital course and was discharged home
on Post-op day 9 in stable condition. His post-operative course
is summarized below by system.
Neuro: While NPO, the patient received IV narcotics with good
effect. This was transitioned to liquid oxycodone and liquid
acetaminophen after he began taken POs and he was discharged
with pain well controlled on oral medications. He has baseline
anxiety which was treated while in house with benzodiazapines
with satisfactory effect.
CV/Fluids/Electrolytes: The patient received adequate fluids
postop and was bolused as needed to maintain SBP. Pressors were
avoided in order to protect the anastamosis. The patient
responded well to these interventions and there were no major
issues during his stay. He received metoprolol IV while NPO and
had some ectopy thought to be related to low Mg, which was
repleted. He was put back on his home dose of atenolol after he
was able to tolerate them enterally. His EKG did not show any
concerning changes.
Pulm: The chest tubes were kept until after the patient had his
barium swallow on POD 6 and it was read as negative. The chest
tubes as well as the neck JP were removed on POD 7. Of note, he
had been complaining of severe back pain thought to be related
to irritation from the chest tubes. EKGs were performed to
assure us that it was not cardiac in origin. This pain
completely resolved with removal of the tubes.
GI/Nutrition: The patient had had previous placement of a Jtube
and had been receiving tube feeds at home. On POD 2, these tube
feeds were restarted through the Jtube for nutritional support.
On POD6, the NGT was removed after a negative barium swallow and
he was started on a clear liquid diet. On POD7, he was advanced
to a soft solid diet, on which he was discharged.
GU: After the patient became ambulatory and was thought able to
handle urinating on his own, the foley catheter was removed and
he was able to void without issue.
ID: The patient received routine antibiotic prophylaxis in the
perioperative period. These were appropriately discontinued
postop.
Heme: The patient had baseline anemia prior to the operation,
requiring transfusions in the months prior to the operation.
Postop, the patient did well, but was noted to have a low
hematocrit. In order to protect the anastamosis, he was
transfused three units packed red blood cells to maintain a
hematocrit of 30. After the initial postop period, he required
no further transfusions.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
2. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
Disp:*600 mL* Refills:*2*
3. Oxycodone 5 mg/5 mL Solution Sig: [**4-10**] mL PO Q3H (every 3
hours) as needed for pain.
Disp:*300 mL* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain .
Disp:*50 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*50 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Peptamen 1.5 Liquid Sig: Seventy Five (75) cc PO qhour:
Please run 75 cc/hr cycled over 12 hours at night.
Disp:*120 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
esophageal cancer s/p esophagectomy with gastric pull-up
Atrial ectopy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER 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 [**4-10**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**3-27**] at 3:45 in his
office.
Call Dr.[**Name (NI) 1482**] office at ([**Telephone/Fax (1) 1483**] for any problems
before then.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD Phone:[**0-0-**]
Date/Time:[**2113-4-13**] 2:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2113-4-13**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15105**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2113-4-13**] 2:30
Your port was deaccessed and heparin locked today ([**2113-3-9**]).
Please remember to get your port flushed and heparin locked per
nursing protocol every month.
|
[
"714.0",
"530.81",
"285.9",
"327.23",
"403.90",
"272.4",
"585.9",
"427.31",
"151.0",
"455.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.99",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6913, 6970
|
2642, 5417
|
313, 369
|
7084, 7084
|
2303, 2619
|
9358, 10122
|
1629, 1767
|
5440, 6890
|
6991, 7063
|
7235, 8213
|
8843, 9335
|
1782, 2284
|
8246, 8827
|
256, 275
|
397, 874
|
7099, 7211
|
896, 1174
|
1190, 1597
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,176
| 196,335
|
33391
|
Discharge summary
|
report
|
Admission Date: [**2108-12-16**] Discharge Date: [**2109-1-11**]
Date of Birth: [**2064-6-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Anemia with acute GI blood loss
Major Surgical or Invasive Procedure:
[**2108-12-24**]: Gastrectomy and gastrojejunostomy
History of Present Illness:
44 yo gentleman known Cholangiocarcinoma S/P L hepatectomy in
[**Month (only) 958**] by Dr.[**First Name (STitle) **]. Microscopic positive margins. Received
chemo radiation followed by chemo Gemcitobine and oxaliplatin.
On his 2nd cycle. Last dose on Mon [**2108-12-17**].
Presented to outside ED with one week history of feeling weak
and
dizzy. Retrospectively says he had been passing dark coloured
stools. Fainted in the ED apparently hypotensive recovered with
fluids. Lowest BP 100 systolic Lowest Hct 11.7. Transfused 6
units PRBC. Hct prior to transfer was 27. EGD outside Bulbar
duodenum nodular mass possibly neoplasm with ooze. Not biopsied
Epinephrine injected, inspite of which there was a slow ooze.
CT Abd done outside reported as normal
Past Medical History:
L1 ruptured disc repair in [**2091**]. Has had several colonoscopies
given mothers h/o colon ca. Last colonoscopy 3 yrs ago s/p
polyp removal.
Social History:
Quit smoking 6 months ago. Prior to that he has smoked 1ppd on &
off since age 17. ETOH - none since 3 weeks ago. h/o heavy
drinking on & off with attendance at AA in the past. Smoked
marijuana as teenager, but denies now and no h/o IVDA. Married
with 4 children ages [**12-5**]. Employed at Sears.
Family History:
Father died at age 80, DM. Mother A&W with h/o Colon CA s/p
resection.
Physical Exam:
Vitals:98.4F, HR 92/min, RR16 sat96%
Gen: A&O,
HEENT: Pale
CV: RRR, no murmurs
Lungs: clear bilat
Abd: NT/ND, soft, No masses no tenderness
Rectal: No masses Guaiac positive
Ext: No edema
Pertinent Results:
At Admission: [**2108-12-16**] Hct-26.0*#
[**2108-12-17**] WBC-13.8*# RBC-3.85* Hgb-12.1* Hct-33.8* MCV-88
MCH-31.4 MCHC-35.9* RDW-18.4* Plt Ct-117*#
PT-12.9 PTT-26.2 INR(PT)-1.1
Glucose-127* UreaN-18 Creat-0.7 Na-141 K-3.9 Cl-110* HCO3-25
AnGap-10
ALT-44* AST-50* AlkPhos-123* Amylase-28 TotBili-0.5
Albumin-2.9* Calcium-7.5* Phos-3.6 Mg-1.9
At Discharge: [**2109-1-9**]
WBC-4.8 RBC-2.82* Hgb-8.6* Hct-26.1* MCV-93 MCH-30.4 MCHC-32.7
RDW-14.6 Plt Ct-316
Glucose-96 UreaN-15 Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-26
AnGap-13
ALT-99* AST-55* AlkPhos-568* TotBili-0.9
Brief Hospital Course:
44yo M s/p L hepatectomy for cholangioCA [**4-21**], tx from OSH w/
UGI bleed (Hct 11 @ OSH), EGD there w/ ? duodenal mass. Given 6U
PRBC at OSH; Nasogastric tube was in place, serial Hct was
followed and he was on IV pantoprazole. He underwent EGD on
[**12-17**] which showed extensive clot and fresh blood oozing in the
duodenal bulb. He was given 3 units pRBCs and Hct slowly drifted
down over the next 2 days.
He was kept NPO and received TPN. H Pylori obtained at admission
was negative. Blood cultures were drawn on HD 3 in response to
temp of 101.2, these were negative. CT of the abdomen was
concerning for duodenal ulcer as well as diffuse thickening of
the stomach.
On [**2108-12-21**] he underwent angiogram which showed Celiac and SMA
arteriogram demonstrated a vascular stump off the common hepatic
artery believed to be the stump of the left hepatic artery, a
replaced right hepatic artery supplied from the SMA, and GDA
coming off of the common hepatic artery. There is no active
extravasation or evidence of active bleeding. No embolization
was performed.
He was continuing to have transfusion requirements to maintain
his hct and received an additional 25 units over the course of
the week with 6 units the day that it was decided to take him to
the OR for an exploratory lap with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
Gastrectomy and gastrojejunostomy . No evidence of malignancy
could be found at the time of exploration. There was concern
that this was an infiltrating cholangiocarcinoma, however frozen
sections did not show evidence of malignancy and final pathology
on the gastrectomy portion submitted showed:
- Extensive hemorrhagic necrosis with associated transmural
ulceration of the distal antrum/pylorus; focal microperforation
is identified
- Fundic and uninvolved antral mucosa with minimal chronic,
inactive inflammation, focal hemorrhage and epithelial
regeneration.
- No carcinoma seen.
On [**12-27**] (HD 13/POD3) He developed ARDS (A-a gradient 198, <
200), possibly secondary to transfusion reaction or possibly
pneumonia. Pt was continued on Zosyn empirically and diuresed
for concern of ARDS. He was placed on lateral ventilation with
turning.
Again on [**12-28**] he spiked temperature 101.8, repeat 101.5 and
was pan cultured. All urine, blood and sputum (from BAL) were no
growth. He was still having low grade fevers through POD 9 and
then on POD day 10 he again had fever to 101.1. He had been
treated with IV Vanco x 7 days, Zosyn x 16 days and fluconazole
8 days from the time of admission. He was re cultured with the
new fever and blood cultures are as yet negative but not
finalized at the time of discharge. He was restarted on Vanco
and Zosyn and then started on PO Augmentin for a 14 day total
course to be completed at home.
On [**12-31**] he was extubated, remained on lasix drip, getting
albumin.
His hematocrit was much more stable following the surgery with a
requirement of 5 more units and then stable from POD 5 until
discharge.
On [**1-1**] he underwent a barium study to determine the patency of
the anastomosis. This showed free flow of contrast from the
stomach to the jejunum, no evidence for leak or obstruction.
He continued to receive TPN for nutritional support. He was
slowly restarted on diet once the anastomosis was judged to be
patent, and is encouraged to use supplements. Teaching was
provided for small frequent meals and the use of the supplements
at home as well.
A culture was obtained from the JP drain (peritoneal fluid) on
[**1-7**] which grew Staph aureus. From [**1-9**] until discharge he
remained completely afebrile, Augmentin will be used upon
discharge.
Additionally, due to a slight increase in the LFTs, an
ultrasound was performed showing patent vasculature and no
biliary dilitation. The LFTs started to trend down again prior
to discharge.
Patient is ambulating, pain well managed, staples and drain are
removed and he is tolerating PO diet. Lasix and Metoprolol were
d/c'd prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. 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*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take as long as using narcotic pain medication and as needed.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed now s/p Gastrectomy and gastrojejunostomy
PMH: Cholangiocarcinoma
Discharge Condition:
Good/Stable
Discharge Instructions:
Please call Dr [**Last Name (STitle) 9411**] office at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, diarrhea, increased abdominal pain,
inability to take food, fluids or medications.
Finish oral antibiotics as prescribed
Report dark stool
Drink enough fluids to keep urine light yellow in color
Take a supplement several times a day (Ensure, carnation instant
breakfast) in addition to your regular diet
Monitor incision for redness, drainage or bleeding
You may shower, pat incision dry, leave open to air
No driving if taking narcotic pain medication
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-1-18**] 3:00
Completed by:[**2109-1-11**]
|
[
"V15.82",
"276.3",
"532.40",
"531.60",
"518.5",
"155.1",
"458.29",
"451.84",
"E879.9",
"511.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.7",
"88.47",
"88.48",
"99.15",
"99.04",
"96.04",
"45.16",
"96.72",
"44.43",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7287, 7293
|
2568, 6599
|
346, 400
|
7418, 7432
|
1980, 2324
|
8059, 8231
|
1683, 1756
|
6654, 7264
|
7314, 7397
|
6625, 6631
|
7456, 8036
|
1771, 1961
|
2338, 2545
|
275, 308
|
428, 1183
|
1205, 1350
|
1366, 1667
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
419
| 111,426
|
43631
|
Discharge summary
|
report
|
Admission Date: [**2113-2-17**] Discharge Date: [**2113-2-26**]
Date of Birth: [**2054-1-15**] Sex: F
Service: MEDICINE
Allergies:
Anzemet
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
febrile neurtropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old female with hypothyroidism, HTN, and recently
diagnosed ALL(Precursor B-phenotype, [**Location (un) 5622**] chromosome
negative) discharged recently after an admission from ([**2113-1-6**]-
[**2113-1-26**]) after induction chemotherapy consisting of hyper-CVAD-
cyclophosphamid, mesna, mtx, doxorubicin, vincristine,
dexamethasone 40 mg/d dys [**12-22**] and [**11-1**]. She was then admitted
from [**Date range (1) 93815**] for part B hyper CVAD and developed febrile
neutropenia with fevers to 101.7 in the clinic. She developed
rhinorrhea and nasal congestion 2 days after being d/c'ed. She
then developed fevers to 101. She received Ertapenem as an
outpatient from [**2-13**] but her fever persisted to 101.7 on [**2-17**] in clinc and thus she was admitted. Her abx were changed to
Vanco/Cefepime on admission. She continued to experience
dyspnea, and CT scan performed on [**2-18**] showed bilateral
infiltrates/opacities, concerning for infection (? bacterial,
fungal, PCP). She was was started on antifungals receiving her
first dose on [**2-17**] along with levofloxacin on [**2-19**] for
atypical coverage.
.
On the day of transfer to the ICU pulmonary was consulted who
recommended sending a DFA, sputum for PCP and [**Name9 (PRE) 93816**] treatment
for PCP consisting of solumedrol and IV bactrim. Later that day
she had an an increasing O2 requirement from 94% on 2L to 90% on
3L to 100% on NRB. She remained febrile. ABG at this time (on
3.5 L) was 7.53/33/56. She was put on 100% NRP, and ABG on this
was 7.55.37.175). Pt was visibly tachypneic and using accessory
muscles to breathe. She was given 40mg IV lasix with net
negative = 1070. She was then transferred to the ICU for further
managemtnt. In the ICU pt improved overnight with gentle
diuresis. Her sputum was negative for PCP, [**Name10 (NameIs) **] did grow GNRs and
GPC. Her fungal coverage was discontinued. She is currently on
Levofloxacin/Cefepime as double coverage of GNR, and Vancomycin
given GPC. She is no longer neutropenic. She denied cough,
headache, abdominal pain, dysuria, n/v, diarrhea, blurred
vision.
.
Past Medical History:
1) ALL, Precursor B-phenotype (Induction with Hyper-CVAD
[**2113-1-7**], Negative for [**Location (un) 5622**] Chromosome)
ONCOLOGIC HISTORY: Obtained from chart review: 58 yo female with
a h/o hypothyroidism who presents for evaluation of possible
ALL. Pt was in USOH until [**12-12**], when she had a cold with dry
cough, fevers and chills, all improved by [**12-18**]. After a few
days, pt had vomiting, abdominal pain, and fatigue increasing
for about a week until [**12-28**], when the pt went to [**Hospital1 3793**] for the above symptoms. She was found to have an
enlarged spleen and thrombocytopenia. Bone marrow biopsy was
suggestive of pre-B ALL. She was discharged [**12-30**] in stable
condition and followed up with Dr. [**First Name (STitle) 1557**] in clinic [**1-5**],
and felt the biopsy should be repeated here to confirm the
diagnosis and possibly begin treatment if positive for ALL.
.
The patient was admitted on [**2113-1-6**] for diagnosis and initiation
of treatment. Bone marrow biopsy was performed on admission and
interpreted as markedly hypercellular bone marrow with
involvement by Acute Lymphoblastic Leukemia, Precursor
B-phenotype. Cytogenetics were negative for [**Location (un) 5622**]
chromosome. A central line was placed, an trans-thoracic ECHO
was performed on admission. Her ECHO revealed cardiac function
within normal limits. Subsequently, induction chemotherapy with
Hyper-CVAD was initiated on [**2113-1-7**]. Her course was complicated
by febrile neutropenia with blood cultures showing
vancomycin-sensitive enterococcus. Her right subclavian line was
removed on [**1-20**]. Screening blood cultures were subsequently all
negative after initiation of vancomycin. A TTE was negative for
endocarditis. On [**2113-2-3**], the patient received 12 mg of
intrathecal methotrexate at 15 mg and intrathecal hydrocortisone
and part B hyper CVAD.
.
2) Vancomycin SENSITIVE enterococcus faecium bacteremia during
induction chemotherapy
3) Hypothyroidism
4) HTN
Social History:
Unmarried, lives with her mother (85) and brother (64). Retired
clerk for insurance company. Rare EtOH use, no smoking, no IVDU.
Family History:
Aunts and Uncles with breast CA and asbestos related lung CA by
report. Father with diabetes.
Physical Exam:
.
98.0, 127/67, RR = 20, HR =80. 96% on 4L, 18,
GENERAL: Overweight caucasian female appearing well, though
slightly tachypneic, resting comfortably in bed.
HEENT: Anicteric sclerae, moist mucous membranes.
NECK: No JVD.
COR: nml S1, S2, 2/6 SEM at LUSB. tachycardic
LUNGS: Dry inspiratory crackles to 2/3 up from the bases.
ABDOMEN: Normoactive bowel sounds, soft, non-tender.
EXTR: No edema. 2+ DP pulses b/l
.
Pertinent Results:
.
CXR [**2113-2-19**]: Worsening appearance of the chest with an appearance
which is suggestive of developing fluid overload or edema.
.
Chest CT with contrast [**2113-2-18**]
When compared with the prior study from [**2113-1-24**], new
small bilateral parenchymal opacities are noted associated with
ground glass opacities and septal thickening. These are present
bilaterally.
.
Echo [**2113-1-25**]
Left Atrium 4.0 cm x 4.5 cm, right atrium 4.6 cm, LV thickness =
1.3 cm, Ejection Fraction = 70% to 80%, nml TRTR Gradient (+ RA
= PASP): 19 to 21 mm Hg (nl <= 25 mm Hg) Conclusions: The left
atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and hyperdynamic
systolic function (LVEF>70-80%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The slightly increased transaortic
gradient is likely related to high cardiac output. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
.
Brief Hospital Course:
.
58 year old female with hypothyroidism, HTN, history of
vancomycin sensitive enterococcus, and ALL (Precursor
B-phenotype, [**Location (un) 5622**] chromosome negative) who was admitted
for febrile neutropenia. She was then transferred to the ICU
with hypoxia and febrile neutropenia.
.
# Respiratory Distress: The patient was on room air on admission
but on her second hospital day as her ANC rose to > 500, she was
found to have a new oxygen requirement with desaturation to 89%
on room air. A chest CT showed new bilateral parenchymal
pulmonary opacities consistent with an infectious process. No
PE was seen on the CT chest. The patient's oxygen requirement
worsened and she was transferred to the ICU for further
monitoring. The patient was on Cefepime, Vanc and Caspo. On
transfer to the ICU, Levofloxacin was added for double coverage
of gram negatives. She was also started on IV Bactrim with
steroids for possible PCP [**Name Initial (PRE) 1064**]. An induced sputum showed
gram negative rods but these were consistent with mouth flora
per the microbiology lab. She did not require intubation. Upon
transfer back to the BMT floor, a repeat CT scan showed
worsened, extensive bilateral ground glass opacities sparing the
lower lobes which appeared to be consistent with an infectious
process. A B-glucan was found to be positive at > 500. Her
Levofloxacin was discontinued and her Cefepime was changed to
Ceftriaxone. The patient was continued on Bactrim and steroids
for presumed PCP [**Name Initial (PRE) 1064**]. Her oxygen requirement decreased
steadily until she was back on room air. Her Vancomycin and
Ceftriaxone were discontinued. The patient will continue
Bactrim and Prednisone to complete a 21 day course for treatment
of PCP [**Name Initial (PRE) 1064**].
.
# Pulmonary edema: A chest xray in the MICU showed evidence of
developing fluid overload or edema. The patient was diuresed
and had some improvement in her O2 saturation. A recent echo
was noted to have a normal EF.
.
# Febrile Neutropenia: Given her history of vancomycin sensitive
enterococus, the patient was continued on Vancomycin and started
on Cefepime. She was given Neulasta as an outpatient. On
admission, her ANC was 40 but jumped to 660 the following day.
Also at this time, the patient's pulmonary status declined
markedly requiring transfer to the ICU. She was initially
covered with Levofloxacin and Cefepime given the GNR in her
sputum culture but per micro lab these were consistent with
normal oral flora. Caspofungin was added when the patient began
to have worsening respiratory function. This was discontinued
in ICU after improvement in her oxygen saturation and a CXR not
c/w fungal pneumonia. RSV was found to be negative.
Additionally, Bactrim was started for concern of PCP. [**Name10 (NameIs) 616**]
transfer back to the BMT service, Levo and Cefepime were
discontinued. The patient was continued on Bactrim and
Vancomycin and switched to Ceftriaxone. She completed
Ceftriaxone x 7 days. A Beta-glucan was found to be positive
with CT scan showing ground glass opacities sparing the bases.
She will be treated for a total 21 day course of Bactrim for
presumed PCP [**Name Initial (PRE) 1064**].
.
# Leukocytosis: The patient's WBC climbed to as high as 42.2.
The patient had gotten Neulasta as an outpatient and
additionally was started on IV Methylpred in the MICU and
continued on Prednisone for treatment of PCP [**Name Initial (PRE) 1064**]. A
differential was checked to ensure that this was not [**1-20**] the
patient's leukemia. Hematopath reviewed the diff and found
early neutrophil precursors consistent with Neulasta effect and
not consistent with leukemia.
.
# ALL: Patient has ALL, Precursor B-phenotype. She has negative
cytogenetics for [**Location (un) 5622**] Chromosome and has completed Part
B of Hyper-CVAD. She receieved intrathecal MTX and intrathecal
hydrocortisone on [**2113-2-3**].
.
# Hypothyroidism: Last TSH in [**Month (only) 404**] normal. Continued on
Levothryoxine.
.
# HTN: Hydralazine was continued as per outpatient regimen.
.
# Prophylaxis: She was discharged on Acyclovir for ppx. Her
Fluconazole and Levofloxacin were discontinued given that she
was no longer neutropenic..
.
# Code Status: Full.
.
Medications on Admission:
Levothyroxine 75 mcg PO daily
Hydralazine 25 mg PO Q6
levofloxacin 500 mg PO daily
Fluconazole 200 mg PO BID
ertapenem IV daily x 1 week
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day) for 14 days.
Disp:*84 Tablet(s)* Refills:*0*
2. Heparin Flush (10 units/ml) 5 ml IV PRN
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
11 days: Please start after you complete the Prednisone 30mg
daily for 3 days.
Disp:*22 Tablet(s)* Refills:*0*
7. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
.
Primary:
Febrile Neutropenia
PCP Pneumonia
ALL
.
Secondary:
Hypothyroidism
Hypertension
.
Discharge Condition:
Good: On room air, ambulating independently, taking good PO
intake
Discharge Instructions:
Please take all medications as prescribed. The following
changes were made in your medication regimen:
- You were started on two new medications for PCP pneumonia,
Bactrim and Prednisone and you should continue to take these
medications for 14 more days after your discharge.
- You were also started on Acyclovir for prevention of HSV.
- You may stop taking Levofloxacin and Fluconazole now that your
WBC has come back up.
.
Please attend all followup visits as listed below.
.
Please call your doctor immediately if you begin to experience
increasing shortness of breath, fevers, nausea, vomiting or
diarrhea.
.
Followup Instructions:
.
You will need to call Dr.[**Name (NI) 6168**] office on Monday at
([**Telephone/Fax (1) 6179**] to set up an appointment to see them on Wednesday,
[**3-1**] for a count check.
.
Completed by:[**2113-2-26**]
|
[
"780.6",
"401.9",
"276.3",
"204.00",
"288.00",
"428.0",
"136.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11789, 11841
|
6564, 10844
|
289, 296
|
11977, 12046
|
5162, 6541
|
12708, 12919
|
4618, 4713
|
11032, 11766
|
11862, 11956
|
10870, 11009
|
12070, 12685
|
4728, 5143
|
229, 251
|
324, 2435
|
2457, 4455
|
4471, 4602
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,881
| 173,663
|
33611
|
Discharge summary
|
report
|
Admission Date: [**2124-3-6**] Discharge Date: [**2124-3-10**]
Date of Birth: [**2059-12-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Intubated
EGD
History of Present Illness:
64 M in USOH until 1d PTA. Pt noted mild epigastric
discomofort, n, vomitting x 1, non-bloody, "brown". No recent
melena. Symptoms persisted on morning of [**3-5**], decreased PO
intake (jello, soup). At 9PM wife heard a thud, and found
husband slumped over toilet in restroom, eyes open, but slow to
respond, +diaphoresis. EMS activated, BP 110/80 HR 92 RR 26 @
2159.
.
Per wife, ROS otherwise negative, no recent f/c/cp/sob/dysuria,
melena, diarrhea, rash.
.
Pt takent to OSH(addison-[**Doctor Last Name **]) where VS 98.6 110/59 82 24
100%RA, EKG, CXR unremarkable, +NGL with dark blood only, no
BRB. At OSH, pt had CT head, cspine, CT abd/pelvis which were
all unremarkable per dictated reports. He was given 1-2U PRBCs
[**1-29**] OSH HCT 28.9 (bl unknown) and 2L IVF, which was still
running upon arrival to [**Hospital1 18**]. Of note, pt was intubated prior
to transport from OSH [**1-29**] significant nausea, vomiting and
concern for airway protection.
.
Upon arrival to [**Hospital1 18**], VS 96 77 101/69 12 100% AC 100%. pt
was guaic positive, abg 7.30/44/520, hct 28.5 wbc 19. Pt given
protonix 80mg iv x 1, and admitted to [**Hospital Unit Name 153**] for GIB.
.
Of note, pt on [**Last Name (LF) 4532**], [**First Name3 (LF) **] [**1-29**] h/o cad s/p stenting >1y ago, he
has also been taking celebrex for last two weeks [**1-29**] shoulder
injury.
Past Medical History:
- cad s/p stenting [**9-1**] w cypher stent to pLAD ([**Telephone/Fax (1) **]),
cardiologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].
- h/o pud (last in college per wife) -- gastroenterologist dr.
[**Last Name (STitle) **],
at [**Hospital **] hospital.
- gerd
- depression
Social History:
lives with wife in [**Name2 (NI) **] ma, works as school teacher, 1ppd x
1yr, quit 50y ago, [**12-29**] wine/month, denies IVDU. no h/o
hepatitis exposures (no tattoo, msm, prison), though ?blood
transfusion < [**2095**] [**1-29**] hernia repair.
Family History:
mother died of amyloid, father of MI in 80s. no family hx of
gastric ca.
Physical Exam:
VS: 95.7 [**10/2087**] 955 12 100% PS 8/5 50% (MMV rate 8)
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, MMM, no LAD, no carotid
bruits. No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: CTA anteriorly, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL.
NEURO: intubated, sedated, alert to voice, PERRLA.
Pertinent Results:
[**2124-3-6**] 01:50AM BLOOD WBC-19.3* RBC-3.07* Hgb-9.8* Hct-28.5*
MCV-93 MCH-32.1* MCHC-34.6 RDW-13.1 Plt Ct-213
[**2124-3-6**] 04:16AM BLOOD WBC-17.8* RBC-2.75* Hgb-8.8* Hct-26.0*
MCV-95 MCH-32.0 MCHC-33.8 RDW-13.3 Plt Ct-154
[**2124-3-6**] 03:30PM BLOOD Hct-24.9*
[**2124-3-7**] 06:08AM BLOOD Hct-23.3*
[**2124-3-8**] 05:09AM BLOOD WBC-9.7 RBC-3.54*# Hgb-11.1* Hct-31.3*
MCV-88 MCH-31.2 MCHC-35.3* RDW-14.8 Plt Ct-149*
[**2124-3-6**] 01:50AM BLOOD Glucose-212* UreaN-38* Creat-1.0 Na-138
K-4.0 Cl-108 HCO3-19* AnGap-15
[**2124-3-6**] 04:16AM BLOOD ALT-23 AST-23 LD(LDH)-166 CK(CPK)-169
AlkPhos-37* Amylase-50 TotBili-1.1
[**2124-3-6**] 01:50AM BLOOD CK-MB-5 cTropnT-0.04*
[**2124-3-6**] 04:16AM BLOOD CK-MB-7 cTropnT-0.06*
[**2124-3-6**] 11:00AM BLOOD CK-MB-18* MB Indx-5.6 cTropnT-0.10*
[**2124-3-6**] 08:59PM BLOOD CK-MB-16* MB Indx-4.0 cTropnT-0.26*
[**2124-3-7**] 03:04AM BLOOD CK-MB-10 MB Indx-2.8 cTropnT-0.25*
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Patchy discontinuous erythema and congestion and NG
tube trauma of the mucosa with no bleeding were noted in the
whole stomach.
Duodenum:
Excavated Lesions A single cratered 11mm ulcer was found in the
distal bulb. A visible vessel suggested recent bleeding. 2 2.5
cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis
with success. Two clips were successfully placed for hemostasis
Impression: Erythema and congestion and NG tube trauma in the
whole stomach
Ulcer in the distal bulb (injection, ligation)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
# GIB Patient has a history of GIB, and has been using NSAIDS
continually over last few weeks. Was found to have coffee
ground emesis on NGT lavage at OSH. He was monitored for an
additional day in the ICU with no evidence of continued bleeding
by stable hematocrit. Patient had a hematocrit of 29 on
admission. Underwent an EGD which showed a duodenal ulcer with
a visualized bleeding vessel. Epinephrine was injected and two
clips were placed. Patient had continued evidence of bleeding
following the EGD, requiring transfusion of 3 units of PRBC. He
had no complaints of abdominal pain, nausea, or vomiting.
Patient was started on a PPI drip, and bleeding decreased. He
should be discharged on [**Hospital1 **] dosage for two months. Patient's
Aspirin and [**Hospital1 4532**] were held at admission. The aspirin should
be restarted after discharge and patient should follow up with
outpatient cardiologist to restart [**Hospital1 4532**]. Pt had intermittent
trace amounts of blood in stool prior to dc, GI team advised
that this was likely left over blood in intestine, rather than
active bleeding. Pt told to have hct checked with PCP [**Last Name (NamePattern4) **] 4 days
after dc, also if still bleeding in one week, needs repeat
endoscopy. Also reminded of need to have colonoscopy.
# pulmonary ?????? The patient was intubated for airway protection
given continued emesis. Per OSH records, ther was no evidence
of hypoxia or hypercarbia. The patient was extubated shortly
after arrival, and has been breathing comfortably.
# syncope - Syncopal episode in setting of GIB while having a
bowel movement. No hypotension at OSH. Likely vaso-vagally
related. Has been maintained on telemetry without any
arrythmia. Patient had CT of head without any intracranial
process and no story of hitting head. C-spine CT was also
unremarkable.
# cardiac -
## ischemia: Patient with a history of CaD, and had a cypher
stend placed in [**2121-8-28**]. Aspirin/[**Year (4 digits) 4532**] in setting of
bleed. Cardiac enxymes were followed, and showed an elevation
up to trop 0.26, and have trended downward. He had no
complaints of CP, no evidence of ischemia on EKG. Likely enzyme
leak in setting of demand ischemia. Pt told to f/u with primary
cardiologist at discharge with follow up aranged in order to
work up progression of CAD and to determine whether aspirin
should be increased to 325 mg from 81mg, now that he is
indefinitely off of [**Year (4 digits) 4532**].
Medications on Admission:
aspirin 81 mg po qdaily
[**Year (4 digits) 4532**] 75mg po qdaily
celebrex 200mg po qdaily
prozac 40mg po qdaily
vicodin - not taking
Discharge Disposition:
Home
Discharge Diagnosis:
bleeding duodenal ulcer
Discharge Condition:
stable
Discharge Instructions:
Please watch for blood in your bowel movements, if there is any
increase in blood please call Dr. [**Last Name (STitle) 19634**], as you will need your
blood level checked sooner.
If you are still having blood in your bowel movements in one
week please talk to Dr. [**Last Name (STitle) 19634**] about having a colonoscopy.
Stop taking [**Last Name (STitle) 4532**]. You may restart aspirin 81 mg per day next
week if bleeding has stopped.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 19634**] on Monday, you will need to have your
blood drawn, and may need to be evaluated by him as well. He
will discuss with you over phone on Monday.
The gastroenterology specialist you saw in the hospital is Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] at [**Telephone/Fax (1) 682**]. You need to be seen by him or your
other gastroenterologist in 2 months, to determine whether you
can decrease the protonix (pantoprazole) dose.
You should see your cardiologist in the next few weeks, to see
if he suggests increasing the dose of aspirin now that you are
not taking [**Telephone/Fax (1) 4532**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2124-3-15**]
|
[
"532.40",
"311",
"V45.82",
"414.8",
"285.1",
"288.60",
"414.01",
"530.81",
"412",
"719.41",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7075, 7081
|
4397, 6891
|
319, 334
|
7149, 7158
|
2802, 4374
|
7649, 8476
|
2355, 2430
|
7102, 7128
|
6917, 7052
|
7182, 7626
|
2445, 2783
|
276, 281
|
362, 1746
|
1768, 2073
|
2089, 2339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,751
| 151,131
|
33426
|
Discharge summary
|
report
|
Admission Date: [**2103-3-19**] Discharge Date: [**2103-3-28**]
Date of Birth: [**2044-2-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
left mandibular swelling and pain
Major Surgical or Invasive Procedure:
[**2103-3-20**]: Left jaw incision and drainage
History of Present Illness:
Mr. [**Known lastname **] is a 59 yo mandarin-speaking only male with a history of
atrial fibrillation (on warfarin and carvidelol), hypertension
and chronic hepatitis B who presented to [**Hospital1 18**] on [**2103-3-19**] with 2
weeks of worsening pain and swelling of the left
maxilla/mandible after a dental appointment for teeth cleaning,
found to have large jaw abcess, now s/p I&D by OMFS on [**3-20**] with
3 drains in place, transferred to [**Hospital1 1516**] for management for atrial
fibrillation.
Following surgery, pt was transfered to the SICU and
intubated for airway protection, sucessfully extubated and
transferred to the floor for monitoring while drains remained in
place.
While in the SICU and on the surgery floor, pt has had
several episodes of asymptomatic afib with RVR to as high as the
200s, for which his home carvidelol dose was restarted on [**3-25**].
He was then switched to metoprolol 25 [**Hospital1 **] on [**3-26**] when he
continued to have afib with RVR. During the most recent episode
of afib this AM, HR maxed in the 200s and BP dropped to the 80s
but responded to a 500 cc bolus, with subsequent decrease in HR
to the 80s-100s after 5 mg IV
metoprolol this morning. Pt was also asymptomatic throughout
this episode as well. Pt is being transferred to [**Hospital1 **] for
titration of
beta- blocker with consideration of cardioversion.
On arrival to the floor, patient's HR is in the 160's,
although he denies any shortness of breath, chest pain,
lightheadedness or dizziness. He was given 5 mg of IV
metoprolol and 25 mg of po metoprolol with a fall in sustained
HR from 160 to 110, increase in SBP in the 80's to 90's.
Past Medical History:
- Atrial fibrillation on warfarin ([**2102-2-24**])
- Hypertension
- Systolic dysfunction (EF of 30-35% in [**2102-5-26**])
- Chronic hepatitis B infection
- History of peptic ulcer disease
- S/p ? vascular surgery of right thigh in [**Country 651**] years ago
(unable to understand exact nature of surgery)
Social History:
Originally from [**Country 651**] and speaks Mandarin. Lives with his
wife, son and daughter. [**Name (NI) 1403**] off-and-on in restaurant work (not
regular employment). No tobacco, no alcohol.
Family History:
unknown
Physical Exam:
Phyiscal Exam on transfer:
VS: T= 98.3 BP= 90/60 HR = 150 RR= 18 O2 sat= 98% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Swellling of left
neck and jaw with three drains in place without any significant
drainage
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles bilaterally
at the bases
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+
Physical Exam on discharge:
VS: Tmax 99.1 BP 108/83 (100'S-110'S/70'S-80'S) p= 63
(70's-90's)RR= 18 O2 sat= 99% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Swellling of left
neck and jaw with three drains in place without any significant
drainage
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles bilaterally
at the bases
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:
Labs on admission:
[**2103-3-19**] 03:15PM BLOOD WBC-16.3*# RBC-5.17 Hgb-15.2 Hct-47.3
MCV-92 MCH-29.3 MCHC-32.1 RDW-13.3 Plt Ct-202#
[**2103-3-19**] 03:15PM BLOOD Neuts-83.1* Lymphs-11.8* Monos-4.7
Eos-0.2 Baso-0.1
[**2103-3-19**] 05:31PM BLOOD PT-150* PTT-66.3* INR(PT)-15.7*
[**2103-3-19**] 07:22PM BLOOD PT-150* PTT-78.7* INR(PT)-15.7*
[**2103-3-19**] 10:31PM BLOOD PT-26.7* PTT-36.9* INR(PT)-2.6*
[**2103-3-19**] 03:15PM BLOOD Glucose-91 UreaN-19 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-26 AnGap-15
[**2103-3-19**] 03:15PM BLOOD AST-27 AlkPhos-55 TotBili-0.4
[**2103-3-19**] 10:31PM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2103-3-22**] 02:18AM BLOOD HBsAg-POSITIVE* HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2103-3-20**] 03:31PM BLOOD Type-ART pO2-415* pCO2-38 pH-7.44
calTCO2-27 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED
[**2103-3-19**] 03:25PM BLOOD Lactate-1.4
[**2103-3-19**] 09:31PM BLOOD Lactate-2.1*
[**2103-3-20**] 06:05PM BLOOD Lactate-2.6*
[**2103-3-21**] 02:32AM BLOOD Glucose-144* Lactate-1.5
Labs on discharge:
[**2103-3-28**] 06:05AM BLOOD WBC-6.6 RBC-4.25* Hgb-12.5* Hct-38.1*
MCV-90 MCH-29.5 MCHC-33.0 RDW-13.0 Plt Ct-142*
[**2103-3-28**] 06:05AM BLOOD PT-32.6* PTT-56.5* INR(PT)-3.2*
[**2103-3-28**] 06:05AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-135
K-4.0 Cl-103 HCO3-28 AnGap-8
[**2103-3-28**] 06:05AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
Imaging:
CT sinus/mandible/maxilla [**3-27**]:
IMPRESSION:
Drain fragment lying deep to the inferior aspect of the left
angle of the
mandible. A neighboring fluid collection surrounding the
inferior aspect of the left side of the mandible has enlarged
since [**2103-3-22**]. Active infection in this region cannot be
excluded by imaging.
COMMENT: The initial findings regarding the retained drain
fragment were
discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) **] (Internal Medicine
service), via
telephone, at the time of interpretation, 7:23 p.m. on
[**2103-3-27**].
Chest PA and lateral [**2103-3-26**]:
Severe cardiomegaly is unchanged. Some of the large amount of
the cardiac
silhouette could be due to pericardial effusion, but there is no
indication that this is hemodynamically significant since
mediastinal veins are normal caliber. Minimal redistribution of
pulmonary circulation to the upper lungs is stable, but there is
no pulmonary edema or more than minimal right pleural effusion,
if any. No pneumothorax.
CXR Portable [**3-23**]:
IMPRESSION: Left lower lung and retrocardiac opacity improved
over last 24 hours, is likely a combination of atelectasis and
small effusion. No new opacities in the lungs.
CT neck with contrat [**3-22**]:
IMPRESSION: Residual prominence of soft tissues involving the
left parotid gland, pterygoid and masseter muscles, status post
drainage of an abscess. No rim-enhancing collections are seen,
but evaluation is suboptimal due to early arterial phase of
contrast enhancement
CT sinus/mandible [**3-19**]:
IMPRESSION:
1. Large multiloculated abscess surrounding the ramus of the
left mandible. There is no retropharyngeal extension. Large
left upper 1st molar periapical lucency concerning for
infection/osteomyelitis.
2. Mild rightward mass effect on the airway, which remains
widely patent.
3. No mandible erosion seen.
Microbiology:
HBV Viral Load (Final [**2103-3-27**]):
1,221 IU/mL.
GRAM STAIN (Final [**2103-3-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2103-3-25**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
WORK UP PER DR. [**Last Name (STitle) 32437**] #[**Numeric Identifier 19455**] [**2103-3-22**].
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH. SECOND
MORPHOLOGY.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2103-3-24**]): NO ANAEROBES ISOLATED.
Blood cultures x 2 [**3-19**]: negative
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 mandarin-speaking only male with a history of
atrial fibrillation (on warfarin), hypertension and chronic
hepatitis B who presented to [**Hospital1 18**] on [**2103-3-19**] with 2 weeks of
worsening pain and swelling of the left maxilla/mandible after a
dental appointment for teeth cleaning, found to have large jaw
abcess, s/p I&D by OMFS on [**3-20**] with placement of five drains on
[**Hospital 77555**] transferred to [**Hospital1 1516**] for management for atrial
fibrillation, discharged on metoprolol and digoxin for rate
control.
Active Issues:
# Mandibular abscess: Given concern that patient would not be
able to protect airway, patient was admitted to TICU. On HD 1 he
remained on room air and his pain was controlled with IV pain
medication. He presented with an INR of 15 he was given FFP
prior to being taken to the OR for incision and drainage. On HD
2 he underwent: extraoral and intraoral incision and drainage of
left masticator, submandibular, lateral pharyngeal,
infratemporal, buccal space infections, extraction of teeth #14,
16, 17, 18, 19, 31, & 32. He tolerated the procedure well and
was left nasally intubated post op given concern for post op
inflammation and airway compromise. ID was consulted and
recommended treatment with unasyn (as culture grew Strep
Viridans and Strep Anginosus) as an inpateint with plan to
transition to augmentin on discharge. He will complete a three
week course of augmentin (last day: [**4-9**]). OMFS pulled [**3-1**]
drains on [**3-27**], although was concern for a retained drain.
Therefore a CT of the mandible and maxilla was performed that
did show a retained drain. OMFS removed the last drain on the
evening of [**3-27**] at bedside. He was scheduled with a f/u with
OMFS with Dr. [**Last Name (STitle) **] on [**4-3**].
# Atrial fibrillation with RVR: During his ICU stay patient had
intermittent episodes of afib with RVR controlled with IV
metoprolol. Once advanced to a soft solid diet he was started
on his home dose of [**Month (only) 42949**] PO, however continued to have
intermittent episodes of RVR. on HD 8, POD 6 he became
hypotensive to 85/60 with an episode of RVR. This improved with
an IV fluid bolus after which the [**Month (only) 42949**] was converted to PO
lopressor 25 [**Hospital1 **]. He was transferred to the medical service for
further management of this. On the medical floor his heart rate
with initially controlled on po metoprolol (up to 37.5 mg [**Hospital1 **])
with stabalization of SBP's in the 90's-100's without symptoms.
However, on the day of discharge he became tachycardic to the
150's-180's with ambulation. Given his relative hypotension, he
was loaded with digoxin 0.25 mg [**Hospital1 **] x 2 days, 0.25 mg daily
afterwards for additional rate control. Given the addition of
digoxin, his metoprolol was decreased to 25 mg XL daily.
As far as anticoagulation, pt's INR was 3.2 on discharge.
We held his coumadin on the day of discharge with a plan to have
his INR rechecked on [**3-30**] with results faxed to Dr. [**First Name (STitle) **]. We
believe that his INR on admission was largely influenced by
addition of augmentin.
# Decreased cardiac output: Pt with decreased EF on echo in
[**2101**]. Pt without CHF signs or symptoms at home or in hospital.
We started lisinopril 2.5 mg for afterload reduction and to
decrease cardiac remodeling. He was also discharged on
metoprolol as above. He will have further follow up of his
decreased cardiac output as an outpt with Dr. [**Last Name (STitle) 73**].
Transitional Issues:
-Pt will be discharged with a KOH to monitor his HR. He will
follow up with Dr. [**Last Name (STitle) 73**] for his a fib and for further
work-up of his decreased cardiac output
-Pt will have INR checked on [**3-30**] with results faxed to Dr. [**First Name (STitle) **]
-Pt will complete a three week course of augmentin for left jaw
abscess and follow up with OMFS on [**4-3**].
Medications on Admission:
- Coumadin 7.5 mg on T,R,Sa, 5 mg on W,F,[**Doctor First Name **]
- [**Doctor First Name **] 3.125 [**Hospital1 **]
- Augmentin 875-125 [**Hospital1 **] (scheduled to finish on [**3-25**])
- Pain medication (patient does not know name/dose of medication
he was taking prior to admission)
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 2 weeks.
Disp:*140 ML(s)* Refills:*0*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
please start on [**2103-3-29**].
Disp:*14 Tablet(s)* Refills:*0*
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient Lab Work
Please have INR drawn on [**2103-3-30**] and have results faxed to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8237**]
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day:
START taking this medication on Friday, [**3-30**].
Disp:*30 Tablet(s)* Refills:*2*
8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO twice a day for
2 days: Take 1 pill twice daily for two days, last dose at night
on Thursday [**3-29**].
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural Home Care
Discharge Diagnosis:
Primary:
Left mandibular abscess
Secondary:
Atrial fibrillation with a rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization at [**Hospital1 69**]. You
were admitted with an abscess in your left jaw. The oral
surgeons drained this infection and you will need to take oral
antibiotics for the next two weeks.
You also had a fast heart rate related to your atrial
fibrillation. We gave you medications called metoprolol and
digoxin, which were successful in slowing your heart rate.
You will need to follow up with the oral surgeons on -----,
as well as your primary care doctor and your cardiologist Dr.
[**Last Name (STitle) 73**].
PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
STARTED METOPROLOL SUCCINATE 25 MG DAILY (please take first dose
tonight)
STARTED DIGOXIN 0.25 MG TWICE DAILY today ([**3-28**]) and tomorrow
([**3-29**]), then ONCE DAILY thereafter
STARTED CHLORHEXADINE RINSE TWICE A DAY FOR THE NEXT 14 DAYS
STARTED LISINOPRIL 2.5 MG A DAY
DECREASED COUMADIN (WARFARIN) TO 2.5 MG DAILY; do not take any
Coumadin today ([**3-28**]), and start tomorrow ([**3-29**]) at this lower
dose. Please adjust dosing based on your blood test (INR level)
and discussions with your primary care doctor
[**First Name (Titles) **] [**Last Name (Titles) **]
Followup Instructions:
100 east [**Location (un) **] BU [**Doctor Last Name **] Dental school [**Location (un) **] at the Oral
and Maxillofacial surgery clinic (Dr. [**Last Name (STitle) **] on Tues [**4-3**] at 8:45
a.m.
Name: [**Last Name (LF) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital3 8233**]
Address: [**Location (un) 13002**], [**Hospital1 392**], [**Numeric Identifier 69655**]
Phone: [**Telephone/Fax (1) 10349**]
When: Tuesday, [**2102-4-2**]:45 AM
We are working on a follow up appt in the Cardiology department
with Dr. [**Last Name (STitle) 73**] within 2-4 weeks. You will be called at home
with the appointment. If you have not heard or have questions,
please call [**Telephone/Fax (1) 62**].
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"286.9",
"682.8",
"V58.61",
"401.9",
"427.31",
"526.5",
"521.00",
"526.4",
"458.29",
"070.32",
"478.6",
"478.22",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.0",
"28.0",
"23.09",
"96.6",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
14237, 14291
|
8711, 9286
|
337, 387
|
14430, 14430
|
4525, 4530
|
15851, 16728
|
2658, 2667
|
13033, 14214
|
14312, 14409
|
12721, 13010
|
14581, 15229
|
2682, 3576
|
3604, 4506
|
12310, 12695
|
15249, 15828
|
264, 299
|
9302, 12288
|
5541, 8688
|
415, 2098
|
4544, 5521
|
14445, 14557
|
2120, 2429
|
2445, 2642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,172
| 125,559
|
4144+55547
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-9-15**] Discharge Date:
Date of Birth: [**2059-10-15**] Sex: M
CHIEF COMPLAINT: 59-year-old male with hemoptysis.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old male
with history of renal cell carcinoma, lung metastases who has
lesions, last one being on [**2119-9-11**]. He came in today for a
follow-up bronchoscopy. Patient was supposed to have a
bronchoscopy and was noted to have coughed up one cup of
blood. Bronchoscopy at the time showed moderate bleeding in
the right lower lobe distally, no bleeding from the
endobrachial lesions. The patient was recently admitted to
[**Hospital1 69**] from [**8-28**] to the
had right lower lobe bleeding mass cauterized at that time.
The patient has had multiple episodes of this hemoptysis at
home.
PAST MEDICAL HISTORY: Included metastatic renal cell
carcinoma diagnosed in [**2116**], status post right nephrectomy
and chemotherapy. The patient was found to have metastatic
disease to the lung and hilum which was treated with x-ray
therapy, laser therapy extending into the right middle lobe
bronchus. In [**8-2**] the patient was found to have metastatic
brain lesion to the right cerebellum status post stereotactic
surgery. In [**2119-5-2**] the patient was found to have
metastatic disease to the left basal ganglia, status post
stereotactic radiosurgery. The patient also has known
hypertension.
MEDICATIONS: Include home O2 as well as Univasc 10 mg q d.
SOCIAL HISTORY: The patient is retired, married, used to
smoke cigars 15 years ago, 2-3 beers per week of alcohol
consumption.
PHYSICAL EXAMINATION: Included a temperature of 98, heart
rate of 90, blood pressure 118/65, 99%. HEENT: Pupils are
equal, round, and reactive to light and accommodation, mucus
membranes moist, extraocular movements intact. Neck, no
jugulovenous distension, supple. Lungs, no rhonchi, no
wheezes, good air movement. Cardiovascular, regular rate and
rhythm, normal, S1 and S2, no murmurs, rubs or gallops.
Abdomen, positive bowel sounds, soft, nontender, non
distended. Extremities, no clubbing, cyanosis or edema, 2+
distal pulses bilaterally. Neurologic, the patient was
sedated. The patient was intubated status post the
hemoptysis for preventative measures. White count on
admission, 10.2, H&H 10.6/31.2, platelet count 571,000. Chem
7 was within normal limits. BUN and creatinine 14/0.8,
calcium 8.9 and magnesium 2.0, phosphorus 4.0. Chest CT from
[**8-24**] showed the worsening of the right lower lobe mass,
infrahilar mass and some satellite visions. EKG from [**3-2**]
showed normal sinus, normal axis, normal intervals, 0.[**Street Address(2) 1755**]
elevations, biphasic T waves in V1 through V3.
HOSPITAL COURSE: The patient was admitted to the medical
Intensive Care Unit. The patient was going to have
interventional radiology for right brachial arterial
embolism. The patient had a chest x-ray done and patient as
monitored in the medical ICU. On [**2119-9-17**] the patient had an
episode of hemoptysis about 30 ml. The patient's hematocrit
at that time went down to 24.8. The patient was going to get
transfusion of 2 units of packed red blood cells and x-ray
radiation therapy was going to be conducted. On that day
patient had a repeat bronchoscopy which revealed fresh blood
clots and clotting of the right bronchus. The patient had
that suctioned and cleared out. The patient had
desaturations as well down to the 40's with increased
respiratory rate and increased blood pressure, positive
hemoptysis. The patient was emergently reintubated with a
single lumen airway placed. Surgery consultation with
thoracic surgery was obtained and they reviewed the chest
x-ray and CAT scan and thought the mediastinal and
hilar parenchymal lesions were located such that
pneumonectomy would not be possible. Plan was again to speak
with radiation oncology and interventional radiology to see
if they would further embolize more of the bronchial artery.
On [**9-18**] the patient spiked a temperature of 102.2. The
patient remained intubated. Blood cultures were taken times
two as well as urinalysis, urine culture. The patient had
right internal jugular line. It was decided that this line
will remain in due to patient's poor peripheral access and
therefore was changed over wire with the tip sent
for culture as well. On [**2119-9-19**] blood cultures grew gram
positive cocci which turned out to be staph aureus. The
patient was started on Vancomycin 1 gm q 12 hours as well as
Ceftaz. The patient remained afebrile that day but however,
the line remained in. Further XRT was planned for patient to
have palliative measures to the bleeding source and the right
lower lobe. The patient was suctioned as needed prn for
increased bleeding as well. On [**9-20**] the patient remained
afebrile with a T max of 101.8. The right IJ culture grew
out gram positive strep and positive cocci. The patient was
continued on his antibiotics, remained hemodynamically
stable. On [**2119-9-21**] the patient was extubated and patient was
made DNI status post extubation with no further intubations
necessary. The patient's cardiovascular exam revealed an
irregular irregular rhythm with a rapid ventricular rate.
The patient was given some Lopressor 5 mg IV and Diltiazem 20
mg IV push and then Diltiazem 30 mg po q d for controlling of
his rate. The patient remained in atrial fibrillation and
transferred to the floor on [**2119-9-21**]. On transfer to the
floor the patient was stable, vital signs were stable at
98.5, 100, 104/64, 24, 96% on 40% CN. HEENT: Pupils are
equal, round, and reactive to light, extraocular movements
intact, anicteric sclera. Neck, no bruits, no jugulovenous
distension. Lungs, diffuse wheezing, rhonchus, decreased
breath sounds on the right. Heart was irregularly irregular,
no murmurs, rubs or gallops. Abdomen soft, nontender, non
distended. Extremities were warm with no edema. Neuro is
alert and oriented times three. The patient was continued on
his Vancomycin 1 gm q 12 hours. The patient had no episodes
of hemoptysis on [**2119-9-21**] while on the floor and remained
afebrile. The patient, on [**2119-9-22**], remained afebrile, no
further episodes of hemoptysis. The patient remained in
house for further XRT treatment, for further palliation of
his bleeding source. The patient had no episodes of
hemoptysis as I said for the last two nights. The patient
was continued on his Diltiazem 30 mg qid, Robitussin DM,
Tylenol 650 mg prn and Vancomycin 1 gm q 12 hours. The
patient remained in atrial fibrillation with a ventricular
response in the 110's and 130's, had some runs of NSVT as
well as VT which were both asymptomatic. The patient was
continued on Diltiazem 30 mg qid. In terms of ID the patient
remained afebrile and will continue the Vancomycin. In terms
of his GI, patient remained stable prophylactically and
patient was given Pneumoboots and Protonix 40 mg q d.
Patient's hematocrit remained stable on the floor with no further
need for transfusion. Patient's vital signs were stable
throughout the course of stay here. He will be transferred
home for hospice care and further palliative care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18106**], MD
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2119-9-22**] 11:00
T: [**2119-9-22**] 11:24
JOB#: [**Job Number 18107**]
Name: [**Known lastname **], [**Known firstname 651**] Unit No: [**Numeric Identifier 2916**]
Admission Date: [**2119-9-15**] Discharge Date: [**2119-9-22**]
Date of Birth: [**2059-10-15**] Sex: M
ADDENDUM:
The patient was discharged home on the following medications:
Diltiazem 30 mg po qid, Robitussin DM 1 tbsp q 4 hours po,
Protonix 40 mg po q d, Tylenol 650 mg po q 4 hours prn,
exsanguinates, Ativan 2-5 mg IV push until patient is
comfortable as he exsanguinates, Vancomycin 1 gm IV q 12
hours until [**2119-10-1**] to finish up a 14 day course for the
positive blood cultures, Ativan 0.5 to 2 mg prn po anxiety.
Patient's and family's wishes were for the patient to be DNR,
DNI and will have further follow-up care with the hospice nurses.
[**Hospital1 536**] with no further event of
any hemoptysis two days prior to discharge.
DR. [**First Name11 (Name Pattern1) 1327**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 904**]
Dictated By:[**Last Name (NamePattern1) 2917**]
MEDQUIST36
D: [**2119-9-22**] 11:02
T: [**2119-9-22**] 12:27
JOB#: [**Job Number 2918**]
|
[
"786.3",
"447.1",
"197.0",
"038.9",
"518.81",
"996.62",
"427.1",
"599.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"38.93",
"88.49",
"33.23",
"33.22",
"88.43",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2762, 8657
|
1645, 2744
|
124, 159
|
188, 821
|
844, 1493
|
1510, 1622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,839
| 150,324
|
2584
|
Discharge summary
|
report
|
Admission Date: [**2192-2-13**] Discharge Date: [**2192-3-2**]
Date of Birth: [**2123-8-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Norvasc / Nifedipine / Atenolol / Codeine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Presented with cervical spondylosis and disc degeneration who
presented for an elective Anterior cervical diskectomy C4-C5,
C5-C6 and C6-C7 and fusion C4-C7 [**2-13**].
Major Surgical or Invasive Procedure:
Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7
Fusion C4-C7 [**2-13**].
History of Present Illness:
68 yo male with cervical spondylosis and disc degeneration for
elective Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7 and
Fusion C4-C7 [**2-13**].
.
[**Name (NI) **] pt increasingly agitated and placed on CIWA scale as
there was concern for ETOH withdrawal. CIWA >20 early [**2-14**] am.
He received total 8 mg ativan since midnight and 17 mg haldol.
Pt gradually more stridorous, Sat 96-98% on rebreather. ENT at
bedside 2pm [**2-14**] and examined pt airway (significant obstruction
of airway by posterior pharyngeal wall and notable edema). Code
blue called, anesthesia fiberoptically intubated pt orally. Pt
sats maintained and HD stable. Pt subsequently transferred to
SICU for further care.
.
In the SICU: The patient was started on a CIWA scale, and
intermittant ativan, in addition to decadron. Over the following
days, the decadron was tapered as was his sedation. A CTA of his
neck demonstrated no acute changes and resolving pharygeal
edema. he was extubated on [**2-21**], taken off the steroids. Despite
discontinuing the steroids, the patient continues to have a
significant leukocytosis, was febrile and, as a result, was
placed on Vanc/Cipro with cultures taken of blood, urine and
wound. Cipro and Vanc were started on the 19th.
Past Medical History:
PMH:
- Cervical spondylosis and diskdegeneration.
- OSA not on CPAP.
- H/o partial empty sella syndrome.
- HTN
- Dyslipidemia
- Seasonal asthma
- Left sided CVA [**23**] years ago (right sided arm weakness)
- Migraines
- Back pain
- L5-S1 disc disease
- Hypothyroidism
- Colitis (hospitalized [**12/2190**] with ischemic colitis),
- H/o liver biopsy related to h/o
- Hemochromatosis
- h/o feeling cold "chattering" teeth, muscle/joint aches x 30
years (he has been followed by Dr. [**Last Name (STitle) 13059**]
- Retinal detachment [**2191**]
.
PSH:
- Carpal tunnel repair 20 yr ago
- liver bx
- [**2191-7-6**] Left shoulder arthroscopic subacromial decompression.
- Arthroscopic rotator cuff repair.
- [**2192-2-13**] Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7.
Fusion C4-C7. Anterior instrumentation C4-C7. Structural
allograft.
Social History:
Social History: The patient is married, a nonsmoker. Drinks
one
6-pack of beer per week. Has 2 cups of coffee a day. Currently
works part time.
Family History:
Family History: His mother died from complications from a
cerebrovascular accident. His father died from "old age." He
has a sister with diabetes, another sister with MS, and a 62-
year-old brother who died from a myocardial infarction.
Physical Exam:
VS: 99.5/[140/82]/88/20/97%RA
General: This is a male NAD. On exam, he was nontoxic appearing.
Neuro: Patient's speech is intermitantly garbled, and
nonsensical, but resolves when he makes a point of speaking more
slowlly.
HEENT: EOMI, PERRL with 1mm difference in pupil diameter. NC/AT
Sclera anicteric. Clear OP, Trachea midline. Neck supple, with
surgical scar sutured and c/d/i.
Pulmonary: Symmetric, good expansion. Breath sounds CTAB. No
rales/ wheezes/rhonchi.
Cardiac: RRR, normal S1, S2. no r/g, Systolic ejection murmur
heard at the apex, harsh in character.
ABD: + BS, soft, NT/ND
EXT: RUE area of cellulitis, and area of drainage form right
anticubital fossa wound, with mild induration.
Skin: No rash/petechiae/ecchymoses.
Pertinent Results:
[**2192-3-2**] 09:10AM BLOOD WBC-6.9 RBC-3.27* Hgb-10.1* Hct-30.0*
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.0 Plt Ct-335
[**2192-3-1**] 12:15PM BLOOD Hct-32.3*
[**2192-3-1**] 06:20AM BLOOD WBC-8.2 RBC-3.12* Hgb-10.0* Hct-29.0*
MCV-93 MCH-32.2* MCHC-34.6 RDW-13.8 Plt Ct-348
[**2192-2-29**] 09:30AM BLOOD WBC-10.1 RBC-3.58* Hgb-11.3* Hct-33.2*
MCV-93 MCH-31.4 MCHC-34.0 RDW-14.1 Plt Ct-377
[**2192-2-28**] 05:50AM BLOOD WBC-11.2* RBC-3.82* Hgb-11.9* Hct-34.8*
MCV-91 MCH-31.1 MCHC-34.1 RDW-14.0 Plt Ct-375
.
[**2192-2-29**] 09:30AM BLOOD Neuts-79.0* Lymphs-16.2* Monos-3.4
Eos-1.1 Baso-0.2
[**2192-2-25**] 07:30AM BLOOD Neuts-83.2* Lymphs-10.4* Monos-4.8
Eos-1.5 Baso-0.1
[**2192-2-23**] 01:36AM BLOOD Neuts-85.4* Lymphs-7.3* Monos-5.4 Eos-1.7
Baso-0.1
[**2192-2-15**] 04:20AM BLOOD Neuts-92.9* Lymphs-4.9* Monos-2.0 Eos-0.1
Baso-0
[**2192-2-14**] 11:20AM BLOOD Neuts-89.1* Lymphs-7.1* Monos-3.6 Eos-0
Baso-0.1
.
[**2192-3-2**] 09:10AM BLOOD Glucose-160* UreaN-19 Creat-1.6* Na-134
K-4.3 Cl-103 HCO3-25 AnGap-10
[**2192-3-1**] 06:20AM BLOOD Glucose-90 UreaN-23* Creat-1.8* Na-139
K-3.8 Cl-104 HCO3-23 AnGap-16
[**2192-2-29**] 03:10PM BLOOD Glucose-115* UreaN-29* Creat-2.3* Na-137
K-4.3 Cl-105 HCO3-24 AnGap-12
[**2192-2-29**] 09:30AM BLOOD Glucose-118* UreaN-26* Creat-2.3* Na-138
K-4.4 Cl-105 HCO3-22 AnGap-15
[**2192-2-28**] 12:15PM BLOOD Glucose-107* UreaN-22* Creat-2.0* Na-136
K-3.8 Cl-101 HCO3-24 AnGap-15
[**2192-2-28**] 05:50AM BLOOD Glucose-110* UreaN-19 Creat-1.4* Na-136
K-3.7 Cl-100 HCO3-27 AnGap-13
[**2192-2-27**] 06:45AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-134
K-3.2* Cl-97 HCO3-26 AnGap-14
[**2192-2-26**] 06:30AM BLOOD Glucose-100 UreaN-12 Creat-0.9 Na-136
K-3.4 Cl-100 HCO3-26 AnGap-13
[**2192-2-25**] 07:30AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-137
K-3.4 Cl-100 HCO3-26 AnGap-14
.
[**2192-2-15**] 04:20AM BLOOD CK(CPK)-315*
[**2192-2-14**] 02:26PM BLOOD ALT-26 AST-45* CK(CPK)-696*
[**2192-2-14**] 11:20AM BLOOD CK(CPK)-689*
[**2192-2-15**] 04:20AM BLOOD CK-MB-4 cTropnT-<0.01
[**2192-3-2**] 09:10AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
[**2192-3-1**] 06:20AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0
[**2192-2-29**] 03:10PM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
[**2192-2-29**] 09:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.2
[**2192-2-28**] 12:15PM BLOOD Calcium-8.8 Phos-4.4# Mg-2.2
.
WOUND CULTURE (Final [**2192-2-26**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
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.
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
.
SENSITIVITIES: MIC expressed in
MCG/ML
.
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
ANAEROBIC CULTURE (Final [**2192-2-28**]): NO ANAEROBES ISOLATED.
.
[**2192-2-23**] 9:03 am URINE Source: Catheter.
.
**FINAL REPORT [**2192-2-25**]**
.
URINE CULTURE (Final [**2192-2-25**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
.
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
.
[**2192-2-23**] 09:03AM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0
[**2192-2-14**] 08:24AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2192-2-23**] 09:03AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-SM
[**2192-2-29**] 06:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
68 yo male with cervical spondylosis and disc degeneration for
elective anterior cervical diskectomy C4-C5, C5-C6 and C6-C7 and
fusion C4-C7 [**2-13**]. The immediate post-op course was complicated
by pharygeal edema and respiratory distress, for which the
patient was intubated and sent to the surgical ICU. In the
SICU: The patient was started on a CIWA scale, and intermittant
ativan, in addition to decadron. Over the following days, the
decadron was tapered as was his sedation. A CTA of his neck
demonstrated no acute changes and resolving pharygeal edema. he
was extubated on [**2-21**], taken off the steroids. Despite
discontinuing the steroids, the patient continues to have a
significant leukocytosis, was febrile and, as a result, was
placed on Vanc/Cipro with cultures taken of blood, urine and
wound. Cipro and Vanc were started on the 19th.
.
On the floor the patient had the following problems and plans:
.
# Fall in the contect of recent Laminectomy: The patient had had
fluctuating mental status, exacerbated at night and had a fall
with head strike and no loss of consciousness. The subsequent
head CT without contrast and XR of the neck demonstrated no
ICH/midline shift or broken or displaced bones. His infections
were treated and a bedalarm was placed to better monitor his
movements. We attempted to provide patient with a soft collar,
which he refused. PT/OT screened the patient for rehab and
worked with him while an inpatient.
.
# AMS: The patient has a difficult time speaking clearly, and is
intermittantly confused her his wife's report - these symptoms
are resolving. The AMS/difficulty speaking may be due to
resolving pharygeal edema, infection or may be associated with
previous sedation. The primary team re-oriented him each
morning, and followed his neuro exam. In addition, we treated
his UTI and soft tissue infections. His mental status has
greatly improved and he is currently A+Ox3 at all times.
.
#ARF: The patient developed a rising creatine from 0.9 to 2.0 in
the setting of starting bactrim. His Cr. now 1.6 represents
improvement in the setting of changing from Bactrim to Levoflox
and IVF supportive therapy.
.
# Infectious Disease - UTI and soft tissue infection: Fever 102
with a leukocytosis of WBC 16 Started Vancomycin and cipro [**2-23**].
Urine culture now positive for Ecoli (sensitive to Cipro and
bactrim) and his skin infections positive for MSSA (sensitive to
keflex and bactrim). We administered Bactrim initially, which
was then transitioned to Levoflox for a 7 day course stated on
[**2-28**].
.
# Inability to swallow: Likely due to pharyngeal edema, though
may have had a hypoxic damage during initial intubation. Follow
speach and swallow recommendations: observed meals of pureed
foods.
.
#HTN: Place on home medications (lisinopril, HCTZ, simvastatin,
diltiazem, losartan).
.
# Hypothyroid: Cont. home dose of synthroid.
Medications on Admission:
Medications at home:
- Cardizem
- Cozaar 100 mg daily
- Cymbalta
- HCTZ
- Lisinopril 40 mg daily
- Oxycodone Hydrochloride
- Synthroid
- Xanax prn
- Zocor 40 mg daily
- Other (testosterone daily)
- MVI
Discharge Medications:
1. Testosterone 1 % (25 mg/2.5 g) Gel in Packet Sig: One (1)
Appl Transdermal DAILY (Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed. Tablet(s)
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO once a
day as needed for constipation.
7. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for muscle spasm.
14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Insulin sliding scale
Please follow the attached protocol.
Discharge Disposition:
Extended Care
Facility:
Academy Manor-[**Location (un) 7658**]
Discharge Diagnosis:
S/p laminectomy
Pharygeal edema
Respiratory distress
UTI
Soft tissue infection
Discharge Condition:
Good
Discharge Instructions:
You presented to the hospital for an elective laminectomy, which
was complicated by pharygeal edema and respiratory distress.
You were intubated and treated with steroids, and recovered.
While on the general floor you developed a urinary track
infection and a soft tissue infection, for which you were
treated with antibiotics.
Discharge instructions: If you experience any of the following,
return to the Emergency Department.
- Fevers and chills
- Inability to use parts of your body.
- Worsening neck pain
- Weakness, dizziness or fainting
- Abdominal (belly) pain or vomiting
- New or worsening weakness, numbness
Followup Instructions:
Dr.[**Name (NI) 12040**] office on [**Hospital Ward Name 23**] [**Location (un) 1773**] with Orthospine:
- [**3-23**], at 11:30am
- [**5-3**] at 10:30am
PCP:
[**Name Initial (NameIs) **] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2192-3-14**] 10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2192-3-2**]
|
[
"996.62",
"438.89",
"327.23",
"451.82",
"478.25",
"291.81",
"272.4",
"E888.9",
"E931.0",
"041.4",
"578.1",
"518.82",
"728.89",
"401.1",
"584.9",
"041.11",
"721.0",
"599.0",
"E849.7",
"682.3",
"276.52",
"244.9",
"722.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"81.62",
"96.72",
"96.71",
"96.04",
"81.02",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13017, 13082
|
8521, 11422
|
484, 562
|
13205, 13212
|
3907, 8498
|
13880, 14345
|
2909, 3134
|
11675, 12994
|
13103, 13184
|
11448, 11448
|
13590, 13857
|
11469, 11652
|
3149, 3888
|
275, 446
|
590, 1845
|
1867, 2710
|
2743, 2876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,332
| 146,820
|
54172
|
Discharge summary
|
report
|
Admission Date: [**2169-10-2**] Discharge Date: [**2169-10-28**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
GIB, hypotension
Major Surgical or Invasive Procedure:
s/p intubation
s/p IR embolization
s/p electrical cardioversion
History of Present Illness:
Mr. [**Known lastname 21160**] is an 87 [**Hospital 100**] Rehab resident with a history of
coronary disease, s/p MI [**2167**], type II diabetes on oral therapy,
dementia, atrial fibrillation on coumadin, s/p recent admission
for hip fracture, with preop cath, found to have 3VD disease,
and s/p TEE cardioversion for atrial tachycardia who now
presents with 2 episodes of BRBPR and melena, 2x times.
.
In ED, HCT was initally 27 but with IVF dropped quickly to 19.
NG lavage negative. He subsequently became tachycardic and
hypotensive despite 6U of PRBC, 2U Factor [**7-23**] and 2U of FFP
transfusions and was intubated and started on dopamine while
waiting for angiography.
Past Medical History:
CAD s/p MI [**2167**], cath [**9-/2169**] with 3VD
Afib on warfarin
Type II diabetes
Dementia
s/p recent r hip fx
Moderate Pulmonary HTN
Social History:
Former bank teller. Lives at [**Hospital 100**] Rehab. Denies ETOH, tobacco.
Has cousins only still living for family. Makes own medical
decisions.
Family History:
Noncontributory
Physical Exam:
Vitals: 98.4 156/84 90
AC 0.6, 550, 14, PIP 25, PEEP 5
Gen: intubated/sedated
HEENT: NC/AT, PERRLA, ET and NG tube in place
COR: Tachy, regular rhythm, no mrg
PULM: diffuse crackles bilaterally
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, mottled feet, ulcer on dorsum of R foot,
multiple scratches on feet, operative wound on R hip well
healing
EXT: 1+ pulsus, 2+ edema up to the groin, scrotal edema
Neuro: moving all extremities, responding to pain, not following
commands, PERRLA, reflexes 1+ b/l
Pertinent Results:
139 110 20 /110 AGap=9
4.6 25 1.2 \
ALT: 15 AP: 94 Tbili: 0.5 Alb:
AST: 15 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 93
.
95
9.4 \ 6.6 / 261
/ 19.5 \
N:85.8 L:6.9 M:5.5 E:1.4 Bas:0.3
Comments: Notified Dr. [**First Name (STitle) 2855**] [**2169-10-2**] @9.50am
Macrocy: 1+
PT: 34.5 PTT: 38.2 INR: 3.7
.
[**2169-10-2**]
09:00a
94
11.8 \ 9.5 / 323
/ 27.4 \
.
[**10-2**] GI bleed study: No active GI bleeding identified.
.
[**10-3**] colonoscopy: Diverticulosis of the colon
Normal mucosa in the colon
[**10-3**] endoscopy: Normal EGD to second part of the duodenum
Brief Hospital Course:
a/p: 87 yo man with afib on coumadin, CHF, DMII, now with
massive lower GIB.
.
# GIB: Bleeding source was felt to be from a lower GI source
given negative NG lavage with BRBPR, neg bleeding scan and EGD.
Colonoscopy c/w diverticular bleed, although no active bleeding
seen. Initially rec'd 6U PRBC w/ appropriate bump in HCT.
however, while in angio, patient rec'd add'l 4U PRBC. HCT
therefore transfused beyond goal, to approx 45. Also rec'd 3U
FFP. Maintained on [**Hospital1 **] PPI. On transfer HCT stable. During
pt's prolonged MICU course, he developed recurrent BRBPR. On
[**10-17**] he underwent a tagged RBC scan which revealed bleeding in
the mid-transverse colon. Selective superior mesenteric
arteriography revealed active extravasation from a third-order
terminal branch of the right middle colic artery and he
underwent successful superselective embolization of the bleeding
vessel using two microcoils and four straight coils with
immediate cessation of bleeding. Pt continued to have guiac
positive stools, but no further intervention was needed.
.
# Shock: initially though likely due to GIB and volume loss. Hx
of diastolic CHF (last EF > 60%) and known 3VD. CXR consistent
with worsening failure. However following volume resuscitation
patient could not be weaned from pressors. Started on Vanco,
Levo, Flagyl which he was maintained on until [**10-6**] (cultures
neg, off pressers). Mvo2 71% and TTE was w/o evidence of
systolic dysfxn. Titrated off norepinephrine on [**10-5**].
Throughout the prolonged MICU course, pt was intermittently
hypotensive, in the setting of diuresis, requiring intermittent
pressors.
.
# Respiratory Failure: Pt had respiratory failure of
multifactorial etiology secondary to diastolic CHF (in the
setting of large blood transfusion and IVF), multi-lobar
pneumonia, and possible ARDS physiology. Pt was diuresed as his
blood pressure tolerated. Pt was briefly extubated initially -
then required re-intubation. At the end of the pt's MICU course,
he was extubated. After discussions with the pt's HCP, he was
made DNR/DNI. During the morning that the pt expired, he was
noted to be breathing comfortably. A few minutes later, pt's
monitor was not [**Location (un) 1131**] a pulse ox. While the nurse and medical
team was at the bedside, pt became bradycardic and asystolic. No
CPR was initiated given pt's code status. He passed away very
quickly.
.
# Atrial fibrilliation: Difficult to control in the recent past.
On Amiodarone and Metoprolol for rate/rhythm control. In SR in
MICU initially. Amiodarone and Metoprolol were re-started when
BP stable. Coumadin was held due to massive GIB. During the
MICU course, pt went into Af/Aflutter. He was seen by the EP
service who cardioverted him, given the possibility that his AF
was contributing to hemodynamic instability. Pt was successfully
converted into SR.
.
# CAD: Known 3VD. Initially held Aspirin, but re-started
following stable hct x48h. Metoprolol as above.
.
# DM II: Maintained intermittently on insulin gtt and RISS
.
# PPX: Maintained on PPI [**Hospital1 **] and heparin sc once stable.
Medications on Admission:
Meds at last discharge:
Acetaminophen 500 mg PO Q4-6H as needed.
Morphine 2 mg/mL Q4H as needed.
Metoprolol Tartrate 50 mg PO Q6H
Amiodarone 200 mg PO daily
Bisacodyl 5 mg PO DAILY
Pantoprazole 40 mg Tablet PO Q24H
Docusate Sodium 100 mg PO BID
Senna 8.6 mg
Aspirin 81 mg Tablet
Oxycodone 5 mg PO Q6-8H as needed.
Enalapril Maleate 2.5 mg PO once a day.
Glyburide 5 mg PO once a day.
Warfarin 1 mg PO once a day
Simvastatin 20mg QD
Wellbyutrin 100mg Qd
Ferrous Sulfate 325mg QD
Insulin sliding scale
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
GIB - diverticular bleed
Diastolic CHF
Multi-lobar pneumonia
Respiratory failure
Atrial fibrillation/A flutter
DM
CAD
Hypotension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"427.31",
"585.9",
"276.52",
"285.1",
"V58.61",
"562.10",
"276.4",
"785.59",
"482.41",
"578.9",
"707.13",
"995.94",
"507.0",
"584.9",
"250.00",
"287.5",
"518.84",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.15",
"96.04",
"38.93",
"96.72",
"96.6",
"45.23",
"93.90",
"44.44",
"96.34",
"99.07",
"99.62",
"99.04",
"00.17",
"38.91",
"45.13",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6269, 6278
|
2572, 5689
|
236, 301
|
6451, 6460
|
1925, 2549
|
6513, 6520
|
1353, 1370
|
6240, 6246
|
6299, 6430
|
5715, 6217
|
6484, 6490
|
1385, 1906
|
180, 198
|
329, 1010
|
1032, 1171
|
1187, 1337
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,691
| 154,558
|
46884
|
Discharge summary
|
report
|
Admission Date: [**2197-7-19**] Discharge Date: [**2197-7-26**]
Date of Birth: [**2133-1-19**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Rhabdomyolysis, Pneumonia
Major Surgical or Invasive Procedure:
RIJ placement
PICC line placement
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 805**] is an 64yo male with
PMH significant for HTN and DM who is being transferred to the
MICU for management of rhabdomyolysis. Since patient is poor
historian, details were obtained from ED records. Patient
presented yesterday evening to the ED with 3d history of back
pain. He has not been out of bed during this time and was found
urinating in the bed. Poor PO intake during this time. Patient
is able to confirm this history and denies any fevers, chills,
chest pain, or SOB.
In the ED, initial vitals were T 98.4 BP 150/79 AR 94 RR 16 O2
sat 100% RA. A RIJ central line was placed on sterile
conditions. He then received 1L NS, Morphine 4mg IV, and was
started on a sodium bicarbonate infusion.
Past Medical History:
Type 2 Diabetes
Hypertension
Peripheral vascular disease
Prostate cancer, followed by Dr. [**Last Name (STitle) **] and [**Doctor Last Name **]
Hepatitis C
Chronic low back pain
hx of osteomyelitis
Cocaine abuse
Social History:
He is unemployed currently, but used to have a geriatric nursing
certificate. He lives with a female partner. [**Name (NI) **] [**Name2 (NI) **], he is an
active smoker and smokes approximately two packs per day. He
does have a history of alcohol abuse and a history of IV drug
use in [**2158**]. His last use of marijuana was in [**2196-6-19**].
Family History:
Diabetes in both mother and father
Physical Exam:
vitals T 97.7 BP 105/70 AR 100 RR 13 O2 sat 99% RA CVP 6
Gen: Patient responsive to commands but falls back asleep
quickly
HEENT: MMM, anicteric sclera, white coating on tongue
Heart: RRR, no m,r,g
Lungs: CTAB, poor air movement at bases posteriorly
Abdomen: Soft, NT/ND, +BS; midline scar
Extremities: No LE edema, 2+ DP/PT pulses bilaterally; diffuse
paraspinal tenderness; superficial ulcer on L buttock
Rectal: Guaiac negative (in ED), good rectal tone
Pertinent Results:
[**2197-7-26**] 05:38AM BLOOD WBC-5.8 RBC-3.00* Hgb-8.9* Hct-26.2*
MCV-87 MCH-29.8 MCHC-34.1 RDW-15.6* Plt Ct-196
[**2197-7-25**] 05:05AM BLOOD WBC-4.9 RBC-2.90* Hgb-8.9* Hct-25.4*
MCV-87 MCH-30.5 MCHC-34.9 RDW-15.1 Plt Ct-164
[**2197-7-24**] 05:52PM BLOOD WBC-4.9 RBC-2.96* Hgb-8.9* Hct-25.6*
MCV-87 MCH-30.2 MCHC-34.8 RDW-15.3 Plt Ct-164
[**2197-7-23**] 06:03AM BLOOD WBC-5.2 RBC-3.03* Hgb-9.1* Hct-26.4*
MCV-87 MCH-30.1 MCHC-34.6 RDW-15.0 Plt Ct-165
[**2197-7-22**] 06:50AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.6* Hct-27.5*
MCV-86 MCH-30.0 MCHC-34.9 RDW-14.9 Plt Ct-189
[**2197-7-26**] 05:38AM BLOOD Plt Ct-196
[**2197-7-25**] 05:05AM BLOOD Plt Ct-164
[**2197-7-24**] 05:52PM BLOOD Plt Ct-164
[**2197-7-26**] 05:38AM BLOOD Glucose-124* UreaN-11 Creat-1.0 Na-138
K-3.7 Cl-106 HCO3-27 AnGap-9
[**2197-7-25**] 05:05AM BLOOD Glucose-106* UreaN-8 Creat-0.9 Na-144
K-4.0 Cl-111* HCO3-23 AnGap-14
[**2197-7-24**] 05:52PM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-139
K-3.6 Cl-109* HCO3-24 AnGap-10
[**2197-7-23**] 06:03AM BLOOD Glucose-129* UreaN-9 Creat-0.9 Na-138
K-3.7 Cl-110* HCO3-23 AnGap-9
[**2197-7-22**] 06:50AM BLOOD Glucose-134* UreaN-12 Creat-0.9 Na-142
K-4.0 Cl-110* HCO3-25 AnGap-11
[**2197-7-26**] 05:38AM BLOOD ALT-36 AST-30 CK(CPK)-647* AlkPhos-50
TotBili-0.3
[**2197-7-25**] 05:05AM BLOOD ALT-39 AST-36 CK(CPK)-1067* AlkPhos-49
TotBili-0.3
[**2197-7-24**] 05:52PM BLOOD ALT-41* AST-41* LD(LDH)-457*
CK(CPK)-1381* AlkPhos-50 TotBili-0.3
[**2197-7-23**] 06:03AM BLOOD ALT-47* AST-58* LD(LDH)-494*
CK(CPK)-2643* AlkPhos-46 TotBili-0.4
[**2197-7-22**] 06:50AM BLOOD ALT-56* AST-92* LD(LDH)-563*
CK(CPK)-4388* AlkPhos-50 TotBili-0.4
[**2197-7-21**] 05:27AM BLOOD ALT-63* AST-125* LD(LDH)-553*
CK(CPK)-6019* AlkPhos-51 TotBili-0.6
[**2197-7-19**] 01:10AM BLOOD ALT-109* AST-337* LD(LDH)-773*
CK(CPK)-[**Numeric Identifier 99460**]* AlkPhos-68 TotBili-0.7
[**2197-7-19**] 04:45AM BLOOD CK(CPK)-[**Numeric Identifier 99461**]*
[**2197-7-19**] 01:10AM BLOOD cTropnT-<0.01
[**2197-7-21**] 05:27AM BLOOD calTIBC-222* Ferritn-384 TRF-171*
[**2197-7-22**] 06:50AM BLOOD HIV Ab-NEGATIVE
[**2197-7-19**] 07:45AM BLOOD Cortsol-27.0*
[**2197-7-19**] 01:10AM BLOOD TSH-0.33
[**2197-7-19**] 04:28PM BLOOD Ammonia-45
[**2197-7-19**] 07:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-7-19**] 01:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
.
[**2197-7-20**] 3:51 pm BLOOD CULTURE
**FINAL REPORT [**2197-7-26**]**
Blood Culture, Routine (Final [**2197-7-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- 0.12 R
Aerobic Bottle Gram Stain (Final [**2197-7-21**]):
GRAM POSITIVE COCCI IN CLUSTERS.
ECHO [**2197-7-25**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-12-16**],
there is no significant change.
Brief Hospital Course:
Mr. [**Known lastname 805**] is an 64yo male with PMH significant for HTN and
DM2 who presents with rhabdomyolysis.
1)Rhabdomyolysis: Patient is admitted with classic presentation
of rhabdomyolysis which includes myalgias, red to brown urine
due to myoglobinuria, and elevated serum muscle enzymes. The
differential diagnosis for rhabdomyolysis includes the
following: trauma, crush injuries, coma, immobilization, extreme
exertion, seizures, extreme heat, malignant hyperthermia,
neuroleptic malignant syndrome, myopathy, alcoholism,
drugs/toxins (statins, colchicine), viral infections, and
endocrinopathies (DKA, non-ketotic hyperglycemia,
hypothyroidism). The most likely cause in this patient is
immobilization given history of lying in bed for the past 3
days. Per his pharmacy, he has not recently been on a statin. He
received 1L NS and sodium bicarbonate infusion in the ED. TSH
and cortisol was normal. He also had a normal urine and serum
tox screen. Upon transfer to the MICU he was continued on D5W +
150mEQ HCO3. His CK trended down as he received IVFs. He
received 8 L NS with sodium bicarb in the MICU. CK started
trending down and he was transferred to floor, continued
hydration, with continued trending down of CK. On [**7-24**] CK
1381->CK 1067->647 on [**7-26**]. IVF d/c with increasing PO and
continued improving CK.
Pneumonia: Patient with infiltrate on CXR, finished 7 day course
of levaquin.
2)Acute renal failure: Patient presents with elevated creatinine
of 2.7 likely [**1-21**] rhabdomyolysis. Baseline Cr is 1.0. His
creatinine returned to baseline after IVFs.
3)GPC bacteremia: Spiked to 101.8. BCx [**12-24**] growing GPCs.
Possible contamination however also with fevers. Started on
vancomycin in the ICU. Concern for possible infectious (HIV,
CMV) causes of rhabdomyolysis. HIV test negative. Given concern
of possible catheter infection, RIJ d/c, tip not cultured but
covered with abx for line infection. CT abd RLL PNA,
peripancreatic stranding. On floor, continued to remain
afebrile. Bcx from [**7-19**] [**12-22**] coag neg staph, Bcx from [**7-20**] [**12-21**]
coag neg staph. Due to culture results and sensitivity data
showing sensitive to oxacillin, vanco was d/c [**7-24**] and pt started
on nafcillin for two week course, remained afebrile. HIV test
negative. He was switched to nafcillin when culture came back
negative for MRSA and on discharge, he was on day #7 of
nafcillin and will need to finish 14 day course of antibiotics
(last day [**2197-8-2**])
4)Transaminitis: AST, ALT, and LDH can be present in many
tissues and increased serum levels are a nonspecific indicator
of an underlying process. Has history of HCV with HCV VL of
9,560,000 IU/mL. in [**2194**]. In this case, likely elevated [**1-21**]
rhabdomyolysis. With resolution of rhabdo, transaminases started
trending down. Serum concentrations are highest in liver
diseases, but increased values are also seen in skeletal muscle,
myocardial disease, and hemolysis. In this patient, elevated [**1-21**]
rhabdomyolysis. LFTs trended downwards once agressively
rescusitated.
5)Low back pain: This a chronic problem for patient. He has no
evidence of vertebral metastases from his prostate cancer. It
appears that he also had a narcotics contract with his PCP
([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]) at [**Company 191**]. Per ED records, patient unable to get out
of bed over the past few days [**1-21**] back pain. On exam, he has
diffuse paraspinal tenderness but this may be due to the rhabdo.
He has no fevers to suggest an underlying infectious process and
he has good rectal tone. Patient was continued throughout his
hospitalization at half his home dose of MS Contin at 30mg [**Hospital1 **]
but with improvement in mental status and return to baseline MS,
patient was brought back up to his home dose of MS Contin 60mg
[**Hospital1 **] without incident. His pain was well controlled.
6)Anemia: Patient's baseline Hct is in the mid 30's. Dropped to
26 but this was in context of receiving 8-9L IVFs. Iron low,
ferritin upper limit nml. His HCT remained stable throughout
the rest of his hospitalization. He was started on iron
supplementation
7)Type 2 DM: Patient is on Metformin as an outpatient. His last
hemoglobin A1C was 5.7 last week. Metformin was held given
elevated creatinine. He was placed on insulin sliding scale and
FS QID. He is going to be restarted on his metformin upon
discharge.
8)Hypertension: Patient is on Lisinopril as an outpatient. This
was initially held given elevated creatinine but then restarted
once creatinine returned to baseline. His blood pressure was
under good control on his home medications.
9)hx of prostate cancer: Patient is followed closely by Dr.
[**Last Name (STitle) **] and [**Doctor Last Name **] in oncology. He received neoadjuvant hormonal
therapy and radiation. Based on recent bone scan, he has no
evidence of metastases. He is on Doxazosin as an outpatient and
after initially holding this medication, he was restarted on the
floor. He will be seen in [**Hospital **] clinic with Dr. [**Last Name (STitle) **]
Thursday [**7-27**].
10)Anxiety/depression: Patient is followed closely by psychiatry
here at [**Hospital1 18**]. He is on Remeron and Clonazepam per [**Hospital1 **]. His
regimen was initially held given his mental status changes.
There was some concern that he was withdrawing from
[**Last Name (LF) 99462**], [**First Name3 (LF) **] he was started on Clonazepam 0.5mg [**Hospital1 **]. He
will not be restarted on his Remeron upon discharge.
12)Smoking: Patient stated desire to quit. He was started on a
nicotine patch with good results while an inpatient. He should
follow up with PCP for additional smoking cessation.
Medications on Admission:
Remeron 45mg PO QHS
Clonazepam 1mg PO BID
Metformin 1000mg PO BID
Doxazosin 4mg PO daily
Lisinopril 40mg PO daily
MS Contin 60mg PO BID
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: Give as
directed per insulin sliding scale Injection ASDIR (AS
DIRECTED).
2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours): Hold for sedation,
RR<12.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for wheezing.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off.
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q6H (every 6 hours) for 7 days: Last day is
[**2197-8-2**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Rhabdomyolysis
Right lower lobe pneumonia
Discharge Condition:
Stable and in good condition
Discharge Instructions:
You were seen for a condition call rhabdomyolysis which was
likely due to prolonged bedrest, and also because of narcotics.
This was treated with IV fluids and you got better.
Additionally, you were found to have bacteria in your lungs and
in your blood. You have been treated with antibiotics which you
will continue at the rehabilitation facility.
Please continue all your home medications except for the
following additions and changes.
- you need to finish 7 more days of nafcillin antibiotics (last
day is [**2197-8-2**])
- you were started on iron supplementation
- you were started on nicotine patch and are encouraged to talk
to your PCP about other methods of smoking cessation
- you were started on a lidocaine patch for pain
You should continue to remain out of bed as much as possible and
walk at least three times per day with assistance. Please call
your physician or return to the hospital if you experience
fever, chills, cough, sweating, chest pain, shortness of breath,
or any new or worrisome symptoms.
Followup Instructions:
Please keep your primary care appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
on Wednesday [**8-23**] at 1:30pm. [**Telephone/Fax (1) 250**]
Please keep your appointment with your oncologist Dr. [**Last Name (STitle) **]
[**2197-7-27**] 11:00.
|
[
"305.1",
"V58.67",
"V10.46",
"041.19",
"728.88",
"724.2",
"486",
"275.3",
"300.4",
"401.9",
"348.30",
"790.7",
"250.00",
"443.9",
"584.9",
"070.70",
"996.62",
"707.05",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13973, 14026
|
6338, 12109
|
298, 333
|
14112, 14143
|
2261, 6315
|
15217, 15508
|
1732, 1768
|
12296, 13950
|
14047, 14091
|
12135, 12273
|
14167, 15194
|
1783, 2242
|
233, 260
|
389, 1114
|
1136, 1350
|
1366, 1716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,694
| 198,699
|
18192+56934
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-9-17**] Discharge Date: [**2178-10-5**]
Date of Birth: [**2115-8-4**] Sex: F
Service: SURGERY
ADMISSION DIAGNOSES:
1. Small bowel obstruction.
2. Ventral hernia.
3. Hypertension.
4. Obstructive sleep apnea.
5. Fibromyalgia.
6. Morbid obesity.
7. Status post total abdominal hysterectomy.
DISCHARGE DIAGNOSES:
1. Ventral hernia--status post repair.
2. Status post lysis of adhesions.
3. Status post partial small bowel resection for
incarcerated, perforated small bowel.
4. Sepsis.
5. Hypertension.
6. Obstructive sleep apnea.
7. Fibromyalgia.
8. Morbid obesity.
9. Status post total abdominal hysterectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
female who was brought to the [**Hospital6 2018**] from [**Hospital3 **] with a diagnosis of small bowel
obstruction and what was noted as a history of incarcerated
ventral hernia. The patient had been noted to initially
present with severe right-sided abdominal pain with
associated nausea and vomiting. She was previously seen at
an outside hospital a few days prior, but had been discharged
home after was diagnosed with a partial small bowel
obstruction, but returned again with similar symptoms.
PHYSICAL EXAM: On initial presentation, the patient's pulse
was in sinus tachycardia in the 110s, with the blood pressure
120 systolic, respiratory rate was noted to be 20, and she
was satting 95% on room air, and was otherwise noted as
afebrile. In terms of initial examination, she was morbidly
obese. The skin evidenced no rash or jaundice. The lungs
were clear. The heart was, as mentioned, in sinus
tachycardia, but there was no rub. The belly was soft.
There was a considerable amount of right-sided abdominal
tenderness with some guarding. Bowel sounds were hypoactive.
A large ventral hernia was notable. Otherwise, the patient's
calves were noted to be nontender.
ADMISSION LABS: When the patient came in, the patient's
[**Known lastname **] count was 16.1, with a hematocrit of 43.5, and a
platelet count of 681. The patient's BUN and creatinine on
admission were 20 and 1.2, respectively, with a potassium of
3.4. Otherwise, labs were unremarkable.
HOSPITAL COURSE - 1) SURGERY: The patient was admitted on
the [**9-17**], and on that same day underwent abdominal
exploration, at which time the ventral hernia was repaired,
and there was significant lysis of adhesions, and the patient
also required a partial small bowel resection for an
incarcerated area of hernia which was somewhat strangulated
and perforated.
The patient's postop course was initially somewhat tenuous.
Postoperatively, she continued to require intubation for her
respiratory status. As noted, she was maintained on sedation
during intubation, but otherwise had no neurologic
deficiencies postoperatively.
2) RESPIRATORY: As noted, the patient did have some evidence
of pulmonary edema secondary to a significant positive
balance in terms of fluids, for which she was aggressively
diuresed during her postoperative course. She was eventually
extubated after this edema had resolved, at which time she
was restarted on her BiPAP.
3) CARDIAC: The patient was ruled out for an MI between
[**9-23**] and [**2178-9-25**]. There was no evidence of
any sort of cardiac damage. The patient had significant
difficulties with tachycardia and although her blood pressure
has remained control, this was attributed to be secondary to
the body stress response, and the patient was on IV
Lopressor. By the time of discharge, her pulse rate was well
controlled in the mid-80s and she had excellent blood
pressures in the 130s/60s. Otherwise, the patient had no
notable cardiac issues.
4) RENAL/GU: The patient did make an excellent amount of
urine, as noted, due to her significant volume overload and
diuresis. Otherwise, the patient's BUN and creatinine came
down significantly throughout her postoperative course to a
BUN and creatinine of 8 and 0.3 at the time of discharge,
which was significantly improved over her admission BUN and
creatinine of 20 and 1.2.
5) FLUID, ELECTROLYTES AND NUTRITION: The patient did
require TPN postoperatively, as she was NPO, and she was
intubated for quite some time. There were no complications
associated with this TPN, and she was taken off her
parenteral nutrition several days prior to discharge. Her
significantly positive fluid balance, as noted previous, was
handled with aggressive lasix diuresis, for which she was
initially on a lasix drip but eventually converted to PO
lasix. This did help relieve her prior pulmonary edema.
6) INFECTIOUS DISEASE: The patient had a significant number
of issues here. Multiple blood cultures were positive for
coag-negative Staphylococcus in aerobic and anaerobic
bottles. She was treated for this with IV vancomycin.
Follow-up cultures drawn after patient had been on her IV
vancomycin had shown no growth prior to discharge. The
patient evidenced no urinary tract infection on any urine
cultures drawn. Her stool did not show any evidence of
Clostridium difficile. Sputum cultures only grew flora, and
no other organisms were noted. Note: Her JP fluid also grew
some coag-negative Staph.
7) HEMATOLOGY: The patient's hematocrit at the time of
discharge was 27.9, which was significantly down from 43.5 at
time of admission, but this was felt to likely be
hemoconcentrated, and this discharge hematocrit had been
trended up gradually postoperatively.
At the time of discharge, the patient was felt to be in good
condition, as she tolerated PO intake without any difficulty,
and was tolerating a general diet. The patient's pain
control was through PO medication. She was able to maintain
adequate hydration, and had no more respiratory difficulties.
Physical therapy had been working with the patient. The
patient's postoperative course antibiotics was to be
determined by the final results of her surveillance cultures.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg delayed-release capsule 1 capsule po
qd.
2. Percocet 5/325, 1-2 tablets po q 4-6 h prn.
3. Lopressor 100 mg po bid.
4. Vasotec: The patient was not discharged home on her prior
dose of vasotec, as she had achieved excellent blood pressure
control.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 13262**]
MEDQUIST36
D: [**2178-10-5**] 12:39
T: [**2178-10-5**] 14:03
JOB#: [**Job Number 50280**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 9357**]
Admission Date: [**2178-9-17**] Discharge Date: [**2178-10-9**]
Date of Birth: [**2115-8-4**] Sex: F
Service:
ADDENDUM: The patient's discharge was delayed secondary to
difficulties with rehab placement. Otherwise, the [**Hospital 1325**]
hospital course was uneventful in the four days subsequent to
dictation of prior discharge summary. She had remained
afebrile and otherwise hemodynamically stable, and
encountered no other problems. Please refer to the discharge
summary dictated on [**2178-10-5**] for patient's HPI,
exam, hospital course, and discharge medications. The
patient was discharged to rehab facility on [**2178-10-9**].
[**First Name8 (NamePattern2) 116**] [**Name8 (MD) **], M.D. [**MD Number(1) 4989**]
Dictated By:[**Last Name (NamePattern1) 9358**]
MEDQUIST36
D: [**2178-11-9**] 11:06
T: [**2178-11-9**] 11:14
JOB#: [**Job Number 9359**]
|
[
"285.1",
"785.52",
"584.9",
"569.83",
"567.2",
"518.5",
"038.19",
"552.29",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.59",
"54.19",
"96.6",
"45.91",
"93.90",
"54.59",
"99.04",
"96.72",
"99.15",
"96.04",
"45.61"
] |
icd9pcs
|
[
[
[]
]
] |
355, 654
|
5962, 7541
|
1232, 1898
|
160, 334
|
683, 1216
|
1915, 5939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,658
| 162,927
|
48943
|
Discharge summary
|
report
|
Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-18**]
Service: [**Last Name (un) **]
The patient is an 82-year-old male with a past medical
history significant for congestive heart failure with an
ejection fraction of 25-30 percent and a CABG x5 in [**2188**], and
a right colectomy in [**12/2194**], who now has an enterocutaneous
fistula that developed since the colectomy. The patient has
had ongoing infections at the ostomy site and had an ostomy
bag in place. Surgery was delayed based upon the patient's
poor cardiac status and was finally only done at the behest
of the patient and his wife.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Congestive heart failure with an ejection fraction of 25
to 30 percent.
3. Diabetes mellitus.
4. Mid thoracic compression fracture.
PAST SURGICAL HISTORY:
1. CABG times five in [**2188**].
2. Right colectomy in [**12-2**].
ALLERGIES:
1. Procainamide.
2. Amiodarone
3. Pronestyl.
MEDICATIONS:
1. Carvedilol 3.125 mg b.i.d.
2. Lisinopril 5 mg q.d.
3. Inspra 25 mg q.d.
4. Lasix 20 and 40 mg on alternating days.
5. Digoxin 0.125 mg q.d.
6. Aspirin 81 mg q.d.
7. Potassium chloride 20 mg q.d.
8. Coumadin 2 mg q.d.
9. Prilosec 20 mg q.d.
10. Colace t.i.d.
PHYSICAL EXAMINATION: Heart rate 77, blood pressure 122/70,
oxygen saturation 97 percent. General - No apparent
distress, frail. Heart - Irregularly, irregular. Chest -
Clear to auscultation bilaterally, no rhonchi or crackles.
Abdomen - Rounded, soft, slight tenderness at ostomy site,
ostomy on the right abdomen, with induration, erythema, and
edema. Extremities - No clubbing, cyanosis, or edema.
PLAN: The patient was admitted to undergo repair of his
enterocutaneous fistula.
HOSPITAL COURSE: On [**2197-4-10**], the patient went an
exploratory laparotomy with resection of his enterocutaneous
fistula resulting in an ileocolic anastomosis. The patient
tolerated the procedure well. Please see dictated op note
for details. The patient went to the ICU postoperatively for
total of three days, where he had an uneventful course and
was gently diuresed. He continued in atrial fibrillation
throughout his hospital course and that atrial fibrillation
was marked by frequent PVCs and short bursts of PVCs. The
patient ultimately was placed back on his digoxin and
carvedilol, but as he continued to have these events, his
carvedilol was increased and his digoxin was decreased to the
discharge doses (see below).
On postoperative day four, the patient complained of some
chest pain and shortness of breath, and EKG was therefore
obtained, which showed no acute ischemic changes. In fact,
there were no changes from his EKG preoperatively. Patient
nevertheless was continued on telemetry and three sets of
enzymes were obtained, and the patient ruled out for a MI.
The patient's abdominal wounds where the fistulas were were
packed throughout the [**Hospital 228**] hospital course with wet-to-
dry's and remained clean throughout his hospital course.
When the patient was discharged, the fistula sites were to be
changed by VNA twice a day with wet-to-dry's.
On postoperative day six, the patient continued to report no
flatus. His diet was advanced nevertheless to sips and 2 mg
of Coumadin was started and continued throughout the
remainder of his hospital course.
On postoperative day seven, the patient had some mild
distention, but reported flatus, and was therefore advanced
to clears diet, which he tolerated well.
On postoperative day eight, the patient continued to report
flatus. He tolerated a regular diet, and was therefore sent
home. His INR upon discharge was 1, and his Coumadin was
continued at 2 per day. The patient also had several bowel
movements on the previous day, but on the day of discharge,
that diarrhea had subsided.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation.
2. Congestive heart failure with an ejection fraction of 25
to 30 percent.
3. Diabetes mellitus.
4. Mid thoracic compression fracture.
5. Status post takedown of enterocutaneous fistula.
DISCHARGE MEDICATIONS:
1. Carvedilol 6.25 mg p.o. b.i.d.
2. Digoxin 0.125 mg p.o. q.o.d.
3. Lisinopril 5 mg p.o. q.d.
4. Furosemide 20 and 40 mg on alternating days p.o. q.d.
5. Warfarin 2 mg p.o. q.d.
6. Prilosec.
7. Colace.
8. Inspra 25 mg p.o. q.d.
9. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. prn.
10. Aspirin 81 mg p.o. q.d.
11. Insulin sliding scale and fixed dose.
FOLLOW-UP PLANS:
1. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30330**] in [**12-2**] weeks.
2. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**], your cardiologist in 1-
2 weeks.
3. Follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-2**] weeks to
regulate your Coumadin doses.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2197-4-22**] 12:45:24
T: [**2197-4-24**] 07:49:56
Job#: [**Job Number 24907**]
|
[
"E878.2",
"560.1",
"428.0",
"998.6",
"427.31",
"997.4",
"427.1",
"518.5",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.79",
"38.93",
"45.93",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
3838, 3869
|
3890, 4105
|
4128, 4491
|
1750, 3816
|
832, 1242
|
1265, 1732
|
4508, 5158
|
646, 809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,058
| 178,537
|
11569
|
Discharge summary
|
report
|
Admission Date: [**2102-6-8**] Discharge Date: [**2102-6-16**]
Date of Birth: [**2040-9-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
Bloody Paracentesis, Encephalopathy
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
61yo man with h/o etoh cirrhosis, ESLD, ascites s/p frequent
taps, FTT, who was admited for w/u of bloody ascites and
management of FTT, who developed worsening MS [**First Name (Titles) **] [**Last Name (Titles) **]
compromise, transferred to MICU for further w/u and management.
Has had marked weight loss continuing over past 3 months. When
healthy his weight was 165-170, currently it is 138 lbs. He was
recently ([**5-6**]) admitted for 4d for this FTT. Pt underwent LVP
(7L) on the day of admit [**2102-6-8**], found to have bloody fluid that
was concerning for tuberculous ascites. After his admission and
the large volume tap, the patient was feeling "a little better".
He had a PPD planted that has since come back negative. His WBC
count was slightly elevated, but he had no fevers initially and
his ascites were negative for SBP, so no abx were started. A
nutrition consult was obtained, he was started on a PO diet in
addition to TF supplements. Blood cultures have been neg to
date. He had a CXR that showed L>R pleural effusion felt to be
from his ascites, as well as a small PTX that was managed
conservatively (no chest tube).
.
In the last several days, the patient developed leukocytosis and
ARF. His tube feeds were decreased [**2-2**] distention, his sodium
went down so his lasix/aldactone were held. A repeat CXR showed
no enlargement of PTX. His WBC has remained elevated though he
has been afebrile, and he was feeling well except for chronic
low back pain. He underwent a diagnostic tap given his WBC and
bandemia, with no evidence of SBP on gram stain and cell count.
He had a repeat u/a, cxr that were unrevealing for infectious
etiology. Given his worsening renal function concerning for HRS,
the pt was started on midodrine, octreotide, albumin. Because of
his worsening LBP, the patient's pain meds were increased this
AM to oxycodone 10mg. He had not had a BM since Thursday despite
lactulose, but a 90ml dose this AM recently had the effect of a
large loose BM.
.
The team found the pt to be withdrawn and lethargic later on
this AM, and called the ICU team for evaluation. He was
responding only to pain. His [**Month/Day (2) **] rate decreased, and an
ABG revealed normal pH but increased pCO2. A repeat CXR is
pending. Pt is being transferred to the MICU for further eval
and management. Prior to transfer, he received 2 doses of Narcan
and a new IV placement, with some mild improvement in his mental
status and increase in his resp rate during this period.
Past Medical History:
EtOH cirrhosis secondary to alcohol use
Recurrent ascites, negative cytology
Endoscopy [**12/2101**] with grade 2 varicies
Prior h/o HTN
Gout
History of pancreatitis, presumably [**2-2**] etoh
.
s/p appendectomy, distant
s/p hernia repair
Social History:
Patient lives with his wife currently. Significant past ETOH use
for 30 years, drinking 4 drinks of hard liquor daily. Per report
from last discharge, quit ETOH use 8 weeks ago. Patient is a
[**Country 3992**] Veteran.
Family History:
No family history of Colon or Pancreatic ca. Father with lung ca
Physical Exam:
Vitals: Tc 95.4 BP 105/63 HR 76 O2 sat 98% on NC O2
.
Gen: Thin, cachetic, weak appearing male in NAD
HEENT: Pupils equal and round, anicteric sclera, dry MM, hoarse
voice
Neck: supple, no LAD
CV: soft S1 S2, RRR, with no M/R/G
Abd: Abd soft, distended, moderate diffuse tenderness to
palpation, + BS
Ext: No pedal edema, 2+ DP pulses
Neuro: + asterixis
Awake, A&O x 3
Pertinent Results:
Admission Labs:
.
[**2102-6-8**] 02:00PM ASCITES TOT PROT-2.9 LD(LDH)-83 ALBUMIN-1.5
[**2102-6-8**] 02:00PM ASCITES WBC-139* RBC-[**Numeric Identifier 28647**]* POLYS-6*
LYMPHS-62* MONOS-27* EOS-1* OTHER-4*
[**2102-6-9**] 04:50AM BLOOD WBC-5.9 RBC-3.17* Hgb-10.4* Hct-31.1*
MCV-98 MCH-32.8* MCHC-33.4 RDW-16.0* Plt Ct-271
[**2102-6-9**] 04:50AM BLOOD Neuts-73* Bands-10* Lymphs-10* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2102-6-9**] 04:50AM BLOOD PT-15.1* PTT-26.6 INR(PT)-1.4*
[**2102-6-9**] 04:50AM BLOOD Glucose-91 UreaN-66* Creat-1.3* Na-133
K-4.6 Cl-93* HCO3-30 AnGap-15
[**2102-6-9**] 04:50AM BLOOD ALT-14 AST-27 LD(LDH)-121 AlkPhos-136*
Amylase-54 TotBili-0.9
[**2102-6-9**] 04:50AM BLOOD Lipase-101*
[**2102-6-9**] 04:50AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.2 Mg-2.1
Pertinent Labs/Studies:
.
[**2102-6-12**] 03:57PM BLOOD CEA-28* AFP-3.7
[**2102-6-9**] 04:50AM BLOOD Lipase-101*
[**2102-6-11**] 07:15AM BLOOD Lipase-63*
.
[**2102-6-11**] 11:58AM ASCITES WBC-500* RBC-[**Numeric Identifier 17227**]* Polys-5* Lymphs-63*
Monos-32*
[**2102-6-8**] 02:00PM ASCITES WBC-139* RBC-[**Numeric Identifier 28647**]* Polys-6* Lymphs-62*
Monos-27* Eos-1* Other-4*
[**2102-6-11**] 11:58AM ASCITES TotPro-2.9 Albumin-1.5
[**2102-6-8**] 02:00PM ASCITES TotPro-2.9 LD(LDH)-83 Albumin-1.5
.
.
.
Microbiology:
Blood cultures:
[**2102-6-11**]: NGTD
[**2102-6-11**]: NGTD
.
Peritoneal Fluid:
[**2102-6-8**]: Gram stain 1+ PMN
Culture - no growth, AFB smear negative, no growth
Adenosine Deaminase - ADENOSINE DEAMINASE,FLUID <1.0
[**2102-6-11**]: No growth
.
.
.
.
Imaging:
.
Chest Pa/Lat [**2102-6-9**]: A small right apical pneumothorax has
developed. The right-sided pleural effusion has decreased in
size. There has also been development of a moderate to large
left-sided hydropneumothorax with decrease in the component of
left-sided pleural effusion. The feeding tube remains in stable
position. The lungs are otherwise clear.
IMPRESSION: Development of bilateral pneumothoraces greater on
the left side with decrease in bilateral effusions.
.
Chest Pa/Lat [**2102-6-10**]: IMPRESSION: Essentially no significant
interval change since the previous study in the bilateral
hydropneumothoraces.
.
Chest Pa/Lat [**2102-6-11**]: There is a feeding tube whose distal
portion is not visualized. There is again seen a moderate
left-sided hydropneumothorax. There has been no significant
interval change in the size of the pneumothorax or the pleural
fluid. There is a loculated right-sided pleural effusion, also
unchanged. The small right apical pneumothorax seen previously
is no longer visualized. Consolidation at the lung bases,
particularly at the right side cannot excluded due to the large
amount of pleural fluid.
IMPRESSION: There has been resolution of the tiny right apical
pneumothorax. Otherwise unchanged.
.
Portable Chest [**2102-6-12**]: IMPRESSION:
1. Moderate-sized left-sided hydropneumothorax which is not
significantly changed from the prior study, with a very tiny
apical pneumothorax component.
2. Moderate-sized right pleural effusion, unchanged.
.
[**2102-6-12**]: CT CHest w/out contrast - 1. Moderate-sized
left-sided hydropneumothorax and moderate-sized right pleural
effusion.
2. Rounded opacity seen in the medial aspect of the right lung
base, probably representing atelectasis, however, followup
imaging is recommended to document resolution and to exclude
mass.
3. No pathologically enlarged mediastinal or hilar
lymphadenopathy is
identified.
4. Large amount of ascites.
.
[**2102-6-14**]: Plain films L-Spine - IMPRESSION: Old compression
fracture of a low thoracic vertebral body accounting for less
than 25% of the normal vertebral body height.
Thoracic and lumbar spondylosis without listhesis.
.
[**2102-6-14**]: Portable Chest - 1. Moderate sized right pleural
effusion, unchanged.
2. Moderate sized left hydropneumothorax is stable with a
persistent small apical pneumothorax component.
.
.
.
Pathology:
[**2102-6-8**]: Cytology Peritoneal Fluid: Negative for malignant
cells. A few mesothelial cells, lymphocytes, and histiocytes.
Discharge Labs:
.
[**2102-6-15**] 05:35AM BLOOD WBC-9.9 RBC-2.98* Hgb-10.0* Hct-29.5*
MCV-99* MCH-33.5* MCHC-33.8 RDW-16.1* Plt Ct-210
[**2102-6-15**] 05:35AM BLOOD Glucose-110* UreaN-79* Creat-1.7* Na-137
K-4.1 Cl-98 HCO3-26 AnGap-17
[**2102-6-15**] 05:35AM BLOOD ALT-12 AST-25 AlkPhos-138* TotBili-1.1
[**2102-6-15**] 05:35AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2102-6-15**] 07:17AM BLOOD Type-ART O2 Flow-2 pO2-141* pCO2-41
pH-7.45 calHCO3-29 Base XS-4 Intubat-NOT INTUBA Comment-NC
[**2102-6-15**] 07:17AM BLOOD Lactate-1.2
Brief Hospital Course:
A/P: 61 yo man with ESLD, presented with bloody ascites, FTT,
encephalopathy.
.
.
#. ESLD: On admission, patient was known to have a history of
Alcoholic cirrhosis with need for repeated paracentesis for
recurrent ascites. As above, the patient has been noted to have
bloody taps concerning for potential underlying malignancy or
TB. The patient additionally had developed renal failure with
concern for possible hepatorenal syndrome. It was the hope
initially that the patient would be eligible for a liver
transplant. However, as described in H+P, the patient was noted
to have rapid decline in functional status with severe cachexia,
concerning for potential secondary process such as malignancy,
or possibly TB given bloody taps, although more likely the
former. At time of admission, the patient was with such poor
functional status that he was not considered eligible for a
liver transplant. It was the hope that with improved nutritional
status and treatment for encephalopathy patient may improve.
Workup was additionally underway for potential underlying
condition such as malignancy or infection that was further
compromising his health. Unfortunately, the patient continued to
decline rapidly clinically throughout the hospital course before
further evaluation could be completed and the patient passed
(see below).
.
#. [**Month/Day/Year **] depression/Altered Mental Status: The patient was
transferred to the MICU because of somnolence thought to be
secondary to underlying encephalopathy and med effect from
Narcotics with decreased hepatic clearance. The patient had an
ABG performed that revealed mild hypoxia, and hypercarbia with
normal pH, possibly from increased OxyContin that was initiated
for increasing back pain. The patient was observed in the MICU
without need for intubation or non-invasive ventilation and was
subsequently transferred back to the floor. The patient was
noted to have ongoing waxing and [**Doctor Last Name 688**] mental status with
difficulty balancing comfort and pain control with maintaining
mental status. The patient was noted again to grow somnolent for
which a repeat ABG was performed which revealed no significant
acid/base disorder, hypercarbia or hypoxia. The patient's
Lactulose was up titrated and rifaximin added to his treatment
regimen with hope to reverse potential underlying
encephalopathy. Narcotics were held without significant
improvement in mental status. Despite these efforts the patient
continued to have ongoing worsening mental status with
significant somnolence. Code status was discussed with the
patient's family where it was clarified that the patient
definitely would not want to be aggressively resuscitated. Given
the patient's rapidly declining clinical status, it was
discussed with the patient's family the treating team's concern
that his short term prognosis may not be good. The patient's
family understood this and additionally were in agreement that
it would be better to treat the patient's pain (which he
reported) than to hold pain meds so as to avoid further
sedation. Around 1:30 a.m. on [**2102-6-16**] the patient was noted to
be developing increasing tachypnea and course upper airway
sounds. For this, he was given a Scopolamine patch and received
Ativan for [**Date Range **] distress. The patient was noted on
telemetry to develop progressive bradycardia until asystolic.
Per the patient's and families wishes, no resuscitation efforts
were made. The patient was reported to appear comfortable at the
time of his passing with his family present. It was discussed
with the patient's family the importance of performing a
post-mortem exam to evaluate for possible underlying malignancy
or infection, which they agreed to.
.
#. Bloody Paracentesis - The patient has had two paracentesis
performed within the last 4 weeks that have bene demonstrated to
be bloody by cell count without evidence of SBP. Cytology on two
samples did not reveal any malignant cells. Given no evidence
for malignancy by cytology, their was additional consideration
of possible tuberculosis, particularly given the patient's
history of 40 pound weight loss. However, despite the negative
cytology, clinical suspicion for underling malignancy remained
high. The patient did not have an elevated AFP this admission
but did have a mildly elevated CEA of 28. AFB smears from
peritoneal fluid were negative for AFB, cultures are all no
growth to date, and Adenosine Deaminase levels from peritoneal
fluid were < 1. A PPD was planted this admission which was
negative. Although suspicion for pulmonary TB was low, the
patient was maintained on [**Date Range **] precautions as induced
sputum was not possible secondary to sedation. The patient's
family was instructed that they should be wearing TB barrier
aerosol masks on entry to the room but declined to do so.
Throughout the patient's clinical course (see below) he
continued to decline with depressed mental status, tachypnea,
and hypotension. The patient passed away on [**2102-6-16**] after
episode of bradycardia, progressing to asystole. The patient's
family was agreeable to autopsy to determine underlying etiology
for patient's rapid decline and cachexia, with concern for TB
and malignancy as above.
.
#. ARF: The patient developed acute renal failure during this
hospitalization with consideration of pre-renal etiology of
possibly hepatorenal syndrome. The patient was given a 1L fluid
challenge while in the intensive care unit without any
improvement in his renal function. The patient was maintained on
octreotide and midodrine for ongoing blood pressure support.
Medications on Admission:
Folic acid 1 mg po qd
CaCO3 0.6 mg po qd
Aldactone 25 mg po qd
Lasix 40 mg po qd -> recently increased [**6-5**] to 40 [**Hospital1 **].
Lactulose 2 tspns qid
MVI qd
Tube feeds
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
End Stage Liver Disease
Renal Failure
Failure to Thrive
Bloody Peritoneal effusion
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"568.82",
"789.5",
"276.51",
"572.3",
"518.82",
"584.9",
"274.9",
"783.7",
"511.8",
"572.2",
"518.81",
"303.90",
"805.2",
"571.2",
"E887"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
14378, 14393
|
8518, 9891
|
350, 364
|
14528, 14538
|
3875, 3875
|
14591, 14598
|
3402, 3470
|
14349, 14355
|
14414, 14507
|
14147, 14326
|
14562, 14568
|
7981, 8495
|
3485, 3856
|
275, 312
|
392, 2887
|
3891, 7965
|
9906, 14121
|
2909, 3149
|
3165, 3386
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,092
| 154,019
|
26060
|
Discharge summary
|
report
|
Admission Date: [**2180-12-16**] Discharge Date: [**2180-12-29**]
Date of Birth: [**2134-1-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
46 yo M s/p MVA unrestrained driver in MVC, t-boned other
vehicle. Pt transferred via medlflight from [**Hospital3 15402**].
Major Surgical or Invasive Procedure:
1. Total laminectomy of C2 and C3.
2. Fusion C2-C3.
3. Autograft.
4. Repair of dural tear.
5. Percutaneous tracheostomy.
6. Percutaneous endoscopic gastrostomy tube placement.
History of Present Illness:
46 yo M s/p MVA unrestrained driver in MVC, t-boned other
vehicle. Pt transferred via medlflight from [**Hospital3 15402**].
Unconscious, unresponsive, not moving extremities on the scene.
Received 5-6 liters of fluid, hypotensive sating 100%, HR in the
60's. Only motor response initially biting on endotracheal tube.
On arrival to [**Hospital1 18**], 1-2 cm laceration over left eyebrow,
cervical collar in place, PERLA, EOMI, and unresponsive to all
stimuli. Rectal with decreased tone GCS=3T.
Past Medical History:
? old MI on EKG
Social History:
police officer
Family History:
non-contributory
Physical Exam:
On arrival to [**Hospital1 18**] trauma bay:
SBP 110-120, HR 70-100, intubated
pupils 2mm bilaterally, non-reactive
C-collar
RRR no MRG
CTA bilaterally
soft, obese
Fast negative
back atruamatic, no stepoffs
skin warm dry
unresponsive to all stimuli
2+ pulses
decreased rectal tone
heme negative
Pertinent Results:
[**2180-12-28**] 03:42AM BLOOD WBC-16.8* RBC-3.17* Hgb-9.5* Hct-27.3*
MCV-86 MCH-30.0 MCHC-34.9 RDW-13.8 Plt Ct-227
[**2180-12-27**] 04:16AM BLOOD WBC-21.2*# RBC-3.42* Hgb-10.4* Hct-29.2*
MCV-85 MCH-30.4 MCHC-35.6* RDW-13.7 Plt Ct-239
[**2180-12-26**] 03:18AM BLOOD WBC-12.6*# RBC-3.43* Hgb-10.2* Hct-30.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.4 Plt Ct-213
[**2180-12-25**] 02:58AM BLOOD WBC-7.9 RBC-3.64* Hgb-10.8* Hct-32.7*
MCV-90 MCH-29.5 MCHC-32.8 RDW-13.3 Plt Ct-220
[**2180-12-24**] 03:00AM BLOOD WBC-11.3* RBC-3.73* Hgb-11.1* Hct-33.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.4 Plt Ct-205
[**2180-12-23**] 02:51AM BLOOD WBC-12.9* RBC-3.98* Hgb-11.7* Hct-34.4*
MCV-86 MCH-29.4 MCHC-34.0 RDW-13.4 Plt Ct-206
[**2180-12-22**] 04:04AM BLOOD WBC-14.2* RBC-4.26* Hgb-12.4* Hct-35.2*
MCV-83 MCH-29.0 MCHC-35.1* RDW-13.2 Plt Ct-217
[**2180-12-21**] 04:16AM BLOOD WBC-11.5* RBC-4.42* Hgb-13.0* Hct-37.2*
MCV-84 MCH-29.5 MCHC-35.0 RDW-13.2 Plt Ct-193
[**2180-12-20**] 02:59AM BLOOD WBC-10.1 RBC-4.05* Hgb-11.9* Hct-34.0*
MCV-84 MCH-29.3 MCHC-34.9 RDW-13.5 Plt Ct-178
[**2180-12-19**] 02:00AM BLOOD WBC-13.1* RBC-4.02* Hgb-11.9* Hct-35.2*
MCV-87 MCH-29.5 MCHC-33.7 RDW-13.8 Plt Ct-197
[**2180-12-17**] 04:08PM BLOOD Hct-36.5*
[**2180-12-17**] 09:21AM BLOOD WBC-13.2* RBC-4.14* Hgb-12.2* Hct-35.4*
MCV-86 MCH-29.4 MCHC-34.4 RDW-13.4 Plt Ct-205
[**2180-12-17**] 01:32AM BLOOD WBC-13.0* RBC-4.32* Hgb-12.6* Hct-36.6*
MCV-85 MCH-29.2 MCHC-34.4 RDW-13.3 Plt Ct-212
[**2180-12-16**] 07:52PM BLOOD WBC-17.6* RBC-4.69 Hgb-13.8* Hct-39.6*
MCV-84 MCH-29.3 MCHC-34.8 RDW-13.4 Plt Ct-272
[**2180-12-16**] 11:50AM BLOOD WBC-17.0* RBC-4.58* Hgb-13.7* Hct-39.3*
MCV-86 MCH-30.0 MCHC-35.0 RDW-13.2 Plt Ct-215
[**2180-12-28**] 03:42AM BLOOD Plt Ct-227
[**2180-12-27**] 04:16AM BLOOD Plt Ct-239
[**2180-12-27**] 04:16AM BLOOD PT-12.8 PTT-24.5 INR(PT)-1.1
[**2180-12-26**] 03:18AM BLOOD Plt Ct-213
[**2180-12-25**] 02:58AM BLOOD Plt Ct-220
[**2180-12-24**] 03:00AM BLOOD Plt Ct-205
[**2180-12-23**] 02:51AM BLOOD Plt Ct-206
[**2180-12-23**] 02:51AM BLOOD PT-13.4* PTT-22.2 INR(PT)-1.2
[**2180-12-22**] 04:07AM BLOOD PT-13.9* PTT-23.4 INR(PT)-1.3
[**2180-12-22**] 04:04AM BLOOD Plt Ct-217
[**2180-12-21**] 04:16AM BLOOD Plt Ct-193
[**2180-12-20**] 02:59AM BLOOD Plt Ct-178
[**2180-12-20**] 02:59AM BLOOD PT-14.0* PTT-24.7 INR(PT)-1.3
[**2180-12-19**] 02:00AM BLOOD Plt Ct-197
[**2180-12-19**] 02:00AM BLOOD PT-14.0* PTT-24.1 INR(PT)-1.3
[**2180-12-18**] 03:12AM BLOOD Plt Ct-250
[**2180-12-18**] 03:12AM BLOOD PT-14.5* PTT-23.8 INR(PT)-1.4
[**2180-12-17**] 09:21AM BLOOD Plt Ct-205
[**2180-12-17**] 04:07AM BLOOD PT-13.7* PTT-24.7 INR(PT)-1.3
[**2180-12-17**] 01:32AM BLOOD Plt Ct-212
[**2180-12-16**] 07:52PM BLOOD Plt Ct-272
[**2180-12-16**] 07:52PM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.2
[**2180-12-16**] 11:50AM BLOOD Plt Ct-215
[**2180-12-16**] 11:50AM BLOOD PT-13.3 PTT-26.9 INR(PT)-1.2
[**2180-12-28**] 03:42AM BLOOD Glucose-134* UreaN-21* Creat-0.6 Na-138
K-4.5 Cl-105 HCO3-25 AnGap-13
[**2180-12-27**] 04:16AM BLOOD Glucose-109* UreaN-23* Creat-0.5 Na-145
K-4.0 Cl-109* HCO3-26 AnGap-14
[**2180-12-26**] 03:18AM BLOOD Glucose-122* UreaN-22* Creat-0.6 Na-145
K-3.8 Cl-109* HCO3-27 AnGap-13
[**2180-12-25**] 02:59PM BLOOD Glucose-140* K-3.8
[**2180-12-25**] 02:58AM BLOOD Glucose-146* UreaN-31* Creat-0.7 Na-144
K-3.8 Cl-108 HCO3-28 AnGap-12
[**2180-12-24**] 03:00AM BLOOD Glucose-103 UreaN-41* Creat-0.7 Na-144
K-3.7 Cl-108 HCO3-29 AnGap-11
[**2180-12-23**] 02:51AM BLOOD Glucose-154* UreaN-45* Creat-0.7 Na-142
K-3.6 Cl-103 HCO3-28 AnGap-15
[**2180-12-22**] 04:04AM BLOOD Glucose-160* UreaN-41* Creat-0.8 Na-141
K-4.2 Cl-102 HCO3-27 AnGap-16
[**2180-12-21**] 04:16AM BLOOD Glucose-178* UreaN-42* Creat-0.8 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
[**2180-12-20**] 02:59AM BLOOD Glucose-96 UreaN-46* Creat-1.0 Na-142
K-4.6 Cl-110* HCO3-25 AnGap-12
[**2180-12-19**] 02:00AM BLOOD Glucose-143* UreaN-32* Creat-0.8 Na-142
K-5.1 Cl-112* HCO3-22 AnGap-13
[**2180-12-18**] 03:12AM BLOOD Glucose-144* UreaN-24* Creat-1.0 Na-142
K-4.5 Cl-111* HCO3-21* AnGap-15
[**2180-12-17**] 04:08PM BLOOD K-3.8
[**2180-12-17**] 09:21AM BLOOD K-3.3
[**2180-12-17**] 01:32AM BLOOD Glucose-167* UreaN-19 Creat-1.0 Na-141
K-3.8 Cl-108 HCO3-20* AnGap-17
[**2180-12-16**] 07:52PM BLOOD Glucose-150* UreaN-17 Creat-0.9 Na-142
K-4.2 Cl-109* HCO3-18* AnGap-19
[**2180-12-16**] 11:50AM BLOOD UreaN-18 Creat-0.9
[**2180-12-25**] 02:58AM BLOOD ALT-169* AST-74* AlkPhos-53 TotBili-0.7
[**2180-12-22**] 04:04AM BLOOD ALT-110* AST-47* LD(LDH)-259* AlkPhos-56
Amylase-25 TotBili-1.2
[**2180-12-17**] 04:08PM BLOOD CK(CPK)-992*
[**2180-12-17**] 09:21AM BLOOD CK(CPK)-369*
[**2180-12-17**] 01:32AM BLOOD ALT-72* AST-40 CK(CPK)-341*
[**2180-12-16**] 07:52PM BLOOD ALT-76* AST-45* LD(LDH)-220 CK(CPK)-201*
AlkPhos-54 Amylase-43 TotBili-1.1
[**2180-12-16**] 11:50AM BLOOD Amylase-43
[**2180-12-17**] 04:08PM BLOOD CK-MB-12* MB Indx-1.2
[**2180-12-17**] 09:21AM BLOOD CK-MB-11* MB Indx-3.0 cTropnT-<0.01
[**2180-12-17**] 01:32AM BLOOD CK-MB-11* MB Indx-3.2 cTropnT-<0.01
[**2180-12-16**] 07:52PM BLOOD CK-MB-7 cTropnT-<0.01
[**2180-12-28**] 03:42AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.8
[**2180-12-27**] 04:16AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.1
[**2180-12-26**] 03:18AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.3
[**2180-12-25**] 02:58AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.4
[**2180-12-17**] 01:32AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
[**2180-12-16**] 07:52PM BLOOD Albumin-3.4 Calcium-8.1* Phos-4.3 Mg-1.4*
Brief Hospital Course:
46 yo M s/p MVA unrestrained driver in MVC, t-boned other
vehicle. Pt transferred via medlflight from [**Hospital3 15402**].
Unconscious, unresponsive, not moving extremities on the scene.
Received 5-6 liters of fluid, hypotensive sating 100%, HR in the
60's. Only motor response initially biting on endotracheal tube.
On arrival to [**Hospital1 18**], 1-2 cm laceration over left eyebrow,
cervical collar in place, PERLA, EOMI, and unresponsive to all
stimuli. Rectal with decreased tone GCS=3T. Imaging is as
follows:
CT Head [**12-16**]
1. No evidence of acute intracranial hemorrhage. No fracture is
seen.
2. Sinus findings as described above, some of which may be
secondary to
intubation.
3. Apparent foreign body present within the oral cavity.
CT C-spine [**12-16**]
1. Acute fracture of the right C2 lamina with multiple osseous
fragments
within the spinal canal producing narrowing of the spinal canal
at
approximately the C2/3 level. As evaluation of the intrathecal
detail is
limited on CT scans, further evaluation with MRI may be
considered.
2. Apparent sponge-like foreign body present within the oral
cavity and
oropharynx extending to the level of the epiglottis.
3. Soft tissue stranding with multiple foci of air present
within the right
posterolateral neck.
CT Chest/ABD/Pelvis [**12-16**]
1. Multiple areas of dense lung parenchymal opacity
predominantly in the
posterior portions of the lung with other areas of ground-glass
opacity and
linear opacity in the lungs. Diagnostic considerations should
include
atelectasis and aspiration. A component of contusion may also be
present.
2. Air tracking along the right iliopsoas muscle. No direct
evidence of
bowel injury is present. This air may be secondary to multiple
repeated
failed attempts at line placement in the right groin that was
conveyed by the
surgical staff.
3. Please refer to reports of head and cervical spine CT
examinations for
further details.
MRI C-spine [**12-16**]
Severe spinal cord injury at the C2 and 3 levels with edema and
hemorrhage within the cord as well as spinal cord compression
due to bony
fragments from the cervical spinal fracture. There is soft
tissue edema as
well.
Pt was taken emergently to the operating room on [**12-16**] by Dr.
[**Last Name (STitle) 363**] and the orthopaedic surgery team for decompression,
hematoma evacuation, and repair of dural tear. See operative
report for details. Pt was intubated in stable condition on
pressors to the PACU.
[**12-17**]- Trauma SICU
n- intubated and sedated, fentayl drip
CV- levophed titrated to MAP>60
Resp- intubated on assist control
GI- NPO
GU -foley with adequate urine output
ID- afebrile, WBC= 13
PPX- pneumoboots/protonix
[**12-18**] - [**Location (un) 260**] filter placed
"There is a widely patent right common iliac vein. We
do see some reflux into the left common iliac vein. There is
brisk forward
flow. There is a widely patent inferior vena cava, which is
approximately
28-29 mm in diameter in its infrarenal portion. There is no
evidence of
thrombus in the right iliac vein or the inferior vena cava. We
clearly do see
the renal veins at the bottom of L1. We see deployment and
atraumatic
placement of an Optease IVC filter 1 cm distal to the lowest
renal vein."
MRSA nasal swab screen:
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin sensitivity performed by agar screen.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- R
[**12-19**] Sedated with midazolam and fentanyl, opens eyes to name,
attempts to mouth word to communicate. Tracheostomy and
percutaneous gastrostomy tube placed. Trophic tube feeds
started.
[**12-20**] Spiked fever overnight, sputum cultures sent. Tube feeds
advanced.
Sputum culture
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
[**12-21**]- sedation weaned, pt able to move head, wife and brother at
bedside. Temp->102.5, hemodynamically stable, trached on assist
control.
[**12-22**] Fever->103 Blood Cultures sent, WBC=14
STAPHYLOCOCCUS, COAGULASE NEGATIVE +
[**12-23**] Evaluated by psychiatry for anxiety, depression, and odd
interactions with his wife. Fever->102.4, can communicate by
mouthing words, no sensation below scapula.
Sputum Culture
GRAM STAIN (Final [**2180-12-23**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2180-12-28**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- 1 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 1 S
PENICILLIN------------ =>0.5 R
Started on 7 day course of vancomycin/unasyn.
[**12-27**] Patient reports area of returned senation on
anterior/superior chest wall and medial right forearm.
CT Chest/Abd/Pelvis
1. Consolidation of the right lower lobe, probably associated
with bronchial
plugging/aspiration. There is a left severe-appearing opacity at
the left
lower lobe, which probably represents a combination of
atelectasis and
consolidation.
2. No evidence of intra-abdominal, thoracic, or pelvic abscess.
3. No mediastinal mass or hematoma.
Patient maintained in stable condition on [**12-27**], sedation weaned
to tylenol and morphine. Cardiovascularly the patient was
stable, off pressors but ventilator dependent by tracheostomy.
Tube feeds were continued, foley was in place with adequate
urine output. Patient continued to spike fevers to 103, CT scan
as above showed RLL pneumonia, on day 5 of 7 day course of
vancomycin and unasyn. WBC=7.9. Rehab placement was arranged for
[**12-28**] by med-flight transport.
Medications on Admission:
none
Discharge Medications:
Active Medications [**Known lastname **],[**Known firstname **] E
1. IV access: Peripheral, 1 ports, Date inserted: [**2180-12-16**] Order
date: [**12-16**] @ 1313 14. Ipratropium Bromide MDI 2 PUFF IH
Q4-6H:PRN Order date: [**12-17**] @ 0059
2. Acetylcysteine 20% 1-10 ml NEB Q4-6H:PRN instill in ET tube
Order date: [**12-21**] @ [**2196**] 15. Lansoprazole Oral Suspension 30 mg
NG DAILY Order date: [**12-24**] @ 1156
3. Acetaminophen (Liquid) 650 mg PO Q4-6H:PRN Order date: [**12-21**]
@ [**2199**] 16. Lorazepam 0.5-2 mg IV Q4H:PRN anxiety Order date:
[**12-22**] @ 0855
4. Albuterol 2 PUFF IH Q6H:PRN Order date: [**12-17**] @ 0059 17.
Magnesium Sulfate 2 gm / 100 ml D5W IV PRN
Mg<2.5 Order date: [**12-16**] @ [**2134**]
5. Artificial Tear Ointment 1 Appl OU PRN Order date: [**12-17**] @
1421 18. Morphine Sulfate 2-6 mg IV Q2H:PRN pain Order date:
[**12-22**] @ 0858
6. Artificial Tears 1-2 DROP OU PRN Order date: [**12-17**] @ 1421
19. [**Location (un) **] Oil *NF* 1 bottle Misc.(Non-Drug; Combo Route)
ongoing
* Patient Taking Own Meds * Order date: [**12-27**] @ 0945
7. Calcium Gluconate 2 gm / 100 ml D5W IV PRN
Ca <8.5 Order date: [**12-16**] @ [**2134**] 20. Potassium Chloride 20 mEq
/ 50 ml SW IV PRN
K<4 Order date: [**12-16**] @ [**2134**]
8. Docusate Sodium (Liquid) 100 mg PO BID Order date: [**12-21**] @
0858 21. Propofol 200 mg IV ONCE Duration: 1 Doses
sedation for bronch Order date: [**12-28**] @ 1518
9. Erythromycin 0.5% Ophth Oint 0.5 in OU QID Order date: [**12-25**]
@ 2115 22. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift Order date: [**12-16**] @
1313
10. Heparin 5000 UNIT SC TID Order date: [**12-17**] @ 0825 23.
Unasyn 3 gm IV Q8H Order date: [**12-23**] @ 0930
11. Ibuprofen 400 mg PO Q8H:PRN fever >102.5 Order date: [**12-22**]
@ 0904 24. Vancomycin HCl 1000 mg IV Q 8H Order date: [**12-28**] @
0915
12. Insulin 100 Units/100 ml NS @ 2 UNIT/HR IV DRIP TITRATE TO
FSG 90-110
Fingersticks every hour Order date: [**12-23**] @ 1140 25. Zolpidem
Tartrate 5-10 mg PO HS:PRN insomnia Order date: [**12-24**] @ 0621
13. Insulin SC (per Insulin Flowsheet)
Fixed Dose Order date: [**12-28**] @ 0915
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 3952**] Center
Discharge Diagnosis:
s/p motor vehicle collision, : C3 laminar fracture, C2-C3 facet
disruption and spinal cord compression as well as dural tear.
Discharge Condition:
quadrapelegic
hemodynamically stable
ventilator dependent
tube feeds
Discharge Instructions:
M.D. [**Last Name (LF) **],[**First Name3 (LF) **] N [**Telephone/Fax (1) 9674**], please call to schedule.
Please call [**Hospital1 18**] trauma clinic with questions [**Telephone/Fax (1) 6439**].
Please see above medication, ventilator, activity and dietary
instructions.
Followup Instructions:
Follow-up with M.D. [**Last Name (LF) **],[**First Name3 (LF) **] N [**Telephone/Fax (1) 9674**], please call to
schedule.
Please call [**Hospital1 18**] trauma clinic with questions [**Telephone/Fax (1) 6439**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2180-12-28**]
|
[
"V46.11",
"482.41",
"482.2",
"518.5",
"E812.0",
"806.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"33.24",
"99.04",
"31.1",
"38.93",
"00.17",
"81.03",
"38.91",
"38.7",
"96.6",
"81.62",
"03.59",
"96.72",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
15797, 15856
|
7028, 13505
|
440, 618
|
16026, 16097
|
1580, 7000
|
16419, 16791
|
1232, 1250
|
13563, 15774
|
15877, 16005
|
13531, 13537
|
16121, 16396
|
1265, 1561
|
276, 402
|
646, 1144
|
1166, 1183
|
1199, 1216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,776
| 185,462
|
17995
|
Discharge summary
|
report
|
Admission Date: [**2115-4-13**] Discharge Date: [**2115-4-18**]
Date of Birth: [**2033-4-15**] Sex: F
Service: MEDICINE
Allergies:
Claritin / Nsaids
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Stent to R common carotid artery
History of Present Illness:
Ms. [**Known lastname 14323**] is an 81 y/oF with h/o cerebrovascular
disease/carotid stenosis including occlusion of left ICA and h/o
CEA on right ICA, COPD, CHF, AF, CAD s/p PCI with h/o Cypher
stent in [**2110**], RA/Sjogren's who is transferred from [**Hospital 1474**]
Hospital with evaluation of syncope.
.
She was admitted there on [**2115-4-11**] after syncopizing at home and
brought to the hospital by EMTs. She was talking with Cardiology
Transfer RN at [**Hospital1 18**] when she suddenly stopped talking, and RN
called EMS. VNA came at around the same time and found the
patient unconscious on the couch, and was present when EMS
arrived. She was noted to spontanesouly regain consciousness. HR
in the field was 68 and BP was 110/p, FSG of 150.
.
At [**Hospital1 1474**], the patient was ruled out for MI. She was reversed
with vitamin K 5mg x1. CT head there demonstrated mild
generalized atrophy with small vessel ischemic changes, no e/o
acute ICH. The patient had tiny calcification sseen in the
brain.
.
She was transferred for further management.
.
Further history:
In talking with the patient's family via telephone, son reports
that she has had several episodes lately where she stops talking
and slumps in her chair, but quickly comes to without
post-ictal-like period; these have been attributed to percocet
in the past because of close temporal relationship. She has
restless leg syndrome and has had shaking legs for many years.
.
Family and patient also report that her handwriting became more
coarse and almost illegible on Tuesday ([**2115-4-9**]). She also
reports symptoms within the last 3 weeks that sounded like TIA,
with pt reporting "left arm was wood and my face was twisted."
.
CTA on [**2115-4-9**] for work-up for these previous episode prior to
this admision showed densely calcified plaque involving origin
of [**Doctor First Name 3098**] with complete occlusion beyond the point of extracranial
ICA with reconstitution via circle. She has h/o right CEA in the
past.
.
She was admitted to the [**Hospital1 **] on [**2115-4-13**] and
transferred to the Cardiac Care Unit after going for vascular
catheterization and getting a stent of her right common carotid
artery.
.
On admission,
(+) Visual changes; needs glasses (over weeks)
(+) Headaches
(+) Constipation
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
palpitations, syncope or presyncope. Pt reports sleeping up on 2
pillows; pt reports 3 days of calf edema.
Past Medical History:
-CAD s/p NSTEMI in [**2-4**] after ERCP s/p BX Velocity Hepacoat
stent to mid-LAD, s/p Cypher DES to mid-RCA and Pixel bare-metal
stent to OM1 in [**11-7**]
-Hypertension
-Hyperlipidemia
-Atrial Fibrillation
-Rheumatic Heart Diseaes
-Former tobacco use
-Atrial fibrillation
-History of lower extremity (femoral) thromboembolism s/p
surgical embolectomy at [**Hospital 1474**] Hospital in [**1-6**]
-s/p GIB in setting of systemic anticoagulation
-History of dilated extrahepatic and intrahepatic biliary ducts
s/p ERCP [**1-6**]
-CRI
-COPD
-Rheumatoid arthritis
-Sjogren's disease
-Restless leg syndrome
-Cholelithiasis
-Diverticulosis and diverticulitis
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION:
VS - 97.9 BP 125/74 HR 48 RR 20 Sat 97% RA
Gen: Elderly frail appearing woman 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 11 cm. b/l bruit [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 49815**] then L
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Low pitched II/VI SM at RUSB.
No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged
by palpation. No abdominial bruits.
Ext: [**1-6**]+ LE pitting edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date except 1 day.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No VF defects grossly. Extraocular movements
intact
bilaterally, no nystagmus. Sensation intact V1- V3. Facial
movement symmetric. Hearing intact to finger rub bilaterally.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
Motor:
UE/LE [**4-8**]. Reflexes symmetric.
No pronator drift. Moves all extremities; legs difficult to
control because of tremor/restless leg
Reflexes:
+2 and symmetric throughout.
Toes difficult to test.
Pertinent Results:
HEMATOLOGY
[**2115-4-13**] 03:23PM WBC-5.3 RBC-3.84* Hgb-10.5* Hct-33.3* MCV-87
MCH-27.3 MCHC-31.4 RDW-15.7* Plt Ct-277
[**2115-4-14**] 06:20AM WBC-5.6 RBC-3.68* Hgb-10.4* Hct-31.2* MCV-85
MCH-28.3 MCHC-33.4 RDW-16.3* Plt Ct-252
[**2115-4-17**] 07:15AM WBC-6.0 RBC-3.52* Hgb-9.9* Hct-30.3* MCV-86
MCH-28.2 MCHC-32.8 RDW-16.9* Plt Ct-297
[**2115-4-18**] 08:02AM WBC-5.7 RBC-3.36* Hgb-9.2* Hct-29.6* MCV-88
MCH-27.3 MCHC-31.0 RDW-16.5* Plt Ct-248
[**2115-4-13**] 03:23PM Neuts-74.8* Lymphs-15.8* Monos-5.5 Eos-3.2
Baso-0.8
[**2115-4-17**] 07:15AM PT-15.9* PTT-70.1* INR(PT)-1.4*
[**2115-4-18**] 08:02AM PT-25.5* PTT-79.9* INR(PT)-2.5*
CHEMISTRY
[**2115-4-13**] 03:23PM Glu-134* UreaN-17 Creat-1.4* Na-136 K-4.0 Cl-99
HCO3-25
[**2115-4-14**] 06:20AM Glu-83 UreaN-18 Creat-1.3* Na-133 K-4.0 Cl-97
HCO3-27 [**2115-4-15**] 05:40AM Glu-86 UreaN-15 Creat-1.2* Na-138 K-3.5
Cl-102 HCO3-27
[**2115-4-17**] 07:15AM Glu-95 UreaN-10 Creat-1.2* Na-136 K-4.1 Cl-100
HCO3-26
[**2115-4-18**] 08:02AM Glu-86 UreaN-13 Creat-1.5* Na-137 K-4.0 Cl-101
HCO3-27
[**2115-4-13**] 03:23PM Calcium-9.1 Phos-3.6 Mg-2.0
[**2115-4-14**] 06:20AM Calcium-8.9 Phos-3.3 Mg-2.1 Cholest-78
[**2115-4-17**] 07:15AM Calcium-9.4 Phos-2.8 Mg-2.5
[**2115-4-18**] 08:02AM Calcium-9.2 Phos-3.1 Mg-2.6
[**2115-4-14**] 06:20AM Triglyc-62 HDL-37 CHOL/HD-2.1 LDLcalc-29
[**2115-4-15**] 05:14PM %HbA1c-6.0*
[**2115-4-17**] 10:39AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2115-4-17**] 10:39AM URINE RBC->50 WBC-[**2-6**] Bacteri-RARE Yeast-NONE
Epi-0-2 TransE-0-2
Blood Culture [**2115-4-17**] NGTD x2
Urine Culture [**2115-4-17**]
[**2115-4-17**] 10:39 am URINE URINE CULTURE (Final [**2115-4-22**]):
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML **
MRSA **
This was negative after 24h and prior to discharge, returning
after discharge
LENIS
No evidence of left lower extremity deep vein thrombosis.
BRAIN MRI?MRA
1. Absent flow signal in the left internal carotid artery could
be due to occlusion in the neck. Small right distal vertebral
artery could be variation. For evaluation of both these
abnormalities MRA of the neck or CTA can help for further
assessment. Otherwise, no abnormalities on the MRA of the head
in the remaining arteries of anterior and posterior circulation.
EEG: Normal awake and drowsy EEG. No focal lateralizing or
epileptiform features were seen.
CAROTID CATHETERIZATION
1. Access via right femoral artery with 6F sheath.
2. Peripheral angiography with non-selective pigtail catheter
revealed
a Type 2 aortic arch with moderate calcification and tortuosity.
We
then enganged the carotid arteries selectively with a 5F
Berenstein.
This revealed the left common carotid artery to be patent with
origin
calcification. The left internal is occluded with faint
reconstitution
from the opthalmic artery to the MCA. The right common carotid
artery
has moderate calcification at the brachiocephalic without a
pressure
gradient noted. The right common carotid has a prior CEA with
proximal
80% restenosis and 30% stenosis distally. The right ICA fills
the right
ACA and MCA with noted cross filling from a patent anterior
communicating to the contralateral ACA. The left MCA is not
seen to
fill but noted competitive filling at the bifurcation with the
ipsilateral ACA.
3. Limited hemodynamics with BP 163/65 with HR 67 in sinus.
Patient
has history of afib/flutter and developed flutter in CCU. There
was no
pressure gradient from our right femoral sheath to the aortic
arch.
4. We elected to proceed with intervention on the right common
carotid
artery. We exchanged for a 6F Shuttle Sheath over a SupraCore
wire.
Heparin was given and a therapeutic ACT was confirmed. We then
crossed
the lesion with a .014 SpartaCore wire and exchanged our wire
for a 5mm
Spider Filter. We then predilated the discrete lesion with a
Quantum
Maverick 4x20mm balloon at 10atm and deployed a self-expanding
Protege
9x40mm stent. We post-dilated the stent with a Viatrac 6x20mm
balloon
at 22atm. We then retrieved our filter without incident. Final
angiography with 10% residual with normal flow. The
intracerebral
circulation was unchanged with normal flow to the contralateral
ACA.
The patient was transferred to the CCU with no neurological
deficits.
ECHOCARDIOGRAPHY
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal mild hypokinesis of
the distal septum. The remaining segments contract normally
(LVEF = 55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated
with borderline normal free wall function. There are three
moderately thickened aortic valve leaflets, and the left
coronary cusp is essentially immobile. There is mild aortic
valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
There is no mitral valve prolapse. There is mild functional
mitral stenosis (mean gradient 4 mmHg) due to mitral annular
calcification. Severe (4+) mitral regurgitation is seen ([**Last Name (un) **] 0.4
cm2, regurgitant volume 68 cc/beat). The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild biventricular systolic dysfunction. Mild aortic
stenosis. Mild mitral stenosis. Severe mitral regurgitation.
Moderate tricuspid regurgitation. Moderate pulmonary
hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2110-2-4**], left ventricular systolic function has
improved, and aortic stenosis has developed. The other findings
are similar.
CHEST XRAY
Small bilateral pleural effusions are new, moderate-to-severe
cardiomegaly is stable, and pulmonary vascular congestion in the
upper lobes has progressed. Septal lines in the right lower lung
appeared to be chronic rather than the manifestations of acute
pulmonary edema, but cardiac decompensation is definite. I see
no radiographic indication of pneumonia.
Brief Hospital Course:
TRANSIENT ISCHEMIC ATTACKS / CAROTID ARTERY STENTING
The patient experienced symptoms of TIA at home prior to her
admission, and she had an episode of syncope prompting emergent
admission. She had a negative head CT and MRI for any stroke.
She had tremors of her legs which she stated she could not
control, and underwent EEG which had no focal seizure activity.
She was not orthostatic. The MRA did show complete obstruction
of the left internal carotid artery. She underwent carotid
angiography which showed 80% stenosis in right former carotid
endarterectomy. She had bare metal stent placed in the right
common carotid with good angiographic result. She was monitored
in the CCU overnight. She had no neurologic sequalae.
The stenting was also part of a protocol ("Carotid
Revascularization with ev3 Arterial Technology Evolution Post
Approval Study") for which the patient consented.
ATRIAL FIBRILLATION
The patient was placed on heparin intravenous infusion while
warfarin was being held for carotid stenting. She was restarted
on coumadin for discharge with INR to be followed by PCP.
FEVER
The patient had a fever two nights prior to discharge;
urinalysis was not decisively positive, pt was asymptomatic
though had had foley during procedure. CXR and blood cultures
were unrevealing. Urine cx after discharge grew 10-100K MRSA but
blood cultures from same day remained negative. This is likely
contamination rather than active infection.
RHEUMATIC HEART DISEASE
Echo findings essentially similar, better ejection fraction and
interval development of mild aortic stenosis.
Medications on Admission:
Flovent 2 puffs [**Hospital1 **]
Percocet 1-2 tablets q6h PRN
Zocor 40mg PO daily
Lasix 40mg PO daily
LOpressor 25mg po bid
oXAZEPAM 10MG o QhsM prn
Gabapentin 100mg PO TID
KDur 40 mEQ PO BID
Protonix 40mg PO daily
Hydroxychloroquine (Plaquenil) 200mg PO daily
Tranadol 50mg PO q6h PRN
ASA 81mg PO daily
[ warfarin held/reversed prev 4mg PO daily]
[Not on plavix seein in pharmacy records going back to [**2112**]]
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months: for one month after procedure.
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day: as directed.
14. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY
Transient Ischemic Attacks
Syncope
Cerebrovascular Disease
SECONDARY
Coronary Artery Disease, (Past revascularization with BMS and
DES)
-Hypertension
-Hyperlipidemia
-Atrial fibrillation
-Rheumatic heart disease
-Chronic Kidney Disease Stage III
-Chronic Obstructive Lung Disease
-Sjogren's disease
-Restless leg syndrome
-Cholelithiasis
-Diverticulosis and diverticulitis
Discharge Condition:
Stable neurologic exam
Discharge Instructions:
You were transferred to [**Hospital1 1474**] for narrowing of the arteries
in the neck, causing you to faint and have stroke like symptoms.
You had an MRI that showed that you did not have an actual
stroke. You had a procedure on your neck and a stent was placed
to open the right carotid artery.
Your medications were changed:
You were started on a medicine called "plavix" which you should
take for one month. You must not skip any doses of this
medication as it prevents blood clots from forming on your new
stent. You should continue on your coumadin.
Anticoagulation: 1 month of Plavix, as prescribed; Coumadin
(warfarin) as instructed by your physician; if you stop coumadin
you should consider restarting plavix. Discuss these medicines
with your physician or physician's office before making ANY
changes.
Please return to the hospital if you have stroke symptoms
including facial droop, inability to move limbs, slurred speech,
visual disturbances, or other concerning symptoms. Please also
return if you develop any chest pressure or worsening shortness
of breath.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 17996**] tomorrow
[**2115-4-19**] 12:30 [**Location (un) **] Office
Records will be sent to [**Doctor First Name **] at FAX # [**Telephone/Fax (1) 49816**]
Please follow-up with Dr. [**First Name (STitle) **] [**5-3**] at 9:40 [**Hospital Ward Name 23**] 7
|
[
"403.90",
"585.3",
"398.90",
"V58.61",
"428.23",
"412",
"V15.82",
"433.30",
"780.6",
"496",
"272.4",
"427.31",
"414.01",
"428.0",
"427.32",
"V45.82",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.61",
"00.40",
"88.41",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
15260, 15331
|
11873, 13461
|
286, 320
|
15757, 15781
|
5507, 11850
|
16908, 17216
|
3702, 3720
|
13927, 15237
|
15352, 15736
|
13487, 13904
|
15805, 16885
|
3735, 3735
|
3757, 4754
|
239, 248
|
348, 2880
|
4916, 5488
|
4793, 4900
|
4778, 4778
|
2902, 3559
|
3575, 3686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,613
| 118,994
|
5886
|
Discharge summary
|
report
|
Admission Date: [**2133-11-12**] Discharge Date: [**2133-11-16**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 86-year-old woman
with history of hypertension and no known coronary artery
disease who presents to [**Hospital6 256**]
from an outside hospital, [**Hospital3 **], following an
episode of chest pain on the day of admission. Patient
reportedly was walking down the stairs in the a.m. of
admission when she reported [**8-28**] chest heaviness with left
arm radiation, nausea, and diaphoresis. Pain reportedly
resolved spontaneously. Emergency medical services were
called. Initial EKG showed 1 to 1.[**Street Address(2) 1755**] elevations in 2,
3, and aVF.
The patient was taken to [**Hospital6 3105**], reporting
4/10 chest pain, and subsequently received 2 mg of Morphine
with subsequent hypotension into the 70s requiring a 250 cc
normal saline bolus with adequate response. Subsequently,
the patient was transferred to [**Hospital1 18**]. When en route the
patient had a questionable episode of nonsustained
ventricular tachycardia, however was otherwise asymptomatic.
She was given aspirin, Heparin, Lasix intravenously and
prepared for catheterization the next day.
ALLERGIES:
1. Penicillin-unspecific reaction.
2. Codeine-hives.
PAST MEDICAL HISTORY:
1. Multiple pneumonias over the last two years.
2. Hypertension.
3. Status post colectomy for colon encapsulated cancer in
[**2122**].
4. History of hysterectomy.
5. Hemorrhoids.
6. Osteoporosis.
7. Cataracts with bilateral eye surgeries.
MEDICATIONS:
1. Norvasc 5 q.d.
2. Albuterol inhalers.
3. Fosamax at home.
SOCIAL HISTORY: Denies alcohol, denies tobacco. Social
alcohol use.
FAMILY HISTORY: Mother with myocardial infarction in her
80s.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 95.3 F,
124/50, 65, 18, 100% on 3 liters. Exam is remarkable for
right surgically repaired pupil. Lungs sounds are clear to
auscultation bilaterally. Heart is regular rate and rhythm.
Abdomen is soft, nontender, nondistended. There is no
evidence of peripheral edema. 2+ pulses distally, radial and
posterior tibial. Neuro exam: Patient is alert and oriented
times three.
LABORATORY DATA ON ADMISSION: Patient had CK of 307, MB
fraction of 23, index of 7.5, and a troponin T of 0.42.
A chest x-ray showed no effusions with mild increased
interstitial markings in the right middle lobe.
EKG from the outside hospital was notable for [**Street Address(2) 4793**]
elevations in 2, 3, and aVF. At [**Hospital1 18**] EKG showed normal
sinus rhythm, rate 56, poor R wave progression with no
evidence of ST elevations.
SUMMARY OF HOSPITAL COURSE: This is an 86-year-old female
with a history of hypertension and no known prior coronary
artery disease who presented on the day of admission with
chest pain, nausea, vomiting, diaphoresis, inferior ST
elevations, and positive CK-MB and troponins consistent with
an inferior MI. Review by problem:
1. Status post MI: On presentation to [**Hospital1 18**] from [**Hospital6 23267**] the patient denied current chest pain, and
EKG showed no evidence of acute ST changes. Patient was
transferred to the CCU for monitoring, was started on aspirin
and Heparin, given Plavix load, started on Integrilin drip,
and was scheduled for a catheterization within 24 hours.
Cardiac catheterization showed a right dominant system
revealing two-vessel coronary artery disease of the left
anterior descending and right coronary artery. Left
ventriculography demonstrated depressed ventricular function
and inferior apical hypokinesis. Successful stenting of the
proximal mid RCA with a Hepacoat stent was performed. Final
angiography showing no residual obstruction, dissection, and
good flow.
The patient was subsequently transferred back to the CCU and
then to the floor without further complication. She was
continued on her current medical management and continued on
aspirin, statin, Plavix, ACE inhibitor, and beta blocker with
nitroglycerin as needed for chest pain.
DISCHARGE CONDITION: Stable, breathing comfortably on room
air, and ambulating without assistance.
DISPOSITION: Will be discharged home with services for blood
pressure checks and medication management/compliance.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg tablet p.o. q.d.
2. Atorvastatin 10 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d.
4. Lisinopril 2.5 mg p.o. q.d.
5. Atenolol 25 mg p.o. q.d.
6. Nitroglycerin 0.4 mg tablets p.r.n. for chest pain.
7. Folic acid.
8. Colace 100 mg p.o. b.i.d.
9. Albuterol inhaler.
10. Protonix 20 mg p.o. q.d.
11. Ipratropium inhaler q. four to six as needed for
shortness of breath or wheezing.
12. Fosamax 70 mg tablet p.o. q. week.
DISCHARGE INSTRUCTIONS:
1. Patient was instructed to see Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
([**Telephone/Fax (1) 4022**]). Call for appointment in two to four weeks
for continued management of cardiac regimen for an outpatient
stress test.
2. Patient was instructed to contact her primary care
physician within one week.
DISCHARGE DIAGNOSES:
1. Inferior myocardial infarction.
2. Acute coronary syndrome.
3. Coronary artery disease.
4. Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2133-12-10**] 13:06
T: [**2133-12-10**] 14:40
JOB#: [**Job Number 23268**]
|
[
"401.9",
"733.00",
"414.01",
"410.71",
"V10.05",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.53",
"99.20",
"88.56",
"36.01",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
4046, 4242
|
1704, 1772
|
5090, 5483
|
4265, 4702
|
4726, 5069
|
2655, 4024
|
113, 1269
|
2212, 2626
|
1291, 1616
|
1633, 1687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,394
| 131,871
|
27936
|
Discharge summary
|
report
|
Admission Date: [**2184-11-30**] Discharge Date: [**2184-12-8**]
Date of Birth: [**2101-9-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Flank pain, Chest pain
Major Surgical or Invasive Procedure:
IVC filter placement ([**2184-12-1**])
History of Present Illness:
This is an 83-year-old gentleman with a pmhx. significant for a
previous C2-C4 epidural hematoma while on coumadin in [**10/2184**],
Afib and PE [**6-/2184**], who stopped coumadin [**10-25**], now presenting
with flank pain on right, found to have extensive PE across
multiple pulmonary vessels. Patient reports that on the morning
of admission he awoke with right flank pain, as well as
pleuritic chest pain that was similar to prior PE. Denies
hemoptysis. Does endorse LE edema, worse on right side, with
right leg pain that he has had over a year. In the ED the pt's
initial vital signs were: 65 127/110 18 97% 3L NC. Once in the
ED the patient triggered for SBP 80, rapid afib in 110 and his
blood pressure improved with 500cc NS. CTA torso showed diffuse
PE. Pt was started on heparin gtt without bolus per ortho spine
recommendations. Patient was admitted to ICU for q2h neuro
checks per ortho spine recs.
Past Medical History:
epidural hematoma (C2-C4) [**10/2184**]: while INR was 3.1, coumadin
stopped
PE: large PE in 7/[**2183**].
Atrial fibrillation: CHADS2 score is 2.
s/p circumcision for phimosis [**3-/2182**]
Paroxysmal a-fib dx [**5-20**]
HTN
BPH
Social History:
Originally from [**Country 13622**] Republic. He lives with his wife. [**Name (NI) **]
reports a remote history of smoking tobacco > 20 years ago (8
pack-years). He denies any alcohol or illicit drug use.
Family History:
No history of bleeding or clotting disorders.
Physical Exam:
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
IMAGING:
[**11-30**] ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular cavity is dilated. 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. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2184-6-8**], the pulomonary artery pressure and tricuspid
regurgitation are significantly worse.
[**11-30**] MRI [**11-30**]:
Interval resolution of previously described cervical epidural
collection.
[**11-30**]
LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) 1417**] of
the bilateral common femoral, superficial femoral, popliteal,
posterior tibial and peroneal veins were performed. The right
popliteal vein is not completely compressible, suggestive of
thrombosis. Sagittal color flow images of the right popliteal
vein show some flow, suggestive of nonocclusive thrombus. These
findings are new compared to prior lower extremity ultrasound
from [**2184-10-26**]. The remainder of the visualized veins
show normal compressibility, flow and augmentation.
IMPRESSION: Non-occlusive thrombus in the right popliteal vein,
new compared to prior examination.
LABS:
[**2184-11-30**] 05:37PM GLUCOSE-104* SODIUM-143 POTASSIUM-3.7
CHLORIDE-110* TOTAL CO2-25 ANION GAP-12
[**2184-11-30**] 05:37PM CALCIUM-8.3* PHOSPHATE-6.5*# MAGNESIUM-1.8
[**2184-11-30**] 07:19AM [**Doctor First Name **]-POSITIVE * TITER-1:320 PAT
[**2184-11-30**] 07:19AM CK-MB-2 cTropnT-0.01
[**2184-11-30**] 07:19AM WBC-11.4* RBC-3.99* HGB-13.3* HCT-39.0*
MCV-98 MCH-33.4* MCHC-34.1 RDW-14.6
[**2184-11-30**] 07:19AM PLT COUNT-167
[**2184-11-30**] 07:19AM PT-13.4 PTT-45.1* INR(PT)-1.1
[**2184-11-30**] 07:19AM ACA IgG-4.0 ACA IgM-7.2
[**2184-11-30**] 01:29AM proBNP-1449*
UA:
[**2184-11-30**] 03:28AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2184-11-30**] 03:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
83 year-old male with atrial fibrillation who had PE when
subtherapeutic INR ([**6-19**]) and C2-C4 epidural hematoma on
coumadin ([**10-20**]) admitted [**2184-11-30**] with pulmonary embolism off
of anticoagulation. Brief hospital course was as follows.
(1) PULMONARY EMBOLUS: History of thrombosis, now with
extensive PE. No evidence of right heart strain on EKG, but on
ECHO there was elevation in right heart pressures and RV
dilatation, in addition to significantly worsened TR. LENIs
showed thrombus in the popliteal vein and an IVC filter was
placed. A limited hypercoagulable work-up was initiated, and
was significant for a mildly positive Beta 2 microglobulin and a
high [**Doctor First Name **] titer. Mr. [**Known lastname **] was continued on heparin gtt
without complication. Hematology was consulted about the
possibility of using another anticoagulant in this gentleman who
is prone to both bleeding and clotting. They recommended
coumadin or Lovenox, and given variable INR on coumadin, patient
decided on Lovenox.
He will follow-up in Hemophilia and [**Hospital 17902**] clinic.
(2) HISTORY OF EPIDURAL HEMATOMA: Developed spontaneously
while on coumadin with therapeutic INR. No sign of neurologic
compromise during admission. An MRI of C spine from [**11-30**]
indicated resolution of prior epidural hematoma. Patient will
follow-up with ortho spine.
(3) PAROXYSMAL ATRIAL FIBRILLATION: Patient had bouts of rapid
heart rates while in the ICU and on the medical service. He
responded well to metoprolol 25mg tid and was metoprolol qoomg
SR. Patient is anticoagulated, as above.
(4) HYPOTENSION: Patient was initially hypotensive in the ED
but responded well to IVF. His doxazosin was held initially,
but restarted prior to discharge and he was able to void with
adequate bladder clearing.
Medications on Admission:
1. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous
every twelve (12) hours.
Disp:*60 syringes* Refills:*2*
2. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) as needed for septic
thrombophlebitis for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
- Pulmonary embolism
- Atrial fibrillation with rapid ventricular rate
- Thrombophlebitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2184-11-30**] with chest pain. You were found to have a pulmonary
embolism, which is blood clots in your lungs. You were also
found to have a blood clot in your right leg. You were
initially monitoring in the intensive care unit and had a filter
placed in the blood vessel which returns blood from your legs to
the heart; this was to prevent more clots from getting to your
heart. You were also restarted on a blood thinner. Your
symptoms continued to improve outside of the intensive care
unit. Given difficulties in controlling your INR in the past on
coumadin, you were started on Lovenox, which is an injectable
blood thinner. As stated on your medication list, you will need
to take this daily. You were also noted to have inflammation of
the veins in one of your arms, thrombophlebitis. You were
started on an antibiotic to treat this.
The cause of your blood clots is not known. You will need
further evaluation in the hematology (blood) clinic after
discharge which has been scheduled for you.
Your medication regimen has changed. Changes include:
(1) Start Lovenox. Continue for at least 3 months as directed
by your primary care physician.
(2) Continue Bactrim antibiotics for 9 more days.
Other than these medication changes, you may continue taking
your home medications as you were prior to this hospitalization.
Followup Instructions:
Please follow-up with your PCP at [**Name9 (PRE) 12091**] health center, and
also with the blood specialists as scheduled below.
Department: RADIOLOGY
When: FRIDAY [**2184-12-17**] at 1 PM [**Telephone/Fax (1) 327**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2184-12-15**] at 10:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Appt: Thursday, [**12-9**] at 1:30pm
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2185-1-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"453.41",
"458.9",
"401.9",
"415.19",
"600.00",
"451.82",
"427.31",
"V15.82",
"V58.61",
"E879.8",
"288.60",
"999.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
7720, 7768
|
4965, 6800
|
328, 368
|
7902, 7902
|
2449, 4942
|
9467, 10720
|
1809, 1856
|
7126, 7697
|
7789, 7881
|
6826, 7103
|
8056, 9444
|
1871, 2430
|
266, 290
|
396, 1317
|
7918, 8032
|
1339, 1570
|
1586, 1793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,167
| 192,292
|
38076
|
Discharge summary
|
report
|
Admission Date: [**2146-5-3**] Discharge Date: [**2146-5-21**]
Date of Birth: [**2079-6-11**] Sex: M
Service: EMERGENCY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
elevated white count
Major Surgical or Invasive Procedure:
Subdural hematoma evacuation
Intubation
History of Present Illness:
Mr. [**Known lastname 85007**] is a 66 yo IDDM who seems to have had some minor
anemia about a year ago and was followed q 3 months for this and
his DM - about 2-3 months ago he and his wife noticed that he
was bruising easily and he was just not feeling all that well.
He was having some problems with dizziness, feeling nauseated in
the mornings and not really wanting to get out of bed. It sounds
like his PCP sent him to the nephrologist because of an elevated
creatinine, he saw the kidney doctor on [**4-28**] and received a call
a short time later that his WBC was high and that he needed to
either see an oncologist or go back to his PCP, [**Name10 (NameIs) 1023**] he saw the
next morning. At around the same time he was having some sore
throat and left sided neck pain and he had a CT of his neck
which he said they told him was normal ([**First Name9 (NamePattern2) **] [**Location (un) **]). At
some point he was started on avelox for this throat issue. He
presents here today to the ED after talking on the phone with
oncology.
He has been [**Location (un) 1131**] online and his conversations with oncology
earlier he believes that he likely has a new leukemia - he notes
that he appreciates people being very frank with him and not
glossing over anything. It is also very important to him to be
front and center in all the decision making and knowing results
in a timely fashion.
He is currently without pain, his complaints are fatigue, nausea
in the a.m., bp that was difficult to control and is now low,
easy bruising and nightime sweats times the last couple of
months.
REVIEW OF SYSTEMS: A complete review of systems was done, and is
negative except as noted above.
Past Medical History:
- Diabetes
- HTN
- Oenal failure (unclear duration)
- Obesity
- He was diagnosed with anemia a couple of months ago
- Cholecystectomy
- undescended testes (age 12)
- right benign hip mass resection
- tonsillectomy
- cataract surgery
Social History:
Married to third wife (other two are deceased), former smoker
(quit [**2123**]), no ETOH/illicits. Had many different jobs, but is
currently retired. Grew up in [**State 3706**]. Likes to garden and
work around the yard
Family History:
2 biological children: one son age 43 had lymphoma 15 yrs ago.
His daughter has diabetes. He is adopted and does not know
anything about his biological family.
.
Physical Exam:
ECOG PERFORMANCE STATUS: 1
PHYSICAL EXAM: VSS temp 99.1
GENERAL:nad, overweight/obese
NODES: No cervical, axillary, groin or supraclavicular
adenopathy
EYES: Wearing glasses, peerl
ENT: missing teeth, oropharnx otherwise normal, ?swelling left
neck?CHEST: Clear to percussion and auscultation, normal
respiratory
effor. Lump on right upper back (says has been there a long
time)
COR: RRR
ABD: Soft, obese, large scar from gb surgery. Bruises from
lantus.
NEURO: Normal cranial nerves, reflexes and strength and
sensation
EXT: slight le edema, oncymycosis both great toes
SKIN: warm, dry. No rashes. Some small areas of bruising on
extremities. IV in left AC
PSYCH: Normal mood and affect
Pertinent Results:
Labs on Admission:
[**2146-5-3**] 07:21PM D-DIMER-5752*
[**2146-5-3**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2146-5-3**] 06:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2146-5-3**] 06:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2146-5-3**] 06:30PM URINE GRANULAR-0-2
[**2146-5-3**] 03:15PM GLUCOSE-164* UREA N-40* CREAT-1.6* SODIUM-140
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2146-5-3**] 03:15PM ALT(SGPT)-42* AST(SGOT)-45* LD(LDH)-788* ALK
PHOS-69 TOT BILI-0.4
[**2146-5-3**] 03:15PM LIPASE-19
[**2146-5-3**] 03:15PM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2146-5-3**] 03:15PM WBC-34.6* RBC-2.28* HGB-7.4* HCT-22.3* MCV-98
MCH-32.5* MCHC-33.2 RDW-19.5*
[**2146-5-3**] 03:15PM NEUTS-6* BANDS-12* LYMPHS-2* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-3* BLASTS-34* NUC RBCS-4*
OTHER-40*
[**2146-5-3**] 03:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2146-5-3**] 03:15PM PLT SMR-VERY LOW PLT COUNT-65*
[**2146-5-3**] 03:15PM PT-13.9* PTT-30.9 INR(PT)-1.2*
[**2146-5-3**] 03:15PM FIBRINOGE-327
[**2146-5-3**] 03:00PM WBC-36.2* RBC-2.33* HGB-7.8* HCT-23.9*
MCV-103* MCH-33.7* MCHC-32.8 RDW-19.8*
[**2146-5-3**] 03:00PM NEUTS-5* BANDS-10 LYMPHS-2 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-3 MYELOS-4 BLASTS-34* NUC RBCS-3 OTHER-42*
[**2146-5-3**] 03:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-1+
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2146-5-3**] 03:00PM PLT SMR-VERY LOW PLT COUNT-69*
.
CT-head non contrast [**2146-5-3**]
No mass lesion or gross bony abnormality to specifically suggest
IAC or
skull base pathology. If clinical concern remains, dedicated MRI
of the brain and IACs, with and without contrast, may be
performed for further evaluation.
.
Echo [**2146-5-5**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. Mildly dilated thoracic aorta.
Head CT [**2146-5-6**]
IMPRESSION:
1. Status post left craniotomy and evacuation of left subdural
hematoma, with
expected changes at surgical bed.
2. Interval resolution of subfalcine and uncal herniation. Mild
remaining
rightward shift of midline structures measuring 5 mm.
3. No intraparenchymal hemorrhage. No subarachnoid hemorrhage.
Brief Hospital Course:
66 yo presented with new leukocytosis, thrombocytopenia, and
anemia. He ultimately had a diagnosis of AML. His hospital
course was complicated by a subdural hematoma, evacuation of
hematoma, respiratory arrest, intubation, febrile neutropenia
and he expired on [**2146-5-21**] (see below).
.
.
Mr. [**Known lastname 85007**] was found to have AML from Bone marrow biopsy on
[**5-4**]. On [**5-6**] he was noted to have acute AMS. STAT CT head
revealed new large left subdural hemorrhage, with significant
mass effect with subfalcine and uncal herniation. He
subsequently underwent emergent left craniotomy and evacuation
of left subdural hematoma. On [**5-7**] he was noted to be febrile to
101.8. He was placed on a Labetolol gtt with goal SBP < 140. He
was febrile again on [**5-8**]. On [**5-9**] his vital signs reflected a new
O2 requirement with 92-100/4L NC. On [**2146-5-12**] patient became more
and more confused and agitated, was thought to be not safe on
the floor, requiring sedation for repeat head Ct. Patient was
given 2 mg IV ativan to enable head CT, and 15 min later was
found to be unresponsive and hypoxic. Code blue was called,
patient was hypoxic with sPO2 of 36 and pCO2 of 80, he had
palpable pulses through out the course of resiscitation with SBP
of 200. He was intubated and oxygenation improved with air bag
ventilation. Flumazenil was given with return of minimal degree
of spontaneous movement. He was transferred to the ICU for
stabilization and subsequently had emergent head CT which did
not show rebleed from his subdural hematoma evacuation. It was
thought that he likely aspirated during the code blue and he was
treated for aspiration pneumonia with broad antibiotics. Over
the next week he continued to remain febrile with neutropenia.
Weaning of sedation was attempted several times, but he would
become dysynchronous from the ventilator and tachypneic and
hypertensive preventing the sedation from being weaned to assess
his mental status. He still had a gag reflex present, but had
not shown any spontaneous movements of his extremitites even
with lightening of the sedation. the ICU team proposed
performing an LP for work up of the fevers, but the family
declined. ID was involved and the patient was kept on broad
spectrum antibiotics including vanc, levofloxacin, keppra,
micafungin, and acyclovir. A head MRI was not able to be
peformed because the patient would not fit in the [**Hospital Ward Name **]
MRI machine, and was too unstable to be transported across the
street for the [**Hospital Ward Name **] MRI machine. He was transfused
platelts 30 units of platelets to attempt to maintain plt at a
goal of 80,000. He also recieved 20 units of RBCs.
On [**2146-5-21**] after discussions with the patient's wife, daughter,
and ICU team it was decided that the patients wishes would be
more in alignment with comfort measures. He was extubated and
his sedation and analgesia was maintained. He expired shortly
after with his family at the bedside.
Medications on Admission:
Lisinopril, Avapro - doses unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Acute Leukemia
SUbdural hematoma
.
Secondary:
Diabetes
Hypertension
Obesity
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"348.4",
"403.90",
"486",
"285.9",
"276.0",
"584.9",
"585.9",
"205.00",
"432.1",
"518.81",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.25",
"96.72",
"96.6",
"38.93",
"99.15",
"96.04",
"33.24",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
9771, 9780
|
6643, 9657
|
293, 334
|
9909, 9918
|
3450, 3455
|
9971, 9978
|
2562, 2726
|
9742, 9748
|
9801, 9888
|
9683, 9719
|
9942, 9948
|
2783, 3431
|
1971, 2052
|
233, 255
|
362, 1952
|
3469, 6620
|
2074, 2309
|
2325, 2546
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,837
| 111,012
|
10733
|
Discharge summary
|
report
|
Admission Date: [**2160-5-29**] Discharge Date: [**2160-6-6**]
Date of Birth: [**2086-7-12**] Sex: F
Service: MEDICINE
Allergies:
Colchicine / Atorvastatin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
Colonoscopy [**2160-5-30**], [**2160-6-1**]
History of Present Illness:
73 y.o. F w/ DM, ESRD on HD, CHF presenting with BRBPR.
underwent a colonoscopy on [**5-21**] (Dr. [**Last Name (STitle) 6880**] for ongoing
diarrhea with biopsy x2. The colonoscopy showed: A single
sessile 7 mm polyp of benign in the cecum. A single-piece
polypectomy was performed using a hot snare. AS per recent note,
polyps coagulated and unavailable for retrieval. A single
semi-pedunculated 1.4 cm polyp of benign appearance was found in
the distal ascending colon. A piece-meal polypectomy was
performed using a hot snare.
.
Recent admission from [**Date range (1) 33900**] with BRBPR, episode of
lightheadedness and syncope in that setting. HCT to 28.5 lowest,
responded to 2 units PRBC, and pt stable at discharge monday.
Wednesday daughter reported [**3-16**] painless clot fulled bowel
movements, dark colored, not black. Associated mild nausea, and
one episode of non bloody, non bilious emesis. This AM, pt felt
lightheaded at HD. 30 minutes into session. Given concern to ED.
Denies fever/chills/abdominal pain/mucus in stool/sick contacts.
.
In ED T 97, HR 58, BP 145/55, 18 stable, 100%RA. Protonix 40 mg
IV given. 300 cc NS given. HCT 26.7 from 33. One unit PRBC
given. GI consulted. Admitted for further work up.
Past Medical History:
-Post polypectomy bleed recent admission [**Date range (1) 35112**] for BRBPR
-ESRD on HD: Right upper extremity fistula. Revision AV limb
[**1-20**], thrombectomy [**1-21**], placement of tunneled right IJ,
[**2159-2-23**] right AV thrombectomy and revision complicated by
bacteremia (+cx tunneled cath)
-CHF: Echo [**11-17**] LVEF >55%, LVH, mild AS, pulm art systolic
hypertension, [**2-13**]+ MR
[**Name13 (STitle) 35113**]
-Type 2 DM: dx 40 years ago, complicated by ESRD, controlled on
insulin
-Sarcoidosis with ocular involvement: seen q3 months for eye
exam
-Gout: last flair [**10-18**]; usually occurs in R toes
-Knee surgery s/p fall
-CVA ~20 yrs ago w/out residual deficits
Social History:
Patient lives with her daugther. She denies tobacco, alcohol or
illicit drug use.
Family History:
HTN, DM
Physical Exam:
98.4, 138/74, 67, 99% RA
GEN: well appearing female in no acute distress
HEENT: OP clear, dry MM
NECK: difficult to assess JVP
CHEST: CTAB, no wheezes, rales
CV: III/VI systolic murmur throughout
ABD: soft, redundant skin, +bowel sounds, non tender, non
distended
EXT: no edema, cyanosis or clubbin
NEURO: AO x3
Rectal: in ED, BRB, no pain. Defer exam as just performed
Pertinent Results:
CHEST (PORTABLE AP) [**2160-5-29**]
IMPRESSION: Low lung volumes and left ventricular enlargement,
with no CHF or infiltrate
.
ECG Study Date of [**2160-5-29**]
Sinus rhythm. Left bundle-branch block. Compared to the previous
tracing
the axis is slightly more to the right.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2160-6-6**] 05:10AM 5.7 3.94* 11.6* 35.0* 89 29.5 33.3 15.4
249
[**2160-5-29**] 01:00PM 5.1 2.85* 8.4* 26.7* 94 29.3 31.3 17.8*
278
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2160-6-6**] 05:10AM 80 19 4.9* 139 4.6 100 29
[**2160-5-29**] 01:00PM 123* 37* 5.4* 139 4.41 102 26
Brief Hospital Course:
ASSESSEMENT/PLAN: 73 yo F with ESRD on HD, DM, chronic diastolic
CHF re-admitted with hematochezia s/p polypectomy x 2 sites ~ 1
week prior to admission. Underwent colonscopy x 2, initial
procedure not effective & pt continued to bleed. Pt received
DDAVP as possibility of uremic platelets given chronic dialysis.
.
# Hematochezia: Likely s/p polypectomy sites which have
continued to bleed. Underwent colonscopy x 2 with good effect -
clips to both polypectomy sites. Pt received total 5U PRBC
during admission. Gastroenterology service were closely
involved. Hematocrit levels have remained stable for at least 4
days prior to discharge; pt had brown bowel movement prior to
discharge, will require stool softners to prevent constipation.
Pt being discharged to rehab prior to d/c home.
.
# HTN: Poorly controlled during admission. Held BP meds
initially with GI bleed, however despite restarting, BP still
poorly controlled. We made some changes to her medication
regimen. We have discontinued Labetalol 600mg po TID. Current
regimen include Irbesatan 150mg po BID including dialysis days,
Toprol XL 100mg po daily, Amlodipine increased from 5mg to 10mg
po daily & Clonidine 0.1mg po BID. Pt will require close
monitoring of BP given recent medication changes.
.
# ESRD on HD: [**Year (4 digits) **]/thurs/sat. Continued pt on hemodialysis
during admission. We continued pt on home regimen Cinacalcet &
Sevelamer.
.
# Chronic diastolic CHF: No evidence of overload, no acute
issues. Continued pt on Irbesatan at home regimen. Aggressive BP
control was done, see above for medication changes.
.
# DM: Initially held NPH 12U qam while pt NPO for colonscopies,
however restarted once pt tolerating regular diabetic diet.
.
# Gout: No evidence of an acute flare. Allopurinol, Lidocaine
TD, Vicodin PRN continued while on admission.
.
# Hyperlipidemia: Continued pt on home regimen Pravastatin
.
FULL CODE
Medications on Admission:
-Allopurinol 100 mg Tablet Sig EOD
-Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
-Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
-Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
-Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
-Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
-Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
-Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
-Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 75mg PO BID on dialysis days tue/[**Last Name (un) **]/sat.
-Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) unit Subcutaneous qam.
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous Every morning.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Last Name (un) **]:*60 Capsule(s)* Refills:*2*
11. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please hold for SBP < 120.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please hold for SBP < 120.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Please hold for SBP < 120 or HR < 60.
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a
day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary:
- Postpolypectomy bleeding
- Acute blood loss anemia
- Accelerated hypertension
.
Secondary:
- CKD stage V on HD
- Diabetes mellitus type II
- Chronic diastolic heart failure
- Sarcoidosis with ocular involvement
- Gout
- CVA NOS
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with bleeding per rectum for which you
underwent procedures (colonscopy x 2) to stop the bleeding. Your
blood count has been stable for several days prior to discharge.
.
We have increased your amlodipine from 5 -> 10mg po daily.
Please take Irbesatan 150mg po BID everyday including on
dialysis days. Please d/c Labetalol, take Toprol XL 100mg po
daily & Clonidine 0.1mg po BID for BP control. We have also
started you on a stool softner, Docusate. Please discuss all
this medication changes with your PCP.
.
Please come to the ED or call your PCP if you develop more
bleeding per rectum, shortness of breath, dizziness or any other
worrisome symptoms.
Followup Instructions:
PCP: [**Name10 (NameIs) 357**] [**Name Initial (NameIs) **]/u with Dr.[**Last Name (STitle) **] on [**2160-6-10**] at 1210pm.
Phone# [**Telephone/Fax (1) 608**]. Location: 545A Centre street, [**Location (un) 35114**] MA
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2160-7-23**] 4:45
|
[
"428.32",
"V45.89",
"135",
"272.4",
"E878.8",
"V12.54",
"276.2",
"585.6",
"287.5",
"403.01",
"998.11",
"211.4",
"285.1",
"250.40",
"562.10",
"211.3",
"274.9",
"458.9",
"428.0",
"V45.1",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7969, 8065
|
3521, 5426
|
296, 342
|
8348, 8357
|
2849, 3498
|
9077, 9460
|
2433, 2443
|
6479, 7946
|
8086, 8327
|
5452, 6456
|
8381, 9054
|
2458, 2830
|
244, 258
|
370, 1605
|
1627, 2317
|
2333, 2417
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,061
| 158,086
|
41888+58483
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-11-20**] Discharge Date: [**2112-11-25**]
Date of Birth: [**2055-7-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Repair of large scalp laceration
History of Present Illness:
57F unrestrained passenger, car struck by snow plow truck from
right side. Initial GCS 15, but then became somnolent on scene,
RSI intubated with 7-0 tube by ALS. Hemodynamically stable BP
120-130 en route by [**Location (un) **] to [**Hospital1 18**]. While landing, became
agitated and received versed and pancuronium.
In the ED, her blood pressure was in the 90s systolic. IV
access was obtained with 4 peripheral 18G IVs and she was given
3 L IV fluid and 1 unit emergency-release PRBC. FAST exam
positive for free fluid in RUQ. ETT advanced to 24 cm at the
lip. Ancef and Td vaccine given.
Past Medical History:
HTN, asthma, chronic back pain, seasonal allergies, left lazy
eye, MVC last year w/ R knee injury
PSH: local excision of breast (benign)
*****Jehova's witness*****
Social History:
unknown
Family History:
non-contributory
Physical Exam:
T:95.5 BP: 142/69 HR: 94 R 23 O2Sats 100% on CMV 100% FiO2
Gen: intubated and sedated (versed/fentanyl held for exam)
HEENT: Pupils: PERRL 2-1.5mm brisk EOMI unable to assess +
cough/gag, right frontal laceration
Neck: in hard collar
Cardiac: RRR, no M/R/G
Abd: Soft, NT
Extrem: Warm and well-perfused.
Mental status: EO to voice off sedation
Orientation: unable to assess
Cranial Nerves:
unable to assess
Motor: MAE's symmetrically antigravity. following commands x4
Sensation: unable to assess
Reflexes: no Clonus
Physical examination: upon discharge [**2112-11-25**]
t=98.9, hr=80, bp=118/76, oxygen saturation 97% room air
General: Right eye swollen, ecchymosis right side face,
laceration right temple
CV: Ns1, s2, -s3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender
EXT: Ecchymosis right leg with swollen right patella,
ecchymosis left leg, + dp bil., no calf tenderness
Ecchymosis elbows bil. (Left>right)
NEURO: Alert and oriented x 3, speech clear, no tremors, full
EOM's bil.
Pertinent Results:
[**2112-11-20**] 10:10AM WBC-13.2* RBC-4.16* HGB-13.4 HCT-39.1 MCV-94
MCH-32.3* MCHC-34.3 RDW-12.5 LIPASE-77*
IMAGING:
CT head [**11-20**]: Large right scalp hematoma and laceration with
hyperdense foci within this region concerning for foreign
bodies. Extension of hematoma and laceration in to the right
eyelid. Small hyperdensity along the left frontal sulcus may
represent a small subarachnoid hemorrhage and less likely
artifact or vessel.
CT c-spine [**11-20**]: There is a small osseous fragment adjacent to
the C3 vertebral body which may represent a chip fracture of the
anterior osteophyte of indeterminate chronicity. No acute
fracture identified.
CT torso [**11-20**] (wet read):
1. Right perihepatic fluid with [**Doctor Last Name **] 61 concerning for
hemoperitoneum. No definite obvious liver laceration, however
subtle contour irregularity along the liver dome may be present.
Additionally, on liver windows hypodensity in right liver lobe
may suggest contusion. There is stranding around the right
adrenal gland which may suggest right adrenal gland injury in
the setting of right liver subtle contusion.
2. Right 8th rib fracture.
3. Bilateral lung opacitieis may represent atelectasis vs fluid
vs blood in setting of trauma.
5. Air colleciton in anterior mediastinum (602b, 51).
Xray knee [**11-20**]: No fracture or dislocation.
CT head [**11-20**] repeat (wet read): Unchanged left frontal
subarachnoid hemorrhage, streak-like parafalcine subdural
hematoma and right frontoparietal subgaleal hematoma.
[**2112-11-20**] 10:10AM
Brief Hospital Course:
Her ICU as follows:
Mrs. [**Known lastname 6818**] was admitted to the Acute Care Surgery Service from
ED to TSICU. Neurosurgery consulted for the subarachnoid
hemorrhage and felt that given the small size of the bleed that
no further intervention warranted. A repeat head CT scan was
done and remained stable. Scalp laceration was repaired at the
bedside by plastic surgery and she was started on Ancef per
plastics recommendations. Repeat head CT grossly unchanged and
she received multiple IV fluid boluses for hypotension with MAP
in 50s. Her pressures subsequently stabilized and she was
extubated on HD 2. There was no evidence of C-spine fracture on
imaging, C-spine was cleared clinically. Antibiotics for the
open scalp laceration were discontinued. Given falling
hematocrit and her inability to receive blood transfusions due
to religious beliefs, she was started on iron, Epogen and
multivitamin supplementation. Once stabilized and improvement in
her mental status she was transferred to the regular surgical
unit.
Her floor course as follows:
She continued to progress slowly once transferred out of the
unit to the floor. The scalp JP drain was removed and it was
recommended that a topical antibiotic be used. She will follow
up within 1 week after discharge in Plastic surgery clinic.
She was noted with pain control issues requiring adjustment of
her pain medications so that at time of discharge she is on an
oral regimen with adequate control of her pain.
Upon return to the surgical floor, her swallowing ability was
re-addressed by Speech and Swallow and she was cleared for
regular diet including liquids and pills. She has been
tolerating a regular diet without any problems.
The decision was made to continue with weekly Epogen injections
with the expectation that once she is out of her acute injury
phase and has stable hematocrits it can be discontinued.
She was seen and evaluated by Physical therapy and
recommendations made for discharge to a rehabilitation following
her acute hospital stay.
Her vital signs are stable and she is afebrile. Her white blood
count is 5.3 and her hematocrit is 27.5, her total bili is 0.4.
She is tolerating a regular diet and voiding without
difficulty. She is preparing for discharge with instructions to
follow up with Plastic Surgery for removal of her sutures.
Medications on Admission:
lisinopril 10', motrin, albuterol prn, loratadine
Discharge Medications:
1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) appl
Ophthalmic QID (4 times a day): apply to OD.
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. epoetin alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection EVERY TUESDAY ().
10. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): apply to scalp laceration.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day:
hold for blood pressure <100, hr <60.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) inh Inhalation every six (6) hours: as needed for
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Left subarachnoid hemorrhage
Large stellate right head laceration
Liver contusion
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory w/ supervision - requires assistance
or aid (walker or cane).
Discharge Instructions:
You were admitted to the hospital after an automobile crash
where you sustained a traumatic brain injury and large scalp
laceration. Your brain injury did not require any operations.
The large scalp laceration was repaired by the Plastic surgery
doctors and [**Name5 (PTitle) **] take some time to heal.
You were seen and evaluated by Physical therapy and being
recommended for rehabilitation following your hospital stay.
Followup Instructions:
For any concerns related to your head injury please contact
neurosurgery clinic at [**Telephone/Fax (1) 1669**]. Otherwise they have
indicatedthat you do not need a follow up appointment.
Follow up next week in Plastic [**Hospital **] clinic with Dr. [**First Name (STitle) 3228**],
call [**Telephone/Fax (1) 5343**] for an appointment.
Follow up with your primary care doctor after you are discharged
from rehab.
Please follow up with the acute care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**],
Completed by:[**2112-11-25**] Name: [**Known lastname 3070**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 14346**]
Admission Date: [**2112-11-20**] Discharge Date: [**2112-11-25**]
Date of Birth: [**2055-7-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 844**]
Addendum:
Of note:
Recommendations made for repeat CT iin 3 months to assess for
paravertebral swelling. Patient in transition in being assigned
new Primary care provider. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA will be
assigned to this patient. She has been informed of this need
for repeat CT.
([**Hospital **] Health Center: # [**Telephone/Fax (1) 14347**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 95**]
([**Hospital3 96**] Center)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]
Completed by:[**2112-11-25**]
|
[
"250.00",
"852.26",
"807.01",
"864.01",
"E812.1",
"873.0",
"724.5",
"493.90",
"852.06",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
9799, 10087
|
3854, 6194
|
327, 362
|
7792, 7930
|
2276, 3831
|
8402, 9776
|
1222, 1240
|
6295, 7471
|
7651, 7771
|
6220, 6272
|
7954, 8379
|
1255, 1567
|
1803, 2257
|
264, 289
|
390, 991
|
1653, 1781
|
1582, 1637
|
1013, 1181
|
1197, 1206
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,122
| 161,108
|
8381+8382+8383
|
Discharge summary
|
report+report+report
|
Admission Date: [**2166-9-19**] Discharge Date:
Date of Birth: [**2112-2-18**] Sex: M
Service: [**Hospital1 **]
Date of discharge not yet determined.
CHIEF COMPLAINT: Pneumonia.
HISTORY OF PRESENT ILLNESS: This is a 54 year old man with
a past medical history significant for diabetes mellitus who
has not seen a physician for approximately two years. He
presents with a one week history of nausea, dry heaves,
fever, and an episode of syncope on the morning of admission.
The patient reports that he was in his usual state of health
until [**2166-9-14**], when he was driving home from [**Location (un) 3844**]
and suddenly became nauseous. He pulled over to the side of
the road and vomited profusely. He reports that the vomit
was mostly digested food which was brown in color. The
patient continued to have nausea over the next five days. In
addition, he had frequent dry heaves and anorexia. In the
week prior to admission, the patient also began to feel
increasingly short of breath and developed a dry cough. He
reports positive dyspnea on exertion.
The patient has been febrile with his temperature maximum of
104.0 F., on the afternoon of [**2166-9-15**]. He has been taking
Tylenol and fluids but his fever has not been below 100.0 F.,
for the past five days. In addition, he notes a waxing and
[**Doctor Last Name 688**] left sided flank pain that begins as a sharp pain and
then gradually dulls and lasts for several hours at a time.
The patient denies any headache.
The patient's only sick contact is his son who has been sick
with bronchitis for approximately two weeks. In addition,
the patient reports that he has been exposed to a "black
fungus" at work since last [**Month (only) **] when his office was moved
to a basement. He does not know what this fungus is but
reports that it has made some of his co-workers ill with a
fever and cough.
On the morning of admission, the patient woke up at
approximately 5:00 a.m. and soon began to feel nauseous. He
was kneeling at the side of the toilet and dry heaving, when
he "passed out". He denies hitting his head. He walked back
into his bedroom and had a second episode of loss of
consciousness while laying on the bed. He continued to feel
dizzy and lightheaded until he arrived in the Emergency
Department.
In the Emergency Department, the patient was febrile to 101.9
F. He received Levofloxacin 500 mg p.o. times one. The
patient's lower left back pain resolved with one tablet of
sublingual Nitroglycerin. The patient also received one half
ampule of D50 and liter of D5 normal saline with a blood
sugar of 51. His blood sugar returned to [**Location 213**] following
this intervention.
In the Emergency Department, the patient was initially
saturating in the mid-90s on room air; however, over the
course of the next several hours, the patient's oxygen
requirement increased to 6 liters nasal cannula to maintain
his oxygen saturation in the mid 90s.
The patient was admitted to the floor for presumed atypical
pneumonia.
PAST MEDICAL HISTORY:
1. Diabetes mellitus diagnosed in [**2147**] and controlled with
insulin.
2. Hernia repair at the age of five.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 81 mg p.o. q. day.
2. NPH insulin 40 units q. h.s.
SOCIAL HISTORY: The patient works for [**University/College **] Program and
is a scout master. He denies tobacco or drug use. He has
approximately one to two glasses of wine two times a week.
His only travel history is that he was in [**Location (un) 3844**] last
weekend but he was not camping during that trip.
FAMILY HISTORY: The patient's mother has hypertension and
was diagnosed with breast cancer several years ago. His
father has hypercholesterolemia and congestive heart failure.
REVIEW OF SYSTEMS: The patient denies headache, visual
changes, hearing changes, runny nose, or sore throat. He
does report occasional edema of his feet and ankles since
[**Month (only) 205**] of this year. He denies chest pain. He denies diarrhea
or constipation. He denies any urinary symptoms.
PHYSICAL EXAMINATION: On admission, temperature maximum
101.9 F.; temperature currently 99.1 F.; blood pressure
104/62; heart rate 104; respiratory rate 20; oxygen
saturation 97% on five liters. In general, this is a
pleasant but diaphoretic man laying in bed in no acute
distress. He is able to talk in complete sentences. HEENT:
normocephalic, atraumatic. Pupils are equal, round and
reactive to light. Extraocular movements intact. Dry mucous
membranes with a light coating over the tongue. No cuts,
bruises, or other injuries from his syncopal episodes.
Cardiac: Regular rate and rhythm, S3. Pulmonary: Diffuse
bibasilar crackles with overall coarse lung sounds. Abdomen
obese, soft, nontender, nondistended, positive bowel sounds.
Extremities with trace lower extremity edema. Two plus
dorsalis pedis pulses. Neurological: Cranial nerves II
through XII intact. Five out of five strength in the upper
and lower extremities bilaterally.
LABORATORY: On admission, white blood cell count 7.1,
hemoglobin 14.7, hematocrit 42.4, platelets 156, 63
neutrophils, 28 bands, 5 lymphocytes, 2 monocytes, zero
eosinophils, zero basophils, one atypical, one meta and one
myelocyte.
Chemistries with sodium 132, potassium 3.9, chloride 95,
bicarbonate 25, BUN 35, creatinine 3.1, glucose 51, ALT 29,
AST 54, CK 854, alkaline phosphatase 70, amylase 18, lipase
15, total bilirubin 0.5. CK MB 4, troponin 0.11. Lactate
1.4. Blood cultures were drawn.
Chest x-ray on admission with cardiomegaly. Pulmonary
vasculature within normal limits. Lungs with diffuse
bilateral coarse nodularity and interstitial opacities with
more confluent areas in the right and left mid lung zones.
No pleural effusions.
SUMMARY OF HOSPITAL COURSE:
1. CARDIAC: Three sets of cardiac enzymes were obtained on
admission. These CK MB were normal but the troponin were
mildly elevated with a maximum of 0.14. The patient had no
chest pain and no EKG abnormalities although past
electrocardiograms were not available. It was decided that
the most probable cause of the elevated troponin was demand
and/or renal failure. However, during the first week of
admission, the patient had three episodes of ventricular
tachycardia.
An echocardiogram was obtained to evaluate his cardiac
function. The left atrium and right atrium were mildly
dilated. The left ventricular wall thickness was normal.
The left ventricular cavity was severely dilated with severe
regional left ventricular systolic dysfunction. No masses or
thrombi were seen in the left ventricle. Wall motion
abnormalities included an akinetic basal inferior, mid
inferior and mid inferior lateral area. The right
ventricular cavity was mildly dilated, although systolic
function was decreased. Two plus mitral regurgitation and
one plus tricuspid regurgitation. Moderate pulmonary
systolic hypertension. There was no pericardial effusion.
Given these echocardiogram findings and the patient's history
of diabetes mellitus, there was concern that the patient was
suffering from a ischemic heart disease; however, given his
acute renal failure, it was decided to further evaluate his
heart without a cardiac catheterization. Therefore, he had a
cardiac MRI on [**2166-9-24**]. This confirmed a fairly decreased
left ventricular ejection fraction. There was coronary
artery disease in the right coronary artery. The left main
appeared fair. The left anterior descending and circumflex
could not be visualized.
2. INFECTIOUS DISEASE: It was felt that the patient's
infection was most likely atypical pneumonia given his
history and chest x-ray. On [**2166-9-20**], a chest CT scan was
obtained to further evaluate his pulmonary process. This
showed no pericardial effusion. There was a trace right
pleural effusion. There were reduced nodular opacities that
were most prominently at the lung bases. There was ground
glass opacification surrounding the nodular densities.
The patient was initially treated for his community acquired
atypical pneumonia with Levofloxacin and ceftriaxone. This
was later changed to Azithromycin and Ceftriaxone. The
patient completed a five day course of Azithromycin and a
seven day course of Ceftriaxone.
Over the course of the first week of admission, the patient's
pulmonary status improved dramatically. He is now saturating
in the high 90s on room air. He continues to have a dry
cough.
3. RENAL: The patient with a severely elevated BUN and
creatinine on admission. He has no known history of chronic
renal failure. An attempt was made to obtain labs from the
[**Last Name (un) **] where the patient was seen approximately two years
ago, however, these were unavailable.
On admission, it was felt that the patient's acute renal
failure was due to dehydration and he was rehydrated with
intravenous fluids with a decrease in his statin. However,
the patient's creatinine remained elevated in the mid to high
2s following rehydration. A urinalysis revealed moderate
blood, negative nitrites, 500 protein, 100 glucose, negative
ketone, negative bilirubin, negative urobilinogen.
A Renal consultation was obtained. Given the patient's
pulmonary and renal processes, Wegener's granulomatosis was
considered to be a possibility, with patient having negative
ANCA. A renal biopsy is planned for [**2166-9-29**].
4. GASTROINTESTINAL: The patient's nausea resolved with
treatment of his atypical pneumonia. His appetite has
returned and he is eating well. Normal liver function tests
on admission.
5. ENDOCRINE: [**Last Name (un) **] is following as the patient was
previously followed there for his diabetes mellitus. On
admission, the patient was hyperglycemic. This continued to
be a problem over the first three days of admission when the
patient was eating very little. However, his blood sugars
have now returned to [**Location 213**] to high range. His insulin
regimen is being adjusted as needed.
Currently he is on NPH q. a.m. and q. p.m. with a Humalog
sliding scale with four times a day finger sticks.
6. FLUIDS, ELECTROLYTES AND NUTRITION: American Diabetic
Association / cardiac diet. Aggressive electrolyte
replacement.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2166-9-27**] 16:44
T: [**2166-9-27**] 21:38
JOB#: [**Job Number 29597**]
DICTATION FOR SUBSEQUENT HOSPITAL COURSE PENDING
Admission Date: [**2166-9-19**] Discharge Date: [**2166-10-17**]
Date of Birth: [**2112-2-18**] Sex: M
Service: Cardiothoracic service. #58
ADDENDUM: Please see the previous dictation which covers the
period from admission on [**9-19**] through [**9-29**].
In summary, the patient was initially admitted with a
diagnosis of pneumonia and acute renal failure. During this
admission, the patient was also found to have congestive
heart failure and ischemic cardiomyopathy with an ejection
fraction of 20% as well as acute renal failure occurring in
conjunction with a component of chronic renal failure, with a
baseline creatinine of 2.8 to 3.0. The patient's past
medical history was significant only for diabetes mellitus as
well as a hernia repair.
The patient had a cardiac magnetic resonance scan. An echo
done during the initial phase of his hospitalization. The
magnetic resonance scan showed severely depressed ejection
fraction of 22% with significant right coronary artery
disease. It was unable to visualize the left anterior
descending and, therefore, it was felt that the patient would
require diagnostic catheterization.
On [**10-2**], the patient was brought to the cardiac
catheterization laboratory. At that time, the cardiac
catheterization showed the left main with 20% distal
tapering, left anterior descending with 60% proximal disease,
left circumflex with 90% disease and a right coronary artery
that was totally occluded.
Following catheterization, cardiothoracic surgery service was
consulted. The patient was seen and accepted for coronary
artery bypass grafting. Prior to coronary artery bypass
grafting, the patient underwent vein mapping. He was seen by
the renal service for control of his renal failure. He was
seen by the [**Last Name (un) 3208**] service for control of his diabetes.
The patient underwent preoperative diuresis with the use of
Natricor, from the period of [**10-1**] through [**10-7**]. Following
that, the patient was brought to the operating room on
[**10-8**]. Please see the operative report for full
details.
IN summary, the patient underwent coronary artery bypass
grafting times three with the left internal mammary artery to
the left anterior descending, saphenous vein graft to the
posterior descending artery and saphenous vein graft to the
obtuse marginal. Cardiopulmonary bypass time was 98 minutes
with a cross clamp of 59 minutes. He tolerated the operation
well and was transferred from the operating room to the
cardiothoracic Intensive Care Unit. At the time of transfer,
the patient had Milrinone at 0.25 mcg per kg per minute,
Neo-synephrine at 1.0 mcg per kg per minute and Propofol at
10 mcg per kg per minute. He had a mean arterial pressure of
75 and he was A-paced at 90 beats per minute. The patient
did well in the immediate postoperative period. His
anesthesia was reversed. He was weaned from the ventilator
and successfully extubated.
On postoperative day number one, the patient continued to be
hemodynamically stable. He was weaned from his cardioactive
drips but remained in the Intensive Care Unit to monitor not
only his hemodynamic status but his renal status, his
creatinine was noted to increase from 3.4 to 3.8 from
postoperative day number one to postoperative day number two.
by the renal and [**Last Name (un) 3208**] service at that time. His Natricor
infusion was reinstituted and, at times, he required
Neo-Synephrine to maintain an adequate blood pressure with
Natricor infusion.
On postoperative day number three, the patient's chest tubes
were removed and he was maintained on his Natricor infusion,
no longer requiring Neo-Synephrine to supplement his blood
pressure.
Also on postoperative day number four, the patient's
Swan-Ganz catheter was removed. Over the next two days, the
patient continued to receive Natricor to assist in diuresis
and on postoperative day number six, the Natricor was
discontinued and he was discharged from the cardiothoracic
Intensive Care Unit to R-2 for continuing postoperative care
and cardiac rehabilitation. Once on the floor, the patient's
activity level was increased with the assistance of the
physical therapy department and the nursing staff. On
postoperative day number nine, it was decided that the
patient was stable and ready to be discharged to home. At
the time of discharge, the patient's physical examination was
as follows.
PHYSICAL EXAMINATION: Vital signs revealed temperature of
98.9; heart rate of 94; blood pressure 128/74; respiratory
rate 20; oxygen saturation 94% on room air. Lungs clear to
auscultation bilaterally. Heart: Regular rate and rhythm.
Abdomen: Soft, nontender, nondistended, with positive bowel
sounds. Extremities are warm and well perfused with 1 to 2+
edema bilaterally. Incisions are clean, dry and intact. The
sternum is stable. Incision was covered with Steri-Strips.
LABORATORY DATA: White count of 4.3; hematocrit of 31.6;
platelets 291. Sodium of 138; potassium of 4.5; chloride
101; C02 of 31; BUN 38; creatinine 3.0; glucose of 161.
The patient's condition at discharge is good. His discharge
diagnosis includes: 1.) Cardiomyopathy. 2.) Coronary artery
disease. Status post coronary artery bypass grafting times
three with the left internal mammary artery to the left
anterior descending; saphenous vein graft to the posterior
descending artery and saphenous vein graft to the obtuse
marginal. 3.) Diabetes mellitus. 4.) Hernia repair. 5.)
Chronic renal failure.
DISPOSITION: The patient is to be discharged to home. He is
to have follow-up with Dr. [**Last Name (STitle) 29598**] of the heart failure clinic as
scheduled. Follow-up with Dr. [**Last Name (STitle) 29599**] of the [**Hospital 3208**] clinic
as scheduled. Follow-up with Dr. [**Last Name (STitle) **] in the renal clinic
as scheduled. He is also to have follow-up in the wound
clinic in two weeks and follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
four to six weeks. The patient is to call the office for an
appointment to arrange that follow-up.
DISCHARGE MEDICATIONS:
Lasix 40 mg twice a day.
Potassium chloride 20 meq. Twice a day.
Aspirin 325 mg p.o. q. day.
Colace 100 mg twice a day.
Percocet 5/325 one to two tablets p.o. every four hours prn.
Albuterol one to two puffs q. six hours prn.
Carvedilol 3.125 mg twice a day.
Atorvistatin 10 mg q. day.
Hydralazine 25 mg three times a day.
Zantac 150 mg q. day.
Epoetin 5000 units three times per week on Monday, Wednesday
and Friday.
NPH insulin 14 units q. a.m., 16 units q. p.m.
Humilog follow the sliding scale as given at discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2166-10-17**] 02:41
T: [**2166-10-17**] 15:50
JOB#: [**Job Number 29600**]
Admission Date: [**2166-9-19**] Discharge Date: [**2166-10-17**]
Date of Birth: [**2112-2-18**] Sex: M
Service:
ADDENDUM: Please see prior dictation dated [**9-29**] for the
initial admission and work-up phase of Mr. [**Known lastname 29601**] admission
to [**Hospital1 69**].
In summary, Mr. [**Known lastname **] was admitted on [**9-19**] for presumed
pneumonia and acute renal failure. During the course of his
work-up, it was found that he had ischemic and cardiomyopathy
with an ejection fraction of 20% as well as congestive heart
failure and acute renal failure on top of a component of
chronic renal failure.
Additionally, the patient's past medical history is
significant for diabetes mellitus and a hernia repair. He
has no known drug allergies.
Upon admission to the hospital, his only medications included
aspirin and NPH.
During this hospitalization, the patient was not only
followed by the medicine service but also by the [**Hospital 3208**]
Clinic service for diabetes control and the cardiology
department for congestive heart failure and assistance in
management of cardiomegaly.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 29602**]
MEDQUIST36
D: [**2166-10-17**] 02:19
T: [**2166-10-17**] 15:41
JOB#: [**Job Number 29603**]
|
[
"486",
"414.8",
"427.1",
"585",
"250.42",
"276.5",
"428.0",
"745.5",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"88.72",
"88.56",
"36.12",
"35.71",
"55.23",
"37.22",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
3636, 3798
|
16712, 18968
|
5843, 15004
|
15027, 16689
|
3818, 4101
|
190, 202
|
232, 3046
|
3068, 3299
|
3317, 3618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,539
| 163,591
|
11150
|
Discharge summary
|
report
|
Admission Date: [**2171-12-15**] Discharge Date: [**2171-12-28**]
Service: MEDICINE
Allergies:
Lasix / Bacitracin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
HPI: 81 y/o male from [**Hospital **] Rehab with acute onset of shortness
of breath, oxygen saturation around 70%, and RR in the 30's.
EMT's noted BP 150/86, with pulse 80-120 in Afib, diminished
breath sounds at bases bilaterally, and cool skin. There was no
improvement with 100 mg edecrine and Albuterol neb. On
presentation to ED, O2 sats did not improve on 100% NRB, and he
was intubated. Also found to be hypothermic. Blood cultures sent
and started on Vanco/Levo/Flagyl.
Past Medical History:
HTN
Hyperlipidemia
AFib
CRI Baseline 1.5
Diastolic Congestive Heart Failure
MRSA PNA
CHF
Prostate Cancer
Myelodysplastic Syndrome
Right lower ext DVT s/p IVC filter, on Coumadin
Chronic Lower ext Edema
Lower extremitiy Cellulitis
Raynaud's
Steroid Myopathy
Social History:
SOCIAL: Coming from [**Hospital 100**] Rehab. Former smoker (stopped [**2125**]),
occassional aclohol, none recently becasue he has been at rehab.
Retired [**Company 2318**] driver.
Family History:
NC (81 y/o)
Physical Exam:
Elederly male, anasarca, faint [**Doctor Last Name **] erythematous rash over
trunck, intubated and sedated with propofol, reacts to painful
stimuli
T 87.7 BP 96/46 HR 55 Vented AC 450 x 20 PEEP 5 FiO2 100%
Pupils unequal with right 2mm and left 3-4 mm and reactive
OG tube in place. ET tube in place. Right EJ line in place. Left
IJ in place.
Rhonchi bilaterally anteriorly
Heart rate brady. No audible abonormal heart sounds.
Abd with severe pitting edema or flanks, abdominal wall
Sacral decubitus ulcer
Scrotal edema, Foley in place
Pitting edema of legs to hips, skin breakdown and weeping over
lower ext
Pertinent Results:
[**2171-12-15**] 09:00PM BLOOD WBC-16.0* RBC-3.60* Hgb-10.6* Hct-32.9*
MCV-92 MCH-29.3 MCHC-32.1 RDW-15.7* Plt Ct-329
[**2171-12-15**] 09:00PM BLOOD PT-39.7* PTT-63.3* INR(PT)-4.5*
[**2171-12-15**] 09:00PM BLOOD Glucose-116* UreaN-33* Creat-2.1* Na-137
K-4.5 Cl-101 HCO3-24 AnGap-17
[**2171-12-15**] 09:00PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 35908**]*
[**2171-12-15**] 09:00PM BLOOD cTropnT-0.17*
[**2171-12-16**] 05:39AM BLOOD Albumin-2.1* Calcium-7.6* Phos-5.2*
Mg-2.1 Iron-24* Cholest-116
[**2171-12-15**] 10:55PM BLOOD Type-ART pO2-121* pCO2-60* pH-7.28*
calTCO2-29 Base XS-0 Intubat-INTUBATED Comment-GREEN TOP
Brief Hospital Course:
1. Dyspnea/Hypoxia/Respiratory Distress:
-Initially felt to be d/t chf, but echo completed, and systolic
fn normal, mild diastolic dysfunction - continued to diures as
tolerated
-with above result (echo), felt that aspiration pneumonia more
likely as inciting event. Covered broadly with levo flagyl
vanc. [**Hospital 100**] rehab called during admission to report that a
sputum cx. sent there showed MRSA. After multiple attempts to
extubate (with two re-intubations for mucus plugging and
respiratory distress), a family meeting was held, and Mr.
[**Known lastname 35909**] family decided to withdraw care. He was extubated on
[**12-26**] in the afternoon, and expired that evening.
Medications on Admission:
Albuterol Q6 hours
Diltiazem 180 QD
Docusate 100 [**Hospital1 **]
Ethacrynic acid 100 mg QD
Metolazone 5 mg QD
Finasteride 5 QHS
Senna 2 tabs QHS
Tiotropium QD
Warfarin
Zinc 220 QD
Discharge Medications:
pt. expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"507.0",
"E912",
"428.0",
"038.11",
"707.14",
"518.0",
"933.1",
"482.41",
"427.31",
"585.9",
"707.12",
"V09.0",
"401.9",
"238.75",
"995.92",
"518.84",
"286.9",
"584.9",
"V12.51",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.04",
"96.05",
"96.72",
"96.6",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
3534, 3543
|
2576, 3266
|
244, 256
|
3594, 3741
|
1921, 2553
|
1262, 1275
|
3498, 3511
|
3564, 3573
|
3292, 3475
|
1290, 1902
|
196, 206
|
284, 765
|
787, 1046
|
1062, 1246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,057
| 188,240
|
37802
|
Discharge summary
|
report
|
Admission Date: [**2165-11-29**] Discharge Date: [**2165-12-3**]
Date of Birth: [**2085-6-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Replacment of Ascending Aorta and hemiarch (32mm
Gelweave)/Aortic valve replacement (21mm CE
pericardial)/Coronary artery bypass grafts x
4(LIMA-LAD,SVG-Dg,SVG-OM,SVG-PDA) [**2165-11-29**]
History of Present Illness:
This 80 year old female had a syncopal epsiode while driving and
was involved in an accident. Her work-up was remarkable for
paroxysmal supraventricular tachycardia and the finding of a
large thoracic aortic aneurysm.
She was referred to Dr. [**Last Name (STitle) 4469**] who peformed an echocardiogram
which showed the aorta to measure 6.9cm at the root, 6.3cm at
the arch to 4.1cm in the descending
thoracic aorta. There was [**2-1**]+ aortic insufficiency without
mention of the leaflet anatomy. Given the size of her thoracic
aortic aneurysm, she is referred for surgical evaluation.
Subsequently cardiac catheterization was done to reveal triple
vessel disease. She was admitted for operation.
Past Medical History:
Thoracic aortic aneurysm
Hypertension
h/o Supraventricular tachycardia
Hyperlipidemia
s/p right mastoidectomy
Social History:
Tobacco: 15 pack year history,quit 15 years ago
ETOH:rare social
Retired
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: 80 Resp: O2 sat: 95% RA
B/P Right: 179/69 Left: 169/70
Height: 60" Weight: 166
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;left lower lid mild
ptosis;OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular []
Murmur: 3/6 SEM radiates to carotids; [**3-8**] diastolic murmur
Abdomen: Soft [] non-distended [x] non-tender [x] bowel sounds
+
[x]
no HSM/CVA tenderness
Extremities: Waxrm [x], well-perfused [x] Edema -none
Varicosities: None []
Neuro: Grossly intact;nonfocal exam; MAE [**5-5**] strengths
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:1+
Pertinent Results:
[**2165-12-2**] 03:17AM BLOOD WBC-9.2 RBC-3.65* Hgb-10.7* Hct-31.7*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-98*
[**2165-12-1**] 01:47AM BLOOD WBC-10.0# RBC-3.60* Hgb-11.1* Hct-31.0*
MCV-86 MCH-30.9 MCHC-35.9* RDW-15.4 Plt Ct-108*
[**2165-12-2**] 03:17AM BLOOD Glucose-111* UreaN-16 Creat-0.6 Na-140
K-3.7 Cl-103 HCO3-34* AnGap-7*
[**2165-12-1**] 01:47AM BLOOD Glucose-136* UreaN-12 Creat-0.7 Na-141
K-3.5 Cl-107 HCO3-30 AnGap-8
[**2165-12-2**] 03:17AM BLOOD WBC-9.2 RBC-3.65* Hgb-10.7* Hct-31.7*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-98*
[**2165-12-3**] 05:39AM BLOOD Na-140 K-3.7 Cl-101 HCO3-34* AnGap-9
[**Known lastname 84616**],[**Known firstname **] [**Medical Record Number 84617**] F 80 [**2085-6-9**]
Radiology Report CHEST (PA & LAT) Study Date of [**2165-12-2**] 2:42 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2165-12-2**] 2:42 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 84618**]
Reason: ?/ effusions
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with Asc Ao/AVR/CABG
REASON FOR THIS EXAMINATION:
?/ effusions
Final Report
PA AND LATERAL CHEST.
HISTORY: Ascending aortic repair, AVR and CABG.
IMPRESSION: PA and lateral chest compared to [**11-30**]:
Moderate left pleural effusion has increased slightly, small
right pleural
effusion is new or increased. Mild postoperative enlargement of
the cardiac
silhouette is stable. Upper mediastinal contour has normal
postoperative
appearance with no indication of recurrent localized bleeding.
Bibasilar
atelectasis is substantial, possibly worsened since [**11-30**].
Upper lungs
are clear. No pneumothorax. Right jugular line tip projects over
the
superior cavoatrial junction.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2165-12-2**] 5:54 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 84616**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84619**] (Complete)
Done [**2165-11-29**] at 12:10:01 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2085-6-9**]
Age (years): 80 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Prosthetic valve
function. Valvular heart disease.
ICD-9 Codes: 440.0, V43.3, 424.1, 424.0
Test Information
Date/Time: [**2165-11-29**] at 12:10 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 5% to 55% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: *6.5 cm <= 3.4 cm
Aortic Valve - LVOT diam: 1.8 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. 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. Normal LV wall thickness and cavity
size. Normal LV wall thickness. Normal LV cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Markedly
dilated ascending aorta. Simple atheroma in ascending aorta.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (?#). No AS. Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. 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: 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 TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is markedly dilated There are simple
atheroma in the ascending aorta. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is a small pericardial
effusion.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
Following same day admission she was taken to the Operating Room
where her operation was performed as noted. See the operative
note for details. She tolerated the procedure, weaning fom
bypass on Epinephrine and neosynephrine. They were quickly able
to be weaned off and she was extubated the following morning.
CTs were removed on the first surgical day, beta blockers and
ACE inhibitors were resumed for control of her hypertension. She
continued to progress and was ready for floor transfer on POD 2.
Physical therapy worked with her for strength and mobility,
diuresis towards her preoperative weight was continued. Beta
blockade and ACE inhibitors were adjusted to provide adequate
blood pressure control. She was evaluated for a rehabilitation
facility to allow further recovery prior to eventual return
home. Pacing wires were removed on POD 3. She was ready for
discharge to rehab on postoperative day four with continued
diuresis and zarolxyn for seven days.
Medications on Admission:
Lipitor 10mg daily
Atenolol 25mg daily
Quinapril 10mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
11. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: please give 30 minutes prior to lasix .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Thoracic aortic aneurysm s/p replacement
Coronary artery disease s/p cabg
aortic insufficiency s/p AVR
Hypertension
paroxysmal Supraventricular tachycardia
Hyperlipidemia
s/p right mastoidectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
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 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:
Please call to schedule appointment
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 22552**] ([**Telephone/Fax (1) 4475**]) after discharge from rehab
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] after discharge from rehab
Completed by:[**2165-12-3**]
|
[
"441.2",
"424.1",
"414.01",
"424.0",
"V45.89",
"V12.72",
"427.89",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"35.22",
"39.64",
"36.15",
"39.57"
] |
icd9pcs
|
[
[
[]
]
] |
10646, 10693
|
8570, 9546
|
285, 476
|
10932, 10939
|
2242, 3276
|
11652, 12060
|
1447, 1464
|
9657, 10623
|
3316, 3355
|
10714, 10911
|
9572, 9634
|
10963, 11629
|
7360, 8547
|
1479, 2223
|
238, 247
|
3387, 7311
|
504, 1206
|
1228, 1340
|
1356, 1431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,156
| 155,841
|
24356
|
Discharge summary
|
report
|
Admission Date: [**2168-9-7**] Discharge Date: [**2168-9-15**]
Date of Birth: [**2092-1-20**] Sex: M
Service: MEDICINE
Allergies:
Zithromax / Haldol / Levaquin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
s/p fall from outside hospital
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 76 year old male with PMH of PUD ([**12-4**]), CAD s/p MI 4
weeks ago (medically managed), ESRD on HD, AFib, COPD, HTN,
dementia, who presented initially to [**Hospital1 18**] from OSH on [**2168-9-7**]
following a mechanical fall which resulted in fracture of C1-2
and R shoulder fracture. Pt was initially admitted to Trauma
service for monitering, then transferred to neurosurgery
service.
Pt was stable neurologically and stable on floor until [**2168-9-14**]
when pt returned from dialysis and had hematemesis of coffee
ground emesis. He also had some grossly melenotic stool. He
quickly developed AFib with RVR to 120's-130's, did not respond
to IV lopressor, transient response to IV diltiazem. BP
remained stable and slightly elevated with SBP 140-170s. Could
not assess O2 sat acurately. Labs taken acutely at this time
notable for normal Hct at 46.1, and elevated WBC to 25.5. GI
was notified, pt ordered for pRBC, OG tube was placed and pt was
transferred to MICU for further care and monitering.
Of note, hospital course otherwise notable for failed speech and
swallow evaluation w/ gross aspiration on [**9-13**].
Past Medical History:
1.CAD (s/p MI 4 weeks ago - medically managed)
2.SVT
3.Afib (rate controlled)
4.COPD
5.Dementia(question [**12-31**] etoh vs. Alzeimer's. (-) TSH, Head CT)
6.HTN
7.ESRD on HD (s/p kidney transplant 9 yr ago)
8.Hyperlipidemia
9.Diverticulitis s/p resection
10.Recurrent skin cancer
11.Recent pna's
12.Hard of hearing
13.PUD s/p bleed in [**12-4**] treated at [**Hospital3 4107**] w/ prilosec
Social History:
Pt is a retired firefighter, lives with his wife. Remote
tobacco and alcohol history.
Family History:
Non-contributory
Physical Exam:
Initial physical exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3 to 2mm bilaterally. EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Pt is hard of hearing and did not have hearing aid in
place, hence, could not hear all instructions/commands.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 throughout
L 5 throughout
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
not assessed
Toes downgoing bilaterally
Rectal exam normal sphincter control
.
.
.
Physical Exam on transfer to the ICU:
Vitals - T 102.8, HR 130, BP 143/78, RR 26, O2 86% NRB
Gen - confused, obtunded
CVS - tachycardic, irregular
Lungs - Scattered rhonci on R
Abd - soft, + gaurding, no noted hepatosplenomegaly
Ext - No LE edema b/l
Pertinent Results:
[**2168-9-7**] 05:20PM GLUCOSE-196* LACTATE-2.8* NA+-135 K+-4.2
CL--91* TCO2-26
[**2168-9-7**] 05:19PM UREA N-44* CREAT-7.6*
[**2168-9-7**] 05:19PM AMYLASE-53
[**2168-9-7**] 05:19PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-9-7**] 05:19PM PLT COUNT-260
[**2168-9-7**] 05:19PM PT-12.5 PTT-26.1 INR(PT)-1.1
[**2168-9-7**] 05:19PM FIBRINOGE-498*
MR HEAD W/O CONTRAST [**2168-9-8**] 7:18 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: eval for potential stroke
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with ? evolving stroke on CT
REASON FOR THIS EXAMINATION:
eval for potential stroke
INDICATIONS: 76-year-old man with question of stroke.
COMPARISONS: CT from [**2168-2-16**].
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain
was performed. An MR angiogram of the circle of [**Location (un) 431**] was also
performed with three-dimensional time-of-flight weighted
imaging.
FINDINGS: There is no mass effect, hydrocephalus or shift of the
normally midline structures. The ventricles, cisterns and sulci
are all similarly prominent, consistent with atrophic change.
There are numerous bilateral cerebral foci of white matter
hyperintensity on T2-weighted imaging, consistent with chronic
small vessel ischemic disease. There are no areas of restricted
diffusion, however, to suggest recent infarction. There are two
focal regions of susceptibility artifact outlining the sulci
along the left temporal convexity, most likely due to siderosis
associated with prior subarachnoid hemorrhage. There is no
indication of recent intracranial hemorrhage, however.
MR ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]: There are no areas of
stenosis or aneurysmal dilatation. The internal carotid and
basilar arteries, and their branches, show appropriate
anterograde flow.
IMPRESSION:
1. Similar atrophic changes.
2. Extensive foci of hyperintensity on T2-weighted imaging, most
suggestive of chronic small vessel ischemic disease.
3. No evidence of recent infarction.
4. Likely siderosis along the left temporal convexity, probably
due to old subarachnoid hemorrhage.
These findings were discussed with Dr. [**Last Name (STitle) 7356**] on [**2168-9-9**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: FRI [**2168-9-9**] 11:23 PM
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT [**2168-9-7**] 5:42 PM
SHOULDER (AP, NEUTRAL & AXILLA; ELBOW (AP, LAT & OBLIQUE) RIGH
Reason: fractures
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p fall from standing with bilateral humeral
head fractures
REASON FOR THIS EXAMINATION:
fractures
INDICATION: 76-year-old man status post fall with bilateral
humeral head fractures.
BILATERAL SHOULDERS, FOUR VIEWS: Limited views secondary to
technique and patient positioning. There is a minimally
displaced fracture through the surgical neck of the humerus.
There is no evidence of dislocation. The surrounding osseous and
soft tissue structures are unremarkable. The left humeral head
appears intact. No fracture is identified, although the gleoid
is not well evaluated. There is no evidence of dislocation on
these two views, but again, an axial view was not obtained. The
surrounding osseous and soft tissue structures show swelling
about the right shoulder and minimal left acromio- clavicular
joint degenerative changes.
RIGHT ELBOW, THREE VIEWS: Limited views secondary to technique.
There is no evidence of a fracture, malalignment, or significant
soft tissue abnormality including effusion.
IMPRESSION: Limited views as described above. Minimally
displaced right humeral head fracture through the surgical neck.
No evidence of joint dislocation. Right shoulder soft tissue
swelling. No definite fracture identified within the left
humeral head or right elbow.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: [**Doctor First Name **] [**2168-9-8**] 10:15 AM
CT C-SPINE W/O CONTRAST [**2168-9-7**] 5:25 PM
CT C-SPINE W/O CONTRAST
Reason: s/p fall
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p fall
REASON FOR THIS EXAMINATION:
s/p fall
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall, neck pain.
CT CERVICAL SPINE: [**Location (un) 5621**]-type comminuted minimally displaced
fracture of the C1 ring is identified. Horizontal fracture of
the body of the odontoid is also seen, with minimal anterior
widening. No other fractures are identified. Minimal soft tissue
swelling is seen. There are extensive degenerative changes of
the cervical spine, with fusion of C3-4 and C6-7, and loss of
disc height at C2-3 and C5-6.
Centrilobular emphysematous changes in both lungs and left lung
apical scarring is noted. There are extensive carotid
calcifications.
IMPRESSION: 1. [**Location (un) 5621**] fracture of C1 and type 2 odontoid
fracture with minimal anterior widening. This is a technically
unstable fracture.
2. Emphysematous changes.
Preliminary findings were relayed to the ED dashboard at the
time of interpretation.
NOTE ADDED AT ATTENDING REVIEW: There is moderate spinal canal
narrowing due to a posterior vertebral body osteophyte at C4-5.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 61688**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: WED [**2168-9-14**] 11:11 AM
Brief Hospital Course:
This 76 y/o white male was admitted to the trauma ICU to the
trauma service for injuries sustained after a mechanical fall.
He sustained a right shoulder fracture as well as a frature of
C1 C2 for whcih he was placed in a cervical collar. He had an
MRi of the brain to r/o CVA. This study was negative for CVA.
Pt sustained right shoulder fracture for which he was seen by
ortho - their plan was to maintain this gentleman in a sling to
right arm for 2 weeks. He is to follow up in the ortho clinic 4
weeks after d/c with Dr. [**Last Name (STitle) 1005**]. He is cleared by ortho for
pendulum exercises after 2 weeks.
From a neurosurgical standpoint this pts cervical spine fracture
treatments were discussed with the family. Given options of
cervical collar/ halo placement or surgical intervention - the
family was requesting that he be stabilized surgically due to
the fact that he is demented and non compliant. They feel the
collar/halo would not be tolerated by the patient and this would
leave him at risk for further injury. He was scheduled for
surgery originally as an add on for thursday [**2168-9-15**] however
the OR is not able to accomidate himnm on that date - he was
then rescheduled for Friday [**2168-9-16**].
Pt has recieved HD during this hospital stay for CRF. Today on
[**2168-9-14**] the pt had HD, and then was to have a NGT placed under
fluro after multiple attempts to place and NGT were
unsuccessful. This was not done as pt was dusky with an
elevated HR on return form HD. An EKG was obtained and the pt
was transferred to the stepdown unit on [**Hospital Ward Name **] 5. HD was contact[**Name (NI) **]
and the RN states there were no difficulties during his session.
CE's x 3 were ordered as well as electrolytes. A medicine
consult was called and the pt was formally evaluated. He was
given metoprolol and diltiazem IV with his HR response coming
down to the 90's. The pts color improved - it was difficult to
assess whether or not he had active chest pain or SOB as he is
unreliable. His lung fields were clear at the time of event.
Dr. [**Last Name (STitle) **], [**First Name3 (LF) **], from nephrology came to see the pt as he just
finished dialysis. He left no new orders.
The medicine team evaluated patient and initially were going to
transfer the patient to general medicine service. However,
during evaluation, patient returned with rapid HR to 130's, had
coffee ground emesis, became diaphoretic and tachypnic and
therefore patient was admitted to MICU give his critical
appearance.
On presentation to MICU, patient was noted to remain in AFib
with HR in 130's, temp noted to be 102.8. BP stable at 140/38.
Had some difficulty placing O2 sat moniter, but upon receiving a
good pleth, noted to have O2 sat of 75-90% on NRB. At this
time, given patient's code status of DNR/DNI, discussions ensued
with pt's wife/HCP.
She was notified of patient's poor condition, given overall
picture of likely GI bleed, need of central line access, C1-2
and shoulder fractures, ESRD on HD, and now ?aspiration with
poor respiratory status, which would require intubation for
rescusitation.
[**Name (NI) **] wife was very clear that patient's wishes were to die
- he had in fact been wanting to discontinue his dialysis. He
was also very clear about the fact that he did not want any sort
of mechanical ventilation or resuscitation.
It was therefore decided by the patient's wife to refrain from
further treatment, including further work up of his fever, line
placement, intubation, and to make him comfort measures only.
Therefore all lab draws and medications were discontinued and
patient was placed on morphine drip for comfort.
[**Name (NI) **] wife is contacting the remainder of his family to come
to the hospital.
Patient died morning after MICU admission. Family was notified.
Medications on Admission:
prilosec 20 mg qam,
renegel 800 mg TID,
phoslo 667 mg TID,
renal soft gel 1 gel q day,
namenda 10 mg q day,
lisinopril 20 mg q day
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
-Respiratory failure and death, likely secondary to aspiration
pneumonia
-s/p Minimally displaced right humeral head fracture through the
surgical neck
-Chronic renal failure
-C1 C2 fracture:[**Location (un) 5621**] fracture of C1 and type 2 odontoid
fracture with minimal anterior widening. This is a technically
unstable fracture.
-AFIB
-MI (4 WEEKS AGO)
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"812.03",
"805.01",
"518.81",
"805.02",
"585.6",
"410.92",
"403.91",
"427.31",
"428.0",
"496",
"E888.9",
"389.9",
"507.0",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13179, 13188
|
9133, 12966
|
319, 326
|
13589, 13599
|
3080, 3605
|
13650, 13656
|
2035, 2053
|
13150, 13156
|
7699, 7724
|
13209, 13568
|
12992, 13127
|
13623, 13627
|
2091, 2305
|
248, 281
|
7753, 9110
|
355, 1498
|
2320, 3061
|
1520, 1914
|
1930, 2019
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,880
| 172,603
|
53014
|
Discharge summary
|
report
|
Admission Date: [**2172-6-17**] Discharge Date: [**2172-6-24**]
Date of Birth: [**2119-10-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
elective PVI complicated by pericardial tamponade
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
Pericardial Drain Placement
Right and left heart catheterization
Transesophageal echocardiogram and cardioversion
History of Present Illness:
This is a 52 year old woman with history significant for
hypertrophic
cardiomyopathy, paroxysmal atrial fibrillation s/p multiple
prior
cardioversions, AF ablation in [**2170**], and PVI in [**2171-2-8**] who
is admitted to the CCU with pericardial tamponade status post
repeat pulmonary vein isolation procedure. Her most recent
cardioversion was in [**2172-3-10**] and at that time she
converted briefly to sinus rhythm and then went back into atrial
fibrillation and has remained in it since then, according to her
report. She experienced recurrent symptoms with fatigue and was
referred for redo pulmonary vein isolation procedure.
.
Patient presented for the procedure on the morning of admission
and underwent catheterization via the R femoral. Around 11:40
AM, she acutely dropped her blood pressures to systolics in the
40s. She was found to be in pericardial tamponade in the setting
of her supratherapeutic INR of 4.1. Bedside echo was performed
and showed a large anterior/apical pericardial effusion with RV
diastolic collapse c/w tamponade physiology. A large clot was
also visualized. The procedure was prematurely terminated, a
pericardial drain was placed. A Swan Ganz catheter was placed in
the left femoral vein for hemodynamic monitoring, and an
arterial line in the R femoral artery. She was hypotensive for
approximately 15 minutes, requiring neosynephrine briefly before
her pressures stabilized after drainage of 300 cc of blood. She
received 2 units of FFP. She was transferred to the CCU intubate
and sedated on propofol, hemodynamically stable off pressors,
for further management.
.
In the CCU, the patient was intubated and sedated and unable to
answer any questions.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-HOCM
-atrial fibrillation s/p cardioversion 2 years ago
-hypercholesterolemia
3. OTHER PAST MEDICAL HISTORY:
-Asthma/COPD
-GERD
-Hepatitis C, genotype IIIa; treated with interferon/ribavirin
-History of severe depression with suicide attempt, overdoses on
Seroquel, currently under good control
-h/o diverticulosis s/p colectomy
-Marijuana dependence
-Tobacco dependence
4. PAST SURGICAL HISTORY
- History of rotator cuff injury to the right shoulder
([**Doctor Last Name **])
- s/p cholecystectomy (per patient)
- s/p incisional hernia repair ([**6-/2167**])
- s/p colectomy for diverticulitis (~[**2159**])
- s/p appendectomy
- s/p ex-laparotomy [**9-/2167**] for epigastric and abdominal pain
(chronic cholecystitis) - found to be in afib during this
hospitalization
5. GYN HISTORY:
Currently going through menopause with active hot flashes as
above
LMP ~2 years ago
Social History:
Married. Lives in [**Hospital1 **] with her husband.
Does not work; on unemployment.
Contact for discharge: Husband; Cell # [**Telephone/Fax (1) 109277**].
Tobacco: 5 cigarettes daily and marijuana on weekends
ETOH: NONE.
Denies IVDU since one episode in [**2147**]; rare and remote h/o
cocaine (~20yrs prior)
Family History:
Father with MI at 38, died 12 years later in cath lab. Mother
with asthma but no cardiac disease. Five living brothers all
without heart disease. Otherwise non-contributory.
Physical Exam:
On Admission:
VS: T= 96.6 BP= 123/81 HR= 112 RR= 22 O2 sat= 100%
GENERAL: intubated, sedated
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. Dry MMM.
NECK: Supple, JVP appx 15 cm at 30 degrees.
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: Wheezes bilaterally anteriorly, coarse BS; no rales
appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.
On Discharge:
VS: T= 97.8 BP= 120/78 HR= 84 RR= 18 O2 sat= 100%
GENERAL: alert, oriented, NAD
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. MMM.
NECK: Supple, JVP to mandible.
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: CTA anteriorly; no rales appreciated.
CHEST: tegaderm dressing over site of previous pericardial
drain: no erythema no discharge
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.
Pertinent Results:
On Admission:
[**2172-6-17**] 07:15AM BLOOD WBC-7.3 RBC-4.81 Hgb-17.0* Hct-47.1
MCV-98 MCH-35.3* MCHC-36.1* RDW-14.5 Plt Ct-163
[**2172-6-17**] 10:00AM BLOOD PT-40.1* PTT-32.8 INR(PT)-4.1*
[**2172-6-17**] 07:15AM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-135
K-7.3* Cl-102 HCO3-25 AnGap-15
[**2172-6-17**] 03:00PM BLOOD Calcium-7.8* Phos-3.6 Mg-1.3*
.
On Discharge:
[**2172-6-24**] 04:22AM BLOOD WBC-5.1 RBC-3.23* Hgb-10.8* Hct-32.9*
MCV-102* MCH-33.5* MCHC-32.9 RDW-15.7* Plt Ct-123*
[**2172-6-24**] 04:22AM BLOOD PT-19.2* PTT-38.5* INR(PT)-1.7*
[**2172-6-24**] 04:22AM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-4.0
Cl-105 HCO3-28 AnGap-11
[**2172-6-24**] 04:22AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
.
TFTs:
[**2172-6-22**] 04:28AM BLOOD TSH-5.7*
[**2172-6-22**] 04:28AM BLOOD T4-6.3
.
Anemia work-up
[**2172-6-22**] 04:28AM BLOOD VitB12-GREATER TH Folate-16.0
[**2172-6-23**] 05:43AM BLOOD Ret Aut-2.9
.
Lactate trend
[**2172-6-17**] 12:27PM BLOOD Glucose-88 Lactate-1.3 Na-140 K-3.7
Cl-110
[**2172-6-17**] 04:45PM BLOOD Lactate-1.0
Imaging:
SERIAL TTE
TTE [**6-17**]
Focused views during ablation procedure complicated by
tamponade.
There is a large pericardial effusion (2.2 cm). The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. The effusion is predominantly
anterior/apical. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. There is
a catheter noted in the transatrial position, one in the
pericardial space and another in the IVC/RA.
After pericardial fluid drainage there is gradual improvement of
the size of the pericardial effusion (clip [**Clip Number (Radiology) **], measuring 1.1 cm)
and resolution of the tamponade physiology.
There was no significant resting LVOT gradient throughout the
procedure (patient has known hypertrophic cardiomyopathy).
.
TTE [**6-17**]: post-pericardiocenthesis
Focused views post pericardial drainage.
There is a small to moderate sized pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the post-pericardiocenthesis images of a few hours
ago, findings are similar.
.
TTE [**6-18**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a small pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements.
Compared with the prior study (images reviewed) of [**2172-6-17**],
the amount of pericardial fluid is slightly less. It has similar
appearance (echo dense) and distribution (over the RV free wall
and apex).
.
TTE [**6-19**]
Overall left ventricular systolic function is normal (LVEF>55%).
There is a small pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2172-6-18**], no
change.
.
TTE [**6-20**]
There is a small pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. No right atrial
or right ventricular diastolic collapse is seen.
IMPRESSION: Small echodense pericardial effusion without
echocardiographic evidence of significant hemodynamic impact.
Compared with the prior study (images reviewed) of [**2172-6-20**]
pericardial effusion is similar.
.
TEE: [**6-24**]
Mild spontaneous echo contrast is seen in the body of the left
atrium and the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A large, nonmobile
thrombus is seen in the left atrial appendage. There is severe
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
free wall is hypertrophied. There are simple calcified atheroma
in the aortic arch and descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened without aortic stenosis.
There are filamentous strands on both the upstream and LVOT
sides of the aortic leaflets (probable noncoronary and left
coronary cusps), measuring 0.5-0.6 cm in length (clips 55, 58,
60, 72, 86, 87). The strands on the aortic valve side are
consistent with Lambl's excresences (normal variant). However,
thrombus or vegetation cannot be excluded. No aortic valve
abscess is seen. Trace central aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**2-9**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
IMPRESSION: Large probable thrombus in the left atrial
appendage. Filamentous strands on the aortic valve, consistent
with Lambl's excresences (cannot exclude thrombus vs.
vegetation, in the appropriate clinical context). Trace aortic
regurgitation. Mild to moderate mitral regurgitation. Small
pericardial effusion without echocardiographic signs of
tamponade.
.
Cardiac Cath: [**6-22**]
COMMENTS:
1. Coronary angiography in this co-dominant system demonstrated
no
obstructive disease. The LMCA had no angiographically apparent
disease.
The LAD had up to 30% stenosis with otherwise minor lumen
irregularities. The LCx had minor lumen irregularities. The RCA
had up
to 30% stenosis in the mid vessel.
2. Resting hemodynamics revealed elevated right and left
ventricular
filling pressures with RVEDP 14 mmHg and LVEDP 24 mmHg. The
pulmonary
artery pressures were elevated with PASP 42 mmHg. The cardiac
index was
depressed at 1.8 L/min/m2. The pulmonary and systemic
resistances were
elevated at 347 and 2133 dyn-sec/cm5, respectively. There was
systemic
arterial normotension and no significant pressure gradient
across the
left ventricular outflow tract from apex to ascending aorta on
catheter
pullback despite the asymmetric septal hypertrophy. Simultaneous
pressure recordings showed no evidence of equalization of the
right and
left heart pressure recordings. There was no evidence of cardiac
tamponade.
FINAL DIAGNOSIS:
1. Coronary arteries are without obstructive disease.
2. Elevated biventricular filling pressures without evidence of
constriction/restriction or tamponade.
3. Moderate pulmonary artery hypertension.
Brief Hospital Course:
52 year old F w/ hypertrophic cardiomyopathy, HCV, and pAF
transferred to the CCU in for treatment of pericardial tamponade
in the setting of repeat PVI procedure.
.
# Pericardial Tamponade: Patient developed large pericardial
bleed and tamponade physiology in setting of pulmonary vein
isolation procedure in EP lab and supratherapeutic INR of 4.1.
Given onset of tamponade early in procedure and presence of
clot, concern for RV perf as etiology. Pericardiocentis
performed and drain placed. INR reversed with 5mg of vitamin K.
On transfer to CCU patient hemodynamically stable with stable
pericardial drain in place. Repeat echo with decreased effusion
and clot size without sign of active bleeding. Effusion
monitored with serial TTE to assess for resolution. Pericardial
drain pulled on HD3. Pain controlled with tylenol, tramadol and
colchicine. Pain improved and effusion stable but TTE. Concern
for lower extremity modeling and elevated JVD prompted right
heart catheterization to discern volume status in patient with
difficult hemodynamics (HOCM, effusion). Cardiac cath
demonstrated 1. Coronary arteries are without obstructive
disease. 2. Elevated biventricular filling pressures without
evidence of
constriction/restriction or tamponade. 3. Moderate pulmonary
artery hypertension. At time of discharge patient
hemodynamically stable without signs of tamponade physiology on
exam.
.
# Respiratory Failure: Patient was intubated and paralyzed for
the PVI procedure. On arrival to the CCU patient continued on AC
ventilation 500/12/50% with ABG pH7.25 pCO251 pO2132 c/w
respiratory acidosis. Current respiratory compromise may be more
related to COPD given she is currently HD stable. Patient
extubated shortly after arrival to the CCU. Home COPD
medications continued. Throughout stay patient complained of
dyspnea on exertion though remained with minimal oxygen
requirement. Patient saturating> 95% on Ra prior to discharge.
OUTPATIENT ISSUES:
-- Outpatient pulmonary consult.
.
# Paroxysmal AF: Patient admitted for PVI procedure which was
aborted [**3-11**] to pericardial effusion. EKG on admission showed
atrial tachycardia with variable block. Patient monitored on
telemetry with predominant rhythm: AF with rates in the low
100s. At home rate controlled with ... and anti-coagulated with
coumadin. On admission, coumadin held as INR supratherapeutic at
4.1. In house patient rate controlled with verapamil,
disopyramide and carvedilol 25mg PO BID. Home disopyuramide
decreased from 400mg TID -> 300mg TID. Attempted
TEE/cardioversion was deferred as TEE with evidence of atrial
clot. Decision made to continue anticoagulation and follow-up as
an outpatient. Prior to discharge patient transitioned from
Coumadin to Pradexa. At time of discharge patient adequately
rate controlled (HRs in 80s).
OUTPATIENT ISSUES
-- Continue rate control with Verapamil, disopyramide and
carvedilol
-- Continue anticoagulation with Pradexa
.
# Large probable thrombus in the left atrial appendage. Seen and
documented on [**6-24**] TEE. Cardioversion deferred in setting of
clot. Per EP appropriate to continue anticoagulation as planned
for treatment of atrial fibrillation.
OUTPATIENT ISSUES:
-- Continue to follow with TTE as outpatient
.
# COPD: Patient with moderate to severe emphysema on CT chest
from [**2171**]. No PFTs in our system. On admission and
intermittently during hospitalization patient with extensive
wheeze on exam. Patient not on standing COPD medications as an
outpatient. Treated with standing and prn nebulizers in house.
Smoking cessation strongly encourage.
OUTPATIENT ISSUES:
-- Pulmonary follow-up and PFTs as an outpatient
-- Continue to encourage smoking cessation
.
.
# Hypertrophic Cardiomyopathy- No signs of obstructive pathology
on serial TTE obtained in house. As an outpatient on verapamil.
Started beta blocker (carvedilol 25mg PO BID) in house.
.
# Hepatitis C. Per report has been treated with interferon in
the past. Stable and per record cleared.
OUTPATIENT ISSUES
-- Hepatology follow-up
.
# Insomnia. Continued on home Seroquel.
.
CODE: Full (confirmed with HCP, husband [**Name (NI) **] [**Name (NI) 15490**])
.
COMM: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 15490**]: [**Telephone/Fax (1) 109278**]; cell [**Telephone/Fax (1) 109279**]
Medications on Admission:
Disopyramide 400 mg TID
Seroquel 100-150 mg qhs prn for insomnia
Verapamil SR 120 mg daily
Coumadin 4.5 mg on all days except for 3 mg on Wednesday
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. disopyramide 100 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
4. Seroquel 100 mg Tablet Sig: 1-1.5 Tablets PO QHS as needed
for sleep.
5. carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Tamponade
Paroxsymal Atrial Fibrillation/Tachycardia
Hypertrophic Cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 15490**],
You were admitted to the hospital after a complication of your
pulmonary vein isolation procedure. You had a bleed around your
heart for which you were treated with the placement of a
pericardial drain and close monitoring. While you were in the
hospital you underwent numerous ultrasounds of your heart as
well as heart catheterization which did not show further
accumulation of blood around your heart. You had a cardioversion
before you were discharged.
.
We have made the following changes to your medications:
- STOP taking coumadin for your atrial fibrillation
- START taking dabigatran 150mg tablet for your atrial
fibrillation, please take 1 tablet twice daily.
- CHANGE your dose of Disopyramide to 300 mg three times daily
for your atrial fibrillation
- START taking carvedilol 25 mg tablet for your atrial
fibrillation, please take one tablet twice daily
.
Please continue to take the rest of your regular medications
withou change.
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - UPPER FALLS
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 3393**]
Appointment: Friday [**2172-7-3**] 11:45am
Department: CARDIAC SERVICES
When: THURSDAY [**2172-8-6**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2172-6-26**]
|
[
"070.70",
"790.92",
"V64.3",
"E849.7",
"518.81",
"997.1",
"427.31",
"998.2",
"416.8",
"276.2",
"423.3",
"423.9",
"425.1",
"496",
"E879.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.71",
"88.72",
"88.52",
"89.64",
"96.04",
"37.23",
"37.0",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
16699, 16705
|
11711, 16007
|
355, 496
|
16842, 16842
|
5211, 5211
|
18094, 18713
|
3556, 3731
|
16205, 16676
|
16726, 16821
|
16033, 16182
|
11486, 11688
|
16993, 17517
|
3746, 3746
|
2337, 2417
|
5577, 11469
|
17546, 18071
|
266, 317
|
524, 2224
|
5226, 5563
|
16857, 16969
|
2448, 3213
|
2246, 2317
|
3229, 3540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,212
| 179,725
|
49969
|
Discharge summary
|
report
|
Admission Date: [**2160-4-28**] Discharge Date: [**2160-5-1**]
Date of Birth: [**2096-7-2**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname **] [**Known lastname 10083**] is a 63-year-
old female, with a past medical history of hypertension,
diabetes, who is status post thyroidectomy, who was found to
have a large retroperitoneal mass. Upon further work-up, she
had urinary catecholamine studies which suggested a strong
possibility of a pheochromocytoma. It was thought best that
the patient have this mass resected, for which she presented
to [**Hospital6 256**] on [**2160-4-28**],
wherein she underwent a laparoscopic left adrenalectomy by
Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY: Hypertension.
Diabetes mellitus.
Thyroid dysfunction, status post thyroidectomy.
Breast CA, status post mastectomy.
Coronary artery disease, status post MI/CVA.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lisinopril.
2. Tiazac
3. Glucophage.
4. Glucotrol.
5. Synthroid.
6. Aspirin.
SOCIAL HISTORY: She denies alcohol and tobacco use.
PHYSICAL EXAMINATION: Temperature 98.5, blood pressure
165/75, respiratory rate 18, heart rate 69, satting 95
percent on room air. Ms. [**Known lastname 10083**] was a well-appearing, well-
nourished, pleasant lady who was in no acute distress. Head
normocephalic, atraumatic. Extraocular movements intact.
Oropharynx was clear. Her neck was supple. There was no
JVD. Her chest was clear with occasional wheezing on the
right. Heart was normal S1, S2. There were no murmurs,
rubs, thrills, or gallops. Abdomen was soft, obese. Bowel
sounds were active. It was nontender. There was no
hepatosplenomegaly appreciated. Distal pulses were intact.
Neurologic exam was nonfocal. She was alert and oriented x
3.
PERTINENT LABORATORIES: A 24-hour urine sample revealed a
VMA of 3.7, epinephrine less than 2, norepinephrine 223,
total catecholamines 223, dopamine 124, metanephrines 85,
normetanephrines 1,598, plasma renin 24.
BRIEF SUMMARY OF HOSPITAL COURSE: Ms. [**Known lastname 10083**] is a 63-year-
old female who presented with a retroperitoneal mass for
which she underwent a laparoscopic left adrenalectomy on [**2160-4-28**] for concern of a pheochromocytoma. The patient
tolerated the procedure well. For further details of the
operation, please refer to the operative note. Initially,
the patient was kept in the recovery room under close
monitoring, and she required pressor support to maintain
adequate blood pressure. This was eventually weaned down,
wherein her blood pressure remained stable. However, it was
noted several hours later that the pressure decreased to the
low-80's. Initially, the patient responded to fluid boluses;
however, the pressure trended downward again to the low-80's,
wherein the patient was restarted on neo for pressor support.
Additionally at this time, the patient received
hydrocortisone 100 mg for 1 dose. The patient's blood
pressure remained stable at this point.
Due to her past medical history of coronary artery disease
and myocardial infarction, it was thought best to rule out
the patient for myocardial ischemic event. Cardiac enzymes
were negative x 3. EKG was unchanged from a prior tracing.
There was no evidence of CHF on chest x-ray. The patient was
transferred to the ICU for closer blood pressure monitoring.
Her hematocrit throughout this time remained stable, and she
did not require any blood transfusions. Endocrine was
consulted regarding her pheochromocytoma and felt that it was
safe to start tapering her steroid dosing. She was to be
discharged on a quick steroid taper. Additionally, during
this course her blood sugars were controlled with insulin.
They felt that it was safe to restart the patient on
Glucophage upon discharge, and to have her call and follow-up
with [**Hospital **] Clinic within 48 hours upon discharge.
The patient was noted to become tachycardic to the 120's. At
this time, it was thought best that the patient be placed on
a beta blocker perioperatively, and the patient was placed on
metoprolol 50 mg po bid. The heart rate remained stable.
The patient was eventually weaned off her pressor support on
hospital day 2. At this point, she did not require any
further support. She was transferred to the floor, wherein
she remained in stable condition. Her diet was advanced
which she tolerated well. She was to be discharged on a
steroid taper with a follow-up with endocrinology in [**12-7**]
weeks upon discharge. The patient's abdominal incision
remained clean without any evidence of infection. She was
scheduled to follow-up with Dr. [**Last Name (STitle) **] in clinic upon
discharge. The patient was stable for discharge on postop
day 3 with follow-up with surgery and endocrinology.
CONDITION ON DISCHARGE: Home.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES: Left adrenal mass. The patient is now
status post left laparoscopic adrenalectomy.
DISCHARGE MEDICATIONS:
1. Vicodin 1-2 tablets po q 4-6 h prn pain.
2. Colace 100 mg 1 tablet po bid.
3. Prednisone 10 mg. The patient is scheduled to take 1
tablet po for 1 dose on [**5-2**]--this is part of the
steroid taper, and is to take prednisone 5 mg 1 tablet po
1 dose on [**5-3**], and to stop taking any steroid at that
point.
4. Metoprolol 50 mg 1 tablet po bid.
FOLLOW-UP PLANS: The patient is to follow-up with
endocrinology with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], at telephone number [**Telephone/Fax (1) 104353**], within 1-2 weeks of discharge. Additionally, they
suggested that the patient call the [**Hospital **] Clinic within 48
hours of discharge to report her daily blood sugars and to
adjust her antiglycemic agents appropriately. She is to
follow-up with Dr. [**Last Name (STitle) **] in 2 weeks for wound check. She
is to call to schedule an appointment.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 23293**]
Dictated By:[**Last Name (NamePattern1) 41748**]
MEDQUIST36
D: [**2160-5-1**] 12:51:54
T: [**2160-5-1**] 13:31:05
Job#: [**Job Number 104354**]
|
[
"244.0",
"V10.3",
"401.9",
"414.01",
"250.00",
"412",
"227.0",
"458.29",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.22"
] |
icd9pcs
|
[
[
[]
]
] |
950, 1006
|
4976, 5061
|
5084, 5450
|
1032, 1114
|
2140, 4894
|
1191, 2111
|
5468, 6222
|
181, 744
|
767, 933
|
1131, 1168
|
4919, 4954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 169,212
|
8700
|
Discharge summary
|
report
|
Admission Date: [**2204-5-7**] Discharge Date: [**2204-5-10**]
Date of Birth: [**2148-10-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Right internal jugular triple lumen catheter
Endoscopy
Colonoscopy
Capsule Endoscopy
Blood transfusion x3
History of Present Illness:
55 year-old male with hepatitis C cirrhosis s/p liver [**First Name3 (LF) **]
with recurrent hepatitis C complicated by ascites/
encephalopathy/ varices/ chronic portal and splenic venous
thrombosis. with melena. Seen in Dr.[**Name (NI) 948**] office today,
found to have BP 90/50. Reports dark stools x3 days, with frank
blood mixed with stool at 3:00am morning preceding admission.
Of note, EGD ([**2203-2-15**]) showed 3 cords Grade I varices, portal
gastropathy.
In the ED, 98.6 66 102/58 16 99%RA. Noted to have dark brown
stool mixed with bloody mucous. NG lavage not performed.
Laboratory data significant for hematocrit 25.9 (baseline 31)
with tbili 1.7, alk phos 258. Written for 2 units pRBCs, has
not received yet. Hemodynamically stable. [**Month/Day/Year 1326**] notified,
but have not seen the patient. Received Protonix, ceftriaxione,
octreotide. On transfer to MICU, 68, 102/57, 18, 100% 2L.
On the floor, reports feeling well. Denies fever, chills,
lightheadedness. Reports nonproductive cough, longstanding.
Denies chest pain, shortness of breath, palpitations. Reports
occasional cramping in lower abdomen. Denies nausea, vomiting,
dysuria, hematuria, bruising.
Past Medical History:
Past Medical History:
-ITP
-SVT last episode approximately [**1-30**], medically managed at this
time
-Hepatitis C
-ESLD s/p liver Tx [**2198-5-20**], s/p revision [**12-27**]; complicated with
rejection and steroid use since [**2199-4-20**] to present; also
complicated with Hepatitis C recurrence and restarted peg
interferon [**2199-6-17**]. Hep C possibly contracted from tatoo [**2171**].
-Thoracic compression fractures: [**5-26**]
-Cognitive disorders: h/o post hypoxic encephalopathy [**2190**].
-Depression /anxiety
-Neutropenia and infections including c. diff x3, streptococcal
septicemia, anal fistula
-History of fistula in anus s/p Fistulectomy [**11/2198**]
-Chronic pain especially rectal pain
-Diabetes : steroid induced, managed at [**Hospital **] Clinic, recent
HBA1C 5.1 % (had received blood transfusions with splenectomy
), insulin requirements decreased
-S/p Appy
-S/p tonsillectomy
-Bilateral inguinal hernia
-S/p hernia repair which has failed
-S/p umbilical hernia repair and right inguinal hernia repair
[**11-22**]
-S/p ccy
-Left sided hydronephrosis due to obstruction from splenomegaly,
s/p left ureteral stent placement [**5-28**].
-Secondary hyperparathyroidism due to CKD managed by Dr. [**Last Name (STitle) 4090**]
at [**Last Name (un) **].
-Splenectomy, distal pancreatectomy, c/w fistula, s/p spent and
then removal [**2201**]
Social History:
Lives with mother in [**Name (NI) 583**] and they both help with ther
health issues. He has a sister that lives in [**State **] that is
very involved in his care. Patient sates he smoked in highschool
socially (only in parties), but quit since then. He denies any
current or past alcohol intake. He also denies at thit time any
illegal substance use, however, he also is denying any past
illegal substance use.
Family History:
Mother has DM2 and HTN. Uncle with cancer in his 80s (unknown
site). Denies any family history of MI, sudden cardiac death,
stroke and lung diseases has DM2
Physical Exam:
98.2, 72, 113/55, 17, 95% RA
General: Alert, oriented, comfortable
HEENT: Sclera anicteric, dry mucous membranes
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI early
systolic murmur LUSB
Abdomen: Normoactive bowel sounds, prior incision scars noted,
soft, non-tender
GU: No foley
Rectal: Per ED, guaiac positive brown stool
Ext: Thin; warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: No asterixis
Pertinent Results:
ADMISSION LABS:
[**2204-5-7**] 01:48PM WBC-6.8 RBC-2.36* Hgb-8.5* Hct-25.9* MCV-110*
Plt Ct-166
[**2204-5-7**] 01:48PM Neuts-52 Bands-0 Lymphs-33 Monos-11 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2204-5-7**] 01:48PM Hypochr-1+ Anisocy-NORMAL Poiklo-1+ Macrocy-3+
Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Target-2+
Schisto-OCCASIONAL Burr-OCCASIONAL Acantho-1+
[**2204-5-7**] 01:48PM PT-13.8* PTT-33.9 INR(PT)-1.2*
[**2204-5-7**] 01:48PM Glucose-97 UreaN-31 Cr-1.0 Na-138 K-4.9 Cl-110*
HCO3-20*
[**2204-5-7**] 01:48PM ALT-39 AST-64* AlkPhos-258* TotBili-1.7*
[**2204-5-7**] 01:48PM Lipase-157*
[**2204-5-7**] 01:48PM Albumin-3.0*
[**2204-5-7**] 04:04PM Lactate-0.9
URINE:
[**2204-5-7**] 03:50PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2204-5-7**] 03:50PM Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2204-5-7**] 03:50PM RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0-2
[**2204-5-7**] 03:50PM Sulf X-MOD
MICRO:
[**2204-5-7**] BCx: NGTD
STUDIES:
[**2204-5-7**] EKG:
Normal sinus rhythm. Tracing is within normal limits. Compared
to the previous tracing of [**2203-9-3**] no diagnostic interval
change.
[**2204-5-7**] EGD:
- Varices at the lower third of the esophagus and
gastroesophageal junction
Erythema, congestion, abnormal vascularity and mosaic appearance
in the stomach compatible with portal hypertensive gastropathy
- Polyp in the proximal body (injection)
- Beyond pylorus, 8 mm non bleeding polyp adjacent to
hepatico-jejunostomy.
- Otherwise normal EGD to second part of the duodenum
Recommendations: Grade I esophageal varix. No stigmata of
bleeding. No gastric varices noted. Bleeding polyp noted in
proximal body of stomach injected with epi with hemostasis.
Polyp adjacent to hepatico-jejonostomy which needs biopsy as
outpatient. Potential source of bleeding from gastric polyp.
Continue IV PPI. Continue abx. DC octreotide gtt. Trend HCT.
[**2204-5-8**] CXR:
Right IJ catheter tip extends to the lower portion of the SVC.
No
evidence of pneumothorax. The far left portion of the chest has
been
eliminated from the image, but there is no evidence of acute
cardiopulmonary disease.
[**2204-5-8**] Colonoscopy:
- Normal mucosa in the colon
- Old blood mixed with bowel prep throughout the colon.
- Area of ? flat lesion noted in the transverse colon.
- Otherwise normal colonoscopy to cecum
Recommendations: please keep pt on clears and proceed with
capsule endoscopy
[**2204-5-9**] Capsule Endoscopy:
several nonbleeding ulcers in the small bowel.
The differential diagnosis includes ASA/NSAID induced damage,
IBD, ulcerative jejunoileitis or infectious etiologies (possibly
viral in nature)
DISCHARGE LABS:
HCT 29.2
Brief Hospital Course:
Mr. [**Known lastname 4042**] is a 55M with hepatitis C cirrhosis s/p liver
[**Known lastname **] with recurrent hepatitis C cirrhosis complicated by
ascites/encephalopathy who was admitted with GIB/melena.
#. LGIB: Initial immediate concern was for UGIB, particularly
variceal bleeding or portal gastropathy in this patient with
decompensated liver disease. Differential also included
gastritis and LGI sources, including hemorrhoids,
diverticulosis, AVM. The patient immediately received 2U PRBCs
post transfusion hct decreased from 25.9 in the ED to 25.8.
Protonix gtt, octreotide gtt and ceftriaxone daily were started.
EGD was performed upon arrival to the ICU which showed
non-bleeding esphageal and gastric varices as well as an oozing
gastric polyp which was injected with epinephrine- nothing to
suggest the cause of patients relatively [**Name2 (NI) 19912**] decrease in
hematocrit. Colonoscopy was performed on HD2 which again did
not show any obvious cause of bleeding. Dark old blood was
noted to be transiting through the colon. Hct trended down
gently on HD2 and another 1U PRBC transfusion was given. The
patient underwent capsule endoscopy on HD2 which showed several
small ulcers in the small bowel.
#. Hepatitis C cirrhosis s/p liver [**Name2 (NI) **]: Tbili slightly
elevated from baseline although AST, ALT, alk phos improved from
baseline. Patient was not clinically encephalopathic while in
the ICU. [**Name2 (NI) 1326**] surgery was consulted and aware of patient.
Tacrolimus 0.5mg PO BID, Lamivudine 100mg PO daily (donor was
HbcAb positive) and Ursodiol 300mg PO BID were continued.
#. Duodenal polyp- a non-bleeding duodenal polyp was seen on EGD
that should be biopsied as an outpatient at a later date.
Medications on Admission:
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly take 30
minutes before other meds or food. Take w/ 8 oz water & remain
upright for 30 min. after dose.
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day
CLINDAMYCIN HCL - 300 mg Capsule - 2 Capsule(s) by mouth x 1 1
hour before dental work or cleanings.
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth weekly
LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth
once a day
LATANOPROST [XALATAN] - 0.005 % Drops - 1 Drops(s) in each eye
HS
(at bedtime) both eyes
LIPASE-PROTEASE-AMYLASE [PANCREASE] - 20,000 unit-[**Unit Number **],500
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by
mouth three times a day with meals
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by mouth twice a day
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- 1 Tablet(s) by mouth three times a day
TACROLIMUS - 0.5 mg Capsule - 1 Capsule(s) by mouth twice a day
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
apply one packet per day daily (Patient should get 5 gram per
day) - No Substitution
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth HS (at bedtime)
as needed for insomnia
URSODIOL - 300 mg Capsule - 1 Capsule(s) by mouth twice a day
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 2 Tablet(s) by mouth
three times daily
CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 unit Tablet - 1
Tablet(s)
by mouth twice a day
SIMETHICONE - 80 mg Tablet, Chewable - 40 mg by mouth three
times
a day
ZINC OXIDE [BOUDREAUXS BUTT PASTE] - 16 % Paste - Apply
topically
three times daily as needed
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia.
5. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for Cough.
7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to 3 bowel movements per day.
9. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day). *** of note, patient on neomycin at home due to lack of
insurance coverage of rifaximin
10. Lipase-Protease-Amylase 16,000-48,000 -48,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
11. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
12. Calcium Citrate + 315-200 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
1X/WEEK ([**Doctor First Name **]).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
15. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet
Transdermal once a day.
16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
17. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
18. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO TID (3 times a day).
19. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Acute Blood Loss Anemia
Compenstated end-stage liver disease
Chronic Pancreatitis
Discharge Condition:
Hemodynamically stable with brown stools, ambulating the unit
independently. Alert, oriented x3. Eating a regualr diet.
Discharge Instructions:
You were admitted with bleeding from your gastrointestinal
tract. The bleeding has stopped and you required 3 blood
transfusions during your stay. You underwent an endoscopy and a
colonoscopy that did not show a clear source for your bleeding
so a capsule study was performed prior to your discharge which
you will need follow up for as an outpatient. Also, a polyp just
past your stomach was found on the endoscopy that needs to be
biopsied as an outpatient.
Please resume a regular diet and all of your home medications.
Please follow up with Dr. [**Last Name (STitle) 497**] as scheduled. Please call the
liver clinic if you develop any further signs of bleeding in
your stool, feel lightheaded, have chest pain, or any other new
concerns.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2204-5-17**]
10:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2204-5-23**] 8:40
Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2204-6-18**] 1:00
|
[
"585.9",
"537.89",
"070.70",
"427.89",
"E878.0",
"733.00",
"E932.0",
"285.1",
"287.31",
"E849.7",
"300.4",
"458.29",
"403.90",
"571.5",
"211.1",
"211.2",
"996.82",
"588.81",
"569.89",
"456.21",
"577.1",
"E879.8",
"249.00",
"578.9",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.23",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
12320, 12378
|
6924, 8674
|
295, 403
|
12534, 12656
|
4189, 4189
|
13448, 13913
|
3463, 3622
|
10426, 12297
|
12399, 12513
|
8700, 10403
|
12680, 13425
|
6890, 6901
|
3637, 4170
|
249, 257
|
431, 1628
|
4205, 6874
|
1672, 3017
|
3033, 3447
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,489
| 157,151
|
34599
|
Discharge summary
|
report
|
Admission Date: [**2177-2-13**] Discharge Date: [**2177-2-17**]
Date of Birth: [**2096-2-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
hyoxia and NSTEMI
Major Surgical or Invasive Procedure:
failed central line placement
History of Present Illness:
Transfer from [**Hospital3 4107**]. 80 F with hx alzheimers, NSTEMI
Dx 6 weeks ago and treated with medical mgmt, had been in rehab,
returned to hospital with right arm and right axillary pain. She
was found to be volume overloaded with low 02 sats, had 2 CXR 3
hours apart showing interval development pulmonary edema, placed
on BiPAP and treated with diuresis and subsequently came off
bipap.She went to the ICU, became hypotensive, started on low
dose dopamine and neeosynephrine for BP support with dopa dc'd
by time of transfer. On arrival, had EKG showing dynamic EKG
changes (inferolateral TWI) with trop tI initially 0.01 on
[**2177-2-12**] then 1.06 without accompanying CKs. She was transfered
to [**Hospital1 18**] for possible cath.
On arrival to the ICU EKG showed dynamic TWI inversions, stable
ST depressions, prominent R waves in precordial leads, ? RH
strain. She was CP free. Cardiac review of systems was notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. A central line placement was attempted but
failed. Her prognosis was discussed with pt/proxy and a plan was
made for medical management and she became DNR/DNI.
Past Medical History:
1)Type 2 Diabetes
2)Peripheral vascular disease: s/p left common femoral to
below-knee popliteal artery bypass with in situ saphenous vein
and an open transluminal angioplasty of the anterior tibial and
below knee popliteal arteries in [**5-12**].
3)Hypertension
4)Hyperlipidemia
5)Hx of R breast ca s/p lumpectomy
6)Depression
Social History:
Lives alone. Has 2 sisters who live in the area. Denies alcohol
or IVDA. 50 pack year history of tobacco use. Continues to smoke
3 ciggarettes/day.
Family History:
Mother with history of CAD.
Physical Exam:
Vs: Tc: HR:71 BP:91/51 RR:25 SP02: 93%
Alert and oriented to person and place, disoriented to time.
No JVP
HR: II/VI SEM heard best at the apex.
Resp: CTA-B, no wheeze, no rales,
ext: cool bilateral lower extremities, no edema
no femoral bruit bilaterally.
-dopplerable pulses bilaterally.
Pertinent Results:
Admission Labs
[**2177-2-13**] 02:32PM BLOOD WBC-12.4*# RBC-3.46* Hgb-10.2* Hct-31.3*
MCV-91# MCH-29.4 MCHC-32.5 RDW-14.0 Plt Ct-231
[**2177-2-13**] 02:32PM BLOOD Neuts-83.1* Lymphs-12.5* Monos-3.6
Eos-0.4 Baso-0.3
[**2177-2-14**] 04:16AM BLOOD PT-13.3 PTT-28.4 INR(PT)-1.1
[**2177-2-13**] 02:32PM BLOOD Glucose-109* UreaN-39* Creat-1.9* Na-141
K-5.7* Cl-109* HCO3-20* AnGap-18
[**2177-2-13**] 02:32PM BLOOD ALT-14 AST-41* CK(CPK)-265* AlkPhos-58
TotBili-0.3
[**2177-2-13**] 02:32PM BLOOD Albumin-3.9 Calcium-8.6 Phos-4.1 Mg-2.3
Discharge Labs
[**2177-2-16**] 07:15AM BLOOD WBC-8.8 RBC-3.75*# Hgb-10.5*# Hct-32.1*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.5 Plt Ct-215
[**2177-2-16**] 07:15AM BLOOD PT-11.8 PTT-26.4 INR(PT)-1.0
[**2177-2-16**] 07:15AM BLOOD Glucose-109* UreaN-39* Creat-1.4* Na-144
K-4.5 Cl-112* HCO3-20* AnGap-17
[**2177-2-16**] 07:15AM BLOOD Calcium-9.3 Phos-2.2* Mg-2.5
Cardiac Biomarkers
[**2177-2-13**] 02:32PM CK(CPK)-265* CK-MB-16* MB Indx-6.0
cTropnT-0.25*
[**2177-2-13**] 08:39PM CK(CPK)-253* CK-MB-15* MB Indx-5.9
cTropnT-0.21*
[**2177-2-14**] 04:16AM CK(CPK)-201 CK-MB-12* MB Indx-6.0 cTropnT-0.19*
[**2177-2-14**] 06:20AM CK(CPK)-204* CK-MB-11* MB Indx-5.4
Urine Studies
[**2177-2-13**] 08:32PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2177-2-13**] 08:32PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2177-2-13**] 08:32PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
[**2177-2-13**] 08:32PM URINE CastHy-1*
[**2177-2-14**] 06:24AM URINE Hours-RANDOM UreaN-786 Creat-95 Na-34
[**2177-2-14**] 06:24AM URINE Osmolal-498
Microbiology:
URINE CULTURE (Final [**2177-2-15**]):
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
Echo ([**2177-2-13**]) - The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Left ventricular
wall thicknesses are normal. The left ventricular cavity is
mildly dilated. There is mild regional left ventricular systolic
dysfunction with akinesis of the inferior and inferolateral
walls. [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 (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Inferior and inferolateral akinesis consistent with
prior infarction. The posterior leaflet of the mitral valve is
tethered with consequent assymetric coaptation of the mitral
leaflets and at least moderate-to-severe mitral regurgitation,
directed posteriorly. Moderate pulmonary artery systolic
hypertension.
CXR ([**2177-2-13**]) - IMPRESSION: Increased perivascular haze in lung
upper zones and left side, possibly beginning pulmonary edema.
The lung areas appear emphysematous. Followup in short interval
is recommended.
Brief Hospital Course:
80 y/o woman with hx alzheimers transfered with dynamic EKG
changes/mild troponin leak equivocal for NSTEMI with decision
for medical management.
#Coronaries: Acute CHF at OSH in setting of CP/troponin leak.
Echo showed tethered MV, overall more consistent with chronic
MR. Troponin peak likely secondary to CHF, versus poor clearance
in the setting of renal failure. Cardiac enzymes trended down.
Medical management was continued with aspirin, atorvastatin.
Home BB/Ace was held given hypotension.
#Respiratory distress: s/p flash pulmonary edema. Tethered
mitral valve, may be chronic MR. Dopamine initially given for
increased CO with concommittent cardiac output augmentation
however she became tachycardic and her blood pressyures were
much improved, and so the dopamine was discontinued and her home
ACE restarted.
# Renal Failure: Baseline Cr 1.3. Increased to 1.9. Unclear if
ATN vs [**1-7**] poor forward flow in the setting of CHF. Urine lytes
showed Feurea 35, indicating a pre-renal state. Creatinine was
improving at the time of discharge.
#Leukocytosis: She was afebrile and there was no evidence of
infection. Could simply have been a stress response. Her WBC was
improving at the time of discharge, and she was afebrile.
#Diabetes: We held metformin in setting renal failure. This
continued to be held at the time of discharge. The patient's
fingersticks should be measured in the morning at her living
facility to determine the need to insulin. Additionally, her
creatinine should be followed. Her metformin can be restarted if
her creatinine continues to improve.
#Dementia: We continued aricept.
Medications on Admission:
Home medications:
Metformin 1000mg PO BID
Lipitor 20mg PO daily
Prozac 20mg PO daily
Triamterene 25mg PO daily
Neurontin 300mg PO TID
Actonel 35mg PO weekly
ASA 81mg daily
.
Medications on Transfer
lisinopril 5mg daily
lopressor 12.5 mg [**Hospital1 **]
trazadone 50 qhs
depakote 125mg daily
remeron 15mg bedtime
zocor 40mg daily
lasix 40mg IV q12-hours PRN
aricept 5mg daily
prozac 20mg daily
neosynephrine drip
IV heparin low dose
plavix 300mg x 1
ASA 325
Discharge Medications:
1. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
8. Outpatient Lab Work
Please check fingerstick glucose on patient every morning.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary -
Troponin leak
Hypotension
Acute renal failure
Secondary -
Type II Diabetes
Hyperlipidemia
Depression
Discharge Condition:
Level of Consciousness: Alert and interactive
Mental Status: Confused - always
Discharge Instructions:
You were transferred to [**Hospital1 **] for a procedure to
evaluate your heart. It was decided, upon arrival after
discussion with your family, to pursue medical management of
your cardiac condition instead. You were treated with
medications to improve your breathing difficulties and have
improved.
Medication changes:
1. You were started on Imdur 30 mg daily to help manage your
cardiac symptoms.
2. You were also started on lisinopril 5 mg daily.
3. Your atorvastatin was increased from 20 mg daily to 40 mg
daily.
4. Your triamterene was stopped.
5. Your metformin was held because your renal function was
impaired. Your doctors should follow your creatinine (measure of
renal function) and restart your metformin if this improves.
Followup Instructions:
You will need to follow up with your primary doctor at your
rehabilitation center.
|
[
"272.4",
"294.10",
"428.41",
"578.1",
"414.00",
"285.9",
"424.0",
"410.71",
"311",
"584.9",
"401.9",
"428.0",
"250.00",
"331.0",
"288.60",
"458.9",
"443.9",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9186, 9266
|
6433, 8057
|
332, 363
|
9422, 9468
|
2514, 6410
|
10296, 10382
|
2158, 2188
|
8566, 9163
|
9287, 9401
|
8083, 8083
|
9527, 9831
|
2203, 2495
|
8101, 8543
|
9851, 10273
|
275, 294
|
391, 1625
|
9483, 9503
|
1647, 1976
|
1992, 2142
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,334
| 129,647
|
6609
|
Discharge summary
|
report
|
Admission Date: [**2140-11-3**] Discharge Date: [**2140-11-15**]
Date of Birth: [**2078-9-23**] Sex: M
Service: Medicine, [**Hospital1 **] Firm
CHIEF COMPLAINT: Gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
Caucasian gentleman with a history of 3-vessel disease,
peripheral vascular disease, congestive heart failure (with
an ejection fraction of 25%), and chronic obstructive
pulmonary disease who presented to the Emergency Department
with depression and question of suicidal ideation.
He had been seen previously the day before after falling from
his wheelchair. Imaging at that time was negative, and he
was sent home. During his Emergency Department evaluation,
he reported nausea, vomiting, and shortness of breath. His
last drink (per patient) was the day before. In the
Emergency Department he became more confused, tachycardic to
the 120s, and hypertensive with systolic blood pressures
between 180 to 200. Laboratories in the Emergency Department
were notable for a hematocrit of 27.6 (down from a previous
baseline of 41), with guaiac-positive melanic stools on
rectal examination, and a nasogastric lavage notable for
coffee-grounds.
A continued workup in the Emergency Department was notable
for a chest x-ray with a right lower lobe infiltrate. An
electrocardiogram revealed increased ST depressions over
baseline in V4 through V6 with the patient tachycardic.
At that time, he was admitted to the Medical Intensive Care
Unit. Gastroenterology was consulted with Protonix 40 mg by
mouth twice per day started. A central line was placed, and
he was transfused two units of packed red blood cells. In
the Medical Intensive Care Unit, an ultrasound-guided
thoracentesis was done on the right pleural effusion and was
negative for empyema; however, he became increasingly hypoxic
and was finally intubated on [**2140-11-4**].
An esophagogastroduodenoscopy (EGD) was done which showed
gastritis, but no other source of bleeding. He had received
two units of packed red blood cells, and his hematocrit
stabilized. His Medical Intensive Care Unit course was
further complicated for a new right middle lobe infiltrate
for which he was started on vancomycin. He was unable to be
extubated until [**11-13**] secondary to congestive heart
failure and multilobar pneumonia.
On [**11-13**], he was transferred from the Medical Intensive
Care Unit to the medicine floor.
PAST MEDICAL HISTORY:
1. Coronary artery disease; catheterization in [**2140-11-2**] which showed 3-vessel disease.
2. Peripheral vascular disease; status post left above-knee
amputation.
3. Congestive heart failure (with an ejection fraction of
25% with 2+ mitral regurgitation).
4. Pulmonary hypertension.
5. Chronic obstructive pulmonary disease.
6. Alcoholism.
7. Depression.
8. Prior suicide attempts (per patient).
9. Prostate-specific antigen.
10. Methicillin-resistant Staphylococcus aureus.
ALLERGIES: There were no known drug allergies.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Aspirin.
2. Desipramine 30 mg by mouth once per day.
3. Toprol 50 mg by mouth once per day.
4. Multivitamin one tablet by mouth once per day.
5. Thiamine.
6. Folate.
7. Isordil 10 mg by mouth three times per day.
8. Lasix 20 mg by mouth once per day.
9. Neurontin 300 mg by mouth three times per day.
10. Trazodone 200 mg by mouth once per day.
11. Zoloft 200 mg by mouth once per day.
12. Lipitor 10 mg by mouth once per day.
13. Captopril 50 mg by mouth three times per day.
14. Flovent.
15. Percocet.
16. Combivent.
MEDICATIONS ON TRANSFER: (On transfer to [**Hospital **]
Rehabilitation included)
1. Oxycodone 5 mg by mouth q.4-6h. as needed.
2. Trazodone 100 mg by mouth twice per day as needed.
3. Captopril 37.5 mg by mouth three times per day.
4. Colace 100 mg by mouth twice per day.
5. Protonix 40 mg by mouth twice per day.
6. Aspirin 325 mg by mouth once per day.
7. Multivitamin one tablet by mouth once per day.
8. Zinc sulfate 220 mg by mouth once per day.
9. Ascorbic acid 500 mg by mouth twice per day.
10. Thiamine 100 mg by mouth once per day.
11. Folic acid 1 mg by mouth once per day.
12. Albuterol meter-dosed inhaler 2 puffs inhaled four times
per day as needed.
13. Clindamycin 600 mg intravenously q.8h. (for three more
days).
14. Levaquin 500 mg intravenously once per day (for three
more days).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature maximum was 98.6 degrees
Fahrenheit, his blood pressure was 114/86, his heart rate was
60s to 90s, his respiratory rate was 12 to 20, and his oxygen
saturation was 100% on room air. The general physical
examination when he was transferred to the floor revealed the
patient was a thin Caucasian gentleman lying in bed with a
left above-knee amputation. His head, eyes, ears, nose, and
throat examination was normocephalic and atraumatic. Pupils
were equal and reactive. Extraocular movements were full.
Cardiovascular examination revealed the patient had a regular
rate and rhythm with distant heart sounds. No murmurs, rubs,
or gallops were noted. Lung examination revealed right
basilar crackles. The abdominal examination revealed normal
active bowel sounds. The abdomen was nontender and
nondistended. No masses. Extremity examination revealed no
clubbing, cyanosis, or edema. There was a left lower
extremity above-knee amputation. Dermatologic examination
revealed he had a right knee abrasion noted as well as a 1-cm
stage 1 sacral decubitus ulceration with Duoderm dressing.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed his white blood cell count was 9, his hematocrit was
31 from 36 (stabilized), and his platelets were 300. His
sodium was 132, potassium was 4.2, chloride was 94,
bicarbonate was 28, blood urea nitrogen was 15, creatinine
was 0.4, and blood glucose was 114. Calcium was 9, phosphate
was 4.2, and his magnesium was 2.1.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient had multilobar
pneumonia. The sputum was notable only for
methicillin-resistant Staphylococcus aureus. He received
seven days of vancomycin intravenously. In addition, on the
day of discharge, he was on day [**12-16**] of Levaquin and
clindamycin given his increased risk of aspiration at the
time of presentation.
2. RESPIRATORY ISSUES: The patient was extubated and
required no oxygen since extubation.
3. GASTROINTESTINAL ISSUES: The patient had no further
bleeding. He had a stable hematocrit. He may need a
colonoscopy as an outpatient, as there was no source of
bleeding found on his esophagogastroduodenoscopy. His
hematocrit was stable, and he required no further blood
transfusions. He was to continue on Protonix 40 mg by mouth
twice per day.
Moreover, he was noted to have elevated transaminases between
90 to 100 with an elevated alkaline phosphatase and elevated
amylase and lipase. However, he was completely stable during
his hospitalization. He was eating and drinking without
nausea, vomiting, or abdominal pain. His most recent values
were an ALT of 96, AST was 116, his alkaline phosphatase was
260, his amylase was 244, and his lipase was 144.
4. ALCOHOL WITHDRAWAL ISSUES: The patient was maintained
initially on benzodiazepines as he had a history of previous
alcohol withdrawal. It was thought that his difficult
extubation was related to the benzodiazepines, and he was
given a trial of flumazenil. He required no further
benzodiazepines since transfer to the floor.
At first the patient was interested in detoxification, but
later during his hospitalization he showed no further
interest.
5. CARDIOVASCULAR ISSUES: The patient had electrocardiogram
changes seen on admission with a positive troponin and
creatine kinase levels which were thought secondary to demand
ischemia. The patient became less tachycardic and he had no
other symptoms during his stay here. He was managed
medically at this time, and we continued him on aspirin, ACE
inhibitor, and beta blocker.
6. PSYCHIATRIC ISSUES: The patient initially denied
homicidal ideation when he first entered the Emergency
Department. However, later it was documented that he
endorsed both suicidal ideation and homicidal ideation; both
of which he promptly denied later.
He was asked daily about suicidal ideation which he denied
for the rest of his hospitalization. On his final day, he
did not endorse further symptoms of depression and continued
to deny suicidal ideation or homicidal ideation. However, he
was not seen by Psychiatry during his admission. The patient
may require a psychiatric followup or Social Work followup to
coordinate an after-care plan.
7. DERMATOLOGIC ISSUES: The patient sustained a fall prior
to being admitted to the hospital and had abrasions to his
right knee and lateral calf. He received wet-to-dry dressing
changes for this area twice per day. In addition, he had a
stage 1 sacral decubitus ulceration measuring approximately 1
cm in diameter. A Duoderm dressing was placed for
protection.
8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
eating and drinking. On the day of discharge, he was noted
by Physical Therapy to be orthostatic. Intravenous fluids
were initiated at 100 cc per hour for a total of one liter.
9. CODE STATUS: The patient is full code.
DISCHARGE DISPOSITION: The patient was to be transferred to
[**Hospital3 7**] at this time.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed and gastritis.
2. Alcohol withdrawal.
3. Coronary artery disease.
4. Pneumonia.
5. Depression with a history of suicidal ideation.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to [**Hospital3 7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Dictator Info 25265**]
MEDQUIST36
D: [**2140-11-15**] 15:40
T: [**2140-11-15**] 15:47
JOB#: [**Job Number 25266**]
|
[
"482.41",
"428.0",
"707.0",
"571.2",
"511.9",
"518.82",
"303.90",
"535.51",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.91",
"96.04",
"96.34",
"96.6",
"38.93",
"96.72",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
9484, 9554
|
9575, 9748
|
3044, 3623
|
6084, 9459
|
9763, 10133
|
183, 208
|
237, 2448
|
3649, 6050
|
2471, 3017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,104
| 148,267
|
6703
|
Discharge summary
|
report
|
Admission Date: [**2175-7-30**] Discharge Date: [**2175-8-3**]
Date of Birth: [**2113-10-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
61yoM with h/o CHF (EF 35-40%), HTN, hyperlipidemia, EtOH abuse,
admitted through ED with hypoxic respiratory failure. Patient
has undergone antihypertensive medication changes over the few
weeks including starting Norvasc to nifedipine, and since that
time has presented to his PCP with worsening lower extremity
swelling and orthopnea. Three days prior to admission he began
vomiting, and then developed worsening shortness of breath
associated with cough productive of yellow sputum. At the same
time, orthopnea worsened. He denied chest pain and fever. He
was brought to [**Hospital1 18**] ED by EMS today with worsening SOB.
.
On presentation to ED, T 98.6 HR 95 BP 162/102 RR 32 86%RA,
88%4Lnc. A NRB mask was applied, and oxygen saturation improved
to 100%. While in the ED he spiked a fever to 102 (rectal),
lactate 4.7. Code sepsis was initiated, and he was given a dose
of Azithromycin and Ceftriaxone. He was also given 1 liter NS.
He then became tachypneic on the NRB with RR 50 and diaphoretc.
He was intubated for hypoxic respiratory failure, and treated
with 40 mg IV lasix. He was transferred to the MICU for further
management. CXR showed multiple bilateral infiltrates c/w CHF
vs atypical infection. Given fever to 102 and increased lactate
to 4.7, code sepsis was initiated, central line placed, and
broad spectrum abx given. Labs were notable for ARF, anemia, and
mildly elevated Tnt. He was transfused 1 unit of PRBC, guiac
negative. His CE were negative x 3.
Pt of note has had his Norvasc changed to nifedipine recently
and lasix was increased from 10 to 20 mg for LE edema. He did
not c/o of any recent CP. He had a cough for the past few days
PTA with minimal sputum production.
Past Medical History:
- Hypertension.
- Cardiomyopathy (nonischemic; Echo [**6-27**]: EF 35-40%)
- h/o pancreatitis in 10/00 (?[**1-25**] to EtOH)
- h/o left thalamic cerebrovascular accident
- EtOH abuse (currently 1 pint vodka/day; 40+ years)
- Gout (not on PPx therapy)
- Glucose Intolerance
.
Social History:
One pint vodka per day; 10 cigarettes per day.
Family History:
Unknown
Physical Exam:
VS: 96.9 124/64 80 25 98%4L I/O negative 900 x 24 hours total,
+1400 LOS
GEN: elderly AA man, NAD
HEENT: pupils small and reactive
NECK: no LAD, elevated JVD 10 cm
CV: RRR, normal S1S2, no M/R/G
RESP: bilateral crackles L>R at bases bilaterally, no wheezes
ABD: soft, NT, ND +BS
EXT: trace edema bilaterally, 2+DPs
SKIN: diffuse hyperpigmented excoriated papular rash on lower
extremities bilaterally; dry, scaly rash on heels bilaterally.
Pertinent Results:
[**2175-8-1**] 03:00AM BLOOD WBC-9.0 RBC-3.09* Hgb-9.8* Hct-28.3*
MCV-92 MCH-31.7 MCHC-34.6 RDW-14.0 Plt Ct-228
[**2175-8-1**] 03:00AM BLOOD Plt Ct-228
[**2175-8-1**] 03:00AM BLOOD Glucose-107* UreaN-38* Creat-1.6* Na-139
K-4.1 Cl-107 HCO3-21* AnGap-15
[**2175-8-1**] 03:00AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.0
.
.
[**2175-8-1**] 9:44 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2175-8-2**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2175-8-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
.
[**2175-7-30**] 7:19 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2175-7-31**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2175-8-2**]):
RARE GROWTH OROPHARYNGEAL FLORA.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
Brief Hospital Course:
61 yo man with h/o CHF (EF 35-40%), HTN, hyperlipidemia, EtOH
abuse with shortness of breath and s/p hypoxic respiratory
failure.
.
1) Shortness of breath: Likely secondary to pulmonary edema and
infection. Will cover for atypical vs aspiration pneumonia. Now
extubated with improved oxygenation. Recent TTE 1 month ago with
EF 35-40%
-continued CTX/Zithromax/Flagyl
-followed cultures
-gently diuresis with prn lasix, goal negative 500-1000cc/day
-fluid restrict 1000cc, low sodium diet
.
2) ARF: Baseline creatinine about 1.0. Likely decreased
perfusion from CHF exacerbation. Improving creatinine.
- held ACEI
- renally dosed meds
- gentle lasix diuresis
3) ETOH ABUSE: h/o 1 pint vodka per day. Recently off versed
gtt.
- will cont to monitor for DT's, CIWA scale
- MVI/Thiamine/folate
.
4) CARDIAC: TnT slightly elevated with nonspecific changes on
EKG. Likely secondary to demand from CHF/Anemia and decreased
clearance from renal failure. Recent cath without significant
disease. Enzymes stable x 3. Pt with h/o nonischemic CM,
?secondary to ETOH abuse.
-continued ASA, BB, lasix prn
-BB and nifedipine for HTN
.
6) ANEMIA: low Hct @ 25, baseline in mid-30's. Iron studies c/w
anemia of chronic disease. Folate wnl, on supplementation. B12
low normal with high normal MCV. Guiac negative. s/p 1unit PRBC.
- Check MMA
- B12 1000 mcg IM QD x 1 week
- will transfuse for Hct < 25
- T+S
.
7) FEN: low sodium diet, diabetic diet, SSI QID for glucose
intolerance
.
8) PPx: SC heparin, PPI
.
9) CODE: FULL
.
10) DISPO: PT consult, improved respiratory status
Medications on Admission:
Atenolol 25 PO daily
Folic acid PO BID
Lipitor 10 mg PO QHS
Lisinopril 40 mg daily
Lasix 20 mg PO QD (recently increased from 10mg)
Magnesium oxide 400 mg PO BID
Nifedipine ER 90 mg PO daily
Potassium chloride 20 mEq PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Take until [**2175-8-15**].
Disp:*37 Tablet(s)* Refills:*0*
5. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours): Take until [**2175-8-15**].
Disp:*12 Capsule(s)* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
twice a day: take until [**2175-8-15**].
Disp:*25 Tablet(s)* Refills:*0*
9. Nifedipine ER 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Cyanocobalamin 1,000 mcg Tablet Sig: Two (2) Tablet PO once
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1) atypical pneumonia
2) CHF
Discharge Condition:
Good
Discharge Instructions:
Please STOP taking lisinopril.
Please the following adjusted and new medicinations:
[ ] cefpodoxime 200mg 1 tab by mouth twice daily until [**2175-8-15**]
[ ] azithromycin 250mg 1 tab by mouth once daily until [**2175-8-15**]
[ ] metronidazole 500mg 1 tab by mouth three times daily until
[**2175-8-15**]
[ ] Vitamin B12(cyanocobalamin) 1 tab daily
[ ] Multivitamin daily.
[ ] Please resume the rest of your outpatient meds as
prescribed. Including nifedipine ER 90mg 1 tab by mouth daily
and magnesium oxide 400mg 1 tab by mouth twice a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter
Return to ED or call your PCP if you experience worsening
shortness of breath, chest pain, fever/chills or any other
worrying symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2175-8-9**] 4:20
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2175-12-3**]
|
[
"276.5",
"038.9",
"285.29",
"274.9",
"584.9",
"428.0",
"401.9",
"303.91",
"782.1",
"794.31",
"272.4",
"995.92",
"486",
"518.81",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6795, 6801
|
3910, 5471
|
341, 353
|
6874, 6881
|
2968, 3887
|
7741, 8096
|
2483, 2492
|
5748, 6772
|
6822, 6853
|
5497, 5725
|
6905, 7718
|
2507, 2949
|
274, 303
|
381, 2103
|
2125, 2402
|
2418, 2467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,803
| 127,911
|
40611
|
Discharge summary
|
report
|
Admission Date: [**2149-6-25**] Discharge Date: [**2149-7-3**]
Date of Birth: [**2069-3-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2149-6-26**] - Redo sternotomy and first-time aortic valve replacement
with a 21-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis,
model #3300TFX, serial #[**Serial Number 88877**].
History of Present Illness:
80 year old female with history of atrial fibrillation, renal
insufficiency, aortic stenosis, and coronary artery disease s/p
CABG in [**2127**] that has progressive shortness of breath. Based on
[**Year (4 digits) 461**] her stenosis has progressively worsened and she
has had worsening edema in her legs over the last week. She is
able to ambulate short distance but then limited by dyspnea and
legs shaking. Additionally she has had increased swelling in
legs over the last few weeks and has taken additional lasix at
lunch time. She now presents for aortic valve replacement.
Past Medical History:
Past Medical History
Aortic stenosis ([**Location (un) 109**] 0.9)
Atrial fibrillation - chronic
Hyperlipidemia
Coronary artery disease s/p Myocardial infarctions and
interventions - CABG [**2127**], multiple stents BMS and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
[**10-30**]
Renal insufficiency (baseline crea 1.3)
Renal artery stenosis.
Gastroesophageal reflux disease.
Left ulnar nerve compression.
Nasal fracture secondary to trauma.
Left first rib fracture secondary to trauma.
Arthritis
Past Surgical History
Coronary Artery bypass Graft x4 (LIMA>LAD, SVG>diag, SVG>Circ,
SVG>RCA) [**Location (un) **] [**State **]
Left Elbow
Hysterectomy
Tonsillectomy
Appendectomy
Social History:
Lives with: spouse (currently staying with daughter)
Contact: [**Name (NI) **] daughter Phone# [**Telephone/Fax (1) 88878**]
[**Name2 (NI) **] Dental Exam: [**2149-5-21**]
Occupation: retired dairy farmer- assists son in ice cream shop
Cigarettes: Smoked no [x] yes []
ETOH: denies
Illicit drug use: denies
Family History:
Mother deceased @81yo- heart failure
Physical Exam:
Pulse: Resp:20 O2 sat: RA 96%
B/P Right:140/81
Height:5'2" Weight:150#
General: AAO x 3 in NAD, pleasant
Skin: Dry [x] intact [x] Well healed sternal incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] Bibasilar rales
Heart: RRR [] Irregular [x] Murmur [x] grade IV/VI at LSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Well healed suprapubic incision
Extremities: Warm [x], well-perfused [x] Edema [x]2+ LLE 1+ RLE
edema, chronic venouse stais changes, well healed leg saph vein
harvest site incision Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:mild bruit vs transmitted murmur
Left:mild bruit vs transmitted murmur
Pertinent Results:
[**2149-6-30**] CT Scan Head
No acute hemorrhage or infarction.
[**2149-6-30**] Carotid Ultrasound
Findings consistent with a 60-69% right ICA stenosis and less
than 40% left ICA stenosis.
[**2149-6-26**] ECHO
PRE-CPB: 1. The left atrium is moderately dilated. Moderate to
severe spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s). No thrombus is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. There is mild to
moderate regional left ventricular systolic dysfunction with
inferior akinesis.
4. The right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
complex (>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen.
7. There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Mild (1+) mitral regurgitation is seen. There is heavy MAC.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of norepinephrine, milrinone. AV pacing
for SR with frequent PVC's. Well-seated bioprosthetic valve in
the aortic position with peak 8, mean 5 mmHg gradient. AI is
trivial. MR remains 1+. LV systolic function is improved
post-cpb on inotropic support. LVEF = 40%. Aortic contour is
normal post decannulation.
Admission Labs:
[**2149-6-26**] 02:24AM BLOOD WBC-7.9 RBC-3.90* Hgb-11.2* Hct-34.7*
MCV-89 MCH-28.7 MCHC-32.3 RDW-16.4* Plt Ct-324
[**2149-6-26**] 02:24AM BLOOD PT-13.0 PTT-22.8 INR(PT)-1.1
[**2149-6-26**] 02:24AM BLOOD Plt Ct-324
[**2149-6-26**] 12:08PM BLOOD Fibrino-207
[**2149-6-26**] 02:24AM BLOOD Glucose-125* UreaN-29* Creat-1.3* Na-140
K-4.2 Cl-102 HCO3-29 AnGap-13
[**2149-6-26**] 02:24AM BLOOD ALT-11 AST-19 LD(LDH)-201 CK(CPK)-30
AlkPhos-64 Amylase-81 TotBili-0.6
[**2149-6-26**] 02:24AM BLOOD Lipase-89*
[**2149-6-26**] 10:06PM BLOOD CK-MB-10 MB Indx-6.8*
[**2149-6-26**] 02:24AM BLOOD CK-MB-2 proBNP-6585*
[**2149-6-26**] 02:24AM BLOOD Albumin-3.9 Calcium-9.0 Phos-4.0 Mg-2.3
[**2149-6-26**] 02:24AM BLOOD %HbA1c-6.2* eAG-131*
Discharge Labs:
[**2149-7-1**] 04:35AM BLOOD WBC-10.8 RBC-3.72* Hgb-11.0* Hct-32.7*
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.8* Plt Ct-195
[**2149-7-1**] 04:35AM BLOOD Plt Ct-195
[**2149-7-1**] 04:35AM BLOOD Glucose-97 UreaN-25* Creat-0.9 Na-140
K-4.0 Cl-96 HCO3-31 AnGap-17
[**2149-7-1**] 04:35AM BLOOD Mg-1.9
CHEST (PORTABLE AP) [**2149-6-29**] 9:23 AM
[**Hospital 93**] MEDICAL CONDITION: 80 yo woman with ^O2
requirement/s/p AVr
Final Report:
A right IJ sheath is present, tip over proximal/mid SVC. The
Swan-Ganz
catheter has been removed.
The patient is status post sternotomy, with prosthetic valve and
multiple
mediastinal clips. There is moderately severe cardiomegaly.
There is upper
zone redistribution and diffuse vascular blurring, consistent
with CHF. There is opacification at the right base, which likely
represents combination of pleural fluid and underlying collapse
and/or consolidation. There is increased density in the
retrocardiac region, but compared with [**2149-6-27**], the left
hemidiaphragm is now visible, suggesting partial interval
clearing.
DR. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Brief Hospital Course:
80 year old woman with known aortic stenosis admitted to cardiac
surgery service for aortic valve replacement with Dr [**Last Name (STitle) 914**] on
[**2149-6-25**]. She was admitted one day prior to surgery for diuresis.
On [**6-26**] she was brought to the operating room for aortic valve
replacement, please see operative report for details. In summary
she had: Redo sternotomy and first-time aortic valve replacement
with a 21-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis,
model #3300TFX, serial #[**Serial Number 88877**]. Her CARDIOPULMONARY BYPASS TIME
was 107 minutes with a CLAMP TIME of 69 minutes.
She tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU on Milrinone,
Levophed, Insulin and Propofol infusions. She was
hemodynamically labile in early post-op course and when she was
allowed to wake she droped her cardiac indices. She was
subsequently resedated. Volume resuscitation including blood
transfusions were given and then she was weaned and extubated
early in the morning of postoperative day one. Inotropes were
weaned off on postoperative day one. All tubes, lines and
drained were removed per cardiac surgery protocol. On
postoperative day two, the patient was noted to be somewhat
oliguric and was treated with diuretics, additionally she
required Bipap after an episode of tachypnea and remained in the
ICU for aggressive pulmonary toilet and to monitor her response
to diuretics. On postoperative day three, she was transferred to
the cardiac surgical stepdown unit for continued recovery. She
remained in atrial fibrillation consistent with her preoperative
rhythm. Plavix and aspirin were continued for anticoagulatuion
for her atrial fibrillation as per preoperatively. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. She complained of some
right sided weakness for which a neurology consult was obtained.
The weakness was similiar to weakness she has had in the past
which resolved over a few days. A head CT scan and carotid
duplex ultrasound were negative for an acute process. Aspirin,
plavix and a high dose statin were recommended. Her weakness
resolved. It was suspected that she likely had an infarct
related to hypoperfusion based on hypodensities noted on CT
scan. The remainder of her hospital course was uneventful. She
worked with nursing and physical therapy to increase her
strength and endurance and although she made some progress she
will benefit from a short stay in rehabilitation before
returning to her home environment. On postoperative day seven,
she was discharged to rehabilitation at [**Hospital1 **]. All follow-up appointments were arranged.
Medications on Admission:
Atenolol 75 mg daily
Atorvastatin 80 mg daily
Cilostazol 100 mg daily
Nexium 40 mg daily
zetia 10 mg daily
Lasix 40 mg daily
Gabapentin 100 mg [**Hospital1 **]
Potassium Chloride ER 20 mEQ daily
Ranexa 500 mg [**Hospital1 **]
Aspirin 81 mg daily
Calcium/Vitamin D3 600 mg / 400 units daily
Plavix 75 mg daily - stopped
Megared fish Oil - 1 tablet daily
Discharge Medications:
1. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily) for 7 days: Please
decrease dose to 20mEq daily when Metolazone has stopped. .
11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Past Medical History:
Aortic stenosis ([**Location (un) 109**] 0.9)
Atrial fibrillation - chronic
Hyperlipidemia
Coronary artery disease s/p Myocardial infarctions and
interventions - CABG [**2127**], multiple stents BMS and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
[**10-30**]
Renal insufficiency (baseline crea 1.3)
Renal artery stenosis.
Gastroesophageal reflux disease.
Left ulnar nerve compression.
Nasal fracture secondary to trauma.
Left first rib fracture secondary to trauma.
Arthritis
Past Surgical History:
Coronary Artery bypass Graft x4 (LIMA>LAD, SVG>diag, SVG>Circ,
SVG>RCA) [**Location (un) 8985**] [**State 3914**]
Left Elbow
Hysterectomy
Tonsillectomy
Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating: bed to chair with assist
Incisional pain managed with: Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema: 2+ bilateral ankle edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Lasix 40mg daily indefinitely. Metolazone 2.5mg 30mins prior
to lasix dose for a total of 7 days. Potassium 40mEq daily for 7
days, then decrease to 20mEq thereafter.
7) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2149-7-22**] 1:30
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Date/Time:[**2149-7-22**] 1:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 88879**] in [**3-25**] 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**
Scheduled Studies:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2149-7-22**]
11:00
Provider:
Completed by:[**2149-7-3**]
|
[
"V70.7",
"790.01",
"414.02",
"272.4",
"427.31",
"V45.82",
"786.09",
"434.91",
"428.0",
"729.89",
"412",
"354.2",
"403.90",
"E878.1",
"424.1",
"458.29",
"585.9",
"414.01",
"530.81",
"428.23",
"416.8",
"997.02",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
11770, 11828
|
6946, 9674
|
327, 530
|
12572, 12772
|
3180, 5020
|
13917, 14687
|
2200, 2239
|
10078, 11747
|
6145, 6923
|
11849, 11849
|
9700, 10055
|
12796, 13894
|
5776, 6108
|
12384, 12551
|
2254, 3161
|
268, 289
|
558, 1144
|
5036, 5760
|
11871, 12361
|
1874, 2184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,581
| 179,326
|
34475
|
Discharge summary
|
report
|
Admission Date: [**2106-9-3**] Discharge Date: [**2106-9-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Syncope/fall with Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 84 yo f w/ PMHx afib on Coumadin, HTN, CHF, who
presented to ED following fall in apt with questionable LOC.
Positive head strike. Pt was evaluated at OSH and found to have
subdural hematoma and transfered to [**Hospital1 18**] for treatment. In ED
she was evaluated by Orthopedics and no it was determined that
no surgical interventions needed at this time. Pt started on
Dilantin x10d and had repeat CT head [**9-4**] which showed stable
SDH. In [**Name (NI) **] pt was found to have PT 20 and was given vit K and
FFP for coumadin reversal. Rec'd vit K and FFP in the ED. During
FFP transfusion pt began complaining of pruritis. She was given
benadryl, completed the transfusion and reported RIGHT shoulder
rash and lip swelling. she was sent to SICU for observation.
Once stable she was transfered to Medicine for syncope work-up.
Past Medical History:
1)anemia,
2)CHF,
3)afib on coumadin,
4) hyponatremia,
5)HTN,
6)Mod severe MR [**First Name (Titles) **] [**Last Name (Titles) **],
7)CRI stage III,
8)sick sinus sp pacemaker [**3-29**]: [**Company 1543**] Sigma 200 SR, model
SSR203B
9)TIA [**9-28**], [**8-/2098**], [**11-30**],
10)COPD,
11)Hemangioma of bowel sp resection
Social History:
Pt lives alone in assissted living apt. Pt drinks ETOH socially
and occassionaly at home. She denies tobacco usage. Pt utilzes
walker at home and has aides to help with ADL weekly.
Family History:
FH: Grandfather had MI, Father w/ [**Name2 (NI) **] CA
Physical Exam:
Vitals: 96.4 122/80 65 20 97%RA
Gen: A+Ox3, in NAD
HEENT: NC, MMM, PERRL, Large eccymosis post head, neck and L
shoulder.
Neck: Supple, no LAD, No JVD
CV: pacemaker. RRR, Norm s1,s2. No murmur noted
Pulm: CTA BL no w/r/r
Abd: +BS, Soft, NT, ND
Ext: Eccymosis R forearm. Palp DP pulses, No edema.
Pertinent Results:
Blood work on admission:
CBC:
[**2106-9-3**] 04:00AM WBC-6.1 RBC-3.13* HGB-9.9* HCT-30.0* MCV-96
MCH-31.6 MCHC-33.0 RDW-17.5*
Coag:
[**2106-9-3**] 04:00AM PT-20.8* PTT-32.7 INR(PT)-2.0*
Chemistry:
[**2106-9-3**] 04:00AM GLUCOSE-92 UREA N-40* CREAT-1.2* SODIUM-131*
POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-25 ANION GAP-18
[**2106-9-3**] 04:00AM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-1.3*
Cardiac enzymes:
[**2106-9-3**] 06:07PM CK(CPK)-68
[**2106-9-3**] 06:07PM CK-MB-NotDone
[**2106-9-3**] 10:50AM CK(CPK)-80
[**2106-9-3**] 10:50AM CK-MB-10 MB INDX-12.5* cTropnT-0.02*
[**2106-9-3**] 04:00AM CK(CPK)-143*
[**2106-9-3**] 04:00AM cTropnT-0.02*
[**2106-9-3**] 04:00AM CK-MB-14* MB INDX-9.8*
[**2106-9-3**] 10:50AM DIGOXIN-0.3*
U/A:
[**2106-9-3**] 05:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2106-9-3**] 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2106-9-3**] 05:20AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
Relevant imaging studies:
[**2106-9-4**] CT HEAD W/O CONTRAST: IMPRESSION: Interval decrease in
the extent of small left parietal subdural hematoma with a
dominant portion of the hematoma measuring unchanged,
approximately 4 mm.
[**2106-9-6**]: CAROTID SERIES, COMPLETE: IMPRESSION: No evidence of
internal carotid artery stenosis on either side.
Brief Hospital Course:
84 yo f w/ PMHx afib on Coumadin, HTN, CHF, who presented to ED
following fall in with questionable LOC and confirmed subdural
hematoma.
1) Fall: Syncope vs. mechanical fall. She recalled the events
leading to the fall, but could not recall the actual fall except
for the part where she hit her head, suggesting a probable
syncopal event. This was unwitnessed, however, and corroboration
could not be obtained. She was initially evaluated at an outside
hospital, where a CT scan of the head showed a small left
parietal subdural
hematoma. She was transferred to [**Hospital1 18**] for further care. At
[**Hospital1 18**], a repeat CT scan of the head without contrast confirmed a
4 mm left parietal subdural hematoma, without midline shift. Her
warfarin-induced coagulopathy was reversed with vitamin K and
FFP in the ED, and she was admitted to the trauma-ICU for close
observation. A follow-up CT scan the following morning
demonstrated interval decrease in the extent of the small left
parietal SDH. She was transferred to the floor for furhter
work-up of her apparent syncopal event.
Per neurosurgery, she is to hold her anticoagulation for 1
month.
2) Syncope: Serial cardiac biomarkers showed a slightly elevated
CK-MBI,
with normal CK and flat troponins X 3. She was observed on
telemetry, without arrhythmic events. The EP service
additionally interrogated her pacer, without evidence of a
recent event. Carotid series were finally obtained, and
demonstrated no evidence of ICA disease. A basic infectious
work-up was negative. The possibility of vasovagal syncope or
orthostasis remains, but could not be confirmed. Orthostatic
vitals obtained at the time of transfer to the floor were
within normal limits. A repeat TTE was not obtained given our
low overall suspicion of a cardiac ischemic event or severe
stenotic valvular disease, but could certainly be considered in
the out-patient setting.
She was evaluated by physical therapy on the day of discharge,
and deemed safe for discharge home with services, including
physical therapy.
Medications on Admission:
Trazodone qHS,
Atentolol 12.5 x1
Pantoprazole 40x1
Calcitriol
Lorazepam 0.5 prn
Lasix
Digoxin 0.125 [**1-27**] x1
Lisinopril 10x1
Coumadin
MVI
Vit B12 Injection
Fosamax 35 qwk
Aranescp 200 qMonth
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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
6. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Syncope NOS
Subdural hematoma
Secondary diagnoses:
Chronic atrial fibrillation, rate controlled
Chronic systolic congestive heart failure
Sick sinus syndrome status post pacemaker placement
Discharge Condition:
Vital signs stable. Good condition
Discharge Instructions:
You were admitted to [**Hospital1 18**] after falling and hitting your head.
It is unclear whether or not you lost consciousness. You were
taken to a different hospital and found to have a subdural
hematoma (a small bleed in your head), at which time you were
transferred to [**Hospital1 18**]. A repeat scan of your head showed the
small bleed to be stable and not increasing in size or volume.
An xray of your shoulder was taken and showed no fractures or
dislocations. You were started on Dilantin while in the
hospital. Please take dilantin for 7 more days after going home.
Also, while in the hospital, your digoxin level was low and your
dosage was increased to 0.125mg daily.
Please take all of your medications as directed. Please go to
all of your follow-up appointments. If you experience fever,
chill, nausea, vomiting, headache, change in vision, loss of
consciousness, or any other concerning symptom, please report to
the emergency room immediately.
Followup Instructions:
Please follow up with PCP: [**Name10 (NameIs) 79226**],[**Name11 (NameIs) 79227**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10508**]
within 2 weeks, and inform them of your stay with us and
treatment rendered.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2106-9-7**]
|
[
"780.2",
"E879.8",
"427.31",
"496",
"427.81",
"852.26",
"397.0",
"999.8",
"403.90",
"V58.61",
"585.3",
"V45.01",
"424.0",
"E888.9",
"428.22",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6580, 6651
|
3551, 5603
|
297, 303
|
6894, 6930
|
2125, 2136
|
7945, 8318
|
1736, 1793
|
5850, 6557
|
6672, 6712
|
5629, 5827
|
6954, 7922
|
1808, 2106
|
6733, 6873
|
2538, 3188
|
222, 259
|
331, 1174
|
2151, 2520
|
1196, 1522
|
1538, 1720
|
3205, 3528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,103
| 137,245
|
4702
|
Discharge summary
|
report
|
Admission Date: [**2148-12-1**] Discharge Date: [**2149-1-5**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
vomiting, abdominal distention
Major Surgical or Invasive Procedure:
[**2148-12-2**]:
Exploratory laparotomy, lysis of adhesions (greater than 2
hours), and Hartmann's procedure with mobilization of the
splenic flexure.
[**2148-12-13**]:
Exploratory laparotomy, extensive lysis of adhesions,
intraoperative colonoscopy, repair of enterotomy.
[**2148-12-16**]:
Exploratory laparotomy, feeding tube jejunostomy, abdominal
washout.
[**2148-12-19**]:
Abdominal washout, [**State 19827**] patch placement.
[**2148-12-24**]:
Percutaneous tracheostomy.
History of Present Illness:
Very pleasant [**Age over 90 **]M presents with nausea and vomiting over the
past 24hrs in the absence of abdominal pain. He noted on
questioning that his abdomen was prominently distended but it's
notable that has a very soft abdomen without any rigidity or
tenderness elicited on physical exam. Notes no prior
exacerbating or palliating factors and notes that that he was
concerned that he might have eaten some "bad food" earlier. He
arrives notably without an elevated wbc but elevated cr from
baseline of 1.4 to 2.6 and a substantially elevated lactate 4.7.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Aortic Stenosis
Hypercholesterolemia
Peripheral Vascular Disease
Hearing Loss
H/o elevated alkaline phosphatase
Past Surgical History:
multiple lower extremity podiatric debridements
Social History:
Lives at home with wife and son. no tobacco, etoh or drugs. Very
active at his church. Moved from Barbados in [**2108**].
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 101.4 84 118/91 18 o2 sat not well monitored
A+Ox3 NAD, responsive talkative and happy
CTAB
softly distended, no tenderness, protuberant, no HSM
MAE
Pertinent Results:
[**2148-11-30**] 09:05PM GLUCOSE-203* UREA N-75* CREAT-2.6*#
SODIUM-136 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
[**2148-11-30**] 09:05PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-261* ALK
PHOS-326* TOT BILI-0.9
[**2148-11-30**] 09:05PM LIPASE-24
[**2148-11-30**] 09:05PM CALCIUM-9.5 PHOSPHATE-4.8*# MAGNESIUM-2.7*
[**2148-11-30**] 09:05PM WBC-9.7 RBC-4.27* HGB-12.9* HCT-38.6* MCV-91
MCH-30.2 MCHC-33.3 RDW-13.6
[**2148-11-30**] 09:05PM NEUTS-81.4* LYMPHS-13.2* MONOS-4.9 EOS-0.1
BASOS-0.4
[**2148-11-30**] 09:05PM PLT COUNT-201#
[**2148-11-30**] 09:05PM PT-12.8 PTT-25.7 INR(PT)-1.1
[**2148-11-30**] 08:57PM LACTATE-4.7*
XR abdomen [**2148-11-30**]:
There are multiple gas-distended loops of bowel throughout the
upper abdomen, with paucity of bowel gas in the lower abdomen,
particularly in the left lower quadrant and the rectum. There
are also multiple air-fluid levels with step-ladder appearance,
and the overall constellation of findings is concerning for
small bowel obstruction. No free intraperitoneal air is seen.
CT abdomen/pelvis [**2148-12-2**]:
1. High-grade small-bowel obstruction with distended small bowel
to the level of the ileocecal valve. Partially collapsed colon
with residual air in the colon and rectum.
2. No evidence of ischemia including no evidence of pneumatosis,
free air or portomesenteric venous gas. However, evaluation is
limited without intravenous contrast.
3. Small bilateral pleural effusions.
4. Trabecular thickening of the L2 vertebral body and right
proximal femur, likely consistent with Paget's disease.
CT abdomen/pelvis [**2148-12-13**]:
1. Moderate-to-severe dilation of the entire small bowel loops
with the exception of the short portion of the terminal ileum,
with a decompressed large bowel. These findings are highly
suggestive of a high grade small-bowel obstruction. Although the
transition point could not be accurately localized, it likely is
within the right lower quadrant.
2. No evidence of pneumatosis, free air or portal venous gas. No
evidence of abscess.
3. Bilateral large pleural effusions, with associated basal
atelectasis, worse since the prior study.
4. Bony changes in L2 vertebral body and right proximal femur,
stable and may represent Paget's disease.
CT face [**2148-12-27**]:
Minimal left maxillary and sphenoid sinus disease. No fracture.
CT torso [**2148-12-27**]:
1. Status post laparotomy, with unclosed postoperative ventral
abdominal wall defect, and overlying mesh and dressings. There
are multiple dilated loops of small bowel, without obvious
transition point. This probably represents ileus, though partial
small-bowel obstruction cannot be entirely excluded.
2. Moderate bilateral pleural effusions, and dependent airspace
opacity, left greater than right. This could represent
atelectasis, but areas of superimposed infection or aspiration
should also be considered, particularly at the left base.
3. No evidence of intra-abdominal abscess, or other definite CT
evidence of intra-abdominal infection.
4. Atherosclerotic vascular calcification, including coronary
calcification, and aortic valvular calcification. Moderate
cardiomegaly.
5. Stable bony changes in L2 vertebral body, and right proximal
femur, probably representing Paget's disease.
Brief Hospital Course:
On [**2148-12-1**], the patient was admitted to the acute care surgery
service for small bowel obstruction. He was made NPO,
resuscitated with IV fluids, and NGT was placed. He failed to
progress, and on [**2148-12-2**], CT abdomen/pelvis showed high grade
SBO, so he was taken to the operating room, where sigmoid
volvulus was found and removed. He was admitted
post-operatively to the SICU for control of atrial fibrillation
on amiodarone gtt and close monitoring of his critical aortic
stenosis. Over the following several days, there was minimal
output of flatus and stool from his colostomy, he was started on
TPN on [**12-9**]. His blood pressure was labile and required neo. On
[**2148-12-13**], CT abdomen/pelvis again showed high grade SBO and he
underwent another exploratory laparotomy, LOA, c-scope, and
repair of enterotomy. His abdomen was left open. He was taken
back to the operating room for repeated attempts at closure, and
a [**State 19827**] patch was placed and progressively rolled at bedside
until a VAC sponge was placed on bowel. Due to prolonged
intubation, he underwent tracheostomy on [**12-24**]. His abdominal
wound started leaking enteric contents likely [**1-29**] enterotomy on
[**12-30**]. His blood pressure remained labile and still required
pressors. After a discussion with the family, he was made CMO on
[**1-4**]. He expired at 20:09 on [**2149-1-5**].
Medications on Admission:
lisinopril 20mg daily, simvastatin 80mg daily, timolol maleate
0.5% 1 drop both eyes [**Hospital1 **], detrol LA 4mg SR QPM, aspirin 81mg
daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
sigmoid volvulus, multisystem organ failure
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"560.81",
"560.1",
"995.92",
"511.9",
"V45.81",
"440.20",
"V12.51",
"V45.82",
"553.8",
"997.4",
"276.2",
"560.2",
"V49.86",
"427.32",
"998.83",
"038.9",
"327.23",
"250.00",
"424.1",
"998.2",
"569.81",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"46.11",
"45.76",
"45.02",
"54.59",
"43.19",
"31.1",
"33.21",
"54.72",
"99.15",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6969, 6978
|
5344, 6747
|
279, 761
|
7066, 7072
|
2056, 5321
|
7124, 7238
|
1753, 1868
|
6941, 6946
|
6999, 7045
|
6773, 6918
|
7096, 7101
|
1549, 1598
|
1883, 2037
|
209, 241
|
789, 1356
|
1378, 1526
|
1614, 1737
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,819
| 197,776
|
3857
|
Discharge summary
|
report
|
Admission Date: [**2160-7-11**] Discharge Date: [**2160-7-13**]
Date of Birth: [**2080-8-8**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
TTE
History of Present Illness:
79 year old with non-radiating pleuritic chest pain without
nausea, vomiting, palpitations, diaphoresis. Usual state of
health until one day PTA w/ chest "congestion" and nonproductive
cough. Continued throughout the day. On morning of admission,
awoke with constant pleuritic cp worse w/ deep inspiration. No
change w/eating or exertion. No prior cardiac history.
.
In the ED, initial vs were: 97.8 113 99/55 16 99. Initial and
repeat trops negative. ECG with no acute ST changes. D-Dimer
positive led to a CTA without PE or aortic pathology. Given
morphine 4mg and zofran for nausea. Pressures were in the 80s,
started on 1 hour of levophed after which pressors were stopped
with BPs in the 115-120s about 4 hours prior to admission.
Patient received 1.5L NS. Treated empirically with Vanc/Zosyn,
blood cultures sent. Guaiac negative. Transfer VS: 93/66 114 T
98.1
.
On the floor, patient denies chest pain. BP 101/78, tachycardic
110s. Patient endorses anxiety. States her pain improved
throughout the course of the day. Pain is not reproducible with
palpation. Feels well and is ready to go home. Patient does
report a decreased appetite over the past 2-3 days and admits to
poor fluid intake.
Past Medical History:
Hyperlipidemia
Osteoarthritis
Osteoporosis
Social History:
Widowed, lives with her daughter and grandchildren. Immigrated
from [**Country 532**] about 10 years ago. No tobacco, social alcohol.
Daughter [**Name (NI) **]: [**Telephone/Fax (1) 17292**] or [**Telephone/Fax (1) 17293**].
Family History:
MI, CVA in mother
Bladder CA in father
Physical Exam:
Physical Exam:
Vitals: T: 97.3 BP: 106/68 P:109 R:20 O2: 94% on RA
General: Alert, oriented, no acute distress; looking pale
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear, no teeth,
whitish/yellow tongue plaques
Neck: supple, JVP not elevated, no LAD
Lungs: fine crackles bilateral lung bases
CV: Mildly tachycardic, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused and symmetric, 2+ pulses, no clubbing,
cyanosis or edema
Pertinent Results:
[**2160-7-11**] 04:14PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2160-7-11**] 01:25PM cTropnT-<0.01
[**2160-7-11**] 07:30AM GLUCOSE-104* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2160-7-11**] 07:30AM cTropnT-LESS THAN
[**2160-7-11**] 07:30AM WBC-8.1# RBC-4.61 HGB-12.7 HCT-38.0 MCV-83
MCH-27.5 MCHC-33.3 RDW-14.1
[**2160-7-11**] 07:30AM PLT COUNT-223
[**2160-7-11**] 07:30AM PT-12.5 PTT-24.8 INR(PT)-1.1
[**2160-7-13**] 06:30AM BLOOD WBC-6.0 RBC-4.00* Hgb-11.1* Hct-32.7*
MCV-82 MCH-27.8 MCHC-33.9 RDW-14.0 Plt Ct-204
[**2160-7-13**] 06:30AM BLOOD Glucose-97 UreaN-5* Creat-0.7 Na-140
K-3.6 Cl-107 HCO3-25 AnGap-12
[**2160-7-11**] 01:25PM BLOOD cTropnT-<0.01
[**2160-7-11**] 07:30AM BLOOD cTropnT-LESS THAN
[**2160-7-13**] 06:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8
ECG [**2160-7-11**]:
Sinus tachycardia. Diffuse non-specific ST-T wave changes which
are
non-specific. Low QRS voltages in the precordial leads. Compared
to the
previous tracing of [**2158-8-12**] there is no significant diagnostic
change.
TRACING #1
CT CHEST/ABD/PELVIS [**2160-7-11**]:
1. No pulmonary embolus or acute aortic syndrome.
2. Basilar atelectasis, without evidence of pneumonia.
3. Trace pericardial fluid with fluid seen tracking in the
pericardial
recesses.
4. Moderate hiatal hernia, with associated atelectasis.
5. No acute intra-abdominal process identified to explain pain.
There is a
small amount of free pelvic fluid, without identifiable cause.
6. Sigmoid diverticulosis without diverticulitis.
7. Questionable thickening of the endometrial cavity, with
possible fluid
within. A non-emergent pelvic ultrasound is recommended for
further
evaluation.
8. Extensive thoracolumbar degenerative change with associated
scoliotic
curvature. No suspicious lytic or sclerotic osseous lesions
identified.
9. Marked degenerative change in the right hip, with
bone-on-bone
articulation, subchondral cystic change and sclerosis.
CXR [**2160-7-11**]:
FINDINGS: There are bibasilar opacities likely related to low
lung volumes.
The lungs are clear with no focal consolidation, effusion, or
pneumothorax.
The cardiomediastinal silhouette is unremarkable. There is a
moderate hiatal
hernia seen, similar in configuration compared with prior. There
is
kyphoscoliosis of the thoracic spine, with severe degenerative
changes
throughout.
IMPRESSION:
1. No acute chest pathology.
2. Hiatal hernia, stable in appearance.
CXR [**2160-7-12**]:
FINDINGS: Again seen is a hiatal hernia. There are bilateral
pleural
effusions, left greater than right that have increased compared
to the study from the prior day. There is increased volume loss
at the left base. A small underlying infectious infiltrate on
the left cannot be excluded.
IMPRESSION: Increasing effusions bilaterally and volume loss on
the left.
ECHO [**2160-7-12**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2156-2-27**],
the degrees of tricuspid regurgitation and pulmonary
hypertension have increased. The other findings are similar.
ECG [**2160-7-12**]:
Sinus tachycardia. Compared to tracing #1 there is no
significant diagnostic change.
Brief Hospital Course:
Assessment and Plan: 79 yof admitted to the ICU for
hypotension, currently doing well.
# Hypotension: Pt was admitted to the ICU for hypotension to the
80's after receiving a dose of Morphine. Pt said her blood
pressure usually drops significantly with opioid's. She said
she told this to the doctors in the [**Name5 (PTitle) **], but it seems to have
gotten lost in translation. Pt recovered from hypotensive
episode after getting levophed and was transferred to the unit.
Pt received fluids and was monitored. Her status improved and
she was ruled out for MI, and PE. On 2nd day of admission a
repeat CXR was done that showed a LLL infiltrate suggestive of
PNA. The patient was transferred to the general medicine floor
and started on levofloxacin every other day. The patient
remained stable and afebrile throughout the night and was
discharged on day 3 of hospitalization with a 10 day total
course of Abx, and follow up with her PCP.
# Tachycardia: Mild in the setting of hypotension, could be
reactive to hypovolemia with a component of anxiety. The
patient had one episode of atrial fibrillation that resolved on
its own in the unit. The patient was in sinus rhythm overnight
on the general medicine floor.
# Pleuritic chest pain: r/o for MI, PE and aortic dissection in
the ED. Pain is not reproducible on exam, making
musculoskeletal less likely. Pt was given Morphine for the
pain, but that caused her to become hypotensive. After that the
patient was treated with NSAIDs for the pain and given
guaifenesin to control her cough as it was believed to be
pleuritic irritation secondary to constant cough. The patient's
pain decreased throughout the hospital course and she was
discharged with instructions to buy cough syrup at the local
pharmacy.
# Osteoarthritis: Patient had some episodes of joint pain that
were controlled by tylenol.
# Hyperlipidemia: Pt took home medications throughout hospital
course. Lipid levels were not evaluated.
# Anxiety: pt became anxious the night she was transferred to
the floor. She was given her medications, but had difficulty
sleeping. She said on the morning of discharge she was just
nervous because there were no doctors and [**Name5 (PTitle) **] one could speak
Russian on the floor.
The patient's condition improved and she was discharged with 1
week supply of antibiotics and follow up with her primary Care
physician.
Medications on Admission:
Citalopram 10 mg
Simvastatin 20 mg Tab
Glucosamine supplements
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours).
Disp:*21 Tablet(s)* Refills:*0*
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*60 ML(s)* Refills:*0*
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Pneumonia
Iatrogenic hypotension
.
Secondary diagnosis:
Osteoarthritis
Hyperlipidemia
h/o L eye surgery as teenager?
Spinal stenosis on R
Scoliosis
Anxiety
Discharge Condition:
Pt is A&Ox3, medically stable for discharge and able to ambulate
on her own.
Discharge Instructions:
You are being discharged from the hospital. You were admitted
after you presented with cough and chest pain associated with
the cough. After receiving morphine your blood pressure became
really low and you were admitted to the intensive care unit for
monitoring. While there you were found to have an isolated
episode of an abnormal heart rate that has since resolved.
Since that one time, it has not repeated itself and your heart
rate has been completely normal. On your second day another
chest X-ray showed that you likely have a pneumonia. You have
been without fevers and your white blood cell count has been
normal. You will be discharged from the hospital on antibiotic
that you should take every other day for 1 week.
.
New medications:
Levofloxacin 750 mg PO/NG every 48 hours
.
The following medications are being continued:
Citalopram 10 mg
Simvastatin 20 mg Tab
Glucosamine supplements
Followup Instructions:
Please call your physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8682**] at [**Telephone/Fax (1) 133**]
and make an appointment to see your doctor in the next to weeks.
Please also get follow up chest x-ray in 4 weeks to reevaluate
PNA.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"486",
"553.3",
"300.00",
"737.30",
"733.00",
"715.90",
"272.4",
"458.29",
"724.00",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9422, 9428
|
6403, 8800
|
278, 283
|
9646, 9725
|
2522, 6380
|
10678, 11103
|
1855, 1895
|
8913, 9399
|
9449, 9502
|
8826, 8890
|
9749, 10655
|
1925, 2503
|
228, 240
|
311, 1530
|
9523, 9625
|
1552, 1596
|
1612, 1839
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,600
| 155,049
|
45642
|
Discharge summary
|
report
|
Admission Date: [**2165-12-15**] Discharge Date: [**2165-12-24**]
Date of Birth: [**2090-4-20**] Sex: M
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
fever, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yoM with a Squamous Cell CA of the Nasopharynx s/p 3 rounds of
chemotherapy, recent course of radiation, s/p PEG who presents
with fever, shakes, productive cough. Per patient and pt's wife,
the patient finished his most recent course of radiation to the
nasopharynx and neck on [**12-10**]. Since that time he has been at
home. The patient has had increased sputum from baseline,
worsening fevers over the past two days, and mild confustion
over the past 24 hrs. Of note the pt also has been undergoing
chemotherapy (s/p 2 cycles of Cisplatin) and now on his third
cycle of chemotherapy having recently been changed to
Carboplatin. During his chemoradiation course the pt has been
experiencing mucositis and has had complaints of coughing and a
sensation of choking with increased phlegm. The patient does
endorse some orthopnea related to the feeling of phlegm going
down his throat when reclining. The pt has also endorsed an
increased concentration in his urine.
.
In the ED, Tc 102.1, 189/92, 99, rr 20, o2 94 on RA. On exam
with cough productive with rhonchi at bases (per report),
diaphoretic, foul appearing urine. CXR unrevealing, CTA revealed
RML PNA. Pt given Vancomycin 1gm, Cefepime 2gm x1, Tylenol 1gm
PR, Motrin 800mg (via GT) in addition to 1.5L. Upon transfer
from the E.D. the patients vitals had stabilized to hr 90's
143/59, RR low 30's, 98 2L.
.
ROS: The patient denies any weight change, vomiting, abdominal
pain, diarrhea, constipation, melena, hematochezia, chest pain,
lower extremity oedema, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
# Poorly Differentiated Squamous Cell CA of the Nasopharynx (Bx
[**2165-9-11**])
# Radiation to the nasopharynx and neck completed on [**12-10**] (total
dose of 6996 cGy over 33 fractions).
# PEG ([**2165-10-16**])
# Colon Cancer Stage IIA (Moderately Differentiated
Adenocarcinoma), s/p laparoscopic right colectomy ([**2163-1-4**])-
Last Colonoscopy ([**7-12**])
# Monoclonal Gammopathy (followed for MGUS since [**9-/2162**])
# Iron Deficiency Anemia
# Diverticulosis
# Diverticulitis
# HTN
# BPH
# GERD
# Arthritis
# AF (in [**2162**], on Coumadin for 6 months)
Social History:
Lives in [**Location **] with wife and adopted 10yo daughter. 80
pack/year smoker, rare ETOH.
Family History:
Mother passed away from breast cancer
Physical Exam:
On discharge:
AF, VSS, on room air
GEN: thin, elderly male, NAD
HEENT: EOMI, PERRL, sclera anicteric, dry some mucositis
NECK: erythematous skin at radiation site
COR: RRR, no M/G/R, normal S1 S2
PULM: L basilar faint crackles, R basilar rhonchi, no W/R/R
ABD: Soft, PEG in place without surrounding erythema, NT, ND,
+BS, no HSM, no masses
EXT: No C/C/E
NEURO:CN II ?????? XII grossly intact. Moves all 4 extremities.
Strength 5/5 in upper and lower extremities.
SKIN: No jaundice, cyanosis, . No ecchymoses.
Pertinent Results:
Admission labs:
[**2165-12-15**] 07:40PM BLOOD WBC-3.6*# RBC-3.31* Hgb-9.7* Hct-27.6*
MCV-83 MCH-29.4 MCHC-35.3* RDW-15.4 Plt Ct-204
[**2165-12-15**] 07:40PM BLOOD Neuts-73* Bands-3 Lymphs-10* Monos-12*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2165-12-15**] 07:40PM BLOOD PT-13.9* PTT-25.4 INR(PT)-1.2*
[**2165-12-15**] 07:40PM BLOOD Glucose-133* UreaN-24* Creat-1.0 Na-127*
K-4.2 Cl-85* HCO3-35* AnGap-11
[**2165-12-15**] 07:40PM BLOOD Calcium-8.8 Phos-2.3* Mg-1.8
[**2165-12-15**] 07:46PM BLOOD Lactate-1.7
[**2165-12-16**] 03:56AM BLOOD Hapto-334*
[**2165-12-16**] 03:56AM BLOOD ALT-21 AST-29 LD(LDH)-304* AlkPhos-251*
TotBili-1.6*
.
Imaging:
[**2165-12-15**]
CTA Chest:
IMPRESSION:
1. No central or main pulmonary embolus or aortic dissection.
Respiratory
motion severely limits evaluation beyond main pulmonary
branches.
2. Right middle lobe pneumonia.
.
Discharge labs:
[**2165-12-24**] 06:25AM BLOOD WBC-4.1 RBC-3.52* Hgb-10.6* Hct-30.4*
MCV-86 MCH-30.3 MCHC-35.0 RDW-15.7* Plt Ct-45*
[**2165-12-24**] 06:25AM BLOOD Plt Ct-45*
[**2165-12-24**] 06:25AM BLOOD PT-17.8* PTT-26.2 INR(PT)-1.6*
[**2165-12-24**] 06:25AM BLOOD Glucose-108* UreaN-20 Creat-0.8 Na-136
K-3.9 Cl-97 HCO3-35* AnGap-8
[**2165-12-23**] 06:34AM BLOOD ALT-19 AST-14 AlkPhos-138* TotBili-0.5
[**2165-12-23**] 06:34AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.6
[**2165-12-18**] 06:07AM BLOOD TSH-0.39
[**2165-12-18**] 06:07AM BLOOD Free T4-1.3
[**2165-12-17**] 06:40AM BLOOD calTIBC-168* Ferritn-1008* TRF-129*
[**2165-12-16**] 03:56AM BLOOD Hapto-334*
[**2165-12-23**] 04:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2165-12-23**] 04:18PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
[**2165-12-23**] 04:18PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
================
VIDEO OROPHARYNGEAL SWALLOW: Study done today in conjunction
with speech and
swallow division. Multiple consistencies of barium were
administered to the
patient under constant video fluoroscopy.
ORAL PHASE: There is moderate reduction in oral phase, with
tongue pumping
and tongue weakness noted.
PHARYNGEAL PHASE: There is mild reduction in the elevation of
the palate,
with mild reduction in laryngeal valve closure and absent
epiglottic
deflection. There was a large amount of residue within the
vallecula after
each swallow, with minimal clearing despite multiple swallows.
ASPIRATION/PENETRATION: Patient had an episode of laryngeal
penetration with
thin liquids. No aspiration was seen.
IMPRESSION: Severe oropharyngeal dysphagia, with large amount of
residue seen
within the pharynx, and an episode of penetration.
===============
AP UPRIGHT CHEST: There has been little change since the most
recent prior
study with poorly defined right heart border with adjacent
patchy opacity. No
new areas concerning for infection are identified, and there is
no evidence of
pulmonary edema. There may be mild posterior blunting of the
right
costophrenic angle.
IMPRESSION: Stable right middle lobe opacity, compatible with
pneumonia.
===============
ECHO
Conclusions
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with mild [1+] mitral
regurgitation. The tricuspid regurgitation jet is eccentric and
may be underestimated. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
===============
COMPARISON: CT torso, [**2165-10-1**].
TECHNIQUE: Axial imaging was performed from the thoracic inlet
to the
diaphragm following the uneventful administration of IV
contrast. Coronal and
sagittal reformations were provided.
CT CHEST WITH IV CONTRAST: There is no central or main pulmonary
embolus or
aortic dissection. However, the timing of contrast bolus, as
well as
respiratory motion significantly limits evaluation of the more
distal branches
and pulmonary parenchyma. There is central right middle lobe
opacification
with air bronchograms, consistent with pneumonic consolidation.
There is also
left basilar atelectasis as well as opacification with mild
mucoid impaction
of the left lower lobe bronchi. The bronchi are otherwise patent
to the
subsegmental level. There is no pleural or pericardial effusion.
A G-tube is
in the expected location. Coronary artery calcifications are not
changed in
appearance.
There is a pattern of diffuse osteopenia. There is moderate
degenerative
change of the thoracic spine.
IMPRESSION:
1. No central or main pulmonary embolus or aortic dissection.
Respiratory
motion severely limits evaluation beyond main pulmonary
branches.
2. Right middle lobe pneumonia.
Brief Hospital Course:
This is a 75 year-old male with a Squamous Cell carcinoma of the
Nasopharnx who presents with fever, shakes, productive cough,
altered mental status.
.
# Right middle lobe pneumonia: Noted on admission chest CT.
Bacterial versus aspiration pneumonia. He was treated with
levofloxacin to complete a 10 day course. He was kept NPO (he
came in NPO, getting nutrition through G tube which was placed
for his chemo/radiation for his cancer). His symptoms improved
and oxygenation remained stable.
.
# Atrial fibrillation: Mr. [**Known lastname 63015**] developed atrial
fibrillation during his hospital course with rapid ventricular
response. His TSH was checked and was normal. His atrial
fibrillation was attributed to his acute illness and recent
radiation. He was given metoprolol (changed from his outpatient
atenolol, short acting for titration) which was titrated up to
150 mg per tube TID.
Coumadin was also initiated after discussion with patient and
cardiology. However, it was held after his platelets dropped
below 50K. The decision to hold until seen in follow up by
oncology was discussed with the patient, his wife, and his
oncology providers. Tentatively, we thought bridging
anticoagulation with lovenox, started after his platelets
increased, would be best in light of the need for future port
placement.
ECHO was obtained and is copied in results section.
Cardiology consult was obtained and assisted with his care
throughout his hospital course, as the patient is followed by
Dr. [**Last Name (STitle) **] as an outpatient.
.
# Thrombocytopenia/Pancytopenia: Patients platelet count was
noted to trend down during his hospital course, and the rest of
his blood lines also trended down. Although this was felt likely
due to his recent chemotherapy with carboplatin, his
subcutaneous heparin was held and a HIT antibody was sent which
was negative. They began to rebound prior to discharge, and
will be followed closely by his outpatient oncologists.
.
# Squamous Cell Carcinoma of the Nasopharynx: Recently completed
radiation course, chemo, changed from Cisplatin to Carboplatin.
His outpatient oncologist followed him throughout his hospital
course and he will follow up with them on discharge.
.
# Mucositis: Related to his recent chemo/radiation as above.
He was treated with viscous lidocaine/maalox/benadryl PRN.
.
# Anemia: Remained stable during hospital course except during
trend down as above (pancytopenia). Attributed to his recent
chemotherapy.
.
# Benign Hypertension: Continued his outpatient medications,
along with titration of nodal blocking agents as above.
.
# Code: Full
Medications on Admission:
Amlodipine 5mg PO Daily
Aprepitant 125mg PEG daily Take 125 mg per PEG on Day 1 of
Chemotherapy, then take 80 mg per PEG on Days 2 and 3.
Atenolol 50mg Po Daily
Chlorpromazine 10mg PO 1-2 Tabs q6hr PRN Hiccups
Clonazepam (Unknown Dose)
Doxazosin 4mg PO Daily
Esomeprazole (Nexium) 10mg Oral Suspension, 40mg packet Daily
Fentanyl 25 mcg/hour Patch 72 hr
Fentanyl 50 mcg/hour Patch 72 hr
Finasteride 5 mg Tablet PO Daily
Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **]
Lisinopril 20mg PO Daily
Lorazepam 0.5mg PO Daily
Ondnsetron 8mg PO q6-8hr PRN Nausea
Oxycodone-Acetaminophen 5mg-325mg 5-10mls Solution PO Q6h PRN
Pain
Prochlorperazine (Compazine) 10mg PO Q8H PRN Nausea
Trazaone 50mg PO Daily
Colace 50mg/5ml Liquid, 10ml Per PEG [**Hospital1 **]
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Doxazosin 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime).
6. Chlorpromazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea.
7. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day): swish and spit.
8. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
9. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mg PO every [**5-12**]
hours as needed for pain.
Disp:*QS 60 ml* Refills:*0*
11. Levofloxacin 250 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO DAILY
(Daily) for 2 days: end date [**12-26**].
Disp:*6 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
13. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
14. Amlodipine 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Home suction device
Suction secretions prn
16. Nutren 2.0
tube feeds goal 45 ml/hr, with water flush 200 ml q4hours.
dispense QS 1 month
Refills none
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary:
Right middle lobe pneumonia - bacterial versus aspiration
Atrial fibrillation
Urinary tract infection
Thrombocytopenia
Secondary:
Squamous cell carcinoma of nasopharynx, with chemo/radiation
Hypertension, benign
GERD
Discharge Condition:
Good. Patient afebrile with stable vital signs, heart rate
controlled.
Discharge Instructions:
You were admitted to the hospital with fevers and altered mental
status, found to have a pneumonia. You were treated with
antibiotics. Your hospital course was complicated by
development of atrial fibrillation, which was controlled with
medication adjustments.
Please take medications as directed. You will need to discuss
anticoagulation with Dr. [**First Name (STitle) 7306**] at your appointment tomorrow, to
begin either coumadin or lovenox after your platelets improve.
Please follow up with appointments as directed.
Please contact physician if develop fevers/chills, shortness of
breath, chest pain/pressure, palpitations, any neurological
symptoms (weakness, numbness, difficulty speaking), any other
questions or concerns.
Followup Instructions:
Please follow up with previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2165-12-25**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2165-12-25**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2165-12-25**] 4:00
Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2037**] on [**1-9**]
at 11:40AM
Call speech therapy as instructed in their directions for a
follow up appointment.
|
[
"507.0",
"600.00",
"599.0",
"V44.0",
"147.8",
"273.1",
"427.31",
"528.01",
"V10.05",
"401.1",
"482.9",
"276.1",
"428.31",
"530.81",
"E933.1",
"428.0",
"284.89",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13742, 13805
|
8471, 11096
|
285, 291
|
14076, 14150
|
3279, 3279
|
14936, 15642
|
2695, 2734
|
11921, 13719
|
13826, 14055
|
11122, 11898
|
14174, 14913
|
4156, 8448
|
2749, 2749
|
2763, 3260
|
229, 247
|
319, 1978
|
3295, 4139
|
2000, 2568
|
2584, 2679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,084
| 128,825
|
9208
|
Discharge summary
|
report
|
Admission Date: [**2168-9-24**] Discharge Date: [**2168-9-30**]
Date of Birth: [**2121-6-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Estrogens / Ancef / Tegretol / Keflex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Nephrostomy tube placement
History of Present Illness:
47 yo F w/ h/o steroid-induced hyperglycemia, SLE w/ h/o
pericarditis, transverse myelitis w/ paraplegia and neurogenic
bladder s/p urostomy w/ ileal conduit, h/o ureteropelvic stone
and urosepsis, and h/o RLE DVT a/w F [**2168-9-24**] transferred to
MICU [**2168-9-25**] for hypotn resistant to IVFs and stress steroids.
Patient initially p/w c/o sudden onset N/abd pain/chills w/ T
103 at NH. Rigors progressed so she was brought to ED. She
reported h/o fatigue and anorexia for the past few days and had
noticed foul smelling urine and some abdominal distension,
similar to prior episodes of pyelo. She also c/o LLQ and groin
pain which responded to tylenol. She denies V or D. No AMS. No
c/o CP. On arrival to ED, temperature was 101.2. CT abd showed
an 8 mm right proximal ureteral stone with right-sided
hydronephrosis and inflammatory stranding, in addition to
pyelonephritis of the left kidney without left sided
hydronephrosis. Labs were remarkable for wbc 23.5 w/ 1% bands
which decreased to 14 today but now w/ 15% bands on vanc (h/o
MRSA urosepsis) and gent (mult drug allergies). AG on admission
18 (bicarb 17, down from 23 on a previous admission), down to AG
15 this AM. ABG prior to transfer (on room air): 7.43/24/69 w/
lactate 1.3 (down from 1.4 on the prior day). Currently, [**1-8**]
blood cx are growing GNR in both anaerobic bottles. Urine cx is
pending. Prior to transfer, patient dropped bp to 68/40s. BP did
not improve despite 2 L NS and 100 mg IV hydrocortisone. A
central line was placed and she was sent to IR for a right
nephrostomy tube.
Past Medical History:
## h/o nephrolithiasis s/p lithotripsy and h/o left
ureteropelvic junction stone '[**65**] spontaneously passing by U/S,
no evidence of right stone on most recent u/s 5 months ago
## h/o pyelo, last episode in '[**65**] (MRSA in blood and urine)
## SLE w/ h/o pericarditis, last flare couple years ago, didn't
flare w/ urosepsis
## Devic's disease: Recurrent transverse myelitis with sequelae
of
paraplegia-exacerbation in 93 Recurrent bilateral optic neuritis
with legal (neurologist: Dr. [**Last Name (STitle) **], [**Hospital1 18**]) - (steroids
increased to 40 qd in [**Month (only) **] for concern for recurrent optic
neuritis which turned out to be capsular ossification)
## blindness in right eye.
## Bilateral knee arthritis
## Suspected glaucoma in left eye, turned out to be capsular
ossification or a secondary cataract, corrected w/ laser surgery
[**2168-8-29**]
## Urostomy s/p ileal loop conduit in [**2160**] for neurogenic
bladder w/ persistent leak
## Steroid-induced hyperglycemia
## Hypothyroid
## Osteoporosis
## Hx of DVT in RLE '[**55**] - on coumadin for a couple years and
then ASA until a couple months ago
Social History:
Retired ICU nurse. [**First Name (Titles) **] [**Last Name (Titles) 31437**] x 15 yrs but maintains her
certification. Lives at [**Location 86**] Home NH x 11 yrs due to chronic
med issues. Her doctor there is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31438**]. No h/o
tobacco, alcohol, or IVDA. Wheelchair dependent + requires [**Doctor Last Name 2598**]
lift. UE strength intact but poor motor movements due to loss of
sensation.
Family History:
Mother died at 51 metastatic [**Name (NI) 31439**]
Father died at 36 aplastic anemia
only child
Physical Exam:
T 100.0 bp 109/56 CVP 11 hr 113 rr 16 O2 95% on 3L NC
mixed [**Last Name (un) **] 82%
genrl: in nad, resting comfortably
heent: perrla (4->3 mm) bilaterally, blind in right visual
field, eomi, dry mm, ? thrush
neck: no bruits
cv: rrr, no m/r/g, faint s1/s2
pulm: cta bilaterally
abd: midline scar (from urostomy), nabs, soft, appears distended
but patient denies, ostomy RLQ c/d/i, NT to palpation
back: right flank urostomy tube, c/d/i, nt to palpation
extr: no [**Location (un) **]
neuro: a, ox3, wiggles toes bilaterally, unable to lift LE, [**4-7**]
grip bilaterally w/ UE, decrease sensation to soft touch in left
UE and LE
Pertinent Results:
[**2168-9-24**] 05:11PM WBC-23.5*# RBC-3.81* HGB-9.4* HCT-29.2*
MCV-77*# MCH-24.6*# MCHC-32.1 RDW-18.1*
[**2168-9-24**] 05:11PM NEUTS-93* BANDS-1 LYMPHS-0 MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-9-24**] 05:11PM GLUCOSE-229* UREA N-25* CREAT-0.8 SODIUM-136
POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-17* ANION GAP-23*
[**2168-9-24**] 05:11PM LD(LDH)-214
[**2168-9-24**] 06:41PM LACTATE-1.4
[**2168-9-24**] 05:11PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2168-9-24**] 05:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-SM
[**2168-9-24**] 05:11PM URINE RBC-21-50* WBC-[**2-6**] BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2168-9-24**] 05:11PM URINE 3PHOSPHAT-OCC
[**2168-9-24**] CT CAP: 1. An 8 x 7 x 7 mm stone in the proximal right
ureter with associated right hydronephrosis and inflammatory
perinephric stranding. Additional smaller non-obstructing right
renal stones.
2. Left renal stones without evidence of hydronephrosis. Ileal
conduit is
not well evaluated.
3. Right breast calcification. Correlation with mammography is
suggested.
.
[**2168-9-24**] CXR: No evidence of pneumonia.
.
[**2168-9-24**] CT AP #2 (with contrast): 1. Eight mm right proximal
ureteral stone with right-sided hydronephrosis and inflammatory
stranding. Pyelonephritis of the left kidney without left sided
hydronephrosis.
2. No evidence of intraabdominal abscess or of diverticulitis.
3. Bilateral round, hypodense renal lesions, too small to
accurately
characterize but likely representing cysts.
4. 1.4 cm hypodense lesion in right lobe of the liver is
incompletely
characterized.
.
[**2168-9-25**] CT CAP: 1. Nephrostomy tube in the right kidney with an
8 mm right ureteric stone.
2. 6 mm nonobstructing calculus in the left kidney.
3. Calcified focus and a small hypodense lesion in the right
lobe of the
liver, incompletely characterized.
4. Bibasilar and dependent atelectasis.
.
[**2168-9-24**] 5:10 pm BLOOD CULTURE 2.
**FINAL REPORT [**2168-9-29**]**
AEROBIC BOTTLE (Final [**2168-9-29**]):
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC BOTTLE (Final [**2168-9-29**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 31634**] [**Last Name (un) **] [**2168-9-25**] 10:35A.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity testing available on
request.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity testing available on
request.
2ND STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 8 I
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 4 S 8 I
.
[**2168-9-25**] 1:50 pm URINE,KIDNEY PERC.NEPH..
**FINAL REPORT [**2168-9-28**]**
FLUID CULTURE (Final [**2168-9-28**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
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.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
[**2168-9-28**] BLOOD CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2168-9-28**] BLOOD CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2168-9-27**] URINE
URINE CULTURE-FINAL No Growth
[**2168-9-27**] CATHETER TIP-IV
WOUND CULTURE-FINAL No Growth
[**2168-9-27**] BLOOD CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
Brief Hospital Course:
47 yo F w/ h/o steroid-induced hyperglycemia, SLE w/ h/o
pericarditis, transverse myelitis w/ paraplegia and neurogenic
bladder s/p urostomy w/ ileal conduit, h/o ureteropelvic stone
and urosepsis, and h/o RLE DVT admitted [**9-24**] w/ left pyelo and
right 8 mm proximal ureteral stone w/ right hydro s/p perc
urostomy tube to relieve right hydro.
.
## GNR sepsis:
Upon admission, pt was febrile to 101.2 with U/A consistent with
UTI. A CT abd showed 8mm obstructing stone, hydro with
stranding consistent with pylonephritis. Her presentation was
thought likely due to urosepsis given h/o foul smelling urine
and in setting of stone w/ hydro + pyelo by CT. The patient went
to IR on [**2168-9-25**] given evidence of right hydronephrosis on
imaging for decompression and drainage. Upon admission, she was
treated with Vancomycin and Gentamycin and Flagyl. She was
started on the MUST protocol with high dose steroids as well and
a goal SVO2 >70%. She was hypoxic requiring 3L nasal cannula
O2. She subsequently developed hypotension with SBP in the 70s.
She was transferred to the MICU where the patient was continued
on the MUST protocol with goais of CVP 10-12, SVO2 greater than
70%. The patient was bolused with NS and did not required
pressors. On the day after admission to the MICU, the patient
was noted to have small oxygen requirement with 2L NC. Repeat
imaging revealed evidence of mild pulmonary congestion which was
thought to account for the patient's mild hypoxia. Given that
the patient had been maintaining a MAP of 60 without fluids or
pressors, her goal CVP was decreased to >8 to avoid fluid
overload. The patient was continued on Vancomycin and Gentamycin
while speciation and sensitivities were pending. Ciprofloxacin
was added on [**2168-9-26**] for synergy when surveillance cultures
were found to be growing again GNR. Gent and Cipro were then
discontinued and changed to meropenem when blood culture
sensitivities became available revealing GNR sensitive to [**Last Name (un) 2830**]
but resistant to both Gent and Cipro. Additionaly surveillance
cultures were drawn daily and the patient was transferred back
to the floor with no subsequent pressor requirement. Blood
cltures from [**9-25**] grew KLEBSIELLA PNEUMONIAE and [**9-26**] grew
KLEBSIELLA PNEUMONIAE and PROTEUS MIRABILIS both sensitive to
the Meropenam which she had already been receiving. Urine
cultures from [**9-25**] grew STAPH AUREUS COAG +, and GRAM NEGATIVE
RODS of two morphologies (not further speciated). She
defervesed by [**9-27**] and remained clinically stable with normal
blood pressures until the day of discharge. At the time of
discharge, blood cultures from [**9-27**] and [**9-28**] have no growth to
date. She received a midline on [**9-29**] with a goal of 16 days of
further antibiotic treatment with Meropenam (for a total of 3
weeks) upon discharge back to the nursing home where she lives.
.
## Right hydronephrosis:
Given right sided hydronephrosis and GNR bactermeia, a
percutaneous nephrostomy tube was placed by IR [**2168-9-25**]. The
patient put out 1385 cc urine the day after placement, 950 cc of
which came from nephrostomy tube. The tube appeared to be
functioning well, draining urine with occasional clot passage.
Urology was notified about the clots and occasional blood tinged
urine but they did not make any further recommendations.
Cultures from urine drawn from the nephrostomy tube are
currently growing > 100K GNR, possibly of two colony
morphologies, speciation and sensitivity pending.
.
## Hct drop:
On admission to hospital patient had Hct of 29.2. In the setting
of Right sublavian line placement as well as nephrostomy tube
placement the patient was noted to have a drifting Hct,
concerning for bleed, with nadir of 22.8 on [**2168-9-26**]. A CT
abdomen was performed which did not demonstrate any
retroperitoneal bleed. Hct stabilized to 24 for three days prior
to discharge. This can be followed as an outpatient. Anemia
workup revealed a picture of anemia of chronic disease (TIBC
225, B12 and Folate normal, Hapto 397, Ferritin 51, TRF 173,
Iron 35).
.
## Hypoxia:
The patient on admission was requiring 3 L NC in the setting of
receiving 2L NS and chest film which demonstrated pulmonary
congestion. The patient was not diuresed but allowed to
auto-diurese any additional fluids and is currently with O2 sats
97-98% on room air. As her BP remained stable she did not
receiving any standing fluids but was be bolused as appropriate
for a MAP < 60 or CVP < 8 with careful monitoring of pulmonary
status. Patient had an echocardiogram in [**2165**] which demonstrated
an EF of 60-65%. her O2 requirement by discharge was 96% on
room air with no SOB.
.
## Steroid-induced hyperglycemia: At home, the patient received
metformin and SSI. The patient's metformin was held and she has
been maintained on SSI qid while in the MICU. As the patient
appeared to be clinically stable, her stress dose steroids were
discontinued and the patient was changed back to her home dose
of Prednisone 40mg PO qd for maintenance with anticipated
decrease in her blood sugars. Her Metformin was re-added 2 days
prior to discharge as well and fingerstick glucoses on the day
of discharge were 93 and 156, respectively.
.
## Hypothyroidism: Repeat TSH and Free T4 were appropriate on
current outpatient regimen. Patient was continued on
Levothyroxine 75mcg po qd.
.
## H/o transverse myelitis/optic neuritis: On stress dose
steroids originally given MUST protocol and sepsis, as patient
clinically stabilized, she was changed back to home dose of
Prednisone 40mg pO qd.
.
## SLE: Currently no sx of active disease. No manifestations of
SLE during this admission.
.
# Osteoporosis- We continued actonel/vit D, Tums
.
## Capsular ossification: We continued eye gtt.
.
## FEN:
She had a low bicarb likely due to renal wasting but there is an
anion gap present. Serum acetone was normal. We followed lactate
while she was in the MICU which was normal. She was NPO
periodically but maintained a normal diet prior to discharge.
.
# PPX- SQ Heparin during this admission, PPI
.
## Communication: patient
.
## Dispo: To nursing home for follow up with Dr. [**Last Name (STitle) 986**]
(urology) this coming Monday, [**10-3**] at 1:30pm and with her PCP
at the nursing home
Medications on Admission:
Home Meds:
Ascorbic Acid 500 TID
Cranberry Extract 425 [**Hospital1 **]
Bisacodyl 10mg
Senna
Dephenhydramine 50mg prn
loperamide prn
famotidine 20mg
KCL 20mg QD
Metformin 1000 qd
tums 1500 [**Hospital1 **]
MVI
Timolol 1 Drop [**Hospital1 **] 0.5% L eye
Synthroid 75 QD
Compro 25mg pr
Citrucel
Vitamin D 50k Qmondays
Oxazepam 15mg qhs
tizamidine 8mg qhs
actonel 35 qwed
Diovan 80 qd
prednisone 40 qd
bactrim ds qmwf
baclofen pump 2-3yrs
Insulin SS
.
Meds on transfer:
Actonel 35 mg Oral qwednesdays
Ascorbic Acid 500 mg PO TID
Sodium Polystyrene Sulfonate 15 gm PO ONCE [**9-24**] @ 2201
Famotidine 20 mg PO DAILY
Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR
Gentamicin 80 mg IV Q8H
Timolol Maleate 0.5% 1 DROP OS [**Hospital1 **]
Heparin 5000 UNIT SC TID
Tizanidine HCl 8 mg PO QHS
Hydrocortisone Na Succ. 100 mg IV Q8H [**9-25**] @ 0906
Valsartan 80 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Vancomycin HCl 1000 mg IV Q 12H
Levothyroxine Sodium 75 mcg PO DAILY
Vitamin D 50,000 UNIT PO QWEDNESDAYS
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Home - [**Location (un) 86**]
Discharge Diagnosis:
GNR Sepsis; Steroid induced hyperglycemia; Hydronephrosis; SLE
Discharge Condition:
Stable
Discharge Instructions:
Pls take all meds as prescribed. Call your doctor immediately
if any new symptoms develop including fevers, rash, increase in
bloody urine in nephrostomy or urostomy bags, etc. Follow up
appointments listed below.
Followup Instructions:
With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**], [**Hospital1 18**], [**Location (un) 470**] [**Hospital Ward Name 23**] on Monday
[**10-3**] at @ 1:30pm (you also have an appointment scheduled with
Dr. [**Last Name (STitle) 986**] for [**11-9**]).
.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-11-2**] 8:30
|
[
"733.00",
"428.0",
"323.9",
"591",
"244.9",
"710.0",
"341.0",
"250.00",
"365.9",
"995.91",
"V12.51",
"285.9",
"590.80",
"V44.6",
"038.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
16912, 16991
|
9554, 15858
|
324, 353
|
17098, 17107
|
4363, 9531
|
17371, 17754
|
3596, 3693
|
17012, 17077
|
15884, 16333
|
17131, 17348
|
3708, 4344
|
273, 286
|
381, 1951
|
1973, 3107
|
3123, 3580
|
16351, 16889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,746
| 184,164
|
35106
|
Discharge summary
|
report
|
Admission Date: [**2134-9-3**] Discharge Date: [**2134-10-1**]
Date of Birth: [**2112-2-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2134-9-4**]
1. Halo placement
[**2134-9-5**]
1. Tracheostomy
2. Percutaneous endoscopic gastrostomy
3. IVC filter
History of Present Illness:
22 y.o female who is s/p motor vehicle crash as an unrestrained
back-seat passenger. Per witnesses, she was forcefully
extricated from the vehicle by friends at the scene. She was
transported to [**Hospital1 18**]; upon arrival to the ED her GCS was 10.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
Upon exam:
T: 91.1 BP:114/71 HR:67 RR 14 O2Sats 100% ACV
Gen: intoxicated appearing young woman in clear discomfort
HEENT: Pupils: PERRLA EOMI
Neck: TTP posteriorly over the entire c-spine
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, appears
intoxicated
Orientation: Oriented to person, place, and date.
Motor: Could partially shrug shoulders, otherwise unable to move
all 4 extremities.
Sensation: No sensation below nipples, or in extremities. Facial
sensation intact bilaterally.
Rectal exam: patient incontintent to stool. No rectal tone after
pharmacological paralyzation/intubation.
Pertinent Results:
[**2134-9-3**] 09:07PM GLUCOSE-113* LACTATE-0.9 K+-3.3*
[**2134-9-3**] 08:56PM HCT-29.6*
[**2134-9-3**] 11:31AM WBC-12.7*# RBC-3.25* HGB-9.9* HCT-29.0*
MCV-89 MCH-30.3 MCHC-33.9 RDW-12.4
[**2134-9-3**] 11:31AM PLT COUNT-199
[**2134-9-3**] 04:00AM ASA-NEG ETHANOL-50* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2134-9-3**] 04:00AM PLT COUNT-287
[**2134-9-3**] 04:00AM PT-11.7 PTT-23.9 INR(PT)-1.0
MRI cervical spine [**2134-9-3**]
FINDINGS: There is grade 1 anterolisthesis of C6 on C7.
Significant
increased STIR signal in the C5 and C6, and to a lesser extent
C4, vertebral
bodies, consistent with known fractures. Please refer to the
dedicated CT of
the cervical spine for further characterization of these
fractures.
There is moderate narrowing of the central canal by the C6-7
retrolisthesis.
On T2 and STIR images, there is increased signal intensity
within the cord
from the left mid C4 level to upper C7 level. There is
associated
susceptibility artifact, which suggests hemorrhagic contusions.
There are multiple ligamentous injuries. The anterior
longitudinal ligament
is disrupted at C5-C6. The posterior longitudinal ligament
appears disrupted
from C4-C6. There is significant abnormal signal within the
interspinous
ligaments, most pronounced at C3-C4 but also at C4-C5. There is
widening of
the interspinous space between C3 and C4. The ligamentum flavum
also appears
disrupted at C3-C4.
There is increased STIR signal intensity in the paravertebral
soft tissues,
consistent with soft tissue injury.
IMPRESSION:
1. Hemorrhaging contusion of the spinal cord at the C4 through
C7 level.
2. Multiple ligamentous injuries as described above involving
the anterior
longitudinal ligament, posterior longitudinal ligament,
ligamentum flavum, and
interspinous ligaments.
3. Abnormal signal within the C4 through C6 vertebral bodies,
consistent with
history of known fractures.
4. Grade 1 retrolisthesis of C6 on C7 with mild-to-moderate
narrowing of the
vertebral canal.
CTA Neck [**2134-9-3**]
FINDINGS: There is normal opacification of the carotid arteries
bilaterally
without evidence for stenosis, occlusion, or other vascular
injury. The
distal cervical internal carotid arteries measure 6.4 mm on the
left and 5.4
mm on the right.
The right vertebral artery is patent from its origin without
evidence for
stenosis, occlusion, or other vascular injury.
The left vertebral artery is occluded just distal to its origin
at
approximately the T1 level. There is apparent reconstitution at
the level of
C6. This could represent retrograde filling or collateral flow.
There is no evidence for contrast extravasation or
pseudoaneurysm formation.
Multiple cervical vertebral fractures as characterized on recent
CT of the
cervical spine from [**2134-9-3**] at 4:41 hours are again
seen. Please
refer to that report for more detailed characterization.
IMPRESSION:
1. Occlusion of the left vertebral at the T1 level with apparent
reconstitution at the C6 level. This could represent collateral
or retrograde
flow.
2. Unremarkable appearance of the bilateral carotid and right
vertebral
arteries.
Portable AP chest radiograph [**2134-9-27**]
There is slight worsening of the left lower lung atelectasis
which now most
likely involves not only the left lower lobe but potentially the
lingula. The
atelectasis is accompanied by small amount of pleural effusion.
The right
infrahilar opacity is grossly unchanged and most likely
represents area of
atelectasis. No pneumothorax is demonstrated. No failure is
present. The
tracheostomy was removed. The multiple orthopedic hardware is
overlying the
patient's chest.
Brief Hospital Course:
She was admitted to the trauma service and transferred to the
Trauma ICU. Neurosurgery was consulted given her spine injuries;
she was placed in a Halo. Vascular surgery was also consulted
for left vertebral artery injury, she underwent CTA of her neck
to determine if acute intervention was warranted and this was
not indicated.
She was taken to the operating room for tracheostomy, PEG and
IVC filter placement; there were no intraoperative
complications. She was eventually weaned off of the ventilator
once her tracheostomy was placed and was later transferred to
the regular nursing unit. She continued to receive tube feedings
via her PEG; Speech and Swallow performed a bedside evaluation
and she was advanced to an oral soft diet. Her tube feedings
were eventually cycled; she is taking in adequate oral solids
and liquids without any difficulty.
She developed a Stage II decubitus on her sacral/coccyx region
and [**Last Name (un) 2501**] there was concern for a deep tissue injury; the Wound
Care Nurse Specialist was consulted and made recommendations
regarding dressing changes; [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] cushion was provided when out
of bed; she has always been on a pressure reduction mattress
throughout her hospital stay. Plastic surgery was consulted for
evaluation of a possible skin graft at some point; she will need
to follow up in [**Hospital 3595**] clinic in [**12-16**] weeks for further
evaluation.
Her tracheostomy was decannulated on HD #25; she initially had
difficulty clearing her secretions and discussions took place
with regards to replacing with a smaller Trach. Patient and her
husband declined this option; she continued to be monitored
closely requiring only intermittent tracheal suctioning. She
continued on nebulizer treatments and was eventually able to
clear her secretions more effectively.
Physical and Occupational therapy were consulted early on and
worked closely with her throughout her hospital stay. Social
work remained closely involved with patient and her husband as
well.
She was screened early on for a spinal cord rehab; there was
lack of insurance so the choices were limited for the her. She
was ultimately accepted at [**Location (un) 86**] Medial Center and plans were
underway to facilitate the transfer.
Medications on Admission:
Denies
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO TID
(3 times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
EVERY OTHER DAY () as needed for IF NO BM EVERY 2 DAYS.
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-16**] Sprays Nasal
TID (3 times a day) as needed for pt request.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. DiphenhydrAMINE 25 mg IV Q6H:PRN pruritis
13. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily): Apply to sacral decubitius daily as directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] - Rehab and SCI
Discharge Diagnosis:
s/p Motor vehicle crash
Cervical spine fractures w/ cord hematoma C3-C6
Respiratory Failure
Grade I liver laceration
Stage II-III sacral decubitus
Discharge Condition:
Hemodynamically stable, maintianing airway, tolerating a
regular, pain adequately controlled
Followup Instructions:
Follow up in [**12-16**] weeks with Plastic Surgery for evaluation of
your sacral decubitus ulcer; call [**Telephone/Fax (1) 5343**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery in 4 weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks, call
[**Telephone/Fax (1) 1669**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2134-10-11**]
|
[
"433.20",
"806.06",
"707.25",
"E816.1",
"707.03",
"344.03",
"518.5",
"482.41",
"112.0",
"268.9",
"864.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"43.11",
"38.7",
"96.04",
"93.41",
"33.24",
"02.94",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
8861, 8920
|
5187, 7497
|
337, 457
|
9111, 9205
|
1496, 5164
|
9228, 9798
|
786, 803
|
7554, 8838
|
8941, 9090
|
7523, 7531
|
818, 1063
|
274, 299
|
485, 740
|
1078, 1477
|
762, 770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,503
| 109,199
|
14021
|
Discharge summary
|
report
|
Admission Date: [**2141-3-24**] Discharge Date: [**2141-4-1**]
Date of Birth: [**2065-9-26**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Codeine / Ticlid / Atorvastatin /
Lipitor / Crestor
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
worsening shortness of breath, paroxysmal nocturnal dyspnea,
non-productive cough, chest pressure
Major Surgical or Invasive Procedure:
none this admission
[**2141-3-15**]
Video-assisted thoracoscopic left lower lobe wedge resection and
mediastinal lymph node dissection.
History of Present Illness:
75 year old female s/p LLL wedge with pathology revealing
moderately-differentiated squamous cell carcinoma without nodal
involvement and negative margins (T1No- stage 1A), with 3 day
history of worsening SOB after discharge; accompanied with
unchanged non-productive cough, complaints of chest pressure,
and PND. She was admitted back to Thoracic surgery service for
atrial fibrillation and workup of shortness of breath.
Past Medical History:
CAD s/p CABG [**2117**], stents [**2128**], [**2134**]
HTN
COPD
bilateral renal artery stenosis s/p right stent placed [**11-28**]
thoracic aortic aneurysm medically managed
atrial fibrillation
anxiety
Barrett's esophagus seen on last EGD [**2134**]- but not on bx
s/p cholecystectomy
s/p appendectomy
s/p oophrectomy
h/o GIB- 2yr ago, EGD/colonoscopy at OSH
Social History:
- lives alone
- tobacco: current smoker, 60pk-yr history
- EtOH: denies
Family History:
mother, grandmother - liver cancer
Physical Exam:
Vitals: T: 96.9 degrees Fahrenheit, BP: 132/44 mmHg supine, HR
132 AF bpm, RR 22 bpm, O2: 98% on 4L NC.
Gen: Pleasant, well appearing.
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RRR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-26**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2141-3-24**] 05:30PM PT-13.1 PTT-30.3 INR(PT)-1.1
[**2141-3-24**] 05:30PM PLT COUNT-281
[**2141-3-24**] 05:30PM NEUTS-78.6* LYMPHS-16.9* MONOS-3.5 EOS-0.7
BASOS-0.3
[**2141-3-24**] 05:30PM WBC-7.1 RBC-3.10* HGB-9.9* HCT-29.4* MCV-95
MCH-32.0 MCHC-33.8 RDW-25.9*
[**2141-3-24**] 05:30PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2141-3-24**] 05:30PM proBNP-8256*
[**2141-3-24**] 05:30PM cTropnT-<0.01
[**2141-3-24**] 05:30PM estGFR-Using this
[**2141-3-24**] 05:30PM GLUCOSE-87 UREA N-31* CREAT-0.9 SODIUM-141
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2141-3-24**] 05:54PM GLUCOSE-84 LACTATE-1.6 NA+-140 K+-4.7 CL--106
TCO2-23
[**2141-3-24**] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2141-3-24**] 09:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
Brief Hospital Course:
Ms. [**Known lastname 784**] was admitted to the Thoracic surgery service on
[**2141-3-24**] for CHF exacerbation and atrial fibrillation with RVR.
.
She was diuresed with lasix, given lopressor IV, and started on
a diltiazem drip on day 1, which did not quiese her atrial
fibrillation. Day 2 she was bolused and started on amiodarone
drip; which unfortunately did not stop her afib with RVR
120's-140's. The patient remained hemodynamically stable. A TEE
was ordered and cardiology consult obtained on [**2141-3-27**]. CTA was
done on [**2141-3-26**] ruling out pulmonary embolism. Serial cardiac
enzymes were negative. The patient remained short of breath, and
given her uncontrolled afib; stayed in the ICU for observation
and management.
.
Patient was transferred to [**Hospital Unit Name 196**] for further management of the
following:
.
#. Afib: Patient underwent TEE/cardioversion on [**3-29**]. She
remained in sinus rhythm subsequently and started amiodarone
400mg daily. She was started on coumadin with heparin bridge.
Patient then switched to lovenox bridge (which was stopped after
hct drop-see below) and d/c'd on coumadin 2 mg daily. Her
outpatient cardiologist was contact[**Name (NI) **]. [**Name2 (NI) **] has history of
stable aortic ulcer, per outpatient cardiologist. She agrees
with anticoagulation given risk of embolic event and will follow
up her INR. Coumadin may be stopped after 1 month, if there are
further concerns for bleeding. Patient should be continued on
amiodarone 400mg daily for 1 month, then 200mg daily.
- INR check by VNA, goal 2-2.5. Followed by outpatient
cardiologist.
- Continue coumadin for at least 1month
- Amlodipine 400mg x1month, then 200mg daily
.
#. Pump: An echo done [**3-27**] showed EF 45% and on TEE [**3-30**] EF
was 55%. She was diuresed as needed with iv lasix 20mg prn, and
continued on her ace-i and beta-blocker. She was discharged
home on lasix 20mg po daily.
- Electrolyte check by VNA. Followed by outpatient cardiologist.
.
#. CAD: Known CABG and PCI in the past. She was continued on
beta-blocker, ace-inhibitor, aspirin and statin.
.
#. UTI: Patient was treated w/ cefpodoxime for ecoli/klebsiella
UTI.
.
#. Anemia: Patient had a hct drop on [**3-31**], to 19.9. Repeat hct
was 26. Her lovenox was stopped. She had several episodes of
small amount of hemoptysis. A CXR was taken and was relatively
unchanged. CT surgery evaluated patient and did not think that
her hemoptysis was significant.
- Hct check by VNA.
.
#. SCC: s/p lung resection. Continued nebs, guaifenisin.
Medications on Admission:
ASA 325mg
simvastatin 80mg
Metoprolol Succinate 50 mg
Sustained Release 24 hr
Amlodipine 10mg
Lisinopril 20mg
Singulair 10mg
Advair 100/50
Pantoprazole 40mg
Tramadol 50q6hp
APAP 325-650 q6h prn
guaiafension 100/5 [**4-3**] mlq6h
Acetylcysteine 20 % (200 mg/mL) 3 ML q6h
Xopenex 1.25/3 1 mL q8h prn
Ativan 0.5mg prn
hydroxyurea 500mg
Atrovent [**11-26**] neb INH q6h prn
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Succinate 50 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*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
7. Hydrea 500 mg Capsule Sig: One (1) Capsule PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. Home Oxygen
Please set up home oxygen to maintain O2 sats >92
10. Outpatient Lab Work
* Please check INR Monday, Wednesday, Friday ([**2143-4-4**], 14)
and fax to [**Telephone/Fax (1) 41857**], Attention Dr. [**Last Name (STitle) 41858**].
* Please check hematocrit, potassium, and creatine Monday [**4-3**]
and fax to above number.
11. Amiodarone 200 mg Tablet Sig: 1-2 Tablets PO once a day:
400mg (2 tablets) once a day for 1month. Then take 200mg (1
tablet) once a day after that.
Disp:*60 Tablet(s)* Refills:*2*
12. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-26**]
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*1*
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
17. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
18. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial fibrillation with RVR
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires [**Company 11807**] or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for your shortness of breath.
You were found to have a very fast irregular heart rate, atrial
fibrillation. You underwent cardioversion to convert your hear
into a normal rhythm. You tolerated this procedure well.
We have made the following changes to your medications:
1. Amiodarone 400mg for 1month then take 200mg after 1month to
maintain you in normal heart rhythm.
2. Metoprolol 50mg daily for blood pressure and heart rate
control.
3. Coumadin 2 daily to prevent clot formation. You should be on
this for at least 1month, you can discuss with Dr. [**Last Name (STitle) **] when
to come off of this medication.
4. Stop Amlodipine.
5. Decreased Zocor dose to 20mg daily. Amiodarone interacts with
zocor, you should only take 20mg zocor while you are on
amiodarone.
6. Start Atrovant as needed for shortness of breath or wheezing.
7. Percocet as needed for pain. Do not take tylenol while you
are taking this medication. This is a sedating medication; do
not take while operating a motor vehicle.
8. Reduced your Aspirin from 325mg to 81mg daily while you are
on coumadin.
9. Start Cefpodoxime for urinary tract infection, for 9 more
days (to end [**2141-4-10**]).
10. Start Lasix 20mg daily.
Call your cardiologist if you have questions or concerns with
your heart rate
Followup Instructions:
Follow up with:
Cardiology: Dr. [**Last Name (STitle) **] on [**2141-4-17**] at 3:00pm. Her telephone
number is [**Telephone/Fax (1) 36510**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]. The phone number is [**Telephone/Fax (1) 5294**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
Completed by:[**2141-4-3**]
|
[
"V10.11",
"238.4",
"428.43",
"V45.81",
"427.31",
"041.3",
"414.00",
"041.4",
"441.2",
"530.85",
"599.0",
"496",
"285.9",
"428.0",
"745.5",
"786.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8525, 8574
|
3356, 5915
|
437, 575
|
8672, 8672
|
2446, 3333
|
10202, 10587
|
1515, 1551
|
6335, 8502
|
8595, 8651
|
5941, 6312
|
8864, 9142
|
1566, 2427
|
9171, 10179
|
300, 399
|
603, 1027
|
8687, 8840
|
1049, 1409
|
1425, 1499
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,157
| 125,190
|
42525
|
Discharge summary
|
report
|
Admission Date: [**2158-1-9**] Discharge Date: [**2158-2-3**]
Date of Birth: [**2109-12-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Type A dissection with chest pain
Major Surgical or Invasive Procedure:
[**2158-1-9**] - Bentall procedure (31-mm St. [**Male First Name (un) 923**] conduit mechanical
valve graft and replacement of the ascending and hemiarch aorta
with a 28-mm Gelweave tube graft under circulatory arrest with
selective antegrade cerebral perfusion).
[**2158-1-9**] - Mediastinal re-exploration with control of left and
right coronary button anastomotic bleeders, chest closure.
[**2158-1-10**] - Right leg four-compartment fasciotomy with debridement.
[**2158-1-12**] - Debridement lateral compartment, proximal.
[**2158-1-16**] - Irrigation and debridement of medial fasciotomy and
delayed primary closure. 2. Irrigation and debridement of the
lateral compartment with debridement of necrotic muscle and
delayed primary closure.
History of Present Illness:
This 48 year old white male presented chest pain starting this
morning at 5am, of gradual onset with progressively increasing
severity. He was evaluated
at [**Hospital **] Hospital ED where a CTA of the chest/abdomen showed
Type A aortic dissection. He was transferred to [**Hospital1 18**] for
cardiac surgery consult.
Past Medical History:
Tobacco abuse, EtOH abuse, h/o MVC 28 years ago with bilateral
leg fractures s/p surgical fixation, chronic dermatitis left
lower leg, gout.
Social History:
Lives with: girlfriend [**Doctor First Name **]
Contact: girlfriend [**Name2 (NI) **] [**Telephone/Fax (1) 92019**]
Occupation: diesel mechanic
Cigarettes: Smoked no [] yes [x] last cigarette _this AM_ Hx: 1
ppd x 40 years
Other Tobacco use:
ETOH: < 1 drink/week [] [**1-10**] drinks/week [] >8 drinks/week [x]
(8
beers/night)
Illicit drug use: none
Family History:
None Noted
Physical Exam:
Pulse: 71 Resp: 18 O2 sat: 98% on 3L
B/P Right: 138/68 Left:
Height: 68 in. Weight: 245 lbs. (estimated)
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x] chronic cellulitis left lower leg
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: non-palp Left: non-palp
PT [**Name (NI) 167**]: non-palp Left: non-palp
Radial Right: palp Left: palp
Carotid Bruit Right: Left:
Pertinent Results:
[**2158-1-9**] ECHO
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
There is a small PFO.
Overall left ventricular systolic function is normal (LVEF>55%),
although unable to obtain transgastric midpapillary view.
The aortic root is severely dilated at the sinus level. A mobile
density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection. The views of the upper descending aorta and aortic
arch were unable to be obtained.
The number of aortic valve leaflets cannot be determined due to
the presence of the mobile echodensity but is suggestive of
bicuspid anatomy. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on in the
operating room.
POSTBYPASS:
The patient is av paced on phenylephrine infusion. Later A paced
on phenylephrine and epinephrine infusions. There is a well
seated mechanical valve in the aortic position. Characteristic
washing jets are appreciated. Bileaflet motion is appreciated.
There is dropout of the ascending aorta consistent with a tube
graft. Peak and mean gradients across the valve are 7mmHg &
4mmHg, respectively with a cardiac output of 3L/m. The remaining
valves are unchanged. Biventricular function is maintained. The
dissection flap can still be seen in the descending aorta. All
findings discussed with surgeons at the time of the exam.
.
CT Chest [**2158-1-19**]
1. Mild hemopericardium, small amount of mediastinal fluid
surrounding the
ascending aortic graft and soft tissue density posterior to the
sternum are likely postsurgical and within normal 8 days after
surgery; however,
superimposed infection cannot be excluded.
2. Bibasilar opacities are likely due to atelectasis; however,
superimposed infection cannot be excluded.
3. No abdominal or pelvic findings that might explain the
patient's rising
white blood count.
.
LE ultrasound [**2158-1-19**]
No evidence of DVT in right or left lower extremity.
.
[**2158-1-12**] PICC Line Placement
IMPRESSION: Successful uncomplicated placement of a 26 cm
tip-to-cuff 15.4
French tunneled hemodialysis line with the tip in the right
atrium. The
catheter is ready to use.
[**2158-2-1**] 04:01AM BLOOD Hct-25.4*
[**2158-1-31**] 04:53AM BLOOD WBC-4.3 RBC-3.02* Hgb-9.2* Hct-25.2*
MCV-84 MCH-30.5 MCHC-36.5* RDW-15.3 Plt Ct-198
[**2158-1-9**] 08:30AM BLOOD WBC-10.5 RBC-3.74* Hgb-12.6* Hct-35.4*
MCV-95 MCH-33.7* MCHC-35.6* RDW-12.5 Plt Ct-175
[**2158-2-1**] 04:01AM BLOOD PT-16.2* PTT-63.8* INR(PT)-1.5*
[**2158-1-31**] 04:53AM BLOOD PT-17.0* PTT-58.9* INR(PT)-1.6*
[**2158-1-30**] 09:48AM BLOOD PT-16.5* PTT-41.4* INR(PT)-1.6*
[**2158-1-29**] 05:20PM BLOOD PT-18.5* PTT-42.1* INR(PT)-1.7*
[**2158-2-1**] 04:01AM BLOOD Glucose-103* UreaN-54* Creat-1.0 Na-136
K-3.7 Cl-100 HCO3-27 AnGap-13
[**2158-1-31**] 04:53AM BLOOD Glucose-94 UreaN-71* Creat-1.2 Na-134
K-3.5 Cl-98 HCO3-27 AnGap-13
[**2158-1-30**] 09:48AM BLOOD Glucose-95 UreaN-78* Creat-1.7* Na-132*
K-3.5 Cl-95* HCO3-27 AnGap-14
[**2158-1-26**] 06:31AM BLOOD Glucose-115* UreaN-149* Creat-4.8*
Na-129* K-5.2* Cl-94* HCO3-18* AnGap-22*
[**2158-1-20**] 03:01AM BLOOD Glucose-87 UreaN-60* Creat-3.3* Na-129*
K-4.1 Cl-93* HCO3-24 AnGap-16
[**2158-1-10**] 11:12PM BLOOD UreaN-31* Creat-3.4* Na-143 K-5.1 Cl-104
[**2158-1-9**] 08:30AM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-107 HCO3-21* AnGap-17
Brief Hospital Course:
He was admitted to the [**Hospital1 18**] on [**2158-1-9**] for surgical management
of his Type A aortic dissection. He was taken directly to the
Operating Room where he underwent repair of his dissection with
a Bentall procedure using a 31-mm St. [**Male First Name (un) 923**] conduit
mechanical valve graft and replacement of the ascending and
hemiarch aorta with a 28-mm Gelweave tube graft under
circulatory arrest with selective antegrade cerebral
perfusion. Please see operative note for details.
Postoperatively he was taken to the intensive care unit with an
open chest. He required multiple blood products and red blood
cells for significant postoperative bleeding. He was later
returned to the Operating Room where he underwent re-exploration
for bleeding, found to be from the coronary buttons. Hemostasis
was achieved and his chest was closed. He was then returned to
the intensive care unit for monitoring.
The orthopedic service was consulted for compartment
syndrome/rhabdomyolysis of the right . On [**2158-1-10**] at the bedside
due to hemodynamic instability, he underwent right lower
extremity fasciotomies and placement of a VAC dressing. This was
debrided on [**2158-1-12**] and again on [**2158-1-16**] when it was ultimately
washed out and closed.
His myoglobins peaked at 60,000 and he became oliguiric. The
Nephrology Service was consulted and CVVHD was started and the
renal service continued to follow him closely. Heparin was
started for anticoagulation given his mechanical aortic valve.
He was treated aggressively for hypertension. Tube feeds were
started for nutritional support.
He developed thick secretions which smelled foul with fever and
leukocytosis. Vancomycin was started and a bronchoscopy was
performed. Cultures were positive for coagulase positive staph
aureas and vancomycin was continued. A chest tube was placed for
a right pneumothorax. He continued with significant leukocytosis
and the Infectious Disease service was consulted. A lower
extremity ultrasound was negative for deep vein thrombosis or
abscess. An initial surface echo did not show any evidence of
endocarditis. Cefepime and ciprofloxacin were started but later
changed to Meropenum. Flagyl was started for presumed c. diff,
however, cultures remained negative and the Flagyl was stopped.
A CT scan showed a small amount of fluid surrounding the aortic
graft but no frank infectious process. He was again transfused
for postoperative anemia. He continued on hemodialysis on a
Tuesday, Thursday and Saturday schedule. On [**2158-1-21**] he was
successfully extubated. Nystain was started for oral
candidiasis. Phenylephrine was slowly weaned off. CVVH was
switched to hemodialysis on [**2158-1-21**].
Coumadin was started for his mechanical valve. Physical Therapy
began to work with him to help with his postoperative strength
and mobility. On [**2158-1-23**], he was transferred to [**Hospital Ward Name 121**] 6 for
further recovery. Heparin was stopped when his INR was
therapeutic. While recovering on the floor he dropped his
hematocrit again which prompted a TTE that revealed a possible
vegetations on the aortic and mitral valves. He therefore
underwent TEE on POD #21 which showed no signs of any
vegetations.
His dialysis tunnelled line was accidently discontinued during a
dialysis run, but his kidney function improved to the point
where a trial off dialysis was given and he continued to make
adequate urine. The renal function slowly improved and he
autodiuresed. He made steady progress and was discharged to
[**Hospital3 **] of [**Location (un) 1121**] in [**Hospital1 3597**], on [**2158-2-3**].
Antibiotics were all discontinued on [**1-31**]. He will follow-up
with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 1005**] (orthopedics) and the renal service
as directed. Staples from the fasciotomy sites were removed and
the wound was healing well.
BUN/creatinine the day of discharge were 20/0.6 rerspectively.
Medications on Admission:
None
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold HR<60,sbp<100.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(two tablets) twice daily for two weeks, then
200mg (one tablet) twice daily for two weeks, then 200mg(one
tablet) daily until instructed to discontinue. Tablet(s)
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours).
10. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR goal [**1-6**].
Should receive 5mg on [**2158-2-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Type A aortic dissection
s/p Bentall(31mm mechanical valved conduit), open chest
s/p reoperaton for bleeding and chest closure
s/p right lower extremity two compartment fasciotomies
s/p closure of fasciotomies
post operative myoglobin induced renal failure
gastrointestinal bleed
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
Fasciotomy - healing well, no erythema or drainage. Staples in
place.
1+ Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Hemodialysis is on a Tuesday, Thursday and Saturday schedule.
7) Leg staples to remain in place until orthopedics removes.
8) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2158-2-21**] at 1:45pm
Cardiologist: Dr. [**Last Name (STitle) 72502**] [**Name (STitle) **] at 9:00a [**Telephone/Fax (1) 92020**]
Orthopedics: Dr. [**Last Name (STitle) 1005**] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2158-2-2**]
10:00
ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2158-2-2**] 9:40
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 8964**] ([**Telephone/Fax (1) 45950**]) in 2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Mechanical Aortic Valve
Goal INR 2.0-3.0
First draw [**2158-1-27**]
Please arrange for outpatient coumadin management upon discharge
from rehab.
Completed by:[**2158-2-3**]
|
[
"E878.8",
"518.81",
"998.89",
"441.01",
"578.9",
"728.88",
"E849.7",
"512.1",
"280.9",
"790.92",
"682.6",
"788.5",
"996.72",
"729.72",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"83.14",
"34.04",
"38.45",
"38.93",
"96.04",
"96.72",
"38.97",
"35.22",
"34.03",
"99.15",
"39.95",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11867, 12003
|
6610, 10582
|
343, 1090
|
12327, 12570
|
2832, 6587
|
13585, 14557
|
1992, 2004
|
10637, 11844
|
12024, 12306
|
10608, 10614
|
12594, 13562
|
2019, 2813
|
270, 305
|
1118, 1442
|
1464, 1607
|
1623, 1976
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,348
| 159,759
|
5889
|
Discharge summary
|
report
|
Admission Date: [**2162-4-5**] Discharge Date: [**2162-4-7**]
Date of Birth: [**2083-4-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
shortness of breath, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt was recently admitted to [**Hospital1 18**] [**Date range (1) 12761**]/07 for CHF
exacerbation. She ruled out for ischemia and was transitioned
from lasix gtt to Torsemide 100mg daily with good effect. On
discharge to [**Hospital **] rehab her family noted that though her
breathing and leg edema were much improved, she was still more
fatigued than at baseline. She did well at rehab until the last
few days PTA, when her family noted the pt to be markedly
fatigued, having difficulty speaking and walking to the bathroom
becuause she felt so tired. For 2d PTA the pt's family also
noticed that she was working harder to breathe and was
accumulating more fluid in her legs. Her family has not noted a
cough, nor has the pt complained of chest pain. 1 day PTA she
complained of abdominal pain and vomited x 1, but had excellent
po intake and no diarrhea or constipation. She was sent from
[**Hospital **] rehab to the [**Hospital1 18**] ED for further evaluation of
lethargy, SOB, and LE edema.
.
On arrival in ED, vitals were: T 99.8, HR 80, BP 110/72, RR 28,
100% on NRB. She received Lasix 80mg IV x1, nitropaste 1". Per
report, she also got a dose of Levaquin prior to arrival in the
ED. ABG was 7.33/110/60, with lactate of 0.8. She was
transferred to the [**Hospital Unit Name 153**] for further management of presumed
hypercarbic and hypoxemic respiratory failure.
Past Medical History:
1) Severe dilated cardiomyopathy with biventricular failure, EF
25-30%, dry weight 160-163lbs per recent d/c summary
2) Severe MR/TR
3) Coronary artery disease s/p cardiac catheterization in
[**10/2158**], with a 70% LAD stenosis s/p stenting and diffusely
diseased RCA.
4) H/o supraventricular tachycardia
5) HTN
6) AFib-- on coumadin
7) DM2
8) CRI (baseline Cr 1.5-2.0)
9) History of breast cancer, infiltrating ductal carcinoma,
s/p lumpectomy and XRT in [**2147**], s/p mastectomy in [**2152**]. The
tumor was ER+/HER-2-NEU positive, and she is undergoing
Tamoxifen therapy.
10) H/o goiter (per family, has been stable for many years)
Social History:
She lives with her husband and son in [**Name (NI) 6607**]. She denies any
tobacco or alcohol use. Her daughter works here in [**Name (NI) 191**].
Family History:
noncontributory
Physical Exam:
T 97.0 P 90 BP 117/66 RR 21 O2sat 100% NRB Wt76.5kg (168.3lb)
Lines: peripheral IV x 3
Gen: tachypneic and groggy appearing.
HEENT: PERRL. watery eye discharge. dry MM.
Neck: enlarged thyroid R>L. supple, no LAD. carotid upstrokes
brisk bl. JVP 20cm.
Lungs: markedly diminished breath sounds on R lung fields, with
end inspiratory crackles and dullness to percussion [**1-23**] way up.
L lung fields w/ end insp. crackles.
Chest: Irreg irreg, nl S1/S2. 3/6 systolic murmur at LLSB,
increasing w/ inspiration. [**2-23**] holosystolic murmur at apex
radiating to axilla.
Abd: soft, nt, nd, hsm not appreciated (but did not lie pt
flat). +normal BS. Abd muscles contracting w/ expiration.
Extrem: 2+ pitting edema to knees bl. 2+ distal pulses, WWP.
Neuro: able to follow commands and moving all 4 extremities.
Mumbles a few words when asked a question but not able to
converse coherently
Pertinent Results:
[**2162-4-5**] 02:25PM BLOOD WBC-11.0# RBC-4.33 Hgb-9.5* Hct-33.0*
MCV-76* MCH-22.1* MCHC-28.9* RDW-18.1* Plt Ct-133*
[**2162-4-5**] 02:25PM BLOOD Neuts-86.0* Lymphs-7.0* Monos-6.7 Eos-0.3
Baso-0.1
[**2162-4-5**] 02:25PM BLOOD PT-27.8* PTT-30.5 INR(PT)-2.9*
[**2162-4-5**] 02:25PM BLOOD Glucose-95 UreaN-123* Creat-2.5* Na-146*
K-4.6 Cl-95* HCO3-43* AnGap-13
[**2162-4-5**] 05:58PM BLOOD ALT-22 AST-41* CK(CPK)-38 AlkPhos-117
TotBili-1.5
[**2162-4-5**] 02:25PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 23277**]*
[**2162-4-5**] 02:25PM BLOOD cTropnT-0.07*
[**2162-4-5**] 05:58PM BLOOD CK-MB-5 cTropnT-0.07*
[**2162-4-6**] 02:49AM BLOOD CK-MB-6 cTropnT-0.07*
[**2162-4-5**] 05:58PM BLOOD TotProt-7.4 Albumin-3.9 Globuln-3.5
Calcium-10.3* Phos-5.4* Mg-2.5 Iron-28*
[**2162-4-6**] 02:49AM BLOOD TSH-<0.02*
[**2162-4-5**] 05:58PM BLOOD calTIBC-499* VitB12-1063* Folate-14.6
Ferritn-19 TRF-384*
[**2162-4-5**] 03:11PM BLOOD Type-ART pO2-160* pCO2-110* pH-7.33*
calTCO2-61* Base XS-25 Comment-C PAP
.
CT Head w/o contrast ([**2162-4-6**]):
There is no evidence of intracranial hemorrhage, hydrocephalus,
shift of normally midline structures, or edema. A linear area
of hyper-attenuation along the falx anteriorly is stable dating
back to [**2154-12-21**] and likely represents a small
meningioma. The paranasal sinuses are well aerated.
.
CXR AP ([**2162-4-5**]):
Multiple regions of mid and lower lung zone opacity, which
appears new concerning for infection. Likely small right
effusion. A lateral view would be helpful. Mild pulmonary
vascular congestion.
Brief Hospital Course:
In the [**Hospital Unit Name 153**], she was started on vanco/Zosyn for empiric coverage
of a suspected hospital-acquired pneumonia. She was initally put
on BiPAP for her respiratory failure, though this was weaned
down to 2L n.c. Of note, her daughter/HCP choose to make her
DNR/DNI with no further positive pressure ventillation. Her
diuretics were held due to her renal failure and she was gently
hydrated with D5W with subsequent normalization of her
hypernatremia. Her code status was made DNR/DNI by her family,
who also wished that she not receive positive pressure
ventillation.
.
She was transferred to the floor where she was initially stable.
Due to concern of L-sided weakness, a head CT was obtained
which showed no evidence of acute stroke. On the morning after
transfer, she was found by her nurse lying on her side with
agonal breathing with approx 4-5 breaths/min. Peripheral pulses
were thready and a NIBP was not obtainable. Shortly thereafter,
the patient lost her pulses, stopped breathing, and expired.
Her family was notified and a post-mortem examination was
declined.
Medications on Admission:
metoprolol 25mg [**Hospital1 **]
aspirin 81mg daily
atorvastatin 10mg daily
gabapentin 100mg [**Hospital1 **]
pantoprazole 40mg daily
ipratropium MDI q6h prn
Senna prn
torsemide 100mg daily
Colace 100mg [**Hospital1 **]
warfarin 5mg qhs
Insulin Lispro qACHS per sliding scale
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure secondary to congestive heart failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"397.0",
"276.3",
"V10.3",
"584.9",
"428.0",
"416.8",
"518.81",
"285.21",
"414.01",
"425.4",
"242.90",
"486",
"428.21",
"403.90",
"427.31",
"585.9",
"250.00",
"276.0",
"276.2",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6577, 6586
|
5124, 6222
|
342, 348
|
6688, 6698
|
3535, 5101
|
6750, 6878
|
2597, 2614
|
6549, 6554
|
6607, 6667
|
6248, 6526
|
6722, 6727
|
2629, 3516
|
273, 304
|
376, 1752
|
1774, 2414
|
2430, 2581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,447
| 136,063
|
3433
|
Discharge summary
|
report
|
Admission Date: [**2177-7-15**] Discharge Date: [**2177-7-30**]
Date of Birth: [**2126-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lithium / Codeine
Attending:[**First Name3 (LF) 15850**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2177-7-17**]
Left chest tube thoracostomy
[**2177-7-17**]
Left pleural pigtail catheter placement
[**2177-7-22**]
Left video-assisted thoracoscopic drainage of
empyema and partial rib resection
History of Present Illness:
50 yo male with h/o COPD/asthma, HCV, multiple burns, presented
to the ED with pleuritic chest pain. The day prior, he had felt
SOB, both with exertion and at rest. Also stabbing chest pain
in the center of his chest through to his back. Denied nausea,
vomiting, fever, chills, increased productive cough. Fell on
his left side 1.5 months ago while trying to catch a bus. PCP
felt it was contusion vs. rib fracture, gave naproxen.
In ED, initial vitals were 99.6, 113, 124/86, 20, 92%. CXR in
ED showed whiteout of left hemithorax. CT showed large pleural
effusion. Got one dose of levofloxacin. Chest tube placed by
IP drained 600cc serosanguinous fluids. Required
non-rebreather. Transferred to the ICU for hypoxia, satting 92%
on non-rebreather pending further evaluation. In the ICU also
received pigtail in addition to chest tube. Pleural fluid:
Protein 5.3, Glucose 85, LDH 349, WBC 500, RBC [**Numeric Identifier 15851**], Poly 25,
Lymph 50, Mono 10, Eos 15, consistent with exudate based on
elevated LDH and protein. In the ICU, chest tube decreased, and
10mg TPA was instilled. Antibiotics were discontinued but
patient remained afebrile, WBC normal.
On arrival to the floor, pt was resting comfortably, though was
in minimal respiratory distress having removed his nasal canula.
Vitals on arrival were 97.2, 135/86, 105, R20, Sat 95% on 3L.
Pt currently complains of mild chest pain on the left, but no
difficulty breathing. No cough.
Past Medical History:
#COPD/asthma - 60 pack year smoking hx, uses advair & albuterol
#Hepatitis C, in remission after interferon rx
#Atopic dermatitis, seborrheic dermatitis
#h/o alcohol use, now sober
#Lower back pain
#Extensive burns after being burned and tortured in [**2151**]
#PTSD after being tortured and burned in [**2151**], had paranoia
preceding this event, however
#Depression, prior hx of suicide attempt on bottle of pills
#Schizoaffective disorder
-Sporadically attends the chronic mental illness group here at
[**Hospital1 18**]. Has been involved with [**Location (un) 15852**] House in the past.
-Multiple medication trials,including Celexa, Remeron,
Klonopin, Zyprexa, Prozac.
Social History:
Assimilated from OMR, SW, and patient:
Pt lives independently in [**Location (un) **], near his brother. [**Name (NI) **]
outpatient psych support at Bay Cove ([**Telephone/Fax (1) 15853**]), where he
also works 3 days a week, 2 hours a day. He has had recent
decline in mobility, with multiple falls, and relies on a cane
to ambulate at home. [**Doctor Last Name 1022**] is his caseworker at Bay Cove.
Pt has a 60 pack-year smoking history, but states he is not
currently smoking. He is not currently smoking or drinking (1
year sober, attends AA). Has a remote history of cocaine abuse
for 15 years, methadone, percocet.
He had a difficult childhood, verbally and physically abused by
father. Dropped out of school after 10th grade for substance
abuse problems. [**Name (NI) **] extensive burns from torture in [**2151**]. In
the past, was charged for aggression, assault.
Family History:
Father with schizophrenia and EtOH abuse.
Mother died of lung cancer at age 86.
Physical Exam:
VS: T 98.2, BP 130/36, P 105, R 20, Sat 95% on 3L
General: Alert, oriented, no acute distress, on 4L NC
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sounds throughout the L lung field
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Ext: skin grafts over large surfaces of the body, R foot
deformed s/p cellulitis and multiple reconstructions
Neuro: CNII-XII intact, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred.
Pertinent Results:
[**2177-7-15**] PLEURAL WBC-500* RBC-[**Numeric Identifier 15851**]* HCT-2* POLYS-25*
LYMPHS-50* MONOS-10* EOS-15*
PLEURAL TOT PROT-5.3 GLUCOSE-85 LD(LDH)-349 CHOLEST-114
GRAM STAIN (Final [**2177-7-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2177-7-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2177-7-17**] 8:17 pm PLEURAL FLUID
FUNGAL CULTURE/ ACID FAST SMEAR AND CULTURE ADDED ON PER
REQ ON
[**2177-7-24**].
GRAM STAIN (Final [**2177-7-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2177-7-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2177-7-23**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2177-7-25**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
IMAGING
[**7-15**]
CT Chest:
1. Large left non-septated pleural effusion with near-complete
compressive atelectasis of the left lung and slight rightward
mediastinal shift.
2. Nonspecific ground-glass opacity in right lung apex.
3. Numerous bilateral subacute-appearing rib fractures.
[**7-15**] CXR:
Interval improvement in aeration of the left upper lung field
status post placement of a left sided chest tube. Large left
pleural effusion, slightly improved in the interval.
[**7-18**] Abdominal US:
1. No ascites.
2. Limited exam due to patient's body habitus. Within this
limitation,
unremarkable abdominal ultrasound exam. Spleen is not
visualized.
[**7-18**] CXR:
Portable upright chest radiograph was obtained. Left PICC and
left
apically directed chest tube are in unchanged position. Left
pleural pigtail catheter is seen with kinks that are less severe
than on the recent prior study suggesting it has been
manipulated. Right lung is well aerated. Left lung
demonstrates nearly resolved left dependent effusion, with
unchanged moderate quantity of pleural fluid tracking along the
mediastinum. Left basal atelectasis is decreased.
Cardiomediastinal contours are unchanged.
[**7-20**] CXR: (after removal of chest tube)
There is a left-sided PICC line with distal lead tip in the
distal SVC.
Pigtail catheter is seen at the left lung base. Since the prior
study, therehas been increase in the pleural effusion on the
left side. There is also increased opacity and volume loss at
the left side. No pneumothoraces areseen. The right lung is
relatively clear. Heart size is within normal limits.
[**7-21**] Chest CT:
Newly introduced left pigtail catheter. Decrease in extent of
the pleural fluid collection, but evidence of loculated fluid
collections
laterally and anteriorly of the thoracic cavity on the left,
associated with pleural thickening and pleural enhancement,
concerning for empyema. Slightly increased size of the still
normal lymph nodes in the mediastinum. Atelectatic changes at
the bases of the left lung. No characteristic ground-glass
opacities in the right lung apex. Older healing rib fractures
on the left.
[**2177-7-24**] Renal US :
No evidence of hydronephrosis or renal abnormality is seen on
this ultrasound.
&/17/12 Chest CT :
1. New, large bore left chest tube, replacing a pigtail drain,
ends in the slightly smaller posterior component of, small,
anteriorly and posteriorly loculated, left pleural fluid
collection. At least one tube sideport is extrathoracic in the
large submuscular collection of mostly air and a small amount of
fluid communicating with large skin defect.
2. Significant thickening of the chest wall musculature right
above the tube likely represents inflammation or intramuscular
bleeding, but proper
assessment of drainable fluid collection or other post-operative
complication is limited by the absence of intravenous contrast
[**Doctor Last Name 360**].
3. Left basilar and lingular atelectasis not significantly
changed compared with prior exam.
4. Central line is 2 cm below the cavoatrial junction in the
right atrium.
[**2177-7-15**] 01:10PM WBC-15.5* RBC-4.59* HGB-13.3* HCT-40.1 MCV-87
MCH-28.9 MCHC-33.1 RDW-13.6
[**2177-7-15**] 01:10PM PLT COUNT-536*
[**2177-7-15**] 01:10PM GLUCOSE-71 UREA N-13 CREAT-1.1 SODIUM-138
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-19
[**2177-7-15**] 01:10PM TOT PROT-6.9 ALBUMIN-3.6 GLOBULIN-3.3
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2177-7-30**] 03:33 911 17 2.4* 145 4.2 112* 22 15
Source: Line-PICC
[**2177-7-29**] 06:35 901 17 2.6* 145 4.3 113* 21* 15
Source: Line-picc
[**2177-7-28**] 06:05 104*1 20 2.7* 146* 4.3 113* 20* 17
Source: Line-picc
[**2177-7-27**] 04:48 931 21* 3.2* 144 3.5 113* 21* 14
Source: Line-PICC
[**2177-7-26**] 05:15 68*1 24* 3.7* 144 3.4 111* 20* 16
Source: Line-L PICC
[**2177-7-25**] 16:45 28* 3.5*
Source: Line-picc
[**2177-7-25**] 10:40 27* 3.6*
Source: Line-L. PICC
[**2177-7-25**] 06:30 921 29* 3.6* 141 3.8 107 23 15
Source: Line-PICC; VANCO TROUGH 6-8AM
[**2177-7-24**] 20:15 140*1 26* 3.4* 140 3.8 104 24 16
Source: Line-PICC
[**2177-7-24**] 05:55 139*1 24* 2.9* 136 3.5 100 24 16
Source: Line-picc; VANCO TROUGH6-8AM
[**2177-7-24**] 01:07 112*1 21* 2.6* 134 3.8 98 25 15
Source: Line-PICC
[**2177-7-23**] 04:03 117*1 13 1.1 136 4.2 98 27 15
[**2177-7-30**] 03:33 12.6* 3.45* 9.5* 29.9* 87 27.6 31.9 14.4
745*
Source: Line-PICC
[**2177-7-29**] 06:35 13.7* 3.57* 9.8* 31.0* 87 27.3 31.4 14.2
820*
Source: Line-picc
[**2177-7-28**] 06:05 16.5* 3.60* 10.0* 31.2* 87 27.8 32.1 13.9
823*
Source: Line-picc
[**2177-7-27**] 04:48 14.1* 3.32* 9.2* 29.0* 88 27.6 31.6 13.8
738*
Source: Line-PICC
[**2177-7-26**] 05:15 11.8* 3.19* 8.8* 27.6* 87 27.5 31.8 13.5
680*
Source: Line-L PICC
[**2177-7-25**] 06:30 12.6* 3.34* 9.2* 29.2* 88 27.7 31.7 13.5
593*
Source: Line-PICC
[**2177-7-24**] 01:07 18.5* 3.88* 10.8* 33.6* 87 27.8 32.1 13.2
659*
Source: Line-PICC
[**2177-7-23**] 04:03 21.2* 4.23* 11.6* 36.7* 87 27.4 31.6 13.0
653*
Source: Line-PICC
[**2177-7-22**] 15:18 18.4* 3.88* 10.9* 33.5* 86 28.1 32.6 13.3
545*
Source: Line-aline
[**2177-7-22**] 05:46 21.3* 3.53* 9.9* 30.2* 86 28.1 32.8 12.8
619*
Source: Line-picc
[**2177-7-21**] 06:17 22.9* 3.95* 11.1* 34.0* 86 28.2 32.8 13.0
537*
Source: Line-picc
[**2177-7-20**] 05:35 15.4* 4.32* 12.4* 37.4* 87 28.6 33.1 13.2
494*
[**2177-7-19**] 07:05 13.8* 4.48* 12.7* 39.3* 88 28.3 32.4 13.4
545*
[**2177-7-19**] 06:19 14.7* 4.46* 12.6* 38.7* 87 28.3 32.7 13.1
561*
Source: Line-picc
[**2177-7-18**] 05:40 16.1* 4.69 13.4* 41.2 88 28.6 32.6 13.5 622*
[**2177-7-17**] 04:03 15.1* 4.33* 12.0* 37.2* 86 27.8 32.3 13.1
503*
[**2177-7-16**] 04:02 18.1* 4.46* 12.6* 38.6* 87 28.4 32.8 13.2
499*
Source: Line-PIV
[**2177-7-15**] 13:10 15.5* 4.59* 13.3* 40.1 87 28.9 33.1 13.6
536*
DIFFERENTIAL
Brief Hospital Course:
50 yo M with h/o COPD/asthma, HCV in remission, depression,
recent injury to left chest wall after a fall (?rib fracture),
p/w SOB on exertion and at rest x 1 day and pleuritic CP which
started last night. CT scan showed large pleural effusion which
was drained via chest tube placement.
.
ACUTE ISSUES:
# Large Exudative Pleural Effusion - High protein and LDH
indicative of exudative pleural effusion. Concern for hemothorax
given large number of RBCs in fluid as well as history of recent
fall on the L side. Also on the differential was malignancy,
though the patient had a normal CT within the last year. Para
pneumonic effusion is also a possibility, though patient was
afebrile. Chest tube was placed and initially drained a
significant amount of serosanguinous fluid. The drainage tapered
off to around 50cc and then 80ccs. Bedside US was preformed by
Interventional Pulmonary which revealed a continued collection,
likely to be amenable to further drainage with adjustment of
chest tube position or placement of a new drainage mechanism.
Intrapleural TPA injected, pigtail inserted, and chest tube
drained copious (1100cc fluid, initially serosanguinous, became
more straw-colored). Serial CXRs showed interval resolution of
effusion. The patient was transferred to Medicine service on
the [**Hospital Ward Name **] for closer care from Thoracic surgery. Pleural
fluid cultures - no growth no acid-fast bacilli, and cytology of
the pleural fluid revealed no malignant cells. Blood cultures
remained negative.
# Hypoxemia: persistent O2 requirement, not using home O2.
Most likely etiology is large pleural effusion. Unlikely COPD
exacerbation because no increased cough or fevers.
# Leukocytosis w/ polys: The patient had an initial leukocytosis
of 15.5 but remained afebrile. The rise was attributed to
possible underlying pneumonia which will be better assessed
after fluid is drained. Given vancomycin and Zosyn to cover
HCAP.
# Tense abdomen: The patient says this is his baseline. However,
given the pleural effusion, Abdominal US was done to rule out
fluid collection/ascities or evidence of cirrhosis. Abd US [**7-18**]
normal.
As Mr. [**Known lastname 15854**] chest CT was essentially unchanged and his
leukocytosis persisted, he was subsequently taken to the
Operating Room on [**2177-7-22**] and underwent a left VATS
decortication. Two large chest tubes were placed and the
incision was left open for packing with saline moist to dry
dressings. He tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics and
his pain was well controlled.
Following transfer to the Surgical floor he remained on IV
Vancomycin and Zosyn and all cultures were negative. His WBC
gradually declined. Unfortunately on post op day #2 his urine
out declined and his creatinine doubled. The Renal service was
consulted and followed him closely. They felt that his [**Last Name (un) **] was
most likely multifactorial but probably contrast nephropathy.
He was rehydrated for 24 hours, renal toxic meds were stopped
and his creatinine peaked at 3.7. His level has been followed
daily and he continued to decline, currently at 2.4 and making
adequate urine daily. His phosphate remained elevated despite
his decreasing creatinine and he was placed on PhosLo TID for 1
week. He will see Dr. [**Last Name (STitle) **] in follow up [**2177-8-11**].
The Infectious Disease service also followed him closely and
changed his antibiotics to Levaquin and Flagyl. All cultures
were negative and possibly
sterilized by abx given in ED which might suggest very
drug-sensitive
organisms like S. pneumoniae, GAS, Neisseria (any of which may
cause pneumonia with large effusions). He will remain on
Levaquin and Flagyl for a total of 4 weeks 9 [**2177-8-23**])and will be
followed closely with weekly blood work.
From a surgical standpoint his wound was starting to granulate
and his chest tubes were converted to one empyema tube which
will be advanced out weekly by Dr. [**Last Name (STitle) 7343**]. He also has a small
chest tube track in his left back which is clean and being
lightly packed with saline damp to dry dressings. He was eating
well, ambulating with his cane and having minimal pain. The
Physical Therapy service felt that he would benefit from some
home physical therapy. His left AC PICC line was removed on
[**2177-7-30**].
After a complicated course, he was discharged to home on [**2177-7-30**]
and will follow up in the Thoracic Clinic in 1 week.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Albuterol Inhaler [**1-13**] PUFF IH Q4H
2. Amantadine 100 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Clobetasol Propionate 0.05% Soln 1 Appl TP [**Hospital1 **]
apply to scalp once daily
5. Desonide 0.05% Cream 1 Appl TP [**Hospital1 **] eczema
Apply to areas of eczema on face twice a day, 1 week on / 1 week
off
6. Diazepam 5 mg PO ONCE Duration: 1 Doses
qAM
7. Diazepam 2 mg PO ONCE Duration: 1 Doses
qHS
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
9. Luvox CR *NF* (fluvoxaMINE) 100 mg Oral [**Hospital1 **]
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. hydrOXYzine HCl *NF* 10 mg Oral [**Hospital1 **]:PRN itchiness
2 tablets by mouth as needed for itchiness
12. Mirtazapine 15 mg PO HS
13. Naproxen 500 mg PO Q12H PRN pain
14. OLANZapine *NF* 30 mg PO HS
15. triamcinolone acetonide *NF* 1 Appl TP DAILY
apply to eczema daily
16. ziprasidone HCl *NF* 60 mg PO qHS
17. Cetaphil *NF* (cetyl & ste alcoh-prop
gly-sls;<br>parab-cety&[**Last Name (un) **] alc-pro
gl-sls;<br>soap;<br>sunscreen) 1 APP Topical DAILY
Apply to skin daily for severe eczema
18. mineral oil-hydrophil petrolat *NF* Topical PRN itchiness
Discharge Medications:
1. Amantadine 100 mg PO BID
2. Amlodipine 10 mg PO DAILY
3. Clobetasol Propionate 0.05% Soln 1 Appl TP [**Hospital1 **]
apply to scalp once daily
4. Desonide 0.05% Cream 1 Appl TP [**Hospital1 **] eczema
Apply to areas of eczema on face twice a day, 1 week on / 1 week
off
5. Diazepam 5 mg PO ONCE Duration: 1 Doses
qAM
6. Diazepam 2 mg PO ONCE Duration: 1 Doses
qHS
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. OLANZapine *NF* 30 mg PO HS
11. Albuterol Inhaler [**1-13**] PUFF IH Q4H
12. Cetaphil *NF* (cetyl & ste alcoh-prop
gly-sls;<br>parab-cety&[**Last Name (un) **] alc-pro
gl-sls;<br>soap;<br>sunscreen) 1 APP Topical DAILY
Apply to skin daily for severe eczema
13. hydrOXYzine HCl *NF* 10 mg Oral [**Hospital1 **]:PRN itchiness
2 tablets by mouth as needed for itchiness
14. Luvox CR *NF* (fluvoxaMINE) 100 mg Oral [**Hospital1 **]
15. mineral oil-hydrophil petrolat *NF* 0 TOPICAL PRN
itchiness
16. Naproxen 500 mg PO Q12H PRN pain
17. triamcinolone acetonide *NF* 1 Appl TP DAILY
apply to eczema daily
18. ziprasidone HCl *NF* 60 mg PO QHS
19. Acetaminophen 650 mg PO Q6H
20. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 tablet(s) by mouth three times a
day Disp #*21 Tablet Refills:*1
21. Docusate Sodium 100 mg PO BID
22. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
thru [**2177-8-23**]
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*66 Tablet Refills:*0
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
please give dose on [**2177-7-19**]
24. Senna 1 TAB PO BID:PRN Constipation
25. Fluvoxamine Maleate 100 mg PO DAILY
26. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg [**1-13**] tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
27. Levofloxacin 500 mg PO Q24H
thru [**2177-8-23**]
RX *Levaquin 500 mg 1 tablet(s) by mouth once a day Disp #*24
Tablet Refills:*0
28. Outpatient Lab Work
Weekly Chem 10, ERS, CRP on Mondays
Fax results to [**Hospital **] Clinic at [**Telephone/Fax (1) 1419**]
ICD 9 510.0
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Primary Diagnoses:
Left empyema
Acute kidney injury
Secondary diagnoses:
COPD, atopic dermatitis, PTSD, Depression, Schizoaffective
disorder, Hepatitis C, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital with chest pain and
shortness of breath. You were found to have fluid in your
lungs, so two chest tubes were placed into your lung cavity to
drain the fluid. Most likely, this fluid developed in your
lungs because of the fall you experienced which caused you to
fracture ribs and injure your lungs.
You ultimately required surgery to drain the infected fluid.
* Your incision is healing from the inside out so will require
twice daily dressing changes. A chest drain remains in place
and will be removed at your appointment with Dr. [**Last Name (STitle) 7343**].
* You have a small tract in your back from a prior tube that is
also being packed. The VNA will help you with this.
* The Infectious Disease service will follow you as well as you
will need long term antibiotics.
* If you develop any chest pain, shortness of breath, high
fevers or any new symptoms that concern you please call Dr.
[**Last Name (STitle) 7343**] at [**Telephone/Fax (1) 2348**].
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2177-8-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: Infectious Disease Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15856**]
[**Telephone/Fax (1) 457**]
Wednesday, [**2177-8-20**] at 10:30 AM
[**Hospital Ward Name 517**]
[**Hospital Unit Name **] [**Last Name (NamePattern1) **]. [**Location (un) 86**] Basement level
Please call Dr. [**Last Name (STitle) **] to set up a follow up appointment in
[**1-13**] weeks.
Completed by:[**2177-7-30**]
|
[
"486",
"790.01",
"311",
"070.54",
"309.81",
"510.9",
"493.20",
"276.2",
"288.60",
"511.89",
"584.9",
"295.70",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.06",
"38.93",
"34.52",
"99.10",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
19521, 19582
|
11535, 16069
|
297, 498
|
19795, 19795
|
4357, 4644
|
21001, 21940
|
3610, 3691
|
17388, 19498
|
19603, 19656
|
16095, 17365
|
19978, 20978
|
3706, 4338
|
19677, 19774
|
5546, 11512
|
5392, 5510
|
247, 259
|
526, 1992
|
4727, 5359
|
19810, 19954
|
2014, 2692
|
2708, 3594
|
4676, 4691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,352
| 196,079
|
39098
|
Discharge summary
|
report
|
Admission Date: [**2137-2-21**] Discharge Date: [**2137-2-27**]
Date of Birth: [**2059-2-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Midline Placement
History of Present Illness:
Mr. [**Known lastname 86647**] is a very pleasant 78 year old man with a PMH
significant for dyslipidemia, hypertension, CKD, COPD, afib,
bladder ca s/po cystectomy/prostectomy with urostomy,
parathyroid resection, and lung nodule resection who presented
to [**Hospital3 26615**] with a day's worth of weaknes. There, he was
found to be hypotense to the 80s sytolic (normally 110s at home
on 2 BP meds), WBC 34,000, a creatinine doubled to 4, and a
lactate of 4.9, with an INR of 4.8. He had a recent U/A at a
PCP's office a week ago which apparently showed a Klebsiella
UTI, for which he was treated with a week's worth of ABX (he is
not sure which kind). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] gave him Levoquin and
Vancomyin. He was also noted at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to have a tropinin
of 0.21.
.
In our ED, he got a CVL for SBPs int he 80s, and got 2 L NS. He
also recieved a dose of Zosyn. Our ED labs were notable for WBC
count of 30.4, with a bandemia of 5%, and a HCT of 37.1, with
plts of 11. Lactate in the ED was 3.1. Levophed was placed at
bedside but not hung.
.
He says that his story started two mondays ago, when he had some
profuse vomiting leading to some back [**Doctor Last Name **], for which his PCP
prescribed him oxycodone. The next Wed (1.5 weeks ago) he
noticed some dark urine; his PCP thus prescribed him an
antibiotic to be taken for a week, which he took diligently. He
A CXR showed a R IJ in place, but no overt pulmonary edema.
.
On arrival to the MICU, he was very pleasant, AAOx3.
.
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 nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Dyslipidemia
Hypertension
CKD (last Cr 2.9 on [**2-1**])
COPD
Atrial fibrillation (paroxysmal, on Coumadin)
Bladder CA s/p cystectomy/prostatectomy
Hyperparathyroidism s/p parathyroid resection [**2135**]
Lung nodule resection (PCP's office has record of adenocarcinoma
of the lung but no info on tx)
Gout
CAD s/p stent placement to LAD and LCx [**2126**]
Social History:
Patient lives [**Location (un) **] with his wife. [**Name (NI) **] a 55 pk/yr history
but quit 10 yrs ago. Has ~2 drinks/week and denies drug use. He
is retired and used to work as at metal worker.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Dry
Neck: supple, JVP not elevated, no LAD
CV: Afib
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: urostomy
Ext: cool
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.8, 98.8, 158/90 (121-158/78-95), 84 (54-84), 20, 99RA
General: Alert, oriented, no acute distress, very pleasant
HEENT: Anicteric sclerae, MMM, oropharynx clear, no JVD,
significant crusting and superficial ulceration of the upper and
lower lips and perioral area
CV: Irregularly irregular rhythm, no m/r/g
Lungs: minimal rales at bases bilaterally, otherwise clear, no
wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, urostomy site clear without bloody output, no
CVA tenderness
Ext: No peripheral edema, no calf tenderness
Pertinent Results:
ADMISSION LABS:
.
[**2137-2-21**] 09:57PM BLOOD WBC-30.4*# RBC-4.07* Hgb-12.6* Hct-37.1*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.1 Plt Ct-111*#
[**2137-2-21**] 09:57PM BLOOD Neuts-87* Bands-5 Lymphs-1* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2137-2-21**] 09:57PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2137-2-22**] 05:42AM BLOOD PT-118.7* PTT-55.3* INR(PT)-12.7*
[**2137-2-22**] 07:39AM BLOOD Fibrino-661*
[**2137-2-22**] 01:38PM BLOOD FDP-0-10
[**2137-2-21**] 09:57PM BLOOD Glucose-135* UreaN-77* Creat-4.6*# Na-138
K-3.7 Cl-100 HCO3-25 AnGap-17
[**2137-2-22**] 05:42AM BLOOD CK(CPK)-438*
[**2137-2-22**] 02:08AM BLOOD CK-MB-15* cTropnT-0.15*
[**2137-2-22**] 05:42AM BLOOD CK-MB-14* MB Indx-3.2 cTropnT-0.15*
[**2137-2-22**] 01:06PM BLOOD CK-MB-12* MB Indx-4.2 cTropnT-0.16*
[**2137-2-22**] 05:42AM BLOOD Calcium-7.5* Phos-5.4*# Mg-1.9
[**2137-2-22**] 01:06PM BLOOD Vanco-9.4*
[**2137-2-22**] 05:52AM BLOOD Type-ART Temp-35.8 pO2-106* pCO2-34*
pH-7.40 calTCO2-22 Base XS--2 Intubat-NOT INTUBA
[**2137-2-21**] 10:04PM BLOOD Lactate-3.1*
[**2137-2-22**] 03:15AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2137-2-22**] 03:15AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2137-2-22**] 03:15AM URINE RBC-7* WBC-86* Bacteri-MOD Yeast-NONE
Epi-0
[**2137-2-22**] 03:15AM URINE Mucous-RARE
.
PERTINENT LABS:
.
[**2137-2-21**] 09:57PM BLOOD WBC-30.4*# RBC-4.07* Hgb-12.6* Hct-37.1*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.1 Plt Ct-111*#
[**2137-2-22**] 05:42AM BLOOD PT-118.7* PTT-55.3* INR(PT)-12.7*
[**2137-2-22**] 07:39AM BLOOD Fibrino-661*
[**2137-2-22**] 01:38PM BLOOD FDP-0-10
[**2137-2-21**] 09:57PM BLOOD Glucose-135* UreaN-77* Creat-4.6*# Na-138
K-3.7 Cl-100 HCO3-25 AnGap-17
[**2137-2-23**] 04:13AM BLOOD ALT-112* AST-63* AlkPhos-309* TotBili-1.1
[**2137-2-22**] 02:08AM BLOOD CK-MB-15* cTropnT-0.15*
[**2137-2-22**] 05:42AM BLOOD CK-MB-14* MB Indx-3.2 cTropnT-0.15*
[**2137-2-22**] 01:06PM BLOOD CK-MB-12* MB Indx-4.2 cTropnT-0.16*
[**2137-2-21**] 10:04PM BLOOD Lactate-3.1*
[**2137-2-22**] 03:15AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2137-2-22**] 03:15AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2137-2-22**] 03:15AM URINE RBC-7* WBC-86* Bacteri-MOD Yeast-NONE
Epi-0
.
DISCHARGE LABS:
.
[**2137-2-27**] 07:20AM BLOOD WBC-7.5 RBC-4.18* Hgb-12.6* Hct-37.7*
MCV-90 MCH-30.1 MCHC-33.4 RDW-15.9* Plt Ct-149*
[**2137-2-27**] 07:20AM BLOOD PT-29.8* INR(PT)-2.9*
[**2137-2-27**] 07:20AM BLOOD Glucose-97 UreaN-39* Creat-2.2* Na-144
K-4.0 Cl-113* HCO3-24 AnGap-11
[**2137-2-27**] 07:20AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0
.
MICRO/PATH:
.
Blood Culture x 2 [**2-22**]: No growth
.
Urine Culture [**2-22**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
MRSA Screen [**2-22**]: No MRSA
.
IMAGING:
.
CXR [**2137-2-21**]:
FINDINGS: There has been interval placement of a right-sided
internal jugular venous catheter. The tip is slightly obscured
by overlapping lead from pacemaker; however, appears to
terminate in the low SVC. A single-lead left-sided pacemaker is
unchanged.Within the lungs, no focal opacity to suggest
pneumonia is seen. No pleural effusion, pulmonary edema, or
pneumothorax is present. There is mild vascular congestion. The
heart size is top normal, unchanged. Chain suture is noted in
the left hemithorax with volume loss suggestive of prior
resection. IMPRESSION: Central catheter in standard position
without pneumothorax.
.
Abdominal U/S [**2137-2-22**]:
IMPRESSION:
1. Small amount of gallbladder sludge. No specific son[**Name (NI) 493**]
sign to
suggest acute cholecystitis. Top normal common bile duct
diameter.
2. Bilateral renal cysts and mild cortical thinning.
Brief Hospital Course:
78 year old man with h/o dyslipidemia, hypertension, CKD, COPD,
afib, bladder ca s/po cystectomy/prostectomy with urostomy,
parathyroid resection, and lung nodule resection who presented
to OSH with a one day of weakness transfered to [**Hospital1 18**] for
evaluation and treatment of sepsis from suspected urinary
source.
.
ACTIVE DIAGNOSES:
.
# Sepsis from Urinary Source: Patient had a UA with 86 WBCs and
large bacteria in setting of unusual urologic anatomy with
urostomy. He was pan-cultured and treated with vanc and zosyn
initially empirically for urosepsis. He was volume resuscitated
with 2L in the ED with CVPs at goal, but continued to by
hypotensive and was started on both levophed and vasopressin in
the MICU. He was able to be weaned off these by the following
day. His antibiotics were changed to vanc/cefepime/flagyl after
obtaining information from his PCP that he had recently been
treated with doxycycline for a Klebsiella UTI (resistant to
ampicillin, nitrofurantoin, piperacillin; sensitive to
cephalsporins; non-ESBL). He was called out to the floor on [**2-23**]
for further management. His antibiotics were narrowed to
ceftriaxone. His fevers, leukocytosis (34K->7K), lactatemia, and
other evidence of end organ ischemia resolved and he no longer
required IV fluids to maintain his pressures. All in-house
culture data was negative or c/w contamination, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
blood cultures were also negative (no urine cultures there). A
midline was placed for him to finish his 10-day total course of
ceftriaxone (last day [**3-3**]).
.
#Acute Renal Failure on CKD, Concern for Acute Tubular Necrosis:
Resolved. Cr peaked in house to 4.6, up from prior baseline of
2.2 but trended back down to 2.2 with pressors and fluids rec'd
in the unit and on the floor. The likely cause for his ARF was
thought to be hypoperfusion secondary to distributive shock from
sepsis causing ATN.
.
# CAD/Troponin Leak: Has known h/o CAD s/p stenting to the LAD
and LCx in [**2126**]. Is not on anti-platelet agents (ASA/plavix)
given h/o heavy bleeding. Was noted at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to have a
tropinin of 0.21 and at [**Hospital1 18**] was 0.15 with normal MB index,
remaining stable on trend. EKG was w/o acute ischemic changes
and pt was asymptomatic. Enzyme leak was attributed to demand in
setting of shock as well as retention from ARF.
.
#. Atrial Fibrillation: Patient presented in AF, but not in RVR,
with supratherapeutic INR (12.7) likely in setting of recent
antibiotics. Per his PCP, [**Name10 (NameIs) **] coumadin dose had recently been
changed from 2 to 1 mg in the setting of his elevated INRs. His
beta blocker and coumadin were held in the setting of his acute
illness and elevated INR. He received 5 mg of vitamin K to help
correct his INR of 12.7. He was restarted on coumadin and his
beta blocker on discharge.
.
# Thrombocytopenia: In setting of elevated INR, concern for DIC-
fibrinogen and FDP were sent and negative. Low platelets were
attributed to septis.
.
# Transaminitis: Likely from mild shock-liver picture from
hypoperfusion. Downtrending and almost wnl's at the time of
discharge. [**Name10 (NameIs) 5283**] U/S unremarkable for structural cause.
.
#Oral Herpes Simplex Recurrence: Not causing many symptoms or
pain. Started during his hospitalization likely related to the
severe stress of medical illness. He was started on a 3-day
course of renally-dosed valacyclovir.
.
CHRONIC DIAGNOSES:
.
# sCHF: Stable. His home diuretic regimen was held during his
acute illness but re-started at the time of discharge.
.
# COPD: Stable. He was continued on his home tioproprium.
.
TRANSITIONAL ISSUES:
.
#Code Status: Patient was Full Code during this admission.
.
#Antibiotics: Patient is receiving a 10 day course of IV
cephalosporins (first cefepime, now ceftriaxone) to end [**3-3**].
.
#Urology Follow-up: Patient may benefit from urology follow-up
for strategies to avoid severe UTI's in the past given his
altered anatomy.
.
#CHF: Patient is not on an Ace inhibitor which is indicated for
his systolic CHF.
.
#Transaminitis: Patient had mild transaminitis on discharge that
was downtrending and almost within normal limits. He had a
relatively unremarkable [**Name (NI) 5283**] U/S. We defer further evaluation of
this issue to the outpatient setting.
.
#INR: This patient will need very tight monitoring of his INR
given his fairly large swings even on low doses.
Medications on Admission:
Coumadin 2 mg Daily (changed to 1 mg [**2-14**])
Allopurinol 100 mg PO BID
Metoprolol Succinate 50 mg Daily
Levoxyl 50 mcg Daily
Simvastatin 10 mg Daily
Isosorbide Mononitrate 30 mg Daily
Furosemide 40-80 mg Daily.
Sodium Bicarb 650 mg QID.
Spectravite
Feosol 65 mg Daily
Stool Softener
Coquenzyme Q-10 100 mg Daily
Spiriva 18 daily
Imdur 30 daily
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day.
Disp:*15 Tablet(s)* Refills:*0*
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO four
times a day.
9. Spectravite Tablet Sig: One (1) Tablet PO once a day.
10. Feosol 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO
once a day.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*0*
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-7**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
Disp:*1 bottle* Refills:*0*
16. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**1-7**]
puff Inhalation four times a day as needed for shortness of
breath or wheezing.
Disp:*1 device* Refills:*0*
17. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 4 days: Last Dose
[**2137-3-3**].
Disp:*4 doses* Refills:*0*
18. valacyclovir 1 g Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
19. Ensure Liquid Sig: One (1) PO three times a day.
Disp:*2 cases* Refills:*0*
20. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*8 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
-Sepsis from urinary source
-Acute Renal Failure
-Mild shock liver
.
Secondary:
-sCHF
-CKD
-Atrial fibrillation
-COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 86647**],
.
It was a pleasure taking care of you! You were transferred to
[**Hospital1 18**] for evaluation and treatment of sepsis from a urinary
tract infection. You were treated in the ICU with fluids,
pressors, and antibiotics and your condition improved
dramatically. You were further evaluated on the floor and you
continued to improve with return of your kidney and liver
function to your prior normal levels. We placed a temporary line
in you for further antibiotic administration to complete your
course.
.
The following changes have been made to your medications:
-START Ceftriaxone 1gram IV once daily for 4 more days (last day
[**3-3**])
-START Valtrex 1gram by mouth once daily for 1 more day (last
day [**2-28**])
-START Ipratropium/Albuterol MDI [**1-7**] inhalations four times a
day as needed for shortness of breath/wheezes
-START Saline nasal spray as needed
-START Senna 1 tab by mouth twice daily as needed for
constipation
-DECREASE Coumadin (warfarin) to 1mg by mouth every other day
(START taking it [**2-28**])
-Continue taking your other home medications as directed
-Please have your INR checked on Friday [**3-1**]
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please follow-up with the appointments listed below.
Followup Instructions:
Name: [**Last Name (un) **],[**Last Name (un) 75760**] A. --Primary Care
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 86648**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 75761**]
Appt: [**3-6**] at 9:45am
Completed by:[**2137-3-2**]
|
[
"V44.6",
"287.5",
"799.02",
"585.9",
"V58.61",
"411.89",
"785.52",
"425.4",
"403.90",
"427.31",
"V45.82",
"V10.46",
"276.2",
"995.92",
"428.22",
"414.01",
"V10.51",
"V10.11",
"570",
"584.5",
"428.0",
"599.0",
"054.9",
"038.9",
"412",
"V45.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15023, 15106
|
8105, 8431
|
312, 332
|
15277, 15277
|
4201, 4201
|
16768, 17075
|
3030, 3113
|
13007, 15000
|
15127, 15256
|
12635, 12984
|
15428, 16745
|
6646, 8082
|
3153, 3579
|
11838, 12609
|
1970, 2418
|
265, 274
|
360, 1951
|
4217, 5656
|
15292, 15404
|
5672, 6630
|
8449, 11817
|
2440, 2798
|
2814, 3014
|
3604, 4182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,742
| 193,069
|
20426
|
Discharge summary
|
report
|
Admission Date: [**2177-4-16**] Discharge Date: [**2177-4-20**]
Date of Birth: [**2111-5-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
bilateral knee pain
Major Surgical or Invasive Procedure:
bilateral total knee replacements
History of Present Illness:
Ms [**Known lastname **] has had progressive bilateral knee pain that has been
refractory to conservative treatment. She elects for definitive
treatment.
This is a 65 year old female with PMH of HTN,
hypercholesterolemia, bilateral osteoarthritis of the knees,
piriformis syndrome, SI joint dysfunction, chronic back pain,
GERD/reflux who is presenting to the [**Hospital Unit Name 153**] s/p bilateral TKA for
further monitoring of post-operative hypotension and atrial
fibrillation. Per anesthesiology, her surgery was long and
complicated by extensive blood loss. She received 3.5 Liters of
IVFs intra-operatively. Post-operatively she was extubated
without difficulty, but did develop atrial fibrillation with a
heart rate between 60s-120s. She was then given an additional 2
Liters of IVFs and 2 units of autologous pRBCs transfusion. She
was also given 10mg of IV metoprolol and spontaneously converted
back to sinus rhythm around 8PM. Unfortunately, she remained
persistently hypotensive as low as the mid 80s systolic despite
these interventions. As a result, an epidural that was placed
for pain control was capped prior to transferring her to the
[**Hospital Unit Name 153**] for further hemodynamic monitoring.
.
In the ICU, the patient was not reporting any pain and was in
normal sinus rhythm. She also reports being asymptomatic with
her low blood pressures and tachycardia. In particular, she did
not experience any palpitations, lightheadedness, dizziness,
headache, change in vision, chest pain, or shortness of breath.
Her main complaint is fatigue.
Past Medical History:
hyperlipid, HTN, pre-DM2, reflux
Social History:
nc
Family History:
nc
Physical Exam:
well appearing, well nourished 65 year old female
no acute distress
alert and oriented
BLE:
-dressing-c/d/i
-incision-c/d/i
-+AT, FHL, [**Last Name (un) 938**]
-SILT
-brisk cap refill
-calf-soft, nontender
-NVI distally
Pertinent Results:
1. Labs on admisison:
[**2177-4-16**] 08:20PM BLOOD WBC-14.1*# RBC-3.93* Hgb-11.2* Hct-34.1*
MCV-87 MCH-28.4 MCHC-32.8 RDW-14.1 Plt Ct-296
[**2177-4-17**] 03:57AM BLOOD PT-14.1* PTT-31.2 INR(PT)-1.2*
[**2177-4-16**] 08:20PM BLOOD Glucose-159* UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
[**2177-4-16**] 08:20PM BLOOD CK(CPK)-65
[**2177-4-17**] 03:57AM BLOOD CK(CPK)-57
[**2177-4-16**] 08:20PM BLOOD CK-MB-2 cTropnT-<0.01
[**2177-4-17**] 03:57AM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-4-17**] 03:57AM BLOOD Mg-1.5*
[**2177-4-19**] 07:30AM BLOOD WBC-8.4 RBC-2.70* Hgb-7.5* Hct-23.7*
MCV-88 MCH-27.8 MCHC-31.7 RDW-13.5 Plt Ct-283
[**2177-4-19**] 07:30AM BLOOD WBC-8.4 RBC-2.70* Hgb-7.5* Hct-23.7*
MCV-88 MCH-27.8 MCHC-31.7 RDW-13.5 Plt Ct-283
[**2177-4-18**] 07:35AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.6* Hct-26.5*
MCV-87 MCH-28.3 MCHC-32.4 RDW-13.6 Plt Ct-290
.
2. Labs on discharge:
Hct 26.5 -> hct 23.7 -> 2u -> hct 28.9.
3. Imaging/diagnostics:
XR B knees good postop.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Patient was transferred to the [**Hospital Unit Name 153**] given hypotension and atrial
fibrillation
Postoperative course was remarkable for the following:
1. epidural - managed by APS. pulled POD1
2. post op anemia - transfused 1 autologous unit on POD0 in PACU
and 1 autologous unit on POD1 then 2u PRBCs on POD 3 for hct
23.7. Posttranx hct prior to DC was 28.9.
Otherwise, pain was initially controlled with a epidural and PCA
followed by a transition to oral pain medications on POD#1. The
patient received lovenox for DVT prophylaxis starting on the
morning of POD#1. The foley was removed on POD#2 and the
patient was voiding independently thereafter. The surgical
dressing was changed on POD#2 and the surgical incision was
found to be clean and intact without erythema or abnormal
drainage. The patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms [**Known lastname **] is discharged to rehab in stable condition.
Medications on Admission:
advil, HCTZ, moexipril, naprosyn, neurontin, omeprazole, vit D,
pravachol
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*50 Tablet(s)* Refills:*1*
3. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing all lovenox injections,
please take as directed with food.
Disp:*42 Tablet(s)* Refills:*0*
4. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 3 weeks.
Disp:*21 syringe* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
10. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
11. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 2
weeks.
Disp:*56 Tablet Extended Release 12 hr(s)* Refills:*0*
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
bilateral knee osteoarthritis
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for an additional three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. ROM as tolerated. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
Physical Therapy:
WBAT
ROM
Mobilize
Treatments Frequency:
dry, sterile dressing changes daily as needed for drainage
wound checks
ice and elevate
staple removal and replace with steris on POD 17
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2177-5-16**] 11:40
Completed by:[**2177-4-20**]
|
[
"E878.1",
"338.29",
"272.0",
"285.9",
"427.31",
"724.5",
"997.1",
"458.29",
"530.81",
"715.36",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6894, 6964
|
3327, 5048
|
325, 361
|
7038, 7038
|
2329, 3196
|
10412, 10644
|
2063, 2067
|
5173, 6871
|
6985, 7017
|
5074, 5150
|
7221, 9409
|
2082, 2310
|
10210, 10229
|
10251, 10389
|
266, 287
|
3215, 3304
|
9421, 10192
|
389, 1970
|
7053, 7197
|
1992, 2027
|
2043, 2047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,812
| 139,832
|
31185
|
Discharge summary
|
report
|
Admission Date: [**2162-8-1**] Discharge Date: [**2162-9-18**]
Date of Birth: [**2132-2-26**] Sex: F
Service: SURGERY
Allergies:
Erythromycin
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
[**Known firstname 402**] [**Last Name (NamePattern1) **] is a 30-year-old female who was transferred by
[**Location (un) **] from [**Hospital **] Hospital [**2162-8-1**] in septic shock and
respiratory failure secondary to a necrotizing soft tissue
infection of the external genitalia, perineum, and lower
abdominal wall
Major Surgical or Invasive Procedure:
1. Radical debridement of necrotizing soft tissue infection
of external genitalia, perineum, and lower abdominal wall.
2. Right chest tube thoracostomy
3. Exploratory laparotomy with gastrostomy tube placement and
diverting sigmoid colostomy.
4. Tracheostomy.
5. Irrigation and debridement of abdominal and perineal wounds
with VAC dressing placement.
6. Flexible bronchoscopy
7.Right apical tube thoracostomy
8. Exploratory laparotomy.
9. Irrigation and drainage of peritoneal sepsis.
10. Removal of gastrostomy tube with gastrorrhaphy.
11. Placement of 18-French gastrojejunal feeding tube.
12. VAC dressing change of lower abdomen and perineum.
13. Meshed skin graft to lower abdomen and perineum.
14. Preparation of wound bed.
15. Placement of wound VAC.
History of Present Illness:
30 yo female with history of cocaine and IV drug abuse, leukemia
as a child (whole brain irradiation and chemotherapy), presented
to the ED on [**8-1**] with anorexia and dehydration, complaining of
pelvic pain and reddened area on right leg. She was diagnosed
with nectrotizing fasciitis of perineum, lower rectum and
abdomen.
Past Medical History:
Cocaine and IV drug abuse, depression, leukemia as a child.
Stroke as a teenager. cognitive difficulty's
Coping with her addiction throughout her adolescence and early
adulthood.
Social History:
IV drug abuse
Family History:
non contributory
Physical Exam:
Temp 98.9, Pulse 90, BP 92/64, RR 18 O2 sats 96% RA
Gen: thin patient with trach tube in place, no acute distress
Chest: clear to ausculation bilat
CV: regular rate and rhythm
Abd: moderately tense, soft, non distended
Perineal wound - split thickness skin graft healing well,
granulation tissue present
Pertinent Results:
[**2162-8-1**] 06:12AM BLOOD Neuts-34* Bands-40* Lymphs-13* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-2* Promyel-1*
[**2162-8-1**] 02:45AM BLOOD WBC-19.9* RBC-3.92* Hgb-12.2 Hct-38.2
MCV-97 MCH-31.1 MCHC-32.0 RDW-13.9 Plt Ct-379
[**2162-8-2**] 02:42AM BLOOD WBC-31.3* RBC-2.58* Hgb-8.0* Hct-24.8*
MCV-96 MCH-30.9 MCHC-32.2 RDW-14.6 Plt Ct-111*
[**2162-8-13**] 03:30AM BLOOD WBC-21.0* RBC-2.50* Hgb-7.4* Hct-22.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.9 Plt Ct-693*
[**2162-8-21**] 03:12AM BLOOD WBC-46.1* RBC-2.47* Hgb-7.4* Hct-22.9*
MCV-93 MCH-30.1 MCHC-32.4 RDW-16.2* Plt Ct-575*
[**2162-9-16**] 06:00AM BLOOD WBC-15.0* RBC-2.92* Hgb-8.7* Hct-26.5*
MCV-91 MCH-29.9 MCHC-33.0 RDW-15.9* Plt Ct-375
[**2162-9-6**] 10:18AM BLOOD PT-14.6* PTT-34.1 INR(PT)-1.3*
[**2162-8-2**] 09:42AM BLOOD WBC-34.8* Lymph-8* Abs [**Last Name (un) **]-2784 CD3%-71
Abs CD3-[**2121**]* CD4%-53 Abs CD4-1487* CD8%-17 Abs CD8-484
CD4/CD8-3.1*
[**2162-8-1**] 02:45AM BLOOD Glucose-187* UreaN-42* Creat-0.7 Na-141
K-3.7 Cl-111* HCO3-15* AnGap-19
[**2162-8-3**] 12:37PM BLOOD Glucose-113* UreaN-48* Creat-1.0 Na-132*
K-4.1 Cl-99 HCO3-20* AnGap-17
[**2162-9-16**] 06:00AM BLOOD Glucose-98 UreaN-18 Creat-0.3* Na-137
K-4.6 Cl-99 HCO3-31 AnGap-12
[**2162-8-1**] 02:45AM BLOOD ALT-432* AST-632* AlkPhos-118* Amylase-5
TotBili-1.2
[**2162-8-6**] 02:27AM BLOOD ALT-96* AST-57* LD(LDH)-550* AlkPhos-81
Amylase-75 TotBili-2.0*
[**2162-9-3**] 03:37AM BLOOD ALT-15 AST-24 AlkPhos-132* Amylase-37
TotBili-0.3
[**2162-8-1**] 05:59PM BLOOD CK-MB-25* MB Indx-1.7 cTropnT-<0.01
[**2162-8-1**] 02:45AM BLOOD Albumin-1.6* Calcium-5.9* Phos-5.0*
Mg-2.7*
[**2162-8-3**] 02:49AM BLOOD Albumin-2.3* Calcium-8.6 Phos-4.1 Mg-2.1
[**2162-8-19**] 03:40AM BLOOD Albumin-1.9* Calcium-8.0* Phos-5.5*
Mg-2.2
[**2162-9-16**] 06:00AM BLOOD Calcium-9.1 Phos-5.2* Mg-1.9
[**2162-8-6**] 02:27AM BLOOD TSH-0.88
[**2162-8-2**] 09:42AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2162-8-1**] 02:48AM BLOOD Type-ART pO2-66* pCO2-48* pH-7.01*
calTCO2-13* Base XS--19
[**2162-8-1**] 09:00PM BLOOD Type-ART Temp-40.1 Rates-16/ FiO2-100
pO2-86 pCO2-46* pH-7.23* calTCO2-20* Base XS--8 AADO2-602 REQ
O2-96 Intubat-INTUBATED Vent-CONTROLLED
[**2162-8-1**] 04:03AM BLOOD Glucose-138* Lactate-4.0* Na-139 K-3.8
Cl-119*
[**2162-8-2**] 08:42PM BLOOD Lactate-3.6*
[**2162-8-25**] 01:17PM BLOOD Glucose-108* Lactate-0.9 K-3.8
[**2162-8-1**] 02:48AM BLOOD freeCa-0.76*
[**2162-8-3**] 10:11AM BLOOD freeCa-1.17
.
CHEST (PORTABLE AP) [**2162-8-1**] 6:20 AM
The right chest tube now lies within the right chest. There is
no pneumothorax.
Bilateral consolidations persist.
IMPRESSION: Chest tube in right chest. No pneumothorax.
.
SPECIMEN SUBMITTED: DEBRIDEMENT OR PERINEUM AND ABDOMINAL WALL.
DIAGNOSIS:
Perineum and abdominal wall debridement:
1. Necrotizing fascitis, see note.
2. One lymph node, no malignancy identified.
.
SPECIMEN SUBMITTED: LABIA.
DIAGNOSIS:
Labia, biopsy:
A. Squamous mucosa and skin with necrosis and acute
inflammation.
B. Fungal organisms, hyphae and yeast forms, present in tissue.
See note.
Note:
A GMS stain highlights the fungal organisms. The fungus is
consistent with [**Female First Name (un) 564**] species, similar to tissue cultures (see
microbiology report).
The fungus is in the necrotic tissue and also appears to be
present within vascular lumens. The presence of fungus does not
necessarily imply a primary fungal infection. The fungus may
have secondarily colonized necrotic tissue. Less likely, the
fungus is a contaminant. Clinical correlation recommended.
.
CHEST (PORTABLE AP) [**2162-8-2**] 4:45 AM
Severe bilateral pulmonary consolidation has improved slightly
on the right, worsened appreciably on the left over the past 24
hours. In the setting of normal heart size, this is probably
noncardiogenic pulmonary edema. Right pleural tube has been
repositioned since 3:00 a.m. on [**8-1**]. The course suggests
fissural placement. There is no appreciable pleural effusion.
Mediastinum is midline. ET tube, right jugular line, and
nasogastric tube are in standard placements.
.
CHEST (PORTABLE AP) [**2162-8-5**] 5:15 AM
There is no change in asymmetric pulmonary edema, punctated
_____ by interstitial pulmonary emphysema. No evidence on this
portable radiograph for pneumothorax is present although note is
made that there is increase in the amount of subcutaneous
emphysema. The right tracheostomy tube is still sharply folded
and could be fissural _____. ET tube and nasogastric tube as
well as right internal jugular vein and transsubclavian
Swan-Ganz catheter are in standard placement. Heart size is
normal and the mediastinum is midline.
.
CT ABDOMEN W/O CONTRAST [**2162-8-5**] 11:17 AM
IMPRESSION: 1) Kinked right-sided chest tube with its tip very
close to the right hilum and pulmonary artery.
2) Small to moderate anterior and posterior right pneumothorax
and marked right subcutaneous emphysema.
3) Diffuse cystic lung disease involving bilateral lungs, most
prominently in right upper and bilateral lower lobes, with
thick-walled appearance of the cysts. This is associated with
diffuse bilateral groundglass opacification and areas of more
dense consolidation/atelecatses at the lung bases.
Overall appearnces in conjunction with the preceding series of
chest radiographs is somewhat unusual and precise etiology is
uncertain. However, given the history of IV drug use and
associated diffuse ground-glass opacity, differntial diagnosis
might include pneumocystis carinii pneumonia. Appearnces are
somewhat atypical for barotrauma with pneumatocele formation. If
the patient is a smoker, Langerhans histiocytosis can be in
consideration, however, the asymmetric distribution is somewhat
unusual. Appearnces are most unusual for other causes of diffuse
cystic diseases such as LIP (lymphocytic interstitial
pneumonia), LAM (lymphangioleiomyatosis), and cystic
bronchiectasis
4) Diffuse ground- glass opacity and bilateral lower lobe
consolidation, likely representing edema or pneumonia.
5) Limited study of the abdominal organs due to lack of IV
contrast [**Doctor Last Name 360**]. Moderate ascites. Hyperdense bile in the
gallbladder.
6) Status post debridement of the lower abdominal wall.
.
CHEST (PORTABLE AP) [**2162-8-13**] 4:30 AM
Reason: s/p tarch with increased FIO2 requirement r/o PNX
IMPRESSION:
1. Slight increase in size of circumferential right
pneumothorax.
2. Slight interval worsening in opacification of the left lung
and stable appearance of diffuse cystic abnormalities likely
pneumatoceles secondary to known Staph aureus infection.
.
[**Numeric Identifier 73612**] CHANGE GASTROSTOMY TUBE [**2162-8-20**] 1:17 PM
IMPRESSION: Unsuccessful attempt to convert G-tube to a GJ tube.
.
CT ABDOMEN W/CONTRAST [**2162-8-27**] 11:14 AM
IMPRESSION:
1. No evidence for developing fluid collection or abscess within
the abdomen/pelvis. Extensive post-surgical changes. Mildly
distended proximal large bowel. No definite obstruction is
identified, however, if contrast does not exit the ostomy within
several hours, a followup KUB could reevaluate.
2. Appropriately located GJ-tube. Persistent right pneumothorax
and diffuse basilar lung disease.
.
VIDEO OROPHARYNGEAL SWALLOW PORT [**2162-9-3**] 8:23 AM
IMPRESSION: Normal oral and pharyngeal phases of swallowing with
no aspiration or penetration.
.
CHEST (PORTABLE AP) [**2162-9-9**] 7:23 AM
Single AP view of the chest reveals a tracheostomy tube in
place. In comparing the present examination with that of
[**2162-8-29**], the right pleural tube has been removed. A PICC line
is noted with the tip in the SVC. The opacities are noted
throughout the lungs, primarily in the right upper and lower
lobes as well as increased markings of the left. However, there
appears to be improvement in the appearance of opacities
throughout both lung fields, although a prominent bleb in the
noted in the right mid lung zone.
CONCLUSION: Improvement in the appearance of the chest since the
examination of [**2162-8-29**].
.
Brief Hospital Course:
The patient was admitted on [**2162-8-1**] for septic shock and
respiratory failure
secondary to a necrotizing soft tissue infection of the external
genitalia, perineum, and lower abdominal wall. She was taken to
the OR for Radical debridement of necrotizing soft tissue
infection of external genitalia, perineum, and lower abdominal
wall. It was also noted there was right sided white out on CXR
and a chest tube x2 was placed on the right. She was noted to
still be hypoxic and placed left side lateral with oxygen
saturation up to 93%. There were multiple vent changes and
arterial blood gases performed. She was also noted to be
febrile to 104.3 and a cooling blanket was placed. Her blood
pressure remained labile with neo/levo/vasopressin drips to keep
MAP>60.
[**8-2**]- Patient swanned in am, high PAP's, lasix given x2 with
minimal effect, 2 units PRBCs given, albumin, TEE. Attempting
to wean neo, prop changed to ativan, remains paralyzed, weaning
vent as tolerated, temperatures 99s, changed to tyradine bed,
1arge air leak with CT. Wound changes conducted, showed copious
amounts of serous drainage, blood cultured, new a line.
[**8-3**] - neo weaned off, slow wean with levophed for Map >60,
Abg's improving, weaning FiO2 down to 50%, 1 unit PRBC for low
SVO2's and chronic anemia with positive effect, tmax 102,
cooling blanket, blood cultured, platelets 40s, heparin held,
hit sent, CXR improving.
[**8-4**] Continued to wean levo drip to keep SBP >90, weaning vent
with PEEP to 18 resp rate 22, ABG's alkylotic, resp rate
30s-40s. Levo up a bit over night, fentanyl and pitressin drips
for SBP>90. No vent changes. ABGs OK. Tachypneic. Platelets and
Hct okay
[**8-5**] Febrile, weaning levo pit remains @2.4. Fentanyl drip
d/c'd. More awake, moving right arm when stimulated, doesn't
follow commands. Withdraws to pain, CT Head/Chest/Pelvis.
Continues to ooze large amount from a-line site. Oozing copious
amounts from abdominal wound. Central line placed left
subclavian. Right internal jugular line was removed and tip sent
for culture. Increased loose stool. Mushroom catheter
discontinued per Dr. [**Last Name (STitle) 1924**] and flexiseal placed for large
amount of brown stool. Lasix x1 was given.
[**8-6**] PA line out, levo weaned, PEEP weaned, AFEB, Lasix x2, 2U
PRBCs, bronched
[**8-8**] Remains off vasopressin. Attempted wean of levophed but BP
labile, 70-100. Keeping MAP>60. WBC up 25 (22). Pan cultured
including pleural fluid, stool, CVL line tip, CVL resited.
Methadone increased. Fentanyl weaned to 100 mcgs/hr. Persistent
severe air leak. Thoracic and SICU made aware off/on loss of
tidal volumes on vent. Many CXRs. On MMV from PS today. PS as
high as 25. Currently weaning PS and PEEP and tolerating.
Following serial ABGS throughout dat. NPO at midnight for
Peg/Trach/ileostomy, NS bolus x1 for low urine output and low
BP.
[**8-9**] OR cancelled, no vent changes made, increased WBC, febrile,
red rash vs cellulitic areas unchanged. Temp spike to 102.9,
pan cultured. New area of rash RLE. TFs resumed, advancing to
goal of 70 cc/hr. Unable to wean levo further than 0.09 mcgs.
[**8-10**] Vent down to CPAP [**5-13**], tol well, unable to wean levo, tol
TFs, dressing change increased to TID. T max 102.3, no cultures
done, pan cultured at midnight [**8-10**]. Tolerating CPAP [**5-13**]. High
residuals, TFs stopped and resumed at 30 cc/hr advancing q6h.
Levo weaned to 0.05 mcg/kg/min unable to turn off. Bp 70s, Map
<55. Placed on [**Doctor First Name **] air bed. Bottom left OTA and kept dry as much
as possible with some improvement. Dressing changes TID dry
packings.
[**8-11**] No vent changes, t mas 102.1, levophed unable to be weaned.
Noticed leak around flexiseal into wound.
[**8-12**] to OR for trach/peg/diverting colostomy. Abdominal wound
debrided further and vac dressing in place. Pt bronched post OR
as she desated x 2 in OR. Tmax 101.6 no cx ordered, levo
continued to maintain BP.
[**8-13**] Anterior CT placed- another leak. Bronchoscopy performed.
Vac intact, remains on fent, levo, methadone increased.
[**8-15**] no temps, started on cisatracurium drip, weaning levo, on
fent and propofol drips, acidosis, CT x 2, colostomy
functioning, TF at goal.
[**8-16**] Worsening resp status, started on roto-prone therapy. Vac
dressing changed by plastics. On fent/versed/cist. Will desat
when not completely sedated and appropriately paralyzed.
[**8-17**] Cont on rotoprone therapy. Pt hypotensive with left lung
down. Degree of rotation adjusted to accomodate adequate SBP. A
line placed ABGs improving PEEP down to 12.
[**8-18**] Continues on rotoprone. WBC better. Stable over night.
Lasix held secondary to hypotension. Diamox cont q6. TF stopped
secondary to high residuals. Restarted at 1/2 strength. FS low
this am received 1 amp of D50. Cont to be supine rotating 60
degrees on each side for 10 min hold. ABGs improving, Peep down
to 8
[**8-19**] AC 40%, 8 PEEP with great ABG. VAC leaking, plastics to
change dressing and then decide to have nursing do wet to dry,
they will put new dressing on [**8-20**]. Patient continued with
moderate residual >200 this am over 2 hours. TF stopped and PEG
tube placed to gravity - dumped 450cc gastric fluid. Green ooze
noted around PEG tube insertion site. T max 101.7 pan cultured
and given tylenol. Urine output dropping and given 1 liter.
[**8-20**] Head/chest/abdomen CT done. Attempted j tube placement in
angio - unable to do. CT showed free air. Off roto prone bed.
WBC elevated, started on vanco/piperacillin.
[**8-21**] s/p exp lap, repair of gastrostomy, placement of g-j tube,
peritoneal irrigation, vac dressing change. Off paralytics, on
CPAP. awake on ativan 8mg/hr. Patient stable, low grade fevers,
good ABGs, no weaning.
[**8-22**] Temp spike 102.4, tachy, no vent changes, tylenol via
colostomy. Patient with periods of desat and low PaO2s. CXR
worsening pneumo. SXn on CT increased to -40 Tolerating TF at
10cc/hr, sats 96-98%, desats on left side, ativan drip at 6mg/hr
[**8-23**] off sedation, CPAP [**10-24**], Tube Feeds to 20, line changed,
TPn started. K/glucose chronically low,. Vac dressing changed.
Patient is slow to [**Last Name (LF) **], [**First Name3 (LF) 2995**] and grimaces to pain. Not following
commands, hypotensive fluid bolus x1, tmas 102.4 motrin given.
[**8-24**] no change, still temp spikes
[**8-25**] received 600mcg Fent for vac change. Foley changed, PS and
PEEP weaned and gases improving.
8/16 PEEP down to 5. tmax 101.6 pan cultured. Restarted
antidepressant, wean methadone.
[**8-27**] tmax 100.6, abd CT done, desat - FiO2 increased to 50% for
a few hours, back to 40%, tachy to 140s, 500cc fluid bolus x2,
CT to water seal.
[**8-28**] vac dressing change by plastics, methadone increased for
pain, ativan for aggitation
[**8-29**] quiet day, ativan for aggitation, more interactive, WCC up
to 21
[**9-2**]- patient comfortable, no issues with aggitation. Visiting
with family. Tolerating PMV very well. bedside swallow done,
patient passed. Tolerating tube feeds, min g tube residuals. OOB
to chair well tolerated.
[**9-3**] Patient continues to have #8.0 Portex Trach with cuff
deflated and PMV on. Pt continues on 0.4 FiO2 via trach mask.
Trach site remains stable, no redness/swelling/pain. IC remains
in place. Sutures removed by Rn. VAC dressing changed, require
600 mcg Fent/2mg ativan for fair pain relief.
[**9-4**] alert and oriented x 3, follows commands, methadone,
ibuprofen, and neurontin as ordered. Transferred to the floor
[**9-5**] Blood cultures, urine analysis and CXR done for t max
101.4. Respiratory saw patient for help with airway suction.
[**9-6**] Plastics performed split thickness graft of skin to
abdominal wall and perineal area. Patient tolerated procedure
well and was returned to the floor.
[**9-7**] PICC line placed, CVL d/c'd.
[**9-11**] Vac down, graft looks good. Xeroform to graft, dry dressing
over xeroform
[**9-14**] Foley catheter changed.
[**9-16**] Tolerating cycled tubefeedings. Continue to encourage PO
intake. Calorie counts revealed 875 kcals with 25 gram protein.
She will eat what her parents bring in from home.
Trach downsized to #7.0 Portex cuffless, non-fenestrated.
Ambulated short distance with PT.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4PRN ().
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed.
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
7. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
9. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
10. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed: for breakthrough pain
.
11. Gabapentin 250 mg/5 mL Solution Sig: Three (3) PO TID (3
times a day).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Quetiapine 25 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for anxiety and insomnia: anxiety and insomnia
.
15. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by
1ml of 100 units/ml heparin (100 units heparin) each lumen QD
and PRN. Inspect site every shift .
17. Caspofungin 70 mg Recon Soln Sig: Fifty (50) mg Intravenous
Q24H (every 24 hours) for 17 days: starting [**8-17**].
end [**10-4**]
.
18. Multivitamins with Minerals Capsule Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
[**2162-8-12**] Post op diagnosis 1. Necrotizing soft tissue infection of
the external genitalia, perineum and lower abdominal wall,
status post radical debridement. 2. Failure to wean from the
ventilator.
.
[**2162-8-12**] Post op diagnosis- Pneumothorax and air leak.
[**8-13**] Bronchopleural fistula.
.
[**8-20**]
1. Intra-abdominal sepsis.
2. Free intraperitoneal air.
3. Leakage of gastric contents via gastrostomy tube site
into peritoneal cavity.
.
[**2162-9-6**] Open abdominal wound status post debridement.
.
Discharge Condition:
Good
Trach downsized on [**2162-9-16**] to Portex #7 cuffless.
Tolerating cycled tubefeedings. Encourage PO intake.
Wound intact with Xeroform dressing
Needs continued PT
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
* Continue with tubefeedings cycled over night and increase your
diet as tolerated.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in [**2-13**] weeks. Call [**Telephone/Fax (1) 7508**]
to schedule an appointment.
.
Please follow-up with Plastic Surgery in [**2-13**] weeks. Call ([**Telephone/Fax (1) 73613**] to schedule an appointment.
|
[
"518.81",
"V10.60",
"567.29",
"112.9",
"995.92",
"512.8",
"785.52",
"510.0",
"438.0",
"285.9",
"512.1",
"996.59",
"038.8",
"305.93",
"728.86",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"44.61",
"43.19",
"93.59",
"54.12",
"96.59",
"99.04",
"33.22",
"96.72",
"99.77",
"89.68",
"86.22",
"54.25",
"83.39",
"31.1",
"86.63",
"34.09",
"43.11",
"88.72",
"46.10",
"44.39",
"34.04",
"97.51",
"96.6",
"71.5",
"38.93",
"99.21",
"71.79"
] |
icd9pcs
|
[
[
[]
]
] |
20629, 20708
|
10379, 18679
|
593, 1354
|
21274, 21447
|
2318, 10356
|
22620, 22887
|
1961, 1979
|
18702, 20606
|
20729, 21253
|
21471, 22597
|
1994, 2299
|
232, 555
|
1382, 1712
|
1734, 1914
|
1930, 1945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,078
| 185,483
|
2455
|
Discharge summary
|
report
|
Admission Date: [**2146-12-5**] Discharge Date: [**2146-12-14**]
Service: [**Hospital Unit Name 153**]
REPORT COVERS ICU COURSE FROM [**0-0-**]: This is
a [**Age over 90 **]-year-old male, a resident of [**Hospital 100**] Rehab, who came to
the Emergency Room with chief complaint of nausea, vomiting,
shortness of breath and fever. He was found to be hypoxic,
hypotensive and febrile by EMS with blood pressure of
80/palp, heart rate 130, respiratory rate 40, O2 sat 79% on 5
liters. He has a history of chronic diarrhea, with a recent
admission in [**2146-9-17**], in which he was found to have
acute proctitis by EGD and colonoscopy, and was currently
scheduled to have a repeat sigmoidoscopy for recurrence of
this diarrhea. On the day of admission, the patient vomited
and acutely became hypoxic and dyspneic after this. At
baseline, he has no dementia and has clear mental status. He
does have right-sided weakness and some dysarthria at
baseline.
Upon arrival to the ED, sepsis code was called, and the
patient received ceftriaxone, vancomycin, and a sepsis line,
as well as 4 liters of normal saline, and was started on
Levophed for his pressors.
PAST MEDICAL HISTORY:
1. Congestive heart failure secondary to diastolic
dysfunction with ejection fraction greater than 60%, mild
left ventricular hypertrophy, 1+ mitral regurgitation, and 1+
aortic regurgitation.
2. Hypertension.
3. Peripheral vascular disease, status post right
femoral-popliteal bypass graft in [**2146-4-17**].
4. Hemorrhagic cerebrovascular accident in [**2137**] with
right-sided weakness and dysarthria.
5. Benign prostatic hypertrophy, status post TURP.
6. Osteoarthritis of the hip.
7. Recurrent pneumonia.
8. Tonsillectomy.
9. Right inguinal hernia repair.
10.Remote peptic ulcer disease.
MEDICATIONS UPON ADMISSION:
1. Tylenol 650 mg q 4 h.
2. Norvasc 5 mg po qd.
3. Aspirin 81 mg po qd.
4. Enalapril 5 mg po bid.
5. Lasix 20 mg q Monday, Wednesday and Friday.
6. Lansoprazole 30 mg po qd.
7. Lopressor 12.5 mg [**Hospital1 **].
8. Multivitamin.
9. Oxybutynin 5 mg po tid.
10.Ambien 5 mg po q hs.
11.Nystatin swish and swallow.
12.Flagyl 500 mg po tid, scheduled to stop on [**2146-12-9**].
ALLERGIES:
1. Sulfa medications.
2. Ether.
SOCIAL HISTORY: The patient is a resident of [**Hospital3 1761**] for 8 years, since his hemorrhagic CVA. He
quit tobacco 40 years ago. He denies alcohol or drug use.
His healthcare proxy is his son, [**Name (NI) **], who lives close
by. The patient does not ambulate at baseline and is in a
wheelchair. He is very active at [**Hospital3 **], and
is the head of the men's club, and is an activist for many of
the residents there.
EXAM ON ADMISSION: Temperature 101.8, pulse 100, blood
pressure 80/50, respirations 30, 93% saturation on nasal
cannula. In general, he was an elderly male, ill-appearing,
dry mucous membranes, flat neck veins. Lungs had bronchial
breath sounds over the left base anteriorly. Heart was
tachycardic, regular, without murmurs. Abdomen soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities - no edema. The patient was awake, moaning,
moving hands and feet to command. Reflexes - trace at the
ankles, 1+ brachial. Skin had no rashes. A small foot
ulcer, dressed, over the ball of the right foot. There was a
right scar from previous vascular surgery on his right leg.
LABS ON ADMISSION: White blood count 27.4, hematocrit 36.4,
platelets 404, sodium 143, potassium 2.6, chloride 114,
bicarbonate 11, BUN 54, creatinine 2.4, glucose 175, anion
gap 18, change in his anion gap/change in his bicarbonate
equals less than 0.5, calcium 9.4, magnesium 1.6, phosphorus
1.7, ALT 9, AST 13, alk phos 95, total bilirubin 0.7, albumin
3.4, LDH 130, total protein 5.5, amylase 94, lipase 48, CK
20, troponin 0.05, PT 14.5, PTT 28, INR 1.4. ABG initially
on room air 7.26/26/64/12, lactate 5.4. Chest x-ray on
admission shows a left lower lobe infiltrate and a right IJ
central line in good position. Urinalysis - specific gravity
1.021, small blood, [**1-20**] white cells, [**10-7**] red cells, 0
bacteria, positive hyaline casts. EKG - sinus rhythm, 96,
normal axis, normal intervals, 0.[**Street Address(2) 1755**] depressions V1
through V3.
PERTINENT STUDIES THIS ADMISSION: [**2146-12-5**], the patient
had a portable KUB to assess for ?bowel obstruction, and it
did show a possibility of early partial small bowel
obstruction, and recommended follow-up. Follow-up study done
on [**2146-12-7**] showed no evidence for intestinal obstruction.
CT of the head without contrast done [**2146-12-9**]--this was
done for a history of prior CVA with now change in mental
status. It showed no acute intracranial hemorrhage, and
tissue loss noted in the left thalamus consistent with his
old known hemorrhagic stroke.
Ultrasound of his right upper extremity done [**2146-12-12**] for
edematous right arm showed nonocclusive clot within the right
IJ and one of his two brachial veins thrombosed.
HOSPITAL COURSE FROM [**0-0-0**]: This is a
[**Age over 90 **]-year-old male, with a history of chronic diarrhea, past
hemorrhagic CVA, who was admitted to the [**Hospital Ward Name 12573**] Intensive
Care Unit with an aspiration pneumonia after vomiting, and
subsequent development of sepsis and respiratory failure.
Postextubation, it was noted that the patient had new left
leg weakness and left facial droop with new dysarthria.
1) SEPTIC SHOCK: This was likely secondary to a SIRS
reaction, status post severe aspiration pneumonia and
pneumonitis. The patient was admitted on the MUST sepsis
protocol. During his first hospital day, he was hypotensive
and required both Levophed and vasopressin to keep his mean
arterial pressure greater than 65, his lactic acidosis peaked
with a lactate level of 6.0, and he was placed on a
bicarbonate drip in the setting of both nongap and anion gap
acidosis. He also required an insulin drip. His cortisol
stimulation test was negative with a baseline cortisol of 100
in the setting of his sepsis which is an appropriate
response. His aspiration pneumonia was treated with a 9-day
course of ceftazidime, vancomycin and Flagyl to cover
nosocomial aspiration. The vancomycin was switched to
oxacillin after sensitivities came back on a Staph aureus
that grew out of his sputum that showed it to be sensitive to
oxacillin.
The patient improved rapidly after his early intervention in
sepsis therapy and was weaned off vasopressors by hospital
day #2. He completed the remainder of his antibiotic course
and did not have any further temperature spikes for the
remainder of his ICU course.
2) RESPIRATORY FAILURE: The patient required intubation for
respiratory distress in the setting of acute aspiration
pneumonia and pneumonitis, as well as increased respiratory
drive from two metabolic acidosis processes. He was able to
be quickly weaned off his ventilator, as his sepsis also
rapidly improved. He was extubated on [**2146-12-8**] after some
diuresis to remove volume that had been given during his
acute sepsis. He remained extubated and has gradually had
improving pulmonary toilet over the past few days. The
patient is currently on a scoop mask with 12 liters of flow
and has had stable O2 sats of 95% or greater since then.
3) NEUROLOGIC: After extubation, it became apparent that Mr.
[**Known lastname 12574**] had a new left-sided facial droop, dysarthria,
dysphagia, and left leg weakness. A head CT done to rule out
any acute bleed was negative and showed only has old known
hemorrhagic infarct, as well as multiple lacunar events. His
neurologic deficits have been gradually improving over the
past few days, and currently his dysarthria is much improved.
He has 3/5 strength to the muscles in his left leg, and has
4/5 strength to muscles in his left arm, and his facial droop
is also improved. He currently is requiring NG tube for
feeding, as he has failed his speech and swallow evaluation.
The plan will be to reevaluate him on Monday, [**12-19**], to
see if his swallowing has improved with his improved
dysarthria. He will be continued on an aspirin a day for
stroke prophylaxis. It is likely that this stroke occurred
in the setting of low-flow during his hypotensive episodes.
4) GI BLEEDING: Upon admission, the patient had guaiac
positive NG output and stool, although there was no gross
blood, melena or coffee grounds from this output. He did
have a total of 3 units of packed RBCs during his
hospitalization with a hematocrit drop from 34 down to 26,
and 3 units of blood required to get him above 30. He was
initially started on Protonix and sucralfate for presumed
stress gastritis. After this intervention, he had no further
signs of GI bleeding, and his hematocrit has remained stable
since [**2146-12-7**]. He was then changed to lansoprazole
therapy only.
5) CHRONIC DIARRHEA: The patient did not have diarrhea while
NPO, and his diarrhea restarted in the setting of his tube
feeds. He had no further nausea or vomiting on admission.
Cultures of his stool were negative. C. difficile x 3 was
negative. Stool Osm gap was also nondiagnostic. He was seen
by his outpatient gastroenterologist, Dr. [**Last Name (STitle) 12575**], during this
hospitalization who feels that he will perform a flexible
sigmoidoscopy when his respiratory status is improved. We
will currently continue Pepto-Bismol for symptomatic relief.
Current output is about 200 cc/D of stool.
6) METABOLIC ACIDOSIS: The patient had both a lactic
acidosis and a nonanion gap acidosis on admission. His
lactic acidosis was from his sepsis, and his nonanion gap
acidosis was likely from chronic diarrhea. These both
improved with hydration and the bicarb drip, and are not
currently an issue.
7) ACUTE RENAL FAILURE: This occurred also in the setting of
sepsis and hypotension. This has resolved to the patient's
baseline creatinine after IV hydration, as well.
8) NON-ST ELEVATION MI: The patient ruled in after admission
with a peak troponin of 0.2. His CKs and MBs were never
positive. This was likely a demand ischemia event in the
setting of sepsis. He had his aspirin restarted and was kept
on beta blocker when his blood pressure tolerated this. He
has had no signs of GI bleeding on the aspirin at this time.
9) RIGHT ARM VENOUS CLOT: This occurred in the setting of a
right IJ central line. The central line was pulled, and the
patient is now on Lovenox and Coumadin. The plan is to
anticoagulate for 1 month in the setting of known intravenous
precipitant for the clot. Edema of the right arm is now
resolved.
10) ENDOCRINE: The patient has no known history of diabetes,
but has had increased blood sugars this entire
hospitalization, even after the sepsis has resolved. He was
initially on insulin drip, and has now been converted to
insulin sliding scale. He will likely need to be converted
to oral insulin therapy upon discharge.
11) FLUIDS, ELECTROLYTES AND NUTRITION: The patient has been
maintained on Criticare tube feeds as a low-residue,
low-osmolar formula to help decrease his diarrhea. His
volume status is currently still volume overloaded, and he is
being actively diuresed with lasix 40 mg IV bid. His volume
status should be assessed daily for adjustment of this and
conversion to PO lasix. Replete potassium to be greater than
4, and magnesium to be greater than 2.
12) ACCESS: The patient has poor IV access after his right
IJ was discontinued. He had a left midline PICC placed by IV
therapy on [**2146-12-14**] for purposes of blood draws, intravenous
lasix, and labs.
13) HYPERTENSION: This is well-controlled on current
Lopressor, ACE inhibitor and Norvasc doses.
14) PROPHYLAXIS: The patient is on lansoprazole for GI
prophylaxis and Risperdal 0.5 mg q hs for sleeping
medication. Communication daily with son, [**Name (NI) **], and his
wife.
DISPOSITION: The patient will be discharged to the medicine
team on the floor today to the geriatric service. He is
currently also being screened for rehab versus return to
[**Hospital 100**] Rehab after improvement in his pulmonary toilets on
the floor.
DNR STATUS: The patient is Do Not Resuscitate, but he would
like to be intubated in the event of respiratory
failure.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Septic shock.
3. Respiratory failure.
4. Stroke.
5. Venous thrombosis.
6. Chronic diarrhea.
7. Congestive heart failure.
8. Non-ST elevation myocardial infarction.
9. Hypertension.
10.Diabetes mellitus.
11.Gastritis and gastrointestinal bleeding.
12.Acute renal failure.
DISCHARGE CONDITION: Good. The patient has better
management of his secretions, as his dysarthria is improving.
TRANSFER MEDICATIONS FROM ICU TO MEDICINE [**Hospital1 **] AS OF
[**2146-12-14**]:
1. Coumadin 5 mg po q hs.
2. Lasix 40 mg IV bid.
3. Bismuth salicylate 15 ml po tid.
4. Risperdal oral solution 0.5 mg po q hs.
5. Lovenox 80 mg subcutaneously q 12 h.
6. Aspirin 81 mg po qd.
7. Nystatin ointment qid prn.
8. Enalapril 5 mg po bid.
9. Amlodipine 5 mg po qd.
10.Miconazole powder.
11.Lansoprazole oral suspension 30 mg NG qd.
12.Insulin subcutaneously, sliding scale.
13.Metoprolol 25 mg po bid.
14.Zinc sulfate 220 mg po qd.
15.Vitamin C 500 mg po bid.
16.Zofran 4 mg IV q 6 prn.
17.Tylenol 325-650 mg po PR q 6 prn.
18.Ativan 0.5-1 mg po q 4 prn.
The patient is currently NPO and all medications are given
via his NG tube which is postpyloric at this time. The
remainder of the [**Hospital 228**] hospital course will be dictated
by the floor team, as well as final disposition plan.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12-ADV
Dictated By:[**Last Name (NamePattern1) 12576**]
MEDQUIST36
D: [**2146-12-14**] 13:42
T: [**2146-12-14**] 13:53
JOB#: [**Job Number 12577**]
|
[
"453.8",
"482.41",
"507.0",
"276.2",
"428.0",
"518.81",
"038.9",
"785.52",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"38.93",
"96.04",
"99.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12596, 13832
|
12274, 12574
|
3389, 12253
|
1195, 1805
|
2256, 2679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,382
| 121,614
|
43231
|
Discharge summary
|
report
|
Admission Date: [**2170-10-3**] Discharge Date: [**2170-10-10**]
Date of Birth: [**2092-10-11**] Sex: F
Service: MEDICINE
Allergies:
Colchicine / Sulfonamides / Augmentin / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
History of Present Illness:
77F with h/o ESRD, MSSA endocarditis with recurrent bacteremia
[**9-15**] and known large thoracic mycotic aneurysm presented to the
ED on [**10-3**] with acute mental status change.
.
Per MICU notes, pt left hospital after last admission with plan
for ongoing Q HD vancomycin inefinately. On the day of
admission, the patient's daughter found her sitting in chair at
home unresponsive.
.
On arrival to [**Name (NI) **], pt was febrile to 101.8, hypotensive to 63/25
without tachycardia. HR only 67 on presentation. Pt was given
1700 normal saline with persistently low MAPs. She was enrolled
in the Sepsis protocol and admitted to the MICU.
.
MICU course notable for:
- Weaned off of pressors on [**10-7**]
- Seen by her [**Month/Year (2) 1106**] surgeon, Dr. [**Last Name (STitle) 23155**] and given option
of surgery, however explained poor prognisis either way. Pt
declinedsurgical intervention.
- Received 1UPRBC for decreasing Hct
- HD was held wkile goals of care were being clarified given
lack of CHF/hyperkalemia and ongoing hypotension then had HD on
[**10-5**]
- Seen by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] of palliative care service
- Weaned off of levophed on [**10-6**]
- Had at one point decided not to pursu ongoing HD, but then
visited by MD friend who encouraged her to comtinue HD tomorrow
- New onset Left foot ischemia on am of [**10-7**]. Seen by [**Date Range 1106**]
surgery who recommended heparin gtt. They recommended
angiography, but pt declines. Pt understands that she is at high
risk for bleeding with heparin gtt and she does not wish to
pursue blood trnasfusions/ aggresive care in that case.
.
Called out to the floor for further work up and treatment on
[**10-7**].
Past Medical History:
PMH:
-Recent MSSA enocarditis (small vegetation on aortic valve) dx'd
end of [**2170-6-15**] s/p 6 weeks vancomycin(PCN allergic) and
gentamycin completed early [**Month (only) **]
-Coronary artery disease, 3VD s/p CABG x2
-HTN
-Type 2 diabetes
-Aortic stenosis
-Thoracic aortic aneurysm, 10 cm L with contained rutpure of
mycotic aneursym of the visceral aortic segment
-End-stage renal disease (on hemodialysis on T/Th/Sa), baseline
Cr 2.4; has R arm AV (basilic vein) fistula (approx. 7 years
old)
-Hypercholesterolemia
-History of cerebrovascular accident
-PVD, s/p L fem-[**Doctor Last Name **] bypass and R fem-fem bypass
-Gout
-Chronic anemia, baseline hct 29-31
-Diverticulosis s/p sigmoid colectomy
-Left intertrochanteric fracture, s/p ORIF
Social History:
Lives alone in building in [**Location (un) **]. Pt has 3 children. 1
daughter lives in [**Name (NI) 47**]. Former smoker x40 years
(quit in [**2149**]), no EtOH, no IVDU.
Family History:
CAD, ESRD (father)
Physical Exam:
PE on Transfer:
VS: T 100.9 HR 68 BP 108/39 RR 20 O2 96% RA
Gen: Comfortable, appearing stated age in NAD
HEENT: pupils 2 mm reactive b/l. mucous membranes moist.
Neck: prominent JV pulse
CV: regular. + 4/6 SEM across entire precordium
Lungs: CTA bilaterally.
Abd: soft. nontender. nondistended. No abdominal bruit noted.
Extr: no edema. Right LE: warm with DP 2+. Left LLE: Cool
without palpable pulses.
right arm fistula nontender, but warm.
Neuro: follows commands.
Pertinent Results:
Blood Cx:
[**8-28**]: NEGATIVE
[**9-4**]: NEGATIVE
[**9-15**]: Coag positive staph MSSA [**1-17**] sets
[**9-16**]: Coag postive staph MSSA [**12-18**] sets
[**9-17**]: NEGATIVE
[**9-18**]: NEGATIVE
[**9-20**] NEGATIVE
[**10-3**]: 2 sets NGTD
[**10-7**]: CDiff neg
.
Cath tip:
[**9-19**]: no growth
.
Stool Cx:
[**10-2**] and [**10-7**]: C dif negative
O&P negative
.
TEE [**9-19**]:
left atrium is mildly dilated. Mild spontaneous echo contrast is
seen in the body of the left atrium. No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There are complex (> 4mm) atheroma in the aortic arch.
The descending thoracic aorta is markedly dilated. There are
complex (> 4mm) atheroma in the descending thoracic aorta. There
is a large, saccular aneurysm
with laminated thrombus seen in the descending thoracic aorta
beginning at 30 cm from the incisors. No thoracic aortic
dissection is seen. The aortic valve leaflets (3) are mildly
thickened (focal thickening b/w non and left coronary cusp may
represent old (healed) endocarditis). No vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild
to moderate ([**12-17**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion. No
valvular vegetations seen. Known thoracic aortic aneurysm with
laminated thrombus. No aortic dissection.
.
EKG( [**10-4**]): Sinus rhythm; Ventricular premature complexes;
Modest nonspecific intraventricular conduction delay;
Possible prior anteroseptal myocardial infarction;
Left ventricular hypertrophy with ST-T abnormalities;
The ST-T abnormalities are diffuse - cannot exclude in part
ischemia - clinical correlation is suggested ; Since previous
tracing of [**2170-10-3**], ventricular ectopy present
.
CXR ([**10-4**]):
1. Mild interstitial edema.
2. Increasing bibasilar opacities, raising concern for possible
aspiration.
.
CT ABD/CHEST: [**10-3**] IMPRESSION:
1. Large right-sided abdominal aortic pseudoaneurysm involving
the origin of the right renal artery. The pseudoaneurysm
appears minimally increased in size in the transverse dimensions
since the prior MRI examination. There are new foci of contrast
enhancement within the mural hematoma. This is a concerning sign
for an impending rupture and close interval follow-up is
recommended if this patient is not a surgical candidate. There
is no hemoperitoneum.
2. Stable appearance of descending thoracic aortic aneurysm.
3. Bilateral renal atrophy.
4. Bibasilar atelectasis.
.
[**10-3**] CT head- 1. No acute intracranial hemorrhage or mass
effect.
2. Chronic small vessel ischemic change and additional prior
lacunar infarct in left thalamus.
.
Brief Hospital Course:
77 F with PMH MSSA endocarditis with aortic valve vegetation s/p
6 weeks vanco and gent complicated by recurrence on blood
cultures 10/1 most likely due to seeding of large thoracic
atheroma with MSSA admitted to MICU [**10-3**] with elevated WBC,
bandemia, fever, hypotension consistent with septic shock from
recurrent infection. On the day after her transfer to the floor
the patient decided that she did not want to pursue further
medical treatment including hemodialysis and with her daugthers
at her bedside she decided to be comfort measures only. Her
antibiotics were stopped as was the heparin drip. She had some
ongoing pain from her ischemic foot, and so she was given
Morphine. Because of increasing pain, she was started on a
Morhpine drip. She passed away on [**10-10**] with her family at her
bedside.
Medications on Admission:
Metoprolol 100 mg 1 tablets TID
Lisinopril 20 mg daily
Allopurinol 100 mg daily
Zoloft 50 mg daily
Nephrocaps daily
Cretor 20 mg daily
Sensipar 30 mg daily
Aspirin 325 mg daily
Fosrenal 500 mg q meal
Digoxin 125 mcg [**12-17**] tablet every other day
vanco QHD
.
Medications on Transfer:
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Ceftriaxone 1 gm IV Q24H
Oxycodone 5 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Gentamicin 80 mg IV QHD
Vancomycin HCl 1000 mg IV QHD
Heparin IV per Weight-Based Dosing Guidelines
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
sepsis
endocarditis
Discharge Condition:
expired
|
[
"250.00",
"274.9",
"V45.81",
"585.6",
"443.9",
"421.0",
"785.52",
"038.9",
"995.92",
"403.91",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7995, 8004
|
6578, 7398
|
339, 339
|
8076, 8087
|
3620, 6555
|
3093, 3113
|
8025, 8055
|
7424, 7687
|
3128, 3601
|
274, 296
|
367, 2112
|
7712, 7972
|
2134, 2887
|
2903, 3077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,395
| 111,542
|
4753+55605
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-1-16**] Discharge Date: [**2144-3-3**]
Date of Birth: [**2081-1-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever/chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 63 yo male with a h/o Type II DM, CAD s/p 4v CABG [**2129**]
and Ulcerative Colitis who p/w fever/chills/NS/weight loss and
enlarging peri-portal lymph nodes on abdominal CT concerning for
a new diagnosis of lymphoma.
.
Pt was recently admitted [**Date range (1) 19970**]/07 for abdominal pain, fevers,
and weight loss of 20 pounds in the last year, and in the
work-up was found to have multiple enlarging lymph nodes on
abdominal CT, the largest being a 1.6cm peri-portal LN. Pt was
discharged [**1-11**] and saw Dr. [**First Name (STitle) 572**] in GI on [**1-13**], who felt the LAD
was less likely infection, and more likely lymphoma, especially
if the fever persisted on antibiotics. The pt was supposed to
have an appointment with Dr. [**Last Name (STitle) **] this AM, but came to the ED
because he was feeling weak, tired and febrile at home. Now
admitted to the BMT service to expedite work-up for lymphoma.
.
Of note, pt was also admitted from [**Date range (1) 19971**] for
hyperglycemia to 900s, thought to be [**2-7**] non-compliance with
insulin [**2-7**] low PO intake [**2-7**] N/V thought to be [**2-7**] diabetic
gastroparesis.
.
Currently pt has no pain at rest. He notes that he has had chest
"discomfort" for weeks, which correlates to when he gets his
fevers. The pain is non-radiating, feels like a pressure and is
worse with inspiration. Pain/fever gets better with tylenol. No
positional/food relationship to pain, but when he coughs, he
gets the pain. His cough is non-productive and has been
relatively stable over the last few weeks. The pain and coughing
was very intense overnight, which brought him into the ED this
AM.
.
He also notes occasional epigastric discomfort that is also not
related to food/position/chest pain/fevers that he has also had
for weeks but goes away on its own.
Past Medical History:
1. Hypertension.
2. Type 2 diabetes (HgbA1c 8.2 in [**2142-8-6**]) complicated by
-retinopathy
-neuropathy.
-autonomic dysfunction, followed by Dr. [**First Name (STitle) **]. Previously on
fludrocortisone and midodrine
3. History of Nissen fundoplication for hiatal hernia [**2136**].
4. Gastroesophageal reflux disease symptoms: Remains on PPI
5. Coronary artery disease, status post 4 vessel CABG [**2129**];
-last stress (pyrimadole-MIBI) in [**2139**] with no anginal symptoms
or EKG changes, no reversible defects
-Echo in Sepetmber [**2143**] revealed LVEF>55%
-Cardiac cath in [**2137-12-6**] revealed native 3-vessel disease,
patent saphenous vein graft to third obtuse marginal, first
diagonal, and right posterior descending artery, a patent left
internal mammary artery with a distal left anterior descending
artery occlusion.
6. Ulcerative colitis times 15 years; recent endoscopy showed
gastritis in prepyloric region, colonoscopy was normal to the
cecum.
7. Gastroparesis
8. Cataract status post left phacoemulsification with posterior
chamber lens implant.
9. Squamous cell carcinoma
Social History:
Recently retired from work running autobody shop, following
multiple knee surgeries. Lives in [**Location (un) **] with his wife.
Adult son lives on [**Name (NI) 1456**]. Approximate 30 pack year smoking
history, but quit in [**2121**]. Denies current alcohol or IVDU.
Monogomous with wife of 37 years. No known blood transfusions.
Family History:
Notable for diabetes. [**Name (NI) **] mother had coronary artery
disease and sister has [**Name (NI) 4522**] disease.
Physical Exam:
PE: 112/58, 98.3, 70, 18, 97% O2 Sats RA, weight 195.7 lbs
Gen: obese male laying in bed in NAD
HEENT: posterior oropharyngeal erythema, no exudates, MMM
NECK: Supple, No LAD, No JVD
LAD: ?Left axillary LN vs fat pad; no cervical or inguinal LAD.
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: +bibasilar crackles, BS BL, No W/R/C
ABD: Soft, +epigastric tenderness, ND. NL BS. +RUQ pain worse
with inspiration. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Initial labs:
[**2144-1-16**] 01:51PM LACTATE-1.5
[**2144-1-16**] 12:10PM GLUCOSE-57* UREA N-11 CREAT-1.1 SODIUM-133
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-30 ANION GAP-15
[**2144-1-16**] 12:10PM CK(CPK)-32*
[**2144-1-16**] 12:10PM cTropnT-<0.01
[**2144-1-16**] 12:10PM WBC-12.8* RBC-3.23* HGB-10.7* HCT-31.9*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.0
[**2144-1-16**] 12:10PM NEUTS-86.6* LYMPHS-8.2* MONOS-4.8 EOS-0.2
BASOS-0.3
[**2144-1-16**] 12:10PM PLT COUNT-329
[**2144-1-16**] 12:10PM PT-14.6* PTT-29.5 INR(PT)-1.3*
CT chest [**2144-1-16**]:
IMPRESSION: The lung findings primarily in the right lung may
have an infectious etiology given the recent cough and fever and
may represent atypical pneumonia such as mycoplasma or viral
pneumonia. Pulmonary lymphoma is less likely given the rapid
development of these findings. Lymphadenopathy may be reactive,
however, lymphoma cannot be excluded and a followup chest CT
eight weeks after antibiotic therapy is recommended.
.
Bm Bx [**1-20**]:
Morphologic features of a lymphoma, infectious process, or a
myelodysplastic syndrome are not seen. A lymph node biopsy,
however, demonstrated focal infiltration by ALK-1 POSITIVE
ANAPLASTIC LARGE T CELL (CD30+, CD4+, CD3+/-) LYMPHOMA.
Immunostains in the bone marrow to rule out minimal involvement
by lymphoma are in progress and will be reported in an
addendum.In summary the morphologic and immunophenotypic
findings combined, are consistent with focal nodal infiltration
by an anaplastic large cell lymphoma. Although the differential
diagnosis includes Hodgkin lymphoma, the lack of
classic/diagnostic [**Doctor Last Name **]-Sternberg cells, the presence of rather
cohesive aggregates of large cells, the presence of CD45, ALK-1
and CD4 immunoreactivity and lack of CD15 expression, all
strongly argue against Hodgkin lymphoma.
Lymph node bx:
In summary the morphologic and immunophenotypic findings
combined, are consistent with focal nodal infiltration by an
anaplastic large cell lymphoma. Although the differential
diagnosis includes Hodgkin lymphoma, the lack of
classic/diagnostic [**Doctor Last Name **]-Sternberg cells, the presence of rather
cohesive aggregates of large cells, the presence of CD45, ALK-1
and CD4 immunoreactivity and lack of CD15 expression, all
strongly argue against Hodgkin lymphoma.
CTA chest [**2144-1-22**]:
IMPRESSION:
1. No pulmonary embolism.
2. Unchanged abnormally enlarged mediastinal and hilar lymph
nodes, probably reactive to the consolidative changes in the
lungs. However, followup chest CT after eight weeks of therapy
is recommended to assess the improvement.
3. Previously seen ground-glass opacities in the upper lobes as
well as in the left lower lobe have evolved to form areas of
consolidation. Small bilateral pleural effusions, left greater
than right. \
.
CXR [**1-22**]:
FINDINGS: Compared with [**2144-1-19**], there is now diffuse increase
in pulmonary vascular and interstitial markings bilaterally,
consistent with moderate pulmonary edema.
A superimposed small area of consolidation in the right mid lung
field as well as in the retrocardiac left lower lobe could
represent superimposed pneumonia.
ECHO [**1-22**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal hypokinesis of the basal half of the
inferior and
inferolateral walls and of the distal septum. The remaining
segments contract
well. Right ventricular chamber size and free wall motion are
normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2144-1-9**],
regional left
ventricular systolic dysfunction is now identified c/w ischemia.
CT Torso [**1-26**]:
. Interval increase in moderate bilateral layering pleural
effusions, and interval worsening of patchy consolidation and
ground-glass opacity in the left upper lobe.
2. Stable chest and abdominal lymph nodes
Ct chest [**2-3**]:
Extensive coalescing peribronchial infiltration succeeding
ground glass abnormality over six days might represent
organizing viral pneumonia, perhaps fibrotic. The rare
diagnosis, acute interstitial pneumonitis is less likely because
of rapid improvement.
Mediastinal lymph nodes are most likely reactive to the ongoing
lung pathology, decreased since [**1-22**], now stable.
Stable intra-abdominal lymph nodes might be also reactive.
Interval decrease in moderate bilateral layering pleural
effusions.
[**2-9**] head CT:
No evidence of acute intracranial hemorrhage. Moderate left
frontal subgaleal hematoma
[**2-27**] pelvic MRI
IMPRESSION:
1. Bilateral retroperitoneal hematomas seen tracking within
bilateral psoas and iliacus (left greater than right) muscles.
Large approximately 10-cm left lateral coronal fascia layering
hemorrhage.
2. No acute fracture or evidence for AVN within the hips.
Discharge labs:
Brief Hospital Course:
ASSESSMENT: The patient is a 63 yo male with a h/o Type II DM,
CAD s/p 4v CABG [**2129**] and Ulcerative Colitis who p/w
fever/chills/NS/weight loss and enlarging peri-portal lymph
nodes on abdominal CT found to be positive for anaplastic T cell
lymphoma hospital course c/b NSTEMI and heart failure as well as
pneumonia.
.
PLAN:
# Lymphadenopathy/fevers: Mr. [**Known lastname **] was admitted for
accelerated workup of lymphoma given his history of fevers,
night sweats, and increasing lymphadenopathy. The differential
on admission included infectious vs neoplastic vs. inflammatory
- constitutional symptoms and length of fevers point toward
neoplastic, but admitted with evidence of PNA and gallstones,
which are potential etiologies of infection. The patient was
recently admitted to the [**Hospital Ward Name **] where he had a negative HIV
test, negative PPD, and negative hepatitis panel. A TEE was
also done to rule out endocarditis which showed no evidence of
vegetations. In addition, blood cultures have all remained
negative. On [**1-17**] a bone marrow biopsy was done given anemia
and lymphopenia. The bone marrow bx was negative. Surgery was
consulted on admission as a 1.6cm peri-portal LN was noted on CT
and was the largest available for biopsy. He had no palpable
lymph nodes on exam. The bx showed anaplastic T cell lymphoma.
A pulmonary consult was also obtained for possible
transbronchial biopsy of lymph nodes on CT, but this was not
done since the bx was revealing. SPEP was also sent and was
within normal limits. He was started on cipro and flagyl given
PNA on chest CT and was shortly switched to Ceftriaxone and
azithromycin given persistent fevers. Overnight on [**1-22**], he
desatted to 70s on 2L and required a nonrebreather. CTA was
negative for PE, but showed a multilobar PNA. Patient was 90%
on NRB, with one set of cardiac enzymes negative, EKG with
baseline ventricular ectopy. He continued to have SOB and no
improvement in his sats the following morning and was
transferred to [**Hospital Unit Name 153**] for hypoxemic respiratory insufficiency.
Second set of cardiac enzymes was positive for NSTEMI and he was
started on heparin gtt. While in the [**Hospital Unit Name 153**] several services were
consulted including ID, rheumatology, and cardiology. He was
also diuresed aggressively. He remained persistently febrile.
In the [**Hospital Unit Name 153**], his oxygenation improved rapidly with supplemental
O2. However, he continued to spike fevers despite adequate
antibiotic coverage for CAP. He was placed in respiratory
isolation and a TB rule out was started. He continued to spike
temperatures during this antibiotic course as well. The last Ct
chest looked better and antbiotics were stopped.
As the patient was ready to be transferred out of the [**Hospital Unit Name 153**], the
final pathology returned from pathology and showed anaplastic
lymphoma. He was transferred back to the BMT service for
management. The patient was initially treated with oral
prednisone and his fevers resolved. He was then tapered down on
the steroids and the fevers returned. This prompted starting
treatment for the lymphoma with CVP. Adriamycin was not given
because of the patient's heart failure. The patient did not have
any fever after starting treatment making it very clear that his
fevers were [**2-7**] lymphoma.
.
# NSTEMI: H/o CABG in [**2129**] however recent negative stress test.
Upon transfer to the [**Hospital Unit Name 153**], in the setting of SOB, cardiac
enzymes were drawn and patient ruled in for an NSTEMI. An ECHO
was performed which showed worsened wall motion abnormalities
and overall worsened pump function. Cardiology was consulted
who recommended aspirin, heparin drip, increased beta blocker
for tight HR control, 80 mg of QD statin, and diuresis as
patient had been fluid positive. He was also transfused 2
units of PRBCs to obtain a Hct>30. Patient's symptoms improved.
Cardiology did not feel any need for intervention beyond
medical management unless patient were to have recurrent
symptoms and evidence of further ischemic evolution. Once the
patient was transferred back to the BMT service, cardiology was
recalled to help [**Hospital Unit Name 4656**] the etiology of his heart failure.
They recommended a cardiac MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for an infiltrative
process in addition to continuing aggressive medical management.
A follow-up echocardiogram revealed improvement in EF back up
from 40% to 50%. During this stay, the patient had a fall and
developed a retroperitoneal bleed. ASA, plavix and sulfasalazine
were stopped and the patient was given at least 12 units of
PRBCs and 2 units of platelets. The patient remained
hemodynamically stable and was chest pain free. He will need to
follow-up with cardiology and eventually will at least need to
restart ASA after the bleed is resolved. The patient's liver
function tests were also elevated and lipitor was held. He is
currently on losartan and metoprolol. Spirinolactone was started
and stopped after 1 week as patient was hyponatremic.
.
# Hypoxia: Covered appropriately for CAP, atypical PNA and
healthcare-associated PNA. He was continued on vancomycin,
ceftriaxone, azithromycin. Blood cultures were negative
throughout. Once back on the BMT service, a CXR was done which
showed a worsening infection despite antibiotic treatment. Out
of concern that he was being inadequately treated Pulmonary was
recalled for evaluation of hypoxia and worsening infiltrate.
They felt that his hypoxia was due to decompensated CHF and that
the radiology would likely lag behind the treatment of
infection. As the patient was improving clinically with
decreasing O2 sat requirement, they recommended completing the
course of antibiotics and continuing to diurese the patient. A
bronchoscopy was considered to obtain more tissue, however, as
the patient had a recent NSTEMI, they felt that bronchoscopy
would be a high risk procedure and would be of low yield. In
addition, the sleep medicine team came to [**Last Name (Titles) 4656**] the patient.
They did not feel that he was a candidate for a sleep study in
his present condition, however they recommended placing him on
2L O2 at night for presumptive sleep apnea. On transfer to
BMT, his antibiotic regimen was Cefepime and Flagyl. On [**1-30**]
the patient developed a rash which was likely related to
Cefepime. His antibiotics were changed on [**1-31**] to levo/flagyl.
Flagyl was d/c'd after one week since no aspiration on video
swallow and levaquin was continued for another week. Patient did
not have an O2 requirement upon leaving the hospital. He was
several liters negative on 20mg IV lasix daily. The patient
continued to have lower extremity edema and likely needs further
diuresis. He was sent home on 40mg PO lasix daily with
instructions to monitor I/O's and daily weights. This dose may
need to be adjusted to optimize volume status.
.
# DM: Severe and uncontrolled at home, associated with
retinopathy, neuropathy, gastroparesis. Takes NPH in home
regimen (75 QAM, 30 QPM) but is not compliant with recent
admission for BG 900s. Last A1c 8.2 in [**8-9**]. He was continued on
NPH x qam, x qhs, and ISS with titration as needed to optimize
BG control.
.
# Ulcerative colitis: He was asymptomatic for GI complaints
throughout admission. Thought unlikely to be causing fevers as
high as 103. Sulfasalazine was discontinued when pt had RP
bleed. Should be restarted as outpt.
.
# Gastroparesis: The patient suffered from frequent bouts of
retching for which he was taking reglan and a PPI. Ativan
seemed to work the best for the patient.
.
# GERD: s/p Nissen fundoplication. He was continued on
pantoprazole 40mg q24h
.
# Hyponatremia- patient persistently hyponatremic. This was
initially thought to be due to intravascular depletion and NS
was given. Patient was diuresed for volume overload and was
euvolemic. Urine lytes difficult to interpret given heavy lasix
doses. In the end it was thought that pt had SIADH given the
fact that his urine osm was 600-800. His thyroid and cortisol
levels were normal. He was put on fluid restriction, given lasix
to poison the tubule and demeclocycline and Na stabilized. It
was also thought that effexor was possibly causing hyponatremia,
so this was tapered off. The effexor can likely be restarted as
this does not seem to be causing the hyponatremia. We also
discontinued spirinolactone as this can cause hyponatremia.
.
Medications on Admission:
1. Ciprofloxacin 500 mg PO Q12H day [**6-16**].
2. Metronidazole 500 mg PO TID day [**6-16**]
3. Aspirin 81 mg Tablet PO once a day.
4. Atorvastatin 10 mg PO DAILY
5. Venlafaxine 150 mg PO DAILY (Daily).
6. Sulfasalazine 500 mg PO BID
7. Folic Acid 1 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. NPH 70U at breakfast and 30U at dinner
10. Lisinopril 30 mg PO DAILY
11. Senna 8.6 mg PO BID prn
12. Docusate Sodium 50 mg/5 mL PO BID
13. Tylenol#3 300-30 mg PO every 4-6 hours as needed for pain.
14. Metoclopramide 10 mg PO QIDACHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
1. Anaplastic lymphoma
2. Pneumonia
3. NSTEMI
4. Heart failure
5. Hyponatremia
6. T2DM
7. HTN
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted for a work-up of your chronic fevers and were
found to have anaplastic lymphoma and a pneumonia. You were
treated with antibiotics for the pneumonia and chemotherapy for
the lymphoma. In addition, you experienced a heart attack while
you were in the hospital. Cardiology was consulted and you were
started on medical management. You should follow-up with
cardiology as an outpatient and you will need a cardiac MRI as
well.
.
You must have your blood drawn within 1 week for monitoring of
your hematocrit, sodium, liver enzymes and bilirubin.
.
Please take all medications as directed. For now you should not
take aspirin, plavix, spironolactone or atorvastatin until you
speak with your cardiologist and are told to do so. Your effexor
was also discontinued and you can discuss this further with Dr.
[**Last Name (STitle) 12375**] at your next appointment.
.
Please follow-up with all outpatient appointments.
.
Please return to the hospital or call your doctor if you
experience chest pain, dizziness, shortness of breath, abdominal
pain, fever > 101.4 or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]), your
oncologist, on [**2144-3-10**] at 3:00PM.
.
Please follow-up with Dr. [**Last Name (STitle) 1016**], a cardiologist, on [**2144-3-26**] 9:00AM. In addition to discussion of you cardiac
medications and your recent heart attack, please also discuss
obtaining a cardiac MRI.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-4-7**]
2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2144-4-17**] 8:15
Name: [**Known lastname 3297**],[**Known firstname **] Unit No: [**Numeric Identifier 3298**]
Admission Date: [**2144-1-16**] Discharge Date: [**2144-3-3**]
Date of Birth: [**2081-1-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 3328**]
Addendum:
Please see discharge meds below.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*240 Tablet(s)* Refills:*2*
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for Nausea or anxiety.
Disp:*60 Tablet(s)* Refills:*0*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Demeclocycline 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Blood draw: Panel 7, CBC, LFT's including total bilirubin. To be
drawn within 1 week of discharge.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
16. Insulin sliding scale
NPH insulin: 25U QAM, 18U QPM
.
Four times daily fingersticks with humalog dosing per insulin
sliding scale.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for neck/back pain.
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 994**] MD [**MD Number(1) 1001**]
Completed by:[**2144-3-14**]
|
[
"428.0",
"536.3",
"372.30",
"920",
"599.7",
"V45.81",
"693.0",
"E930.5",
"327.23",
"486",
"250.62",
"556.9",
"410.71",
"253.6",
"V45.3",
"V58.67",
"786.2",
"202.88",
"401.9",
"E884.4",
"459.0",
"530.81",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.21",
"99.05",
"93.90",
"99.20",
"40.11",
"99.28",
"99.25",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
23420, 23659
|
9716, 18255
|
281, 288
|
19061, 19100
|
4514, 9286
|
20255, 21245
|
3639, 3760
|
21268, 23397
|
18936, 19040
|
18281, 18813
|
19124, 20232
|
9693, 9693
|
3775, 4495
|
229, 243
|
316, 2143
|
9295, 9675
|
2165, 3268
|
3284, 3623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,499
| 149,422
|
24958
|
Discharge summary
|
report
|
Admission Date: [**2115-4-23**] Discharge Date: [**2115-5-13**]
Date of Birth: [**2039-10-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
Minimally invasive esophagogastrectomy with abdominal
conversion, exploratory laparoscopy, feeding jejunostomy,
splenectomy.
History of Present Illness:
Mr. [**Known lastname **] is a 75-year-old man diagnosed with T3 N1
adenocarcinoma of the distal esophagus treated with neoadjuvant
chemoradiation who presents for elective esophagectomy.
Past Medical History:
Emphysema, hypercholesterolemia, positive PPD, arthritis, BPH,
and hypertension.
Social History:
Married, retired service technician for gas company x 43 years.
Significant asbestos exposure in past. Former smoker, 2 to 3
packs per day x40 years.
Quit smoking 4 years ago. Heavy alcohol use history, 3 to 4
"strong drinks" daily for the past 20 years.
Family History:
Half-brother died of lung cancer at age 47. Father died of
leukemia at age 75.
Physical Exam:
Wt. 175.4 lbs P 96 BP 137/78 RR 16 T 97 %O2 Sat 96
Gen- NAD
Chest- CTAB, no wheezes or rales
Heart- RRR, nl S1S2, no M/G/R
Abd- soft, NTND, +BS
Ext- warm, no C/C/E
Pertinent Results:
[**2115-4-23**] calcHCT-32
Pathology Examination
SPECIMEN SUBMITTED: Esophageal Gastrectomy Specimen, SPLEEN,
PARA ESOPHAGEAL LYMPH NODE & SUBCARINAL LYMPH NODE.
DIAGNOSIS:
I. Esophagogastrectomy (A-Q):
1. Adenocarcinoma, see synoptic report.
2. Extensive Barretts esophagus with dysplasia.
3. Eleven lymph nodes, no carcinoma seen.
II. Subcarinal lymph node (R):
One lymph node, no carcinoma seen.
III. Paraesophageal lymph node (S):
One lymph node, no carcinoma seen.
IV. Spleen, 75 grams (T-V):
No diagnostic abnormalities recognized.
Esophagus: Resection Synopsis
MACROSCOPIC
Specimen Type: Esophagogastrectomy.
Tumor site: Gastroesophageal junction.
Tumor Size
See comment.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Not applicable due to irradiation.
EXTENT OF INVASION
Primary Tumor: pT2: Tumor invades muscularis propria.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 13.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Circumferential (adventitial) margin: Uninvolved by
invasive carcinoma.
Distance of invasive carcinoma from closest margin: 1 mm
(Circumferential). Keratin immunostains evaluated.
Lymphatic (Small Vessel) Invasion: Absent.
Venous (Large vessel) invasion: Absent.
Additional Pathologic Findings: Intestinal metaplasia,
dysplasia.
Comments: 1. The tumor size is difficult to assess because of
treatment effect. The grossly described nodule which measures
2.2 cm shows scattered tumor nests with very prominent
fibroblastic reaction.
2. There are rare, small mucinous collections in the adventitia
of the esophagus with no associated tumor cells as being
evaluated by immunostains.
Clinical: Esophageal cancer - status post chemotherapy.
Gross:
The specimen is received fresh labeled with "[**Known lastname **], [**Known firstname **]"
and the medical record number and "esophagogastrectomy specimen"
and consists of a segmental resection of esophagus and proximal
stomach measuring 26 cm in length. There is a stapled proximal
resection margin measuring 2.5 cm in length and a stapled distal
resection margin measuring 8.5 cm. There is an additional
staple line present 4 cm from the proximal resection margin. The
attached fat measures up to 5 cm in length. The outer portion
of the specimen is remarkable for an area of firmness felt
around the gastroesophageal junction. This area is inked in
black. The specimen is opened to reveal a fungating pink tan
mass measuring 2.2 x 2.2 x 0.7 cm at the GE Junction along the
side of the greater curvature. This mass lies 2.5 cm from the
distal resection margin and 24 cm from the proximal resection
margin. The total length of esophagus measures 24 cm. The
mucosa from the GE junction appears tan, [**Location (un) 2452**] and irregular,
suggestive of Barrett's esophagus and extends for 12 cm. There
is an irregular Z-line that lies 10 cm from the proximal
resection margin. The mass is sectioned to reveal invasion into
the muscular layer. It does not appear to extend through the
serosa. The gastric mucosa appears unremarkable. Multiple lymph
nodes are identified measuring up to 4.2 cm. The specimen is
represented as follows: A = stapled distal resection, B =
stapled proximal resection margin of esophagus, C = distal
resection margin, D-F = tumor, G = GE junction, H = stomach, I =
Z-line, J = esophagus, K = area near second staple line near
proximal resection margin, L = area of largest lymph node, M-Q =
individual lymph nodes.
Part 2 is additionally labeled "subcarinal lymph node" and
consists of a 0.9 x 0.8 x 0.3 cm lymph node that is bisected and
entirely submitted in R.
Part 3 is additionally labeled "para-esophageal lymph nodes and
consists of a lymph node and associated fat measuring 1.2 x 0.7
x 0.4 cm. It is bisected and entirely submitted in S.
Part 4 is additionally labeled "spleen" and consists of a 75
gram spleen measuring overall 8.5 x 6 x 2.5 cm. There is a
stapled resection margin at the hilum measuring 6 cm. The
specimen is sectioned to reveal unremarkable beefy red cut
surfaces. No abnormalities are noted. Representative sections
are submitted in T-U.
Cardiology Report ECHO Study Date of [**2115-5-3**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 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: 5.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.33 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.67
Mitral Valve - E Wave Deceleration Time: 151 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%). Suboptimal technical quality, a
focal LV wall motion abnormality cannot be fully excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. LV inflow
pattern c/w impaired relaxation.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
1. The left atrium is mildly dilated.
2. 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.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened.
5. There is a trivial/physiologic pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2115-5-3**] 14:54.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Brief Hospital Course:
The patient was admitted to the Crimson Surgery service and
underwent minimally invasive esophagogastrectomy converted to
open with splenectomy and feeding jejunostomy on [**2115-4-23**] by Drs.
[**Last Name (STitle) **] and [**Name5 (PTitle) 952**] (see op note for details). He remained
intubated postoperatively and was transferred to the CSRU in
stable condition. The patient was resuscitated with crystalloid
and packed red blood cells POD 1 due to low urine output. He
remained sedated and intubated.
POD 2, trophic tube feedings were initiated. He was extubated
and remained in stable condition. Ativan and Haldol had to be
administered a couple of times for agitation, confusion, and
tube/IV pulling. However, once his mentation normalizes, he
progressed nicely. He was maintained on a heparin drip for his
paroxysmal afib and received nutrition via tube feeding.
On POD 15 he was transferred to the cardiac floor where he
stayed until day of discharge.
On POD 16 he passed his bedside swallow evaluation for pureed
foods and nectar thick liquids. He continues to aspirate thin
liquids, however this is expected to improve.
On POD 17, he was give Pneumovac, H. influenza B, Meningicoccus
vaccines. His INR was therapeutic on warfarin (given for
paroxysmal afib, pt currently in sinus rhythm, goal INR 2.0) and
the heparin drip was discontinued.
On POD 20 he was dishcarged to a rehabilitation center in fair
condition with specific instructions for post-hospital care and
follow-up.
Medications on Admission:
[**First Name9 (NamePattern2) **]
[**Last Name (un) **]
lipitor
ASA
nexium
MVI
vitamin E
seaweed
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: [**2-11**] Inhalation Q4H
(every 4 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: [**2-11**] Inhalation Q4H
(every 4 hours).
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: dose
varies depending on INR. Pt had been getting 5 mg QHS.
13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northwest [**Hospital1 **]
Discharge Diagnosis:
Esophageal cancer, status post
neoadjuvant chemoradiation.
Discharge Condition:
Fair and Stable
Discharge Instructions:
[**Month (only) 116**] return to taking outpatient medications. Please follow
directions as discussed previously with Dr. [**Last Name (STitle) **].
Please take medications as prescribed and read warning labels
carefully. If signs of infections such as purulent discharge
from wound, increased pain and redness at wound, please call or
go to the emergency room. If signs and symptoms of bowel
obstruction, such as abdomenal pain with vomiting and
distention, please go to the emergency room. Remember to call
for a follow up appointment (bellow). Light activities until
seen in clinic. [**Month (only) 116**] have thickened fluids. Absolutely no
smoking.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks. Call his office at
([**Telephone/Fax (1) 1483**] to schedule your appointment.
Please remember to follow up your Coumadin dosing with your
primary care provider. [**Name10 (NameIs) **] to do so may result in dangerous
levels of the anti-coagulation medication that can result in
complications such strokes, internal bleeding, and easy
bruising. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 62715**]
|
[
"492.8",
"V64.41",
"518.5",
"427.31",
"401.9",
"V15.3",
"151.0",
"530.85",
"998.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.5",
"96.04",
"96.05",
"99.04",
"46.39",
"54.21",
"33.24",
"42.41",
"96.6",
"41.5",
"40.3",
"96.72",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
10732, 10805
|
7798, 9299
|
333, 459
|
10908, 10926
|
1348, 7665
|
11638, 12165
|
1069, 1149
|
9446, 10709
|
10826, 10887
|
9325, 9423
|
10950, 11615
|
1164, 1329
|
276, 295
|
487, 676
|
7697, 7775
|
698, 781
|
797, 1053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,551
| 133,160
|
24703
|
Discharge summary
|
report
|
Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-17**]
Date of Birth: [**2035-8-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol / Iodine / Latex / Betadine
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Chemotherapy
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
66 y.o. female with a h/o severe PVD including AAA status post
repair and stenting, and metastatic Ca of unknown
primary complicated by T7 destructive lesion here in [**12-26**], s/p
T3-T11 fusion by Dr. [**Last Name (STitle) 363**] status post radiation with left
pelvic
metastasis, s/p XRT to chest and cervical subcutaneous soft
tissue mass consistent with small cell lung cancer metastasis
and paraneoplastic syndrome manifest with diffuse lower
extremity weakness who was admitted to [**Hospital1 18**] from her rehab for
initiation of chemotherapy.
She was started on IVIG for paraneoplastic weakness during her
recent admission ([**2102-4-27**] to [**2102-5-31**]) and discharged to rehab
where she did not continue to receive IVIG. She was seen in
clinic today with noted growth of her neck mass with associated
[**2104-7-28**] pain in right shoulder despite current pain medication
regimen.
.
She is being admitted for chemotherapy
carboplatin/etoposide(over 3 days) and received day 1 today with
2 more days of etoposide. Pain control is the other objective of
her admission.
.
She states that other than the growth of her neck mass and
associated right shoulder pain, she has no other specific
complaints or concerns. Her weakness in her lower extremities
improved status post IVIG so that she can now move both feet and
has some fine motor control of both hands (right-handed) as she
is now able to stitch which she could not do before. She also
reports numbness of LE b/l that is unchanged since IVIG and
paresthesias in UE b/l. She has sensation in both her legs
below the knee which is also improved from prior.
Past Medical History:
# HTN
# COPD
# Osteopenia
# PVD: s/p aortobifem [**2091**] and [**2095**], s/p right SFA and [**Doctor Last Name **]
angio,
# s/p right SFA stenting, s/p a right common iliac to left renal
artery bypass, s/p right renal artery stenting, s/p right
profunda femoris to posterior tibial bypass
# AAA repair with stenting
# Hypercholesterolemia
# Carcinoma of unknown primary w/ T7 lesion, L Pelvic
metastasis, s/p XRT, and Cervical subcutaneous soft tissue mass
# History of thrombocytopenia (has not been formerly worked up.
With concern for possible HIT, avoiding heparin SQ for DVT
prophylaxis)
Social History:
Former heavy smoker. Quit [**2092**] but with 40 pack years. Denies
other drugs. Uses EtOH rarely. Widowed with 5 children.
Family History:
Mother had CABG in her 60's. Father died at age 45 from a "clot
to the brain". Son has aorta grafting at age 37 and has had
clots in the leg. Daughter has a "leaky valve".
Physical Exam:
Tc= 97 P=82 BP=114/64 RR = 16 95% on RA
.
Gen - No distress, alert and oriented x 3
HEENT - PERLA, EOMI, no carotid bruits
Heart - RRR, no MRG
Lungs - CTAB
Abdomen - distended, nontender, active bowel sounds. no fluid
wave.
Ext - no edema/cyanosis.
Back - surgical scar along spine. Roughly baseball-sized firm
mass over cervical spine, nontender to palpation with no
associated erythema.
Skin - No rashes.
Neuro - CN II-XII grossly intact. There is no increase in
paresthesias with neck flexion, extension, abduction or
trapezius action.
Motor/Sensory: Able to move feet bilaterally feet (strength
3+/5). Sensation intact below the knee bilaterally. UE 4+/5
throughout and [**3-25**] at hands b/l.
Pertinent Results:
Labs on admission:
[**2102-6-29**] 12:00PM BLOOD WBC-11.7*# RBC-3.16* Hgb-9.7* Hct-30.3*
MCV-96 MCH-30.5 MCHC-31.9 RDW-16.5* Plt Ct-586*#
[**2102-6-29**] 12:00PM BLOOD Neuts-83.6* Lymphs-11.2* Monos-2.8
Eos-2.1 Baso-0.2
[**2102-6-29**] 12:00PM BLOOD PT-11.7 PTT-25.1 INR(PT)-1.0
[**2102-6-29**] 12:00PM BLOOD Glucose-151* UreaN-23* Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-24 AnGap-16
[**2102-6-29**] 12:00PM BLOOD ALT-12 AST-10 LD(LDH)-208 AlkPhos-61
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2102-6-29**] 12:00PM BLOOD TotProt-5.6* Albumin-3.1* Globuln-2.5
Calcium-8.9 Phos-3.8 Mg-2.1
EKG - Sinus rhythm. Normal tracing. Compared to the previous
tracing of [**2102-5-2**] the findings are similar.
CT [**6-30**]:
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Air bronchogram
containing right
lower lobe consolidation is not significantly changed from [**5-4**], [**2101**]
examination. Additionally, more anteriorly within the right
lower lobe, a new
4-mm pulmonary ground-glass nodule is noted. Post-radiation
changes along the
mediastinum bilaterally including scattered regions of
ground-glass opacity
and linear fibrosis are stable. Large left infrahilar mass is
grossly stable
from [**5-4**] examination but significantly increased from
[**2101-11-18**]
examination measuring 18 x 24 mm currently and displays mass
effect on the
adjacent lower lobe bronchus. No pleural or pericardial effusion
is
identified. 14-mm right axillary enhancing node has
significantly increased
in size from [**Month (only) 116**] examination where it measured approximately 7
mm. Additional
nodes within the mediastinum are grossly stable, the largest
subcarinally
measuring 7 mm in short axis. No pleural or pericardial effusion
is
identified. Mild coronary artery calcification and aortic
calcification is
again noted. Large soft tissue lesion posterior to T1 has also
increased in
size from [**Month (only) 116**] examination from 33 x 52 mm to 38 x 74 mm on
today's exam (3:1).
Hypoattenuating thyroid lesions are noted within the isthmus and
lower lobes
bilaterally. Increased soft tissue is also noted surrounding the
bronchus
intermedius, not present on [**2102-4-20**] exam.
CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST: The liver,
spleen,
stomach, small bowel, adrenal glands, and left kidney appear
unremarkable.
Atrophic right kidney with mild rim-enhancing normal parenchyma
within the
upper pole is again noted. Prior [**Year (4 digits) 1106**] bypass including
bifemoral bypass
and bypass supplying the left renal artery are again noted and
remain patent.
No free air, free fluid, or pathologically enlarged lymph nodes
are identified
within the abdominal cavity.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Intrapelvic
bowel,
uterus, and urinary bladder appear normal. No free fluid or
pathologically
enlarged lymph nodes are present within the pelvic cavity.
Multiple small
soft tissue attenuating lesions are noted within the anterior
abdominal wall,
increased from [**2101-10-20**] exam. Increased mild anasarca is
also noted
within the surrounding soft tissues.
BONE WINDOWS: Healing left superior and inferior rami pubic
fractures are
again noted and there is stable appearance to osseous harvest
site along the
left ilium. No malignant-appearing osseous foci are identified.
Extensive
thoracic spine surgical spine hardware remains in position.
IMPRESSION:
1. Enlargement of known metastatic C7-T1 posterior soft tissue
lesion.
Increased size to single left axillary lymph node and increased
mediastinal
soft tissue surrounding the right bronchus intermedius are all
worrisome for
progression of disease. The right axilla node is atypical for
lung cancer and
may warrant breast evaluation.
2. Stable left infrahilar mass from [**Month (only) 116**] examination but
significant
progression from [**2101-10-20**] examination. Mild mass effect on
the adjacent
left lower lobe bronchi. Single new right lower lobe
ground-glass pulmonary
nodule, likely inflammatory or infectious, but should be
followed up on
subsequent exams.
3. Stable right lower lobe consolidation. In absence of response
to
antibiotics, a cryptogenic organizing pneumonia or post
obstructive/radiation
induced pneumonitis are also within the differential.
4. Multiple new soft tissue nodules within the anterior
abdominal wall,
likely related to injections. Attention needed on followup
exams.
5. Hypoattenuating isthmic and thyroid lesions, likely benign.
If clinically
indicated, this could be further evaluated with dedicated
thyroid ultrasound
if not already completed.
Brief Hospital Course:
Pt is a 66 year-old female with a history of small cell lung CA,
COPD, peripheral [**Year (4 digits) 1106**] disease, and paraneoplastic neurologic
disorder who was initially admitted for chemotherapy and
eventually transferred to the ICU on [**7-14**] for hypoxia,
tachycardia, and mental status changes. Originally, patient was
going to be discharged after receiving chemotherapy and IVIG for
her neurologic disorder, but had developed febrile neutropenia.
While receiving her course of antibiotics
(Cefepime/Vancomycin/Metronidazole) for the neutropenia, she
developed headaches in the setting of thrombocytopenia (Plt
count 16). On [**2102-7-12**], due to concern for intracranial
hemorrhage secondary to thrombocytopenia, patient was ordered
for transfusion. Halfway through the transfusion, patient
experienced desaturation and transfusion was stopped and labs
for transfusion reaction were sent. Chest x-ray at that time
demonstrated interstitial infiltrates. The patient was managed
supportively with oxygen, and no diuretics were given at the
time. After midnight on [**7-13**], patient began experiencing
increasing oxygen requirement and received 10mg IV furosemide,
with a 300cc diuresis, and some improvement in her respiratory
status. Later that morning, patient again became increasingly
hypoxic, requiring 5 litres nasal cannula, and received 10mg IV
furosemide with 600cc diuresis and no significant improvement in
oxygen requirement. She remained asymptomatic during this
period, other than small amounts of hemoptysis. At 8PM on [**7-14**],
patient became febrile to 102 and tachycardic (while on
Vancomycin [**7-3**], Cefepime [**7-5**], and metronidazole [**7-8**]),
appeared dehydrated, and received 750cc IV fluids.
.
At 1:30AM on [**7-14**], the patient triggered for desaturation to
80s% with mental status changes. Oxygenation improved to mid-90%
on non-rebreather. Blood gas showed 7.39/41/53 presumably while
on 5 litres nasal cannula. She received 10mg IV furosemide with
1 litre diuresis. On morning of ICU transfer, she continued to
remain tachycardic, with oxygen requirement of 70% facemask,
saturating in high 90s. She continued to have hemoptysis with
progressively worsening anemia, with a hematocrit of 22.
Transfusion then was considered but was deferred due to unclear
volume status, and question of possible TRALI with prior
platelet transfusion. Due to persistent hypoxia, diagnosis of PE
was entertained, although thought unlikely as patient had been
on low-dose fondaparinux for prophylaxis. CTA was deferred, but
bilateral LENIs, chest x-ray, and echocardiogram were ordered.
Patient complained of some jaw discomfort similar to her chronic
angina, relieved with nitroglycerin earlier that morning. ECG
showed sinus tachycardia at 120 bpm, normal axis and intervals,
normal QRS norphology, no specific ST or T-wave changes. CXR on
transfer showed increased bilateral parenchymal interstitial
markings, evolving left peri-hilar opacification, and persistent
right-lower perihilar infiltrate, with no effusions.
.
Pt continued to be hypoxic, requiring nasal cannula and face
tent,and continued to be hypotensive as well. An infectious
work-up was initiated to evaluate further for an additional
etiology for her symptoms, in addition to the SCLC. However, on
[**7-15**] family decided that at this point it would be best for her
to be made CMO. She was made comfortable on a morphine drip, and
was discharged to home with hospice services.
Details below pertain to her hospitalization prior to transfer
to the ICU:
# Metastatic Ca of unknown primary and cervical subcutaneous
soft tissue mass consistent with small cell lung cancer
metastasis: Patient received carboplatin and etoposide.
# Fever - On HD#4 patient spiked a fever to 101.5. She was
asymptomatic, with exception of scant wheezes throughout. She
was pancultured with negative UCx, negative Legionella Ag in
urine, and BCx pending to date. WBC increased to 28K. Although
temporally this was associated with Filgastrim, due to high risk
of infection, patient was treated for HAP: started on Vancomycin
(4), Levofloxacin(2d), then switched to Cefepime (2d) for
pseudomonal coverage (days of AB on day of discharge) to be
most likely [**1-21**]. Pt was continued on ipratropium nebulizers q6h
daily. CXR from HD# 6 revealed a new left perihilar opacity,
suggestive of PNA in comparison to CXR from [**5-30**]. Pt was now
with productive cough of brown dark sputum. Sputum Cx showed
GPCs and GNRs. By HD#8, the WBC count had dropped to 6K as part
of a pancytopenic response to the chemotherapy.
# Pain control - Oxycontin was increased to 60 Q8h and oxycodone
for breakthrough at 5mg q4h prn and gabapentin 300 mg [**Hospital1 **]. By
HD#3, patient reported significant improvement in pain, [**5-30**].
This pain was described as soreness and improved with frequent
patient repositioning to [**1-29**]. With PT and movement from OOB to
chair, patient's pain had dissipated by HD#5 and she did not
require prn oxycodone by HD#6. She continued to receive
oxycontin 60mg TID.
# Lower extremity weakness/numbness - most likely [**1-21**] a
paraneoplastic syndrome. Pt was status post IVIG during last
admission. Dr. [**Last Name (STitle) 1206**] of neurology was consulted and a
recommendation was made to readminister an IVIG regimen x5d at
0.4g/kg/day of IVIG x 5 days. This was started on HD#5 and
completed on HD#10. Initially there was mild improvement in
motor function of LE (4+/5 strength with flex/ext of feet b/l,
2+/5 proximally b/l) and decrease in numbness improved in LE and
paresthesias in UE. It was difficult to delineate the [**Doctor Last Name 360**] of
change as multiple interventions were performed in parallel
(chemo/IVIG). It was considered that no benefit was obtained
from the Dexamethasone 1mg QD dosing. A taper of 1mg to 0.5mg
qd for 5 days was initiated on [**7-5**] to be changed to prednisone
0.5mg EOD by [**7-10**] and completed by [**7-17**].
# CAD - ASA was continued at 162mg daily as were her statin,
b-blocker, nitrates and ACE-I. Nitrates changed to PM dose as
transient episode of hypotension in AM on [**2102-7-1**] (HD#3).
.
# PVD - patient was continued on plavix, statin and aspirin. No
acute issues. Admission ECG consistent with baseline.
.
# COPD - Patient was continued on nebs q6h.
.
#FEN - Patient on regular diet as tolerated.
.
#Access - PICC was placed.
.
#PPX - Fondaparinux for DVT prophylaxis.
.
#Code - DNR/DNI
Medications on Admission:
1. Doxepin 25 mg Capsule (3) Capsule PO HS
2. Clopidogrel 75 mg Tablet (1) Tablet PO DAILY
3. Lisinopril 5 mg Tablet (1) Tablet PO DAILY
4. Amlodipine 2.5 mg Tablet (1) Tablet PO DAILY
5. Fondaparinux 2.5 mg/0.5 mL (1) Subcutaneous DAILY
6. Aspirin 81 mg Tablet, Chewable (2) Tablet, Chewable PO DAILY
7. Dexamethasone 2 mg Tablet 0.5 Tablet PO DAILY
8. Metoprolol Tartrate 50 mg Tablet (1) Tablet PO BID
9. Alprazolam 0.25 mg Tablet (1) Tablet PO TID prn
10. Oxycodone 5 mg Tablet 1-2 Tablets PO Q4H as needed for
breakthrough pain.
11. Oxycodone 40 mg Tablet Sustained Release 12 hr (1)Tablet
Sustained Release 12 hr PO Q8H
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
(1) Tablet Sustained Release DAILY
13. Atorvastatin 40 mg Tablet (2) Tablet PO DAILY
14. Gabapentin 300 mg Capsule (1) Capsule PO Q12H
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL 15-30 MLs PO
QID
16. Pantoprazole 40 mg Tablet, PO Q24H
17. Nystatin Five (5) ML PO QID
18. Albuterol Q6H (every 6 hours) as needed
19. Ipratropium Bromide neb Q6H (every 6 hours).
20. Miconazole Nitrate twice a day.
21. Guaifenesin 100 mg/5 mL 5-10 MLs PO Q6H as needed.
22. Acetaminophen 650 mg Tablet (1) Tablet PO every six hours.
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once).
Disp:*30 Patch 72 hr(s)* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: 0.25 mL PO every
4-6 hours as needed for pain.
Disp:*1 bottle* Refills:*3*
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-21**]
Drops Ophthalmic PRN (as needed).
6. PICC Line
Please maintain PICC line.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] hospice and palliative care
Discharge Diagnosis:
Small cell lung cancer
HTN, COPD, Osteopenia, PVD, AAA, Hypercholesterolemia,
Thrombocytopenia
Discharge Condition:
Hemodynamically stable with improved pain control, will go home
with hospice care
Discharge Instructions:
You were admitted to [**Hospital1 18**] for chemotherapy treatment, pain
management and treatment of your leg weakness. You will be
discharged home with hospice care with the goals made to
maximize comfort. At time of discharge, you had no pain on your
medication regimen.
.
Followup Instructions:
Home with Hospice
Completed by:[**2102-7-19**]
|
[
"379.42",
"999.8",
"780.09",
"198.89",
"427.89",
"198.5",
"787.91",
"357.3",
"287.4",
"733.90",
"307.81",
"E933.1",
"288.00",
"374.30",
"375.15",
"162.9",
"584.5",
"284.89",
"276.6",
"443.9",
"507.0",
"786.3",
"585.9",
"V58.11",
"403.90",
"E879.8",
"458.9",
"413.9",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
16602, 16681
|
8274, 14763
|
323, 339
|
16820, 16904
|
3685, 3690
|
17227, 17276
|
2774, 2947
|
16022, 16579
|
16702, 16799
|
14789, 15999
|
16928, 17204
|
2962, 3666
|
271, 285
|
367, 1998
|
3705, 8251
|
2020, 2616
|
2632, 2758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,615
| 145,337
|
29661
|
Discharge summary
|
report
|
Admission Date: [**2153-12-31**] Discharge Date: [**2154-1-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
L cerebellar hemorrhage - transfer from OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 89yo RHM with hx of paroxysmal Afib but no on
Coumadin, HTN, hyperlipidemia and hx of strokes transferred from
[**Hospital1 1474**] after CT scan showing large left cerebellar hemorrhage.
Per patient and per records, patient presented to [**Hospital1 1474**] on
[**12-29**]
with abdominal pain and nausea but no vomitting, fever/chills,
CP
or SOB. He was initially admitted for abdominal pain work up
but
patient was found to have slurring of speech per daughter who
spoke to him overnight and upon further probing, patient reports
that he fell the day prior to admission at home while chasing a
cat. He also reports to have been feeling lightheaded for a
long
period. He uses walker at baseline and he does report feeling
nauseated for ~2 days.
Given the large L cerebellar hemorrhage extendling midline into
R
cerebellum, patient was transferred for further evaluation and
care. BP on admission to OSH was 150/98.
He reports some nausea currently but no vertigo. There is no
vomitting. He denies any headache.
Past Medical History:
1. hx of strokes
2. paroxysmal afib not on coumadin
3. HTN
4. Hyperlipidemia
5. CKD with Cr 1.5
6. AAA - 4.4 cm
Social History:
Lives at home and denies any smoking, EtOH
Family History:
NC
Physical Exam:
T 98.9 BP 165/93 HR 94 RR 15 O2Sat 98% RA
Gen: Lying in bed, appears comfortable but reports +nausea
CV: RRR, no murmurs/gallops/rubs
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person and hospital. Attentive. Speech is
fluent with normal comprehension and repetition; naming intact.
No dysarthria. No right left confusion. No neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV & VI: Extraocular movements intact bilaterally with fine
endgaze nystagmus bilaterally.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Generalized bulk loss but normal tone bilaterally. No observed
myoclonus or tremor. No asterixis; left pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE TF
R 5- 5- 5 5 5 5 5 5 5 5 5 5 5
L 5- 5- 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick and cold throughout.
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally
Coordination: Positive dysmetria more on L than R and slower and
clumsy [**Doctor First Name **], again more on L than R.
Gait: Deferred.
Pertinent Results:
[**2154-1-1**] 01:59AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.5* Hct-32.4*
MCV-92 MCH-32.6* MCHC-35.3* RDW-14.7 Plt Ct-186
[**2154-1-1**] 01:59AM BLOOD PT-13.0 PTT-26.3 INR(PT)-1.1
[**2154-1-1**] 01:59AM BLOOD Glucose-127* UreaN-25* Creat-1.6* Na-140
K-4.2 Cl-108 HCO3-24 AnGap-12
[**2154-1-1**] 01:59AM BLOOD CK(CPK)-131
[**2154-1-1**] 01:59AM BLOOD CK-MB-6 cTropnT-0.11*
[**2154-1-1**] 01:59AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 Cholest-130
[**2154-1-1**] 01:59AM BLOOD Triglyc-94 HDL-67 CHOL/HD-1.9 LDLcalc-44
[**2154-1-1**] 01:59AM BLOOD TSH-3.6
NCHCT [**2154-1-1**]:
large left and smalle right cerebellar hemorrhages of unclear
etiology, though
underlying mass cannot be excluded. Edema cause mass effect on
the 4th
ventricle, though it remains patent without frank hydrocephalus
though there
are no priors for comparison. Chronic small vessel ischemic
changes with old
left temporoparietal infarct.
Brief Hospital Course:
89 M, transferred from OSH to [**Hospital1 18**] ICU for L cerebellar
hemmorrhage as outlined in the HPI. He was monitored overnight
in the ICU, where his neurological exam remained unchanged (mild
dysarthria, LUE and LLE ataxia, and mild L tricep weakness). His
SBP was controlled in the 130 to 160 range. He was then
transferred to the floor.
His neurological exam remained stable.
His course was complicated by UTI and he was treated with
bactrim. He also went into slight CHF exacerbation but recovered
with a dose of IV lasix. His mental status and overall clinical
picture has continued to improve. He should be kept at a
balanced fluid status in order to avoid further CHF
exacerbation. He was started on a full aspirin and should
continue this indefinately.
Medications on Admission:
1. Amlodipine 10mg daily
2. Lipitor 10mg daily
3. Imdur 30mg daily
4. Metoprolol XL 12.5mg daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Ondansetron 4 mg IV Q8H:PRN nausea
8. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6 HOURS () as needed for sbp>160.
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cerebellar hemorrhage
Discharge Condition:
Improved
Discharge Instructions:
You were admitted because of bleeding in the back of your brain.
You will need to continue rehabilitation in order to improve
function. If you have any new symptoms please return to the ER.
Followup Instructions:
Dr. [**First Name (STitle) **]
|
[
"784.5",
"272.4",
"041.19",
"585.9",
"428.0",
"E885.9",
"403.90",
"431",
"781.3",
"441.4",
"348.30",
"427.31",
"599.0",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5776, 5848
|
4036, 4810
|
315, 321
|
5914, 5925
|
3113, 4013
|
6166, 6200
|
1596, 1600
|
4958, 5753
|
5869, 5893
|
4836, 4935
|
5949, 6143
|
1615, 1764
|
232, 277
|
349, 1384
|
2049, 3094
|
1803, 2033
|
1788, 1788
|
1406, 1520
|
1536, 1580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,055
| 135,131
|
9420
|
Discharge summary
|
report
|
Admission Date: [**2185-6-18**] Discharge Date: [**2185-6-23**]
Date of Birth: [**2122-8-12**] Sex: F
Service: GENERAL SURGERY
CHIEF COMPLAINT: Fever and chlils.
HISTORY OF PRESENT ILLNESS: This is a 62 year-old female
status post proctocolectomy and ileostomy in [**2184-9-15**]
for ulcerative colitis. The patient complains of fever and
chills since 9:00 p.m. on [**2185-6-17**] and bloody ostomy
output. The patient with a fever of 101.8. She has had
nausea and vomiting as well as chills. She denies chest
pain, shortness of breath. There is no stool in her ostomy
site.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Pancreatic insufficiency.
3. Depression.
4. Anal fistula.
PAST SURGICAL HISTORY: Proctocolectomy and ileostomy in
[**2184-9-15**].
SOCIAL HISTORY: She lives with her husband. She denies
smoking or alcohol abuse.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Zoloft.
2. Evista.
3. NPH 25 units in the morning and night time, regular 10
units in the morning and in the p.m.
PHYSICAL EXAMINATION: Temperature current 101.1. Heart rate
98. Blood pressure 107/43. Respirations 18. O2 sat 95%.
Cardiovascular examination was regular rate and rhythm. Lung
examination clear to auscultation bilaterally. Abdominal
examination was soft, obese. No rigidity. Minimal tympany.
Nondistended. No hernia at the ostomy site. Slight bloody
output and malodorous output from the ostomy site.
LABORATORY EVALUATION: CBC white blood cell count 11.9,
hematocrit 39.8, platelets 148. Neutrophils 67%. Chem 7
143, 4.4, 106, 22, 11, 0.8, 93. CPK 113. AST 19, ALT 20,
alkaline phosphatase 131. CT of her abdomen showed no free
air, no contrast to the ostomy site. Positive for hernia.
Chest x-ray within normal limits. Electrocardiogram with
normal sinus rhythm at 93 beats per minute.
HOSPITAL COURSE: The patient was admitted to the Surgery
Service.
1. Ischemic ostia with hernia: The patient was taken to the
Operating Room on [**2185-6-18**] for ileo volvulus ileo
resection and resite ileostomy. The surgery was
uncomplicated. However it was found that the patient had a
peristomal hernia with gangrenous bowel. Immediately
postoperatively, the patient was transferred to the surgical
Intensive Care Unit, intubated on pressure support only.
Immediately postoperatively, the patient did well. She had
ostomy bowel output by postoperative day number two. Her
pain was well controlled. She had adequate urine output.
She was ambulating by postoperative day number three without
complications.
2. Respiratory status: The patient immediately
postoperatively was difficult to extubate. The patient went
to the Surgical Intensive Care Unit on pressure support. She
was weaned on postoperative day number one. She was
maintained on a 40% oxygenated face mask with oxygenation
saturations between 97 to 100%. On postoperative day number
two the patient was switched to 3 liters of nasal cannula at
which time her oxygen saturations were again between 97 to
100% and on postoperative day number four the patient was
transferred to a regular room and kept on room air where her
oxygenations remained stable.
3. Hemodynamic status: The patient remained hemothymically
stable. Her blood pressure and heart rate were all within
normal limits. There was no evidence of acute hemodynamic
instability throughout her Intensive Care Unit course. The
patient was given Lopresor 5 mg q 6 hours prophylactically.
She was on postoperative day number three switched over to
Lopressor 12.5 mg po b.i.d.
4. Hematology: The patient was admitted with a hematocrit
of 39.8%, which is her baseline. Immediately postoperatively
her hematocrit was 33.8% Serial hematocrits were obtained
all of which were stable. She did not receive any blood
product and her discharge hematocrit was 27.5%. Her coags
were all within normal limits. There were no abnormalities.
5. Infectious diseases: The patient was initially admitted
with a preliminary diagnosis of ischemic ostomy infection
with a hernia. She was immediately started on Levofloxacin
as well as Flagyl. On hospital day number two the patient
was switched to Flagyl 500 mg intravenous q 8 hours,
Ampicillin 2 grams q 6 hours, Levofloxacin 500 mg q 24 hours.
This was continued for a total of three and a half days at
which time all of her antibiotics were discontinued. The
patient remained afebrile throughout her hospital course.
Her white blood cell count upon admission was 11.9% with 67
PMNs and at the time of discharge her white blood cell count
was 9.2. Her blood cultures and urine cultures all were
negative. There are no other infectious disease issues.
6. Endocrinology: The patient has a history of diabetes and
was initially kept NPO. Finger sticks were checked all of
which were within normal limits. She was gradually advanced
to and tolerating a full diabetic diet by hospital day number
four. Her finger sticks again remained normal. The patient
was started on her regular NPH and regular insulin regimen of
NPH b.i.d. and regular 10 units b.i.d. by hospital day number
four. Her electrolytes were all within normal limits and
were repleted as necessary.
7. Gastrointestinal: The patient initial was taken to the
Operating Room because her ostomy site was not producing any
bowel movements. Initially the patient was kept NPO and
gradually started on a full diabetic diet by hospital day
number four without complications. Her ostomy site produced
bowel movements by hospital day number three. There are no
other gastroenterology issues.
DISCHARGE DIAGNOSES:
1. Ulcerative colitis.
2. Ischemic bowel.
3. Ischemic ostia.
4. Diabetes.
5. Pancreatic insufficiency.
6. Depression.
7. Perirectal fistula.
DISCHARGE MEDICATIONS:
1. Zoloft.
2. Evista.
3. NPH 25 units q.a.m. and p.m. and 10 units regular a.m.
and p.m.
4. Percocet total of sixty tablets will be dispensed to be
taken as needed.
FOLLOW UP:
1. The patient will need to follow up with Dr. [**Last Name (STitle) 1888**] in one
to two weeks for a postoperative visit.
2. Her primary care physician should she need further
medical treatment.
[**Last Name (LF) **], [**First Name3 (LF) 1112**] G.
Dictated By:[**Last Name (NamePattern1) 1892**]
MEDQUIST36
D: [**2185-6-23**] 09:46
T: [**2185-6-27**] 09:54
JOB#: [**Job Number 32146**]
|
[
"250.00",
"577.8",
"569.61",
"556.9",
"560.2",
"569.69",
"557.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"46.23",
"46.51"
] |
icd9pcs
|
[
[
[]
]
] |
5624, 5773
|
5796, 5966
|
1871, 5603
|
736, 787
|
5977, 6408
|
1066, 1853
|
162, 181
|
210, 601
|
623, 712
|
804, 1043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,607
| 100,672
|
3999
|
Discharge summary
|
report
|
Admission Date: [**2187-7-25**] Discharge Date: [**2187-7-30**]
Date of Birth: [**2130-6-17**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 57 year old male
patient with known history of coronary artery disease, who
underwent a previous angioplasty with stent to the left
anterior descending in [**2183**]. He has had a recent increase of
shortness of breath and fatigue and his cardiac
catheterization on [**2187-7-25**], revealed a 70% left main
occlusion with normal left ventricular function. He is
referred for coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Coronary artery disease with previous percutaneous
transluminal coronary angioplasty.
2. Atrial fibrillation times five years.
3. 70 to 100 pack year smoking history, quit two years ago.
4. Asthma.
5. Chronic obstructive pulmonary disease.
6. Daily ETOH intake of two to six beers per day.
PREOPERATIVE MEDICATIONS:
1. Coumadin 5 mg p.o. once daily.
2. Ramipril 10 mg p.o. once daily.
3. Inderal 20 mg p.o. twice a day.
4. Lipitor 10 mg p.o. once daily.
5. Aspirin 81 mg p.o. once daily.
6. Coenzyme Q10, 60 mg p.o. once daily.
ALLERGIES: The patient states no known drug allergies but
has had previous intolerable side effects from beta blockers,
which include insomnia, fatigue and impotence.
LABORATORY DATA: Preoperative laboratory values were
unremarkable with the exception of baseline INR of 1.5.
Preoperative chest x-ray revealed chronic obstructive
pulmonary disease with bullous changes. Preoperative
electrocardiogram showed atrial fibrillation with no acute
ischemia.
PHYSICAL EXAMINATION: Preoperatively, his physical
examination was unremarkable.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2187-7-26**], where he underwent an off pump coronary artery
bypass graft times two with left internal mammary artery to
the left anterior descending and saphenous vein to the obtuse
marginal. Postoperatively, he was on Neo-Synephrine,
Nitroglycerin and Propofol intravenous drip. He was
transported from the operating room to the Cardiac Surgery
Recovery Unit in good condition. On the day of surgery, the
patient was weaned from mechanical ventilation and extubated.
The patient had some ventricular arrhythmias through the
course of the night of surgery felt to be related to his
pulmonary artery catheter. Once this was removed, he had no
further ventricular arrhythmia. The patient remained on
Neo-Synephrine drip for a few hours the following day
postoperative day one, but ultimately that was weaned off
with blood pressure above 90 systolic and the patient was
asymptomatic tolerating that well. The patient had his chest
tubes removed on peripheral pulses day one and begun beta
blockers and diuretic. The patient began cardiac
rehabilitation on postoperative day two, began to ambulate on
the telemetry floor, was placed on intravenous Heparin drip
due to his chronic atrial fibrillation and Coumadin was
initiated the evening of postoperative day two. The patient
progressed with cardiac rehabilitation over the next couple
of days and has remained hemodynamically stable in atrial
fibrillation with a resting heart rate of about 100. His
beta blocker was increased. His Coumadin was given at his
preoperative dose of 5 mg p.o. once daily His INR had not
yet bumped. After discussion with Dr. [**Last Name (STitle) 1537**] and the patient,
it was felt appropriate for the patient to have his Heparin
discontinued and allow him to be discharged home on his
preoperative Coumadin dose.
CONDITION ON DISCHARGE: Neurologically, the patient is
intact with no apparent neurologic deficits. On pulmonary
examination, his lungs are clear to auscultation bilaterally.
Cardiac examination is irregular rate and rhythm. His
abdomen is obese, soft, benign. His sternal incision is
clean and dry with no erythema and no sternal drainage. He
does, however, have a small amount of serosanguinous drainage
oozing from his chest tube site.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. twice a day.
2. Aspirin 81 mg p.o. once daily.
3. Percocet one to two tablets q4-6hours p.r.n. pain.
4. Ibuprofen 400 mg p.o. q6hours p.r.n. pain.
5. Lasix 20 mg p.o. twice a day times seven days.
6. Potassium Chloride 20 meq twice a day times seven days.
7. Lipitor 10 mg p.o. once daily.
8. Coumadin 5 mg p.o. today, [**2187-7-30**], tomorrow [**2187-7-31**],
and then he is to have an INR checked and the results are to
be called to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1683**], whose office will dose continued Coumadin. They have
been contact[**Name (NI) **] and have agreed to do this and the patient has
the appropriate information regarding Coumadin dosing to be
done by his primary care physician.
DISCHARGE STATUS: The patient is discharged in good
condition.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2187-7-30**] 14:20
T: [**2187-7-30**] 17:54
JOB#: [**Job Number 17678**]
|
[
"411.1",
"427.31",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"88.53",
"88.56",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
4981, 5316
|
4057, 4959
|
1729, 3586
|
951, 1628
|
1651, 1711
|
184, 603
|
625, 925
|
3611, 4031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,216
| 178,939
|
23776
|
Discharge summary
|
report
|
Admission Date: [**2198-11-11**] Discharge Date: [**2198-11-16**]
Date of Birth: [**2170-4-19**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
28 year old male with DM1 complicated by nephropathy,
retinopathy, and severe gastroparesis requiring multiple
admissions and gastric pacer placement, who presented to the ED
from home complaining of nausea and vomiting for over 2 days.
The patient is uncomfortable and only limited history can be
obtained. He reported multiple bouts of emesis similar to his
usual flare of gastroparesis. Came to the ED after he failed po
reglan in addition to his other regimen at home. His emesis was
initially clear/yellow and then turned brown which he states is
not unusual for him. He denies any fevers, chills, abdominal
pain. His last BM was earlier today. No [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] red blood in
emesis. No BRBPR or melena. He denies any focal complains. His
last Glargine dose was yesterday [**2198-11-10**]. He took Humalog
today.
.
In the ED initial VS 99.7; 119; 164/93; 16; O2 sat 99%. He was
given 2 liters of NS, as well as dolasetron 12.5 mg IV,
promethazine 12.5 mg IV x2, and metoclopramide 10 mg IV x 2.
Past Medical History:
1) Type 1 Diabetes Mellitus: Diagnosed at age 2, complicated by
retinopathy (blind in left eye), neprhopathy (see below),
gastroparesis. Followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **].
2) Chronic renal insufficency: baseline Cr ~ 1.6-2; +
proteinuria
3) Gastroparesis: Since [**2194**]. Received Botox injection to the
pylorus in 3/[**2197**]. Had Gastric stimulator placed on [**2197-11-10**] by
Dr. [**Last Name (STitle) **]. Flare regimen includes reglan, Zelnorm,
phenergan, compazine, and anzemet. Pacer last interrogated
06/[**2198**].
4) History of hypoglycemic seizure
5) Hypertension
6) Migraines
7) Depression
8) Anemia
9) Gastritis/esophagitis
Social History:
Patient lives with his wife who is very dedicated to his care.
Denies tobacco, alcohol, and illicit drug use. He is currently
unemployed and on disability.
Family History:
Paternal grandfather with [**Name (NI) 59282**]
Mother and sister with thyroid disease
Physical Exam:
VS: T: 97 (axillary); BP 170/88; HR 118; RR 18; 100% on RA
GENERAL: Very uncomfortable appearing male, vomiting small
amounts of dark coffee ground material throughout the interview.
NECK: supple, no LAD
HEENT: PERRL, no scleral icterus, MM tachy
CV: regular, tachycardic, no murmurs/rubs/gallop appreciated.
PULM: CTA bilaterally
ABDOMEN: Hyperactive bowel sounds, soft, non-tender,
non-distended. Gastric pacer is palpable.
EXTR: No edema, warm.
NEURO: alert, answers questions appropriately
Exam abbreviated due to the patient's discomfort.
Pertinent Results:
[**2198-11-11**] 06:30PM BLOOD WBC-8.0 RBC-4.60 Hgb-12.0* Hct-35.8*
MCV-78* MCH-26.0* MCHC-33.4 RDW-12.7 Plt Ct-384
[**2198-11-12**] 07:59PM BLOOD WBC-13.9* RBC-3.45* Hgb-9.5* Hct-26.9*
MCV-78* MCH-27.4 MCHC-35.2* RDW-12.9 Plt Ct-315
[**2198-11-16**] 05:35AM BLOOD WBC-9.2 RBC-3.30* Hgb-9.0* Hct-25.6*
MCV-78* MCH-27.3 MCHC-35.2* RDW-12.7 Plt Ct-241
[**2198-11-11**] 06:30PM BLOOD Neuts-64.3 Lymphs-25.3 Monos-5.7 Eos-3.3
Baso-1.4
[**2198-11-12**] 05:40AM BLOOD Neuts-94* Bands-0 Lymphs-5* Monos-0 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2198-11-16**] 05:35AM BLOOD Neuts-56.5 Lymphs-28.9 Monos-10.8 Eos-3.4
Baso-0.3
[**2198-11-13**] 03:06AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2198-11-11**] 06:30PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1
[**2198-11-12**] 05:40AM BLOOD PT-12.2 PTT-17.8* INR(PT)-1.0
[**2198-11-14**] 06:36AM BLOOD PT-12.7 PTT-21.9* INR(PT)-1.1
[**2198-11-11**] 06:30PM BLOOD Glucose-150* UreaN-23* Creat-2.3* Na-139
K-4.0 Cl-99 HCO3-27 AnGap-17
[**2198-11-12**] 07:59PM BLOOD Glucose-309* UreaN-28* Creat-2.0* Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
[**2198-11-14**] 06:36AM BLOOD Glucose-103 UreaN-12 Creat-1.8* Na-141
K-4.1 Cl-109* HCO3-23 AnGap-13
[**2198-11-16**] 05:35AM BLOOD Glucose-133* UreaN-19 Creat-1.8* Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
[**2198-11-11**] 06:30PM BLOOD ALT-16 AST-17 AlkPhos-93 Amylase-104*
TotBili-0.3
[**2198-11-11**] 06:30PM BLOOD Lipase-21
[**2198-11-12**] 05:17PM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
[**2198-11-14**] 12:39AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8
[**2198-11-16**] 05:35AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1
[**2198-11-12**] 07:59PM BLOOD Acetone-SMALL
[**2198-11-12**] 08:11AM BLOOD Type-ART pO2-108* pCO2-33* pH-7.39
calTCO2-21 Base XS--3
[**2198-11-12**] 06:45PM BLOOD Type-ART pO2-48* pCO2-39 pH-7.40
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2198-11-12**] 07:23PM BLOOD Type-ART pO2-106* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2198-11-12**] 08:11AM BLOOD Lactate-1.6
[**2198-11-12**] 06:45PM BLOOD Lactate-3.9* K-3.9
[**2198-11-12**] 07:23PM BLOOD Lactate-3.1* K-4.0
[**2198-11-12**] 07:59PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2198-11-12**] 07:59PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-11-12**] 07:59PM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2198-11-13**] 03:07AM URINE Hours-RANDOM Creat-47 Na-94
[**2198-11-13**] 3:07 am URINE Site: NOT SPECIFIED
**FINAL REPORT [**2198-11-14**]**
URINE CULTURE (Final [**2198-11-14**]): NO GROWTH.
[**2198-11-12**] Blood cultures PENDING
[**2198-11-11**] ECG: Sinus tachycardia. Otherwise, tracing is within
normal limits.
[**2198-11-12**] Abd XRay: PORTABLE ABDOMEN: Single view of the abdomen
shows some stool and small amount of gas are seen in the rectum
and in the ascending colon. The remainder of the abdomen is
gasless. No loops of bowel are seen. A neuro stimulating device
over the thoracolumbar spine is again noted. Bony structures are
within normal limits.
IMPRESSION: No definite evidence of obstruction, however,
gasless abdomen makes evaluation of small bowel loops difficult.
[**2198-11-12**] CXR: The heart size is normal, and there are no
mediastinal or hilar abnormalities. The lungs are clear, and no
pleural abnormalities are evident on this single projection.
Gastric stimulator leads project over the upper abdomen,
unchanged.
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
28 yo M with DM1 and severe gastroparesis s/p gastric pacer
placement with recurrent admissions for gastroparesis flares
presents with nausea and vomiting, most likely secondary to
recurrent gastroparesis flare with suspicion of overlying
infection.
.
# Nausea and vomiting: Anion gap acidosis. Abdomen soft and
benign on exam. LFTs and lipase are WNL. EKG with sinus tach.
Gastroparesis flare is the most likely etiology as the patient
reports that his symptoms are similar to his usual symptoms with
gastroparesis flare. Small bowel obstruction is also in the
differential but given reassuring abdominal exam and history
will defer further imaging at this time.
.
Pt was kept NPO and given IVF. His home PO medicines were held.
He was given IV anzemet, compazine, reglan, and phenergan for
nausea. He was having coffee grounds emesis, which per pt is
usual for his episodes of gastroparesis, but emesis was
gastroccult negative. GI and [**Last Name (un) **] were made aware of pt. Pt
was given IV hydralazine for BP control and IV protonix for GI
ppx. Labs and HCT were followed to watch for DKA and bleeding.
Pt refused NG lavage and HCT was stable, pt had PIVx2 and active
type and crossmatch. Pt was kept on telemetry to follow HD
stability as he was tachycardic. Urine and blood cultures were
obtained as pt was febrile and had a leukocytosis. Pt was given
slightly less glargine than usual as he was NPO and covered with
SS humalog.
.
Pt had critical BS levels x3 fingersticks. Pt had FS at 4:30pm
which was >500 and pt was given 18units of humalog insulin. BS
was checked again at 5pm and BS was again >500. Labs were drawn
and 1L LR was given (pt has been getting 200cc/hr). BS at 5:15pm
was 561 on his chem panel. 8 units of regular insulin were given
IV at 5:45pm and at 6pm his BS was >500 on finger stick. At this
point the decision was made with the primary care team in
conjunction with the [**Last Name (un) **] attending, Dr. [**First Name (STitle) 3636**], for the pt to be
transferred to the ICU for an insulin drip in order to control
his blood glucose. The MICU resident was notified and an ICU bed
obtained. At 6:15pm the pt's BS was 445. Pt was then transferred
to the MICU.
.
****ICU Course****
Pt was maintained on insulin drip for improved glycemic control
until HD#5 when he was able to tolerate POs and again take his
lantus and humalog insulin injections. He was given aggressive
IVF hydration and anti-emetics on HD#5 and although he had a
small anion gap HD#2 it had resolved by HD#3 and never went into
DKA although there were small amounts of ketones in his blood at
the time of his transfer to the ICU. He was maintained on the
anti-emetic, PPI, IVF as before. He required hydralazine and
metoprolol IV to control his tachycardia and HTN until he was
able to take POs and restart his home meds. His acute on
chronic renal failure improved with fluid hydration to his
baseline around 1.7. Once he was tolerating POs and off the
insulin drip, he was transferred back to the floor. When the pt
was tolerating POs he was restarted on his home tegaserod. GI
recommended erythromycin as a prokinetic but the pt refused to
take it as it upset his stomach.
.
HD#5 pt was transferred to floor. He was able to tolerate a
diet and his blood sugars were controlled on his home regimen.
His HCT was stable at his baseline around 26. He was taking his
home PO medications to control his HTN. His WBC was normal
HD#6. No antibiotics were ever given as no source of infection
was ever determined and pt stated that he normally has a fever
and increased WBC during his episodes of gastroparesis.
.
10. Full code
Medications on Admission:
1. Metoclopramide 10 mg PO TID PRN nausea
2. Tegaserod Hydrogen Maleate 6 mg PO BID
3. Valsartan 80 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. Pantoprazole 40 mg Q12H
6. Insulin Glargine 25 Units SQ QHS
7. Ferrous Sulfate 325 PO BID
Discharge Medications:
1. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
7. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
8. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) UNITS
Subcutaneous at bedtime.
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-6 UNITS
Subcutaneous four times a day as needed for FSBG >150: Per
Sliding Scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Gastroparesis
Secondary Diagnosis:
1. Metabolic Acidosis- Starvation Ketosis
2. Volume Depletion
3. Diabetes type I
Discharge Condition:
stable. tolerating PO's. off IV pain control, anti-emetics
Discharge Instructions:
You were admitted for gastroparesis and treated with insulin and
intravenous fluids. If you have recurrent abodminal pain,
nausea, vomiting, fever >101, or other concerning symptoms
please see your primary care physician or present to the
emergency department for evaluation.
Followup Instructions:
Please call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] to make an
appointment with a new PCP [**Last Name (NamePattern4) **] [**2-9**] weeks. The clinic is located
in the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**] of [**Hospital1 771**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"276.51",
"427.89",
"362.01",
"401.9",
"311",
"250.53",
"585.9",
"285.9",
"V58.67",
"250.63",
"536.3",
"346.90",
"250.43",
"276.2",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11329, 11335
|
6512, 10163
|
299, 306
|
11518, 11579
|
2950, 6489
|
11903, 12304
|
2280, 2369
|
10453, 11306
|
11356, 11356
|
10189, 10430
|
11603, 11880
|
2384, 2931
|
240, 261
|
334, 1386
|
11414, 11497
|
11375, 11393
|
1408, 2089
|
2105, 2264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,487
| 159,655
|
26378
|
Discharge summary
|
report
|
Admission Date: [**2181-3-13**] Discharge Date: [**2181-3-20**]
Date of Birth: [**2107-1-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal Aortic Aneurysm
Major Surgical or Invasive Procedure:
Open repair of Abdominal Aortic Aneurysm
History of Present Illness:
74F with known AAA who was found to have an acute increase in
diameter from 4 to 5 cm over several months. Patient had
previously required coronary revascularization, and was seen in
the clinic with an additional increase in AAA diameter to 5.6
cm, involving both renal arteries as well as an iliac aneurysm,
and so was planned for elective repair.
Past Medical History:
Past medical history is significant for COPD, ventricular
tachycardia, coronary artery disease, cardiomyopathy,
hyperlipidemia, cerebrovascular disease with noted left carotid
stenosis above, gastroesophageal reflux, type 2 diabetes, which
is managed with oral medications, juxtarenal abdominal aortic
aneurysm measuring 3.5 x 5.1 cm, osteoarthritis, anxiety and
depression, diverticulosis, and left common iliac aneurysm
measured 2.8 cm. She also has history of GI bleed and hiatal
hernia. Also additional medical history is of spinal stenosis.
Past surgery is significant for cholecystectomy, tubal ligation,
and right subclavian bypass with Dr. [**Last Name (STitle) 23638**]
Social History:
1 ppd tob.
Family History:
Son w/ MI at age 32
Physical Exam:
Physical Exam:
VS: Tm 98 Tc 97.9 HR 78 BP 135/76 RR 18 O2 sat 97 RA
gen: WA/ WD, NAD
CV: RRR
pulm: CTA b/l
abdomen: NSB, ND/NT, left mid-abdominal/flank incision c/d/i
w/staples in place, no discharge
extremities: no edema
Pertinent Results:
admission:
[**2181-3-13**] 08:16PM HCT-32.9*
[**2181-3-13**] 01:52PM UREA N-20 CREAT-0.9 SODIUM-135 CHLORIDE-109*
TOTAL CO2-18*
[**2181-3-13**] 01:52PM CALCIUM-7.6* PHOSPHATE-2.9 MAGNESIUM-1.2*
[**2181-3-13**] 01:52PM WBC-21.2*# RBC-3.28*# HGB-10.1*# HCT-29.5*#
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.9
[**2181-3-13**] 01:52PM NEUTS-85.3* LYMPHS-11.7* MONOS-2.2 EOS-0.2
BASOS-0.5
[**2181-3-13**] 01:52PM PLT COUNT-160#
discharge:
[**2181-3-20**] 05:35AM BLOOD PT-53.6* INR(PT)-5.9*
[**2181-3-20**] 05:35AM BLOOD Glucose-139* UreaN-15 Creat-1.1 Na-139
K-4.1 Cl-101 HCO3-29 AnGap-13
[**2181-3-14**] 09:49PM BLOOD Glucose-158* K-4.4
imaging: [**2181-3-16**]
Thrombosis within the left internal jugular vein, causing almost
complete
occlusion of the vessel. Loss of respiratory variability on
Doppler imaging of the left subclavian vein is suggestive of
possible thrombus in the left brachiocephalic vein.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
treatment of her abdominal aortic aneurysm. She tolerated the
surgery well. After a brief, uneventful stay in the PACU, the
patient arrived on the ICU intubated, on no vasopressive
medications, NPO, on IV fluids, with a foley catheter, and PCA
for pain control. The patient was hemodynamically stable. She
was extubated on POD 1 without any complications. She remained
in the ICU until POD2, she was subsequently transferred to the
floor.
Neuro: The patient received PCA with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications, which controlled her pain
well.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient remained
afebrile and did not recieve any antibiotics. Her incision
remined clean, dry and intact with minimal to no drainage.
Endocrine: The patient's blood sugar was monitored throughout
her stay.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible. She was continued on
aspirin and was started on plavix. She was treated with coumadin
for a few days for the blood clot found in her left internal
jugular vein and possible thrombus in the left brachiocephalic
vein. It was determined that the risks of the treatment
outweighs the benefits and the anticoagulation was stopoped.
Patient is being discharged to home on aspirin and plavix only.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Aspirin 81 mg Tablet
Pantoprazole 40 mg Tablet QD
Simvastatin 10 mg Tablet QD
Metformin 500 mg [**Hospital1 **]
Carvedilol 6.25 mg [**Hospital1 **]
Imipramine 50 mg daily
Lisinopril 5 mg QD
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for Pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Imipramine HCl 50 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Clonazepam 0.5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO once a day as needed for anxiety .
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Abdominal Aortic Aneurysm
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-3**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Please call the clinic to make an appointment with Dr.
[**Last Name (STitle) **] in approximately 2 weeks. ([**Telephone/Fax (1) 18181**]
Completed by:[**2181-3-20**]
|
[
"041.4",
"276.6",
"433.10",
"272.4",
"V45.81",
"441.4",
"530.81",
"553.3",
"440.1",
"425.4",
"250.00",
"496",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"38.46"
] |
icd9pcs
|
[
[
[]
]
] |
6420, 6475
|
2730, 5321
|
339, 382
|
6545, 6545
|
1795, 2707
|
9405, 9574
|
1510, 1531
|
5561, 6397
|
6496, 6524
|
5347, 5538
|
6690, 8952
|
8978, 9382
|
1561, 1776
|
274, 301
|
410, 760
|
6559, 6666
|
782, 1465
|
1481, 1494
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,689
| 107,597
|
10797+10798+56179+56180+56181
|
Discharge summary
|
report+report+addendum+addendum+addendum
|
Admission Date: [**2155-10-24**] Discharge Date: [**2155-11-12**]
Service: VASCULAR
CHIEF COMPLAINT: Bilateral lower extremity swelling and
right lower extremity painful ulcerations with back and thigh
pain.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old female
status post right femoral-popliteal bypass in [**2131**] which then
failed six months later, history of congestive heart failure,
coronary artery disease, peripheral vascular disease, history
of myocardial infarction in [**2123**], who presented with a
two-week history of swelling of the lower extremities and
painful ulcerations of the toes in the right lower extremity.
She also complained of posterior thigh and calf pain; this
was unclear whether this pain was at rest or with ambulation.
She did have some rest pain and some discomfort at 10-15 feet
walking. She denied chest pain and shortness of breath. She
is a resident of [**Hospital3 **] Center.
PAST MEDICAL HISTORY: Femoral-popliteal bypass, right, in
[**2131**], occluded. Pacemaker two years ago. Congestive heart
failure. Ejection fraction reported at 25%. Coronary artery
disease. History of myocardial infarction in [**2123**]. History
of hypertension. History of hypercholesterolemia. History
of [**Doctor Last Name 35251**] disease status post lumbar sympathectomy.
History of chronic renal insufficiency with a baseline
creatinine of 1.5 to 2.0. History of chronic obstructive
pulmonary disease. History of peptic ulcer disease with
melena. History of MRSA. History of neuropathic pain.
PAST SURGICAL HISTORY: Tonsillectomy. Hysterectomy.
Appendectomy. Right finger amputation secondary to trauma.
Right femoral-popliteal bypass graft, failed.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Enteric Coated Aspirin 81 mg q.d.,
Wellbutrin 75/37.5 mg, 75 in the morning, and 37.5 in the
afternoon, Os-Cal 500 mg b.i.d., Colace 100 mg b.i.d., Lasix
20 mg Monday and Wednesday, Isordil 5 mg b.i.d., Prevacid 30
mg q.d., Zestril 10 mg b.i.d., Multivitamin, Vitamin C q.d.,
Zocor 40 mg q.d., Mylanta p.r.n., Compazine p.r.n., Milk of
Magnesia p.r.n., Tylenol p.r.n., Darvocet [**2-5**] p.r.n.
PHYSICAL EXAMINATION: Vital signs: Temperature 95??????, blood
pressure 180/70, heart rate 78. General: The patient was an
alert, oriented female in no acute distress. Left arm was
with bruises and well-healing lower extremity ulcerations.
Heart: Distant sounds. Regular, rate and rhythm. Chest:
With a left pacemaker implantation in the anterior chest.
Lungs clear to auscultation. Abdomen: Unremarkable.
Extremities: Left index finger missing. Left arm with
bruising and left lower extremities with excoriations. The
left foot was with ulcerations on all five toes. There was
pitting edema bilaterally, left greater than right. There
was tenderness of the toes on palpation. Pulse exam showed
carotids palpable with no bruits. Radials palpable. Femoral
Dopplerable. Popliteals Dopplerable. Dorsalis pedis pulses
monophasic and posterior tibial biphasic signals only.
LABORATORY DATA: On admission white count was 5.6,
hematocrit 44.1, platelet count 130; PT and INR were normal;
BUN 38, creatinine 1.7, potassium 5.1, glucose 153.
HOSPITAL COURSE: The patient was continued on her current
preadmission medications. Cardiology was requested to see
the patient in anticipation for potential revascularization.
They felt that she was intermediate risk and will require
Persantine Thallium prior to surgery to rule out any
significant coronary artery disease. Pain MIBI demonstrated
a moderate fixed inferior and inferolateral wall Persantine
defect. The ejection fraction was 15%.
Chest x-ray on admission showed left lower lobe opacification
concerning for pneumonia. There may be a small associated
pleural effusion. She had a dual-chamber pacemaker and leads
adequately positioned. She had cardiomegaly with no evidence
of failure.
The patient underwent arterial study on [**10-27**] which
demonstrate severe ostial stenosis of the renal arteries
bilaterally. The was significant ostial stenosis of the
origin of the celiac and superior mesenteric arteries,
occlusion of the right iliac and femoral arteries, and
occlusion of the left hypogastric artery. The patient had
diffuse calcified left common and external iliac arteries and
significant stenosis of bilateral subclavian arteries. The
patient had episodes preprocedure of left brachial artery
spasm which with incomplete response of intra-arterial
vasodilators.
A CT of the head was obtained at the same time requested for
mental status changes, and this was negative for any acute
intracranial hemorrhage or infarct.
Postinterventional procedure, the patient was noted to have
changes in her left arm pulses with absence of the pulse,
associated with the mental status changes, and she had
dysarthria. This was the reason for the head CT. The
patient was begun on intravenous Heparin with a [**2153**] U bolus
and a 600 U/hr with serial PTTs to maintain her PTT at 50-60.
The patient underwent on [**10-28**] an urgent left brachial
artery exploration with [**Doctor Last Name **] thrombectomy and a right
axillo-bifemoral bypass with 6 mm PTFE. The patient required
6 U of packed cells intraoperatively, 2 [**Location 16678**], and 1 U
platelets. The intraoperative findings was a thrombus at the
proximal left brachial artery. The right axial artery inflow
was good. The bilateral SFAs were occluded. The bilateral
profundas were patent, and the right profunda was
endarterectomized. The patient had bilateral Dopplerable
dorsalis pedis pulses at the end of this procedure. Her
postoperative hematocrit was 38.1. Her BUN and creatinine
remained stable. Her total CK was 808. Chest x-ray was
without pneumothorax. Electrocardiogram was with no acute
ischemic changes. She was transferred to the SICU for
continued monitoring and care.
On postoperative day #1, there were no overnight events. She
remained in the SICU intubated and sedated but responding
appropriately to pain. T-max was 99.3??????, heart rate was
60-70, blood pressure 110/58, respirations 22, oxygen
saturation 98%, CVP 5, PAP 54/25, wedge 10, index 1.3, SVR
26.11. She was on Dobutamine 5 mcg/kg/min for inotropic
support. Her postoperative hematocrit was 40.6, PTT 49.3,
INR 1.8, BUN 36, creatinine 1.7; CKs rose to 1700, MBs were
34, troponin was 1.4.
On postoperative day #2, she remained hemodynamically stable
but intubated. She was weaned off her Dobutamine. Diuresis
was continued. On postoperative day #3, there were no
overnight events. She was extubated. Her gases were 7.44,
32, 65, 22, base excess 0. Hematocrit remained stable at
38.2, BUN 51, creatinine 2.4, potassium 3.7, which was
supplemented; INR 1.8, PTT 55. Her pulse exam remained
unchanged. Her urine had E. coli urinary tract infection
which was treated with Levaquin. She was begun on p.o.
intake. Protonix was converted to p.o. She was transferred
to the VICU for continued monitoring and care.
Nutritional Services evaluated the patient and felt that she
was not meeting her caloric needs, and if she remains with
poor intake, recommendations were to start tube feeds until
p.o. intake was adequate.
The patient continued with clinical improvement in her mental
status. On postoperative day #4, her exam remained
unchanged. Her mental status continued to improve. Her
pulse exam was unchanged. Tube feeds were begun, and they
were at goal. She was continued on her Levofloxacin.
On postoperative day #6, the patient removed her NG tube, and
this was replaced. BUN was 63, creatinine improved to 2.0.
Lopressor was converted from IV to p.o.. She was continued
on hydration. Levofloxacin was continued. Case Management
was involved for anticipation of discharge planning.
Respiratory Therapy recommended treatment with Albuterol and
Atrovent nebulizers and pulmonary toileting. The patient
remained afebrile, and hematocrit remained stable.
On postoperative day #7, she was delined and transferred to
the regular nursing floor. Speech and swallow was requested
to see the patient on [**2155-11-4**], because of questions
whether the patient was aspirating. The bedside exam showed
frank aspirations, and recommendations were to make the
patient NPO and continue feeding by tube. TPN was begun at
this time on [**2155-11-6**]. Over the next 24-48 hours, the
patient's respiratory status improve with being NPO. Her
triple line was changed on [**2155-11-6**]. GI was consulted
on [**2155-11-7**], for placement of PEG. They felt that the
patient was a candidate for PEG placement and discussed the
options with the daughter-in-law.
Medicine was consulted on [**11-8**] because of hyponatremia,
and recommendations were for free water and adjustment in her
TPN osmolarity. Her maximum sodium was 151. With adjustment
in her TPN and free water replacement, her hyponatremia
resolved over the next 48 hours. Neurology was requested to
see the patient on [**2155-11-10**], because of mental status
changes. They felt most of this was related to her
hyponatremia, pneumonia, and the current treatment plan was
adequate but to consider decreasing sedation medications.
The patient underwent PEG placement in Interventional
Radiology on [**2155-11-11**]. Her constipation was relieved
with enemas and digital disimpaction. The patient continued
to have episodes of hypoxia. The etiology was probably
pulmonary versus cardiac.
TPN will be continued for several days until tube feeds were
met at goal rate before discontinuing. Consideration to
transfer the patient to the Medical Service was discussed.
Further addendum to the discharge summary will be made at the
time of the patient's discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2155-11-11**] 17:55
T: [**2155-11-11**] 18:59
JOB#: [**Job Number 6288**]
Admission Date: [**2155-10-24**] Discharge Date: [**2155-11-13**]
Service: Vascular
NOTE: This is an addendum to the initial discharge summary
which was begun on [**2155-11-11**].
The patient's remaining hospital course was unremarkable.
She was discharged to the acute care facility at the [**Hospital3 1761**] in stable condition, tolerating her tube
feeds. TPN was continued until time of discharge, then this
was discontinued.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg intravenous qd
2. Heparin 5000 units subcutaneous q 12 hours
3. Protonix intravenous or per tube 40 mg qd
4. Lopressor 10 mg intravenous q6h
5. Levofloxacin 250 mg intravenous or via tube feed q 24
hours
6. Miconazole powder 2% to affected areas tid and prn
TUBE FEEDS:
1. Ultracal full strength at 30 cc per hour. Goal rate was
55 cc per hour. Tube feeds were advanced 10 cc q4h until
goal rate met. Residuals be checked q4h and held if greater
than 100 cc. A tube will be flushed q8h with water 30 cc.
FOLLOW UP on a prn basis with Dr. [**Last Name (STitle) 1476**].
DISCHARGE DIAGNOSES:
1. Right extremity claudication and rest pain with back pain
2. She underwent arteriogram which was complicated with a
left brachial artery thrombus.
3. She underwent on [**10-28**] left brachial artery exploration
thrombectomy, right axillo fem-fem bypass with PTFE.
4. She had a PEG placement on [**2155-11-11**].
5. She has history of MRSA.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2155-11-12**] 14:34
T: [**2155-11-12**] 14:59
JOB#: [**Job Number 35252**]
Name: [**Known lastname 6276**], [**Known firstname 3192**] Unit No: [**Numeric Identifier 6277**]
Admission Date: [**2155-10-24**] Discharge Date: [**2155-11-13**]
Date of Birth: Sex:
Service: [**Doctor Last Name **] MEDICINE
Mrs. [**Known lastname **] is an 83-year-old female postoperative status post
right axillofemoral bypass who was transferred to the
Medicine Service on [**2155-11-13**] for increasing
respiratory rate and increased shortness of breath since
[**2155-11-10**]. The patient was in clear respiratory
distress and we were called to see her. She was febrile with
a low-grade temperature of 99.6. She also had an elevated
white count on [**2155-11-13**] of 15.9. Her respiratory
rate was in the 40s and she was using accessory muscles to
help with breathing. The Surgical Team had requested the
Neurology Service to see the patient for changes in mental
status. A note from Neurology on [**2155-11-10**] recommended
treatment for a pneumonia. The patient was started on
levofloxacin but only treated for a days long course.
On review of the patient's data, the chest x-ray that were
portable from [**2155-11-8**] and [**2155-11-10**] showed a
left lower lobe opacity versus atelectasis and with the
patient's white blood count increasing up to 15 it was felt
by the Medicine Team that the patient was likely suffering
from an aspiration pneumonia from aspiration of tube feeds
that had been started on [**2155-11-11**] via PEG.
For management of the patient's pneumonia, the patient was
initially started on vancomycin with her history of MRSA UTI
and she was started on levofloxacin for gram-negative and
pseudomonal coverage. The patient was also noted to have a
UTI on urinalysis on [**2155-11-13**] and so levofloxacin was
thought to cover.
The patient's left lower lobe pneumonia was noted on portable
chest x-rays from [**2155-11-8**], [**2155-11-10**] and now
[**2155-11-13**]. The patient was started empirically on
vancomycin as she had a history of a MRSA UTI and she was
also started on levofloxacin for empiric coverage of
gram-negatives, atypicals, and for pseudomonal coverage. As
the patient was calculated to only have a creatinine
clearance of 19, she was started on 250 mg of levo per her
PEG tube q. 48 hours and 500 mg IV of vancomycin q. 24 hours.
These medications were started on [**2155-11-13**]. Also for
the patient's pneumonia, the patient was ordered to have
aggressive nasotracheal suction q. eight hours. She was
placed on albuterol nebulizers p.r.n. and Atrovent nebulizers
q. six hours and a sputum culture was sent. The sputum
culture on [**2155-11-13**] came back with gram-positive
cocci in clusters and pairs as well as 1+ gram-negative rods.
The sputum culture eventually grew out heavy growth of
Staphylococcus aureus coagulase-positive so the patient was
continued on vancomycin for likely MRSA. The sample had
greater than 25 PMNs but also greater than 10 epithelial
cells so it was not immediately speciated; however, it was
requested that the sputum be further speciated and it grew
out MRSA which was sensitive to ampicillin and vancomycin;
however, the patient had a history of ampicillin allergy so
she was kept on vancomycin.
The urine culture that was obtained on [**2155-11-13**] came
back with vancomycin-resistant Enterococcus. The patient had
been treated empirically for a UTI based on her positive
urinalysis findings including red blood cells, white blood
cells, and a few bacteria, treated empirically with
levofloxacin. However, with the development of positive VRE
on urine culture, the patient was initially started on
nitrofurantoin on [**2155-11-16**]. However, ID was
consulted as it was realized that in patient with low
creatinine clearance, nitrofurantoin often cannot concentrate
in the urine and can sometimes be toxic. ID recommended that
the nitrofurantoin be discontinued and linazolid be started
which would also cover the MRSA in the patient's sputum.
Therefore, linazolid 600 mg per G tube q. 12 hours was
started on [**2155-11-16**] and on the same day, [**2155-11-16**], the vancomycin was discontinued.
The patient improved from a clinical standpoint. Her white
blood count decreased from 15 to 8. Her respiratory rate
declined from in the 40s to in the 18-24 range and she
appeared more comfortable. As the patient was thought to
possibly have an aspiration pneumonia from aspiration of PEG
feedings, the patient was started on Flagyl on [**2155-11-13**].
On [**2155-11-15**], the patient was noted by the nursing
staff to have increased leakage of a yellow-greenish material
from the J tube. The material was nonpurulent, nonbloody and
was found to be drainage from the stomach and also thought to
be bile. A KUB was ordered to rule out obstruction in this
setting which showed no obstruction of the PEG. Contrast was
injected at the bedside, roughly 20 cc of barium and it was
noted to traverse through the PEG without problem and was
seen to flow through the small intestine.
Interventional Radiology had placed the PEG on [**2155-11-11**] so they were consulted on the evening of [**2155-11-15**] in regards to the increased leakage from around the
tube. They agreed with our management of obtaining a KUB and
felt that this was a nonurgent situation and came to see the
patient on [**2155-11-16**].
On [**2155-11-16**], they felt that this drainage did indeed
represent gastric acid and bile refluxing from around the
tube and was not a problem with the tube itself. They
recommended that the ostomy nurses come and see the patient
to protect her skin from breakdown from the gastric acid
secretion. The ostomy nurses did come and dressed the wound
appropriately on Monday, [**2155-11-17**]. However, the PEG
continued to leak significant amounts of fluid ranging from
300-500 cc per 24 hours of the same nonpurulent
yellow-greenish material. Follow-up KUBs were obtained on
[**2155-11-17**] and again showed no evidence of obstruction.
Tube feeds were held from [**2155-11-16**] to [**2155-11-17**].
IR was reconsulted on [**2155-11-17**] as the patient
continued to have significant leakage and it was felt that
she may benefit from placement of a new tube. The patient
did go down to the Interventional Radiology Suite on [**2155-11-18**] and a new wider sized tube was placed in the
jejunum.
Over the course of the day on [**2155-11-18**], the patient's
urine output dropped, likely secondary to tube feeds being
held for 24 hours in the setting of increased leakage from
the J tube. The patient's central line that had been in
place for roughly 1 1/2 months was discontinued on [**2155-11-17**] feeling that it would likely only service another
infectious risk and the patient was receiving adequate
nutrition from the tube feeds. However, with the acute drop
in urine output over a 12 hour period, it was felt that the
patient would benefit from aggressive hydration and a central
line was replaced on the evening of [**2155-11-18**], a left
internal jugular line, and the patient received IV fluids.
Her urine output picked up nicely and responded to the
hydration so that by the morning of [**2155-11-19**] the
patient was putting out roughly 30-40 cc of urine per hour.
Also, on [**2155-11-18**], tube feeds were restarted via the
PEG as IR thought it would be fine to use the tube after it
had been replaced for nourishment.
On [**2155-11-20**], the patient continued to have drainage
from the PEG even after placement of the new tube, roughly
700 cc in 24 hours. The ostomy nurses created an ostomy bag
that nicely protected the skin. The patient also had a small
bowel follow through to rule out obstruction and the small
bowel follow through showed no obstruction, no ileus, and
showed that the contrast flowed freely through the
jejunostomy tube and into the colon. Therefore, it was felt
that that PEG would be safe to use for tube feedings and that
the patient did indeed require the tube feedings for
nutrition with an albumin of only 2.1.
GI was also consulted on [**2155-11-20**] for assessment of
the PEG to make sure that no further action could be taken to
help decrease the reflux from the tube of gastric acid and
bile. GI felt that the reason for the leakage around the PEG
was slow healing time in a patient with so many medical
comorbidities and with such a low albumin that it would take
time for the wound to fistulize and that this type of
drainage was to be expected. They had no other
recommendations at the time other than continuing the ostomy
care and recommending continuation of tube feeds for
nutrition.
On [**2155-11-20**], the patient's platelet count was noted
to drop from 185,000 to 168,000. The platelet count was
followed and on [**2155-11-21**], it dropped from 168 to 127.
On [**2155-11-22**], it dropped from 127 to 102. On [**2155-11-23**], it continued to decline from 102 to 90. It was
felt that this isolated thrombocytopenia was likely
iatrogenic. The patient was on three medications that could
possibly be causing the platelet count drop. These included
a PPI, lansoprazole, heparin subcutaneous, and linazolid.
The patient had been on the PPI for many years. The heparin
had been on for roughly two months and the linazolid was the
newest medication that was started; [**2155-11-23**] was day
number seven of this medication.
As it was felt that linazolid could be causing the platelet
drop, it was decided to stop the antibiotic as the patient
had been on it for seven days and a seven day course would
likely treat a VRE UTI. The urine was sent for urinalysis
and culture to make sure that the urine infection had indeed
resolved, essentially in the setting of stopping the
linazolid. Vancomycin was restarted to continue treatment of
the MRSA and pneumonia. The patient had been treated for a
total of seven days for the MRSA with linazolid and also
three days prior to starting linazolid with vancomycin. This
is a ten day course of antibiotics in total for MRSA
pneumonia and it was decided by the team that a 14 day course
of antibiotics would be sufficient for treatment of this
pneumonia so she would only require vancomycin for four days
further for the pneumonia.
ID was called and they agreed with our management and they
felt that the urinalysis and urine culture should be sent and
if the UTI had not resolved we could reconsult them as to
what medication to restart to treat the urinary tract
infection.
The ultimate goals in our care of this patient were to
stabilize the patient so that she could return to [**Hospital3 6278**] Center where she had come from. The patient
was DNI/DNR but the family did not wish to make her comfort
measures so we continued in our aggressive treatment of her
infection and our goal was to maintain adequate nutrition.
The tube feeds were increased to 55 cc per hour of Ultracal
on [**2155-11-23**] which for nutrition was her feeding goal.
She was tolerating these tube feeds well with only minimal
leakage around the PEG.
A family meeting was scheduled for Monday, [**2155-11-24**],
to help discuss ultimate plans for this patient in terms of
whether or not she should be made comfort care and whether or
not she was ready for discharge back to the rehabilitation
facility.
Dictated By:[**Last Name (NamePattern1) 1644**]
MEDQUIST36
D: [**2155-11-23**] 15:28
T: [**2155-11-23**] 15:49
JOB#: [**Job Number 6279**]/[**Numeric Identifier 6280**]
Name: [**Known lastname 6276**], [**Known firstname 3192**] Unit No: [**Numeric Identifier 6277**]
Admission Date: [**2155-10-24**] Discharge Date: [**2155-11-13**]
Date of Birth: Sex:
Service: [**Doctor Last Name **] MEDICINE
Mrs. [**Known lastname **] is an 83-year-old female postoperative status post
right axillofemoral bypass who was transferred to the
Medicine Service on [**2155-11-13**] for increasing
respiratory rate and increased shortness of breath since
[**2155-11-10**]. The patient was in clear respiratory
distress and we were called to see her. She was febrile with
a low-grade temperature of 99.6. She also had an elevated
white count on [**2155-11-13**] of 15.9. Her respiratory
rate was in the 40s and she was using accessory muscles to
help with breathing. The Surgical Team had requested the
Neurology Service to see the patient for changes in mental
status. A note from Neurology on [**2155-11-10**] recommended
treatment for a pneumonia. The patient was started on
levofloxacin but only treated for a days long course.
On review of the patient's data, the chest x-ray that were
portable from [**2155-11-8**] and [**2155-11-10**] showed a
left lower lobe opacity versus atelectasis and with the
patient's white blood count increasing up to 15 it was felt
by the Medicine Team that the patient was likely suffering
from an aspiration pneumonia from aspiration of tube feeds
that had been started on [**2155-11-11**] via PEG.
For management of the patient's pneumonia, the patient was
initially started on vancomycin with her history of MRSA UTI
and she was started on levofloxacin for gram-negative and
pseudomonal coverage. The patient was also noted to have a
UTI on urinalysis on [**2155-11-13**] and so levofloxacin was
thought to cover.
The patient's left lower lobe pneumonia was noted on portable
chest x-rays from [**2155-11-8**], [**2155-11-10**] and now
[**2155-11-13**]. The patient was started empirically on
vancomycin as she had a history of a MRSA UTI and she was
also started on levofloxacin for empiric coverage of
gram-negatives, atypicals, and for pseudomonal coverage. As
the patient was calculated to only have a creatinine
clearance of 19, she was started on 250 mg of levo per her
PEG tube q. 48 hours and 500 mg IV of vancomycin q. 24 hours.
These medications were started on [**2155-11-13**]. Also for
the patient's pneumonia, the patient was ordered to have
aggressive nasotracheal suction q. eight hours. She was
placed on albuterol nebulizers p.r.n. and Atrovent nebulizers
q. six hours and a sputum culture was sent. The sputum
culture on [**2155-11-13**] came back with gram-positive
cocci in clusters and pairs as well as 1+ gram-negative rods.
The sputum culture eventually grew out heavy growth of
Staphylococcus aureus coagulase-positive so the patient was
continued on vancomycin for likely MRSA. The sample had
greater than 25 PMNs but also greater than 10 epithelial
cells so it was not immediately speciated; however, it was
requested that the sputum be further speciated and it grew
out MRSA which was sensitive to ampicillin and vancomycin;
however, the patient had a history of ampicillin allergy so
she was kept on vancomycin.
The urine culture that was obtained on [**2155-11-13**] came
back with vancomycin-resistant Enterococcus. The patient had
been treated empirically for a UTI based on her positive
urinalysis findings including red blood cells, white blood
cells, and a few bacteria, treated empirically with
levofloxacin. However, with the development of positive VRE
on urine culture, the patient was initially started on
nitrofurantoin on [**2155-11-16**]. However, ID was
consulted as it was realized that in patient with low
creatinine clearance, nitrofurantoin often cannot concentrate
in the urine and can sometimes be toxic. ID recommended that
the nitrofurantoin be discontinued and linazolid be started
which would also cover the MRSA in the patient's sputum.
Therefore, linazolid 600 mg per G tube q. 12 hours was
started on [**2155-11-16**] and on the same day, [**2155-11-16**], the vancomycin was discontinued.
The patient improved from a clinical standpoint. Her white
blood count decreased from 15 to 8. Her respiratory rate
declined from in the 40s to in the 18-24 range and she
appeared more comfortable. As the patient was thought to
possibly have an aspiration pneumonia from aspiration of PEG
feedings, the patient was started on Flagyl on [**2155-11-13**].
On [**2155-11-15**], the patient was noted by the nursing
staff to have increased leakage of a yellow-greenish material
from the J tube. The material was nonpurulent, nonbloody and
was found to be drainage from the stomach and also thought to
be bile. A KUB was ordered to rule out obstruction in this
setting which showed no obstruction of the PEG. Contrast was
injected at the bedside, roughly 20 cc of barium and it was
noted to traverse through the PEG without problem and was
seen to flow through the small intestine.
Interventional Radiology had placed the PEG on [**2155-11-11**] so they were consulted on the evening of [**2155-11-15**] in regards to the increased leakage from around the
tube. They agreed with our management of obtaining a KUB and
felt that this was a nonurgent situation and came to see the
patient on [**2155-11-16**].
On [**2155-11-16**], they felt that this drainage did indeed
represent gastric acid and bile refluxing from around the
tube and was not a problem with the tube itself. They
recommended that the ostomy nurses come and see the patient
to protect her skin from breakdown from the gastric acid
secretion. The ostomy nurses did come and dressed the wound
appropriately on Monday, [**2155-11-17**]. However, the PEG
continued to leak significant amounts of fluid ranging from
300-500 cc per 24 hours of the same nonpurulent
yellow-greenish material. Follow-up KUBs were obtained on
[**2155-11-17**] and again showed no evidence of obstruction.
Tube feeds were held from [**2155-11-16**] to [**2155-11-17**].
IR was reconsulted on [**2155-11-17**] as the patient
continued to have significant leakage and it was felt that
she may benefit from placement of a new tube. The patient
did go down to the Interventional Radiology Suite on [**2155-11-18**] and a new wider sized tube was placed in the
jejunum.
Over the course of the day on [**2155-11-18**], the patient's
urine output dropped, likely secondary to tube feeds being
held for 24 hours in the setting of increased leakage from
the J tube. The patient's central line that had been in
place for roughly 1 1/2 months was discontinued on [**2155-11-17**] feeling that it would likely only service another
infectious risk and the patient was receiving adequate
nutrition from the tube feeds. However, with the acute drop
in urine output over a 12 hour period, it was felt that the
patient would benefit from aggressive hydration and a central
line was replaced on the evening of [**2155-11-18**], a left
internal jugular line, and the patient received IV fluids.
Her urine output picked up nicely and responded to the
hydration so that by the morning of [**2155-11-19**] the
patient was putting out roughly 30-40 cc of urine per hour.
Also, on [**2155-11-18**], tube feeds were restarted via the
PEG as IR thought it would be fine to use the tube after it
had been replaced for nourishment.
On [**2155-11-20**], the patient continued to have drainage
from the PEG even after placement of the new tube, roughly
700 cc in 24 hours. The ostomy nurses created an ostomy bag
that nicely protected the skin. The patient also had a small
bowel follow through to rule out obstruction and the small
bowel follow through showed no obstruction, no ileus, and
showed that the contrast flowed freely through the
jejunostomy tube and into the colon. Therefore, it was felt
that that PEG would be safe to use for tube feedings and that
the patient did indeed require the tube feedings for
nutrition with an albumin of only 2.1.
GI was also consulted on [**2155-11-20**] for assessment of
the PEG to make sure that no further action could be taken to
help decrease the reflux from the tube of gastric acid and
bile. GI felt that the reason for the leakage around the PEG
was slow healing time in a patient with so many medical
comorbidities and with such a low albumin that it would take
time for the wound to fistulize and that this type of
drainage was to be expected. They had no other
recommendations at the time other than continuing the ostomy
care and recommending continuation of tube feeds for
nutrition.
On [**2155-11-20**], the patient's platelet count was noted
to drop from 185,000 to 168,000. The platelet count was
followed and on [**2155-11-21**], it dropped from 168 to 127.
On [**2155-11-22**], it dropped from 127 to 102. On [**2155-11-23**], it continued to decline from 102 to 90. It was
felt that this isolated thrombocytopenia was likely
iatrogenic. The patient was on three medications that could
possibly be causing the platelet count drop. These included
a PPI, lansoprazole, heparin subcutaneous, and linazolid.
The patient had been on the PPI for many years. The heparin
had been on for roughly two months and the linazolid was the
newest medication that was started; [**2155-11-23**] was day
number seven of this medication.
As it was felt that linazolid could be causing the platelet
drop, it was decided to stop the antibiotic as the patient
had been on it for seven days and a seven day course would
likely treat a VRE UTI. The urine was sent for urinalysis
and culture to make sure that the urine infection had indeed
resolved, essentially in the setting of stopping the
linazolid. Vancomycin was restarted to continue treatment of
the MRSA and pneumonia. The patient had been treated for a
total of seven days for the MRSA with linazolid and also
three days prior to starting linazolid with vancomycin. This
is a ten day course of antibiotics in total for MRSA
pneumonia and it was decided by the team that a 14 day course
of antibiotics would be sufficient for treatment of this
pneumonia so she would only require vancomycin for four days
further for the pneumonia.
ID was called and they agreed with our management and they
felt that the urinalysis and urine culture should be sent and
if the UTI had not resolved we could reconsult them as to
what medication to restart to treat the urinary tract
infection.
The ultimate goals in our care of this patient were to
stabilize the patient so that she could return to [**Hospital3 6278**] Center where she had come from. The patient
was DNI/DNR but the family did not wish to make her comfort
measures so we continued in our aggressive treatment of her
infection and our goal was to maintain adequate nutrition.
The tube feeds were increased to 55 cc per hour of Ultracal
on [**2155-11-23**] which for nutrition was her feeding goal.
She was tolerating these tube feeds well with only minimal
leakage around the PEG.
A family meeting was scheduled for Monday, [**2155-11-24**],
to help discuss ultimate plans for this patient in terms of
whether or not she should be made comfort care and whether or
not she was ready for discharge back to the rehabilitation
facility.
Dictated By:[**Last Name (NamePattern1) 1644**]
MEDQUIST36
D: [**2155-11-23**] 15:28
T: [**2155-11-23**] 15:49
JOB#: [**Job Number 6279**]/[**Numeric Identifier 6280**]
Name: [**Known lastname 6276**], [**Known firstname 3192**] Unit No: [**Numeric Identifier 6277**]
Admission Date: Discharge Date: [**2129-4-4**]
Date of Birth: Sex:
Service: [**Doctor Last Name **] MEDICINE
ADDENDUM:
Mrs. [**Known lastname **] is an 83-year-old female postoperative status post
right axillofemoral bypass who was transferred to the
Medicine Service on [**2155-11-13**] for increasing
respiratory rate and increased shortness of breath since
[**2155-11-10**].
The patient was in clear respiratory distress and we were
called to see her. She was febrile with a low-grade
temperature of 99.6. She also had an elevated white count on
[**2155-11-13**] of 15.9. Her respiratory rate was in the
40s and she was using accessory muscles to help with
breathing.
The Surgical Team had requested the Neurology Service to see
the patient for changes in mental status. A note from
Neurology on [**2155-11-10**] recommended treatment for a
pneumonia. The patient was started on levofloxacin but only
treated for a days long course.
On review of the patient's data, the chest x-ray that were
portable from [**2155-11-8**] and [**2155-11-10**] showed a
left lower lobe opacity versus atelectasis and with the
patient's white blood count increasing up to 15 it was felt
by the Medicine Team that the patient was likely suffering
from an aspiration pneumonia from aspiration of tube feeds
that had been started on [**2155-11-11**] via PEG.
For management of the patient's pneumonia, the patient was
initially started on vancomycin with her history of MRSA UTI
and she was started on levofloxacin for gram-negative and
pseudomonal coverage. The patient was also noted to have a
UTI on urinalysis on [**2155-11-13**] and so levofloxacin was
thought to cover.
The patient's left lower lobe pneumonia was noted on portable
chest x-rays from [**2155-11-8**], [**2155-11-10**] and now
[**2155-11-13**]. The patient was started empirically on
vancomycin as she had a history of a MRSA UTI and she was
also started on levofloxacin for empiric coverage of
gram-negatives, atypicals, and for pseudomonal coverage.
As the patient was calculated to only have a creatinine
clearance of 19, she was started on 250 mg of levo per her
PEG tube q. 48 hours and 500 mg IV of vancomycin q. 24 hours.
These medications were started on [**2155-11-13**]. Also for
the patient's pneumonia, the patient was ordered to have
aggressive nasotracheal suction q. eight hours.
She was placed on albuterol nebulizers p.r.n. and Atrovent
nebulizers q. six hours and a sputum culture was sent. The
sputum culture on [**2155-11-13**] came back with
gram-positive cocci in clusters and pairs as well as 1+
gram-negative rods. The sputum culture eventually grew out
heavy growth of Staphylococcus aureus coagulase-positive so
the patient was continued on vancomycin for likely MRSA. The
sample had greater than 25 PMNs but also greater than 10
epithelial cells so it was not immediately speciated;
however, it was requested that the sputum be further
speciated and it grew out MRSA which was sensitive to
ampicillin and vancomycin; however, the patient had a history
of ampicillin allergy so she was kept on vancomycin.
The urine culture that was obtained on [**2155-11-13**] came
back with vancomycin-resistant Enterococcus. The patient had
been treated empirically for a UTI based on her positive
urinalysis findings including red blood cells, white blood
cells, and a few bacteria, treated empirically with
levofloxacin. However, with the development of positive VRE
on urine culture, the patient was initially started on
nitrofurantoin on [**2155-11-16**].
However, ID was consulted as it was realized that in patient
with low creatinine clearance, nitrofurantoin often cannot
concentrate in the urine and can sometimes be toxic. ID
recommended that the nitrofurantoin be discontinued and
linazolid be started which would also cover the MRSA in the
patient's sputum. Therefore, linazolid 600 mg per G tube q.
12 hours was started on [**2155-11-16**] and on the same day,
[**2155-11-16**], the vancomycin was discontinued.
The patient improved from a clinical standpoint. Her white
blood count decreased from 15 to 8. Her respiratory rate
declined from in the 40s to in the 18-24 range and she
appeared more comfortable. As the patient was thought to
possibly have an aspiration pneumonia from aspiration of PEG
feedings, the patient was started on Flagyl on [**2155-11-13**].
On [**2155-11-15**], the patient was noted by the nursing
staff to have increased leakage of a yellow-greenish material
from the J tube. The material was nonpurulent, nonbloody and
was found to be drainage from the stomach and also thought to
be bile. A KUB was ordered to rule out obstruction in this
setting which showed no obstruction of the PEG. Contrast was
injected at the bedside, roughly 20 cc of barium and it was
noted to traverse through the PEG without problem and was
seen to flow through the small intestine.
Interventional Radiology had placed the PEG on [**2155-11-11**] so they were consulted on the evening of [**2155-11-15**] in regards to the increased leakage from around the
tube. They agreed with our management of obtaining a KUB and
felt that this was a nonurgent situation and came to see the
patient on [**2155-11-16**].
On [**2155-11-16**], they felt that this drainage did indeed
represent gastric acid and bile refluxing from around the
tube and was not a problem with the tube itself. They
recommended that the ostomy nurses come and see the patient
to protect her skin from breakdown from the gastric acid
secretion. The ostomy nurses did come and dressed the wound
appropriately on Monday, [**2155-11-17**]. However, the PEG
continued to leak significant amounts of fluid ranging from
300-500 cc per 24 hours of the same nonpurulent
yellow-greenish material. Follow-up KUBs were obtained on
[**2155-11-17**] and again showed no evidence of obstruction.
Tube feeds were held from [**2155-11-16**] to [**2155-11-17**].
IR was reconsulted on [**2155-11-17**] as the patient
continued to have significant leakage and it was felt that
she may benefit from placement of a new tube. The patient
did go down to the Interventional Radiology Suite on [**2155-11-18**] and a new wider sized tube was placed in the
jejunum.
Over the course of the day on [**2155-11-18**], the patient's
urine output dropped, likely secondary to tube feeds being
held for 24 hours in the setting of increased leakage from
the J tube. The patient's central line that had been in
place for roughly 1 1/2 months was discontinued on [**2155-11-17**] feeling that it would likely only service another
infectious risk and the patient was receiving adequate
nutrition from the tube feeds. However, with the acute drop
in urine output over a 12 hour period, it was felt that the
patient would benefit from aggressive hydration and a central
line was replaced on the evening of [**2155-11-18**], a left
internal jugular line, and the patient received IV fluids.
Her urine output picked up nicely and responded to the
hydration so that by the morning of [**2155-11-19**] the
patient was putting out roughly 30-40 cc of urine per hour.
Also, on [**2155-11-18**], tube feeds were restarted via the
PEG as IR thought it would be fine to use the tube after it
had been replaced for nourishment.
On [**2155-11-20**], the patient continued to have drainage
from the PEG even after placement of the new tube, roughly
700 cc in 24 hours. The ostomy nurses created an ostomy bag
that nicely protected the skin. The patient also had a small
bowel follow through to rule out obstruction and the small
bowel follow through showed no obstruction, no ileus, and
showed that the contrast flowed freely through the
jejunostomy tube and into the colon. Therefore, it was felt
that that PEG would be safe to use for tube feedings and that
the patient did indeed require the tube feedings for
nutrition with an albumin of only 2.1.
GI was also consulted on [**2155-11-20**] for assessment of
the PEG to make sure that no further action could be taken to
help decrease the reflux from the tube of gastric acid and
bile. GI felt that the reason for the leakage around the PEG
was slow healing time in a patient with so many medical
comorbidities and with such a low albumin that it would take
time for the wound to fistulize and that this type of
drainage was to be expected. They had no other
recommendations at the time other than continuing the ostomy
care and recommending continuation of tube feeds for
nutrition.
On [**2155-11-20**], the patient's platelet count was noted
to drop from 185,000 to 168,000. The platelet count was
followed and on [**2155-11-21**], it dropped from 168 to 127.
On [**2155-11-22**], it dropped from 127 to 102. On [**2155-11-23**], it continued to decline from 102 to 90. It was
felt that this isolated thrombocytopenia was likely
iatrogenic. The patient was on three medications that could
possibly be causing the platelet count drop. These included
a PPI, lansoprazole, heparin subcutaneous, and linazolid.
The patient had been on the PPI for many years. The heparin
had been on for roughly two months and the linazolid was the
newest medication that was started; [**2155-11-23**] was day
number seven of this medication.
As it was felt that linazolid could be causing the platelet
drop, it was decided to stop the antibiotic as the patient
had been on it for seven days and a seven day course would
likely treat a VRE UTI. The urine was sent for urinalysis
and culture to make sure that the urine infection had indeed
resolved, essentially in the setting of stopping the
linazolid. Vancomycin was restarted to continue treatment of
the MRSA and pneumonia.
The patient had been treated for a total of seven days for
the MRSA with linazolid and also three days prior to starting
linazolid with vancomycin. This is a ten day course of
antibiotics in total for MRSA pneumonia and it was decided by
the team that a 14 day course of antibiotics would be
sufficient for treatment of this pneumonia so she would only
require vancomycin for four days further for the pneumonia.
ID was called and they agreed with our management and they
felt that the urinalysis and urine culture should be sent and
if the UTI had not resolved we could reconsult them as to
what medication to restart to treat the urinary tract
infection.
The ultimate goals in our care of this patient were to
stabilize the patient so that she could return to [**Hospital3 6278**] Center where she had come from. The patient
was DNI/DNR but the family did not wish to make her comfort
measures so we continued in our aggressive treatment of her
infection and our goal was to maintain adequate nutrition.
The tube feeds were increased to 55 cc per hour of Ultracal
on [**2155-11-23**] which for nutrition was her feeding goal.
She was tolerating these tube feeds well with only minimal
leakage around the PEG.
A family meeting was scheduled for Monday, [**2155-11-24**],
to help discuss ultimate plans for this patient in terms of
whether or not she should be made comfort care and whether or
not she was ready for discharge back to the rehabilitation
facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D.
Dictated By:[**Last Name (NamePattern1) 1644**]
MEDQUIST36
D: [**2155-11-23**] 15:28
T: [**2155-11-23**] 15:49
JOB#: [**Job Number 6279**]/[**Numeric Identifier 6280**]
|
[
"507.0",
"496",
"428.0",
"482.41",
"599.0",
"997.2",
"440.24",
"444.21",
"707.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"43.11",
"38.03",
"99.15",
"96.04",
"39.29",
"38.93",
"00.14",
"88.48",
"97.01",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
11146, 46332
|
10527, 11125
|
1783, 2179
|
3253, 10504
|
1581, 1756
|
2202, 3235
|
114, 222
|
251, 942
|
965, 1557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,221
| 169,763
|
23337
|
Discharge summary
|
report
|
Admission Date: [**2161-9-7**] Discharge Date: [**2161-9-14**]
Date of Birth: [**2084-8-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Lung cancer
Major Surgical or Invasive Procedure:
[**2161-9-7**] Right thoracotomy, right upper lobectomy, right middle
lower wedge resection
History of Present Illness:
The patient is a 76-year-old woman with a biopsy-proven
non-small cell lung cancer arising from the right upper lobe.
The patient's recent history dates to an XRay done in [**3-/2161**] for
a R humeral fracture that disclosed an
abnormality in the right upper lobe. A CT scan of the chest at
[**Hospital3 **] on [**2161-5-11**] shows a 2.6-cm nodule in the right
lung apex. There is no significant mediastinal or hilar
lymphadenopathy. The nodule in the right upper lobe is
spiculated. There is also a right lower lobe nodule that is 7 x
9 mm and, in addition, a nodule within the left lateral major
fissure that measures 2.1 cm. Finally, there is a left lower
lobe nodule that is 6 x 8 mm. A subsequent PET-CT scan on
[**2161-5-29**] shows the right upper lobe nodule to be FDG avid,
although an SUV is not provided on this report. No other
abnormal hypermetabolic focus was seen in the chest.
Specifically, the other nodules noted on the CT scan were FDG
non-avid. She is being admitted for Right upper lobectomy.
Past Medical History:
Rheumatoid Arthritis
Asthma
Social History:
She lives alone. Her son lives nearby. She is a former
80-pack-year smoker quit 15 years ago.
Family History:
Significant for mother with ovarian cancer. She
states that on her father's side many family members had cancer,
but none with lung cancer.
Brief Hospital Course:
Mrs. [**Known lastname 59907**] was admitted on [**2161-9-7**] for Right video-assisted
thoracoscopy -converted to right thoracotomy. Decortication of
right lung. Right upper lobectomy.
Right middle lobe wedge. Mediastinal lymphadenectomy. The
procedure was complicated by near-complete pleural symphysis.
Coagulopathy. She had 1300 mL intraoperative blood loss.
Respiratory: she was transferred to SICU intubated. She
remained intubated overnight and was successfully extubated
POD1. Aggressive pulmonary toilet and nebs were continued
Chest-tube: 2 right chest tubes were removed once the drainage
decreased. No pneumothoraces following CT removal.
CXR; she was followed by serial chest film. the right middle
lobe hematoma improved. Atlectasis was seen.
Cardiac: she had an episode of atrial fibrillation HR 140's
which she converted to sinus rhythm 50-60's with IV lopressor.
She was converted to PO lopressor and remained in sinus rhythm.
Her cardiac enzymes were negative. She vasovagal with nausea and
HR in the 20's but quickley returned to her baseline of 60.s
She remained hemodynamically stable.
GI: she had intermittent nausea. Once the narcotics were stopped
her nausea improved. She tolerated a regular diet once the
nausea resolved. A KUB showed nonspecific dilitation and stool
in the rectal vault. Cathartics were administered and symptoms
improved following bowel movement.
Incision: right thoracotomy site clean, well approximated
margins.
Heme: Basline HCT 35. She was transfused 6 units of PRBC for a
1300 mL blood loss in the operating room to a HCT of 27 which
remained stable. On HD 5 she was transfused 1 unit PRBC for Hct
in high 20's but SOB with activity.
Renal: her renal function was elevated with a Peak Cre of 2.0
immediately postoperative. Fluids were gently administered and
her Cre return to her baseline of 1.0-1.3 with excellent urine
output.
Neuro: no neurological events during her hospitalization
Rheum: Rheumatoid arthritis medications were held
post-operatively but are to be resumed at time of discharge.
Disposition: she was followed by physical therapy who
recommended rehab.
Medications on Admission:
Etodolac 400mg daily
Hydrochloroquine 200mg [**Hospital1 **]
Sulfazine EC 500mg daily
glucosamine/chondroitin 1500mg [**Hospital1 **]
Magnesium 500 prn,
Advair 500/50 1 puff [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for severe pain.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal infection breast.
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Etodolac 400 mg Tablet Sig: One (1) Tablet PO once a day.
15. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Sulfazine EC 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center
Discharge Diagnosis:
Right lung nodules
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Incision develops drainage
-Chest tube site remove dressing and cover with a bandaid
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**2162-9-24**]:00am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 24**].
Chest X-RAY 45 minutes before your appoinment on the [**Location (un) 861**]
Radiology Deparment
|
[
"225.2",
"518.0",
"197.0",
"286.9",
"162.3",
"997.1",
"998.0",
"198.5",
"427.89",
"427.31",
"714.0",
"998.12",
"E878.6",
"530.85",
"493.20",
"511.0",
"V64.42",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.49",
"32.29",
"34.51",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
5721, 5779
|
1804, 3945
|
312, 406
|
5842, 5858
|
6155, 6426
|
1638, 1781
|
4187, 5698
|
5800, 5821
|
3971, 4164
|
5882, 6132
|
261, 274
|
434, 1458
|
1480, 1509
|
1525, 1622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,797
| 164,252
|
23987
|
Discharge summary
|
report
|
Admission Date: [**2127-6-18**] Discharge Date: [**2127-6-23**]
Date of Birth: [**2062-4-7**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate / IV Dye, Iodine Containing
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea on exertion, Observation post-pericardial drainage.
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
Ms [**Known lastname 61077**] is a 65-year-old female with left renal cell
carcinoma s/p nephrectomy ([**2117**]), who was found to have a
pericardial effusion.
.
A CT scan last wednesday ([**6-11**]) revealed volume overload with
increased pleural and pericardial effusions, pulmonary and
periportal edema and ascites. She also felt unwell and developed
a cough with purulent sputum. She was started on Levaquin as an
outpatient, but continued to have shortness of breath. This
shortness of breath lasted for the last 2 weeks but became worse
in the past 24 hours. She could not ambulate up a flight of
stairs and had to be assisted into a wheelchair, and ended up
cyanotic and diaphoretic by the time she reached her follow-up
appointment. An echocardiogram that afternoon revealed an EF of
>70% and early signs of cardiac tamponade (collapsed right
atrium but not ventricle). She was transferred to the cardiac
floor for further management.
.
On arrival to the floor, her initial vitals were as follows: T
97.7 BP 149/96 HR 95 RR 18 SaO2 98% on room air. Labs and
imaging were significant for Na 131, Cr 0.9 and ALT 51. Her
urinalysis was negative.
.
On review of systems, she reports some occasional rib pain on
her posterior back. She also had a lot of nausea and vomiting
last week but that has resolved. She did not have any TB
exposure or recent travel.
.
Otherwise, she denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dizziness, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
500ccs were drained during pericardiocentesis by Dr [**Last Name (STitle) **].
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Left renal cell carcinoma s/p nephrectomy ([**2117**])
- Motor vehicle accident - complicated by pneumothorax, rib
fractures and incidental findings of pulmonary nodules ([**2119**])
- Right mid, left lower lobectomy for spread of renal cancer
([**2121**]) - nodules in lobes were found to be malignant with
histology compatible to those from a primary renal cell
carcinoma source
- Hypothyroidism
- C-section x2
- Appendectomy
- Hemochromatosis gene carrier (reported by patient)
Social History:
- Family: Married. Has 5 children and 14 grandchildren.
- Occupation: Works as a nurse ~3 days/week at acute rehab
facility, but reports it has been increasingly difficult to go
to work due to shortness of breath.
- Tobacco history: Ex-smoker, quit over 20 years ago. Smoked 40
pack years.
- ETOH: Occasionally.
- Illicit drugs: None.
Family History:
- Grandfather had possible throat cancer
- 3 children have hemochromatosis
- Sister has systemic lupus erythematosus
- Father has Alzheimer's Disease
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
PULSUS 8
GENERAL: No acute distress, oriented x3, mood is appropriate.
Able to carry a full conversation w/o appearing short of breath;
no accessory muscle use.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple with JVP of 8cm. 2 right supraclavicular lymph
nodes, non-matted, non-tender. 1cm and 2cm in size.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills. No S3/S4.
LUNGS: Decreased breath sounds on right below nipple line and
posterior below inferior angle of scapula. Clear to auscultation
bilaterally, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, nontender, nondistended, +bowel sounds. Left
nephrectomy scar noted.
EXTREMITIES: No cyanosis or peripheral edema.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
On Discharge:
GENERAL: No acute distress, oriented x3
HEENT: PERRL, EOMI. MMM
NECK: supple with JVP of 8cm , hard multilobulated monbile
lymphnode in right lateral neck
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills. No S3/S4.
LUNGS: clear to auscultation bilaterally, no crackles, wheezes
or rhonchi, reduced air entry lower right chest
ABDOMEN: soft, nontender, nondistended, + bowel sounds.
EXTREMITIES: no cyanosis or peripheral edema.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
CBC trend:
[**2127-6-18**] 01:17PM BLOOD WBC-10.4 RBC-5.28 Hgb-15.7 Hct-47.2
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.5 Plt Ct-319
[**2127-6-19**] 07:00AM BLOOD WBC-9.1 RBC-4.66 Hgb-14.1 Hct-41.1 MCV-88
MCH-30.2 MCHC-34.2 RDW-14.9 Plt Ct-277
[**2127-6-20**] 05:09AM BLOOD WBC-13.8*# RBC-5.29 Hgb-15.8 Hct-47.0
MCV-89 MCH-29.8 MCHC-33.5 RDW-15.2 Plt Ct-301
[**2127-6-21**] 06:20AM BLOOD WBC-15.0* RBC-5.21 Hgb-15.1 Hct-46.0
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.5 Plt Ct-318
[**2127-6-22**] 05:55AM BLOOD WBC-12.2* RBC-5.08 Hgb-15.3 Hct-44.5
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.3 Plt Ct-315
[**2127-6-23**] 06:20AM BLOOD WBC-11.1* RBC-5.17 Hgb-15.4 Hct-45.7
MCV-88 MCH-29.9 MCHC-33.8 RDW-15.3 Plt Ct-335
.
Chemistry Trend:
[**2127-6-18**] 01:17PM BLOOD UreaN-18 Creat-0.9 Na-131* K-4.1 Cl-96
HCO3-27 AnGap-12
[**2127-6-19**] 07:00AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-135
K-4.2 Cl-101 HCO3-25 AnGap-13
[**2127-6-20**] 05:09AM BLOOD Glucose-166* UreaN-17 Creat-0.9 Na-135
K-4.4 Cl-103 HCO3-22 AnGap-14
[**2127-6-21**] 06:20AM BLOOD Glucose-102* UreaN-17 Creat-0.7 Na-134
K-4.4 Cl-101 HCO3-26 AnGap-11
[**2127-6-22**] 05:55AM BLOOD Glucose-93 UreaN-14 Creat-0.9 Na-132*
K-4.6 Cl-98 HCO3-26 AnGap-13
[**2127-6-23**] 06:20AM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-135
K-4.8 Cl-99 HCO3-28 AnGap-13
.
Ca/Mg/PO4 Trend
[**2127-6-18**] 01:17PM BLOOD Calcium-9.5 Phos-3.0 Mg-2.1
[**2127-6-19**] 07:00AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.0
[**2127-6-20**] 05:09AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
[**2127-6-21**] 06:20AM BLOOD Calcium-9.6 Phos-2.4* Mg-2.1
[**2127-6-22**] 05:55AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.1
[**2127-6-23**] 06:20AM BLOOD Calcium-10.8* Phos-4.0 Mg-2.2
.
LFTs
[**2127-6-18**] 01:17PM BLOOD ALT-51* AST-36 LD(LDH)-244 AlkPhos-92
.
TFTs
[**2127-6-19**] 07:00AM BLOOD TSH-12*
[**2127-6-22**] 05:55AM BLOOD Free T4-1.3
.
Serum Osmolality Levels:
[**2127-6-20**] 05:09AM BLOOD Osmolal-291
.
Pericardial Fluid:
WBC RBC Polys Lymphs Monos Eos Mesothe Macro
250* [**Numeric Identifier **]* 41* 13* 8* 1* 3* 34*
PERICARDIAL FLUID
TotProt Glucose LD(LDH) Amylase Albumin
4.1 101 285 41 2.7
.
Micro:
[**2127-6-19**] 6:15 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2127-6-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
.
[**2127-6-19**] 6:15 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERICARDIAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH
.
Pericardial Fluid Cytology:
Pending On Discharge
.
STUDIES:
[**6-18**] TTE: 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 70%). 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 or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is a large pericardial effusion. The
effusion appears circumferential. No right ventricular diastolic
collapse is seen. There is brief right atrial diastolic
collapse.
IMPRESSION: large circumferential pericardial effusion with
evidence of early cardiac tamponade
[**6-18**] EKG: Sinus rhythm at upper limits of normal rate. Low
voltage T wave abnormalities. Since the previous tracing of
[**2123-3-13**] the rate is faster. T wave abnormalities are new.
Clinical correlation is suggested.
[**6-19**] TTE: Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a large pericardial effusion. Saline
contrast injected via a pericardial drain is seen within the
pericardium prior to removal of pericardial fluid. 500 ml of
pericardial fluid was removed with resolution of the pericardial
effusion visualized by echocardiography.
Compared with the prior study (images reviewed) of [**2127-6-18**],
post tap resolution of the pericardial effusion is seen.
[**6-20**] CXR: Bibasilar opacities likely due to association of
atelectasis and
bilateral pleural effusion. No pneumothorax is noted.
[**6-21**] TTE: There is a trivial/physiologic pericardial effusion.
There are no echocardiographic signs of tamponade. The
epicardial surface of the right ventricular free wall
(particularly toward the apex) appears somewhat thickened,
suggestive of residual organized effusive material, thrombus,
neoplastic tissue, or possibly even fat pad.
[**6-23**] TTE: There is a very small pericardial effusion. There are
no echocardiographic signs of tamponade.
Brief Hospital Course:
65-year-old female with history of metastatic renal cell
carcinoma who presented to the outpatient clinic with worsening
shortness of breath secondary to a large pericardial effusion
with right atrial tamponade.
.
# Large Pericardial Effusion with Right Atrial Tamponade:
Effusion had likely gone on for weeks and was likely a malignant
effusion. Patient was HD stable but found to have tamponade
physiology as shown by echocardiography. She underwent
pericardiocentesis with drainage of 500cc ([**2127-6-19**]) with
serosanguinous exudative fluid. A pericardial drain was placed
and drained another 400cc over the next 48 hours. In the CCU,
the patient was hemodynamically stable with pulsus ~8, which was
within normal limits. An echo done on [**6-21**] showed no
reaccumulation of fluid. Drainage from the pericardial drain
subsequantly stopped and the drain was removed on [**6-22**]. Repeat
TTE on [**6-23**] showed a very small pericardial effusion, but no
echocardiographic signs of tamponade. Pericardial fluid cytology
was still pending at discharge. Patient was discharged for
continued out-patient follow-up with oncology and cardiology.
.
OUTPATIENT ISSUES:
- F/u pericardial fluid cytology
- TTE planned for 7 days post discharge; will need to be
arranged
- Cardiology appointment
- Oncology appointment
.
# Renal Cell Cancer: History of RCC s/p left nephrectomy ([**2117**])
+ right lung lower & middle lobectomy ([**2121**]). She has since
progressed on several treatment regimens including
interleukin-2, Avastin, pazopanib, Everolimus and as shown on
radiology has involvment of lungs, bones and thoracic and
abdominal lymph nodes. For the last couple of months prior to
this admission she was back on Avastin. She did miss one dose
last month when her father died. Oncologist Dr [**Last Name (STitle) **] was
emailed regarding prognosis and treatment options and his
thoughts were to do what was necessary (including pericardial
window placement if indicated- ultimately was not needed). Plan
is to f/u with her oncologist in the outpatient setting and
resume Avastin.
.
OUTPATIENT ISSUES:
- Oncology f/u
.
# Hypothyroidism - TSH = 12, FT4 = 1.3 Continued levothyroxine
125mcg daily
.
OUTPATIENT ISSUES:
- f/u Thyroid function
.
# GERD: Remained stable and asymptomatic with regards to GERD
this admission. She was continued on her home dose of omeprazole
40mg PO daily.
.
# Hyponatremia: Had mild euvolemic hyponatremia with Na stable
at 131. Her serum and urine indices were consistent with SIADH
which is likely [**3-5**] to her malignant pulmonary involvment.
.
OUTPATIENT ISSUES:
- f/u Na
.
# DVT prophylaxis: The patient was treated with subcutaneous
heparin during this admission.
.
# CODE Status: Was full during this admission
# COMM: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 61078**], Daughter ([**Telephone/Fax (1) 61079**])
Medications on Admission:
- Levothyroxine 125mcg qd
- Lorazepam 5mg q6-8h prn anxiety
- Omeprazole 40mg [**Hospital1 **]
- Zofran 8mg [**Hospital1 **]
- Acetaminophen 1000mg qd
- Melatonin 3mg qHS
- Ipratropium 42mcg [**Hospital1 **]
- Multivitamin
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**7-9**]
hours as needed for anxiety.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
7. ipratropium bromide Powder Inhalation
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO once a day
as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pericardial Effusion
Metastatic Renal Cell Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 61077**],
It was pleasure taking care of you.
You were admitted to [**Hospital1 18**] for further evaluation and management
of your shortness of breath. Work-up of your symptoms revealed a
collection of fluid in the lining surrounding your heart. A
drain was placed to facilitate removal of the fluid. With
drainage, your symptoms improved. It is important that you
follow up at the cardiology appointment below- you will need a
repeat echocardiogram (ultrasound of your heart) in one week to
assess if there is reaccumulation of the fluid.
We have made no changes to your home medications.
Again it was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Please follow up at the following appointments:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2127-6-25**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 18267**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 7167**],[**First Name3 (LF) **] T.
Location: SJ FAMILY MEDICAL CENTERS
Address: [**Location (un) 61080**], [**Location (un) **],[**Numeric Identifier 61081**]
Phone: [**Telephone/Fax (1) 61082**]
Appt: [**7-2**] at 4:30pm
Please follow up at your previously scheduled appointments:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2127-6-25**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], 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: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2127-6-25**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2127-6-25**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2127-6-25**]
|
[
"V10.52",
"198.89",
"198.5",
"486",
"196.8",
"276.1",
"420.90",
"530.81",
"423.3",
"197.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
13942, 13948
|
10157, 13033
|
372, 393
|
14054, 14054
|
5174, 7640
|
14925, 16569
|
3442, 3710
|
13306, 13919
|
13969, 14033
|
13059, 13283
|
14205, 14902
|
3725, 3725
|
2483, 2559
|
7768, 10134
|
4601, 5155
|
273, 334
|
421, 2376
|
3739, 4587
|
7723, 7738
|
14069, 14181
|
2590, 3074
|
2398, 2463
|
3090, 3426
|
7672, 7687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,567
| 154,272
|
3877
|
Discharge summary
|
report
|
Admission Date: [**2206-8-19**] Discharge Date: [**2206-8-21**]
Date of Birth: [**2143-6-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Adenosine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 y/oF with h/o of COPD with multiple admissions and
intubations (last [**5-6**]) most recently admitted on [**7-6**] who
presents to the ED with severe resp distres of 24-48h. No
fever/CP/vomiting. Home o2, nebs didn't improve symptoms. Of
note, she has difficulty paying for her medications, and has
been without the serevent recently, as well as the clopidogrel
since her discharge from rehab on [**2206-7-22**]. She has been having
some cough more last week, less so most recently.
Her symptoms include chest tightness, which is not entirely
typical with her straight COPD admissions according to her. Her
chest tightness in the ICU improved with nebulizer treatment,
and she denies any frank chest pain, jaw pain, or pleuritic
pain.
In the ED, she was treated with 3 combivent nebs, steroids,
azithromycin. Sats have been okay, mainly tachypnea and
tachycardia which were symptoms. Lungs were diffusely wheezy and
she was initially limited in her speech, though this improved
with the above treatment. Her labwork was notable for a trop of
0.03, but CK of 55 and ECG without acute changes.
Past Medical History:
- COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated several times in
the past. on 2L home O2, most recently intubated in [**5-6**].
- IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**], no
treatment with IVIG recently.
- CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in
[**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
- Hypertension
- Hyperlipidemia
- Gastritis, on PPI
- Osteoporosis, with history of multiple compression and rib
fractures from coughing
- History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy
- Depression
- Tremor
Social History:
patient was recently at home, but before that in [**Hospital **] rehab
in rehab after her previous hospitalization in [**Month (only) 216**]. She now
lives in her apartment with daughter and family. Has difficulty
getting around, but when she gets up uses a cane or walker. Has
30 pack yr smoking history but quit several years ago. No
etoh/illicts.
Family History:
Mother with DM, father with pancreatic cancer.
Physical Exam:
Tmax: 36.8 ??????C (98.3 ??????F)
Tcurrent: 36.8 ??????C (98.3 ??????F)
HR: 120 (115 - 121) bpm
BP: 144/85(101) {130/62(79) - 144/85(101)} mmHg
RR: 26 (23 - 26) insp/min
SpO2: 90%
Heart rhythm: ST (Sinus Tachycardia)
GEN: Mild respiratory distress with intercostal retractions, but
able to articulate most of her speech now
HEENT: ?thrush on tongue, otherwise OP clear. NO LAD
CHEST: improved to minimal wheeze, prolonged E:I ratio
COR: HS regular but tachy, no murmur appreciated on limited exam
ABD: soft, nt/nd
Pertinent Results:
CBC on admission notable for WBC of 16.3 that fluctuated down to
12 and up to 19.3 on discharge, thought possibly due to steroids
in absence of other infectious signs and fever.
[**2206-8-19**] 08:20PM BLOOD WBC-16.3* RBC-4.07* Hgb-10.2* Hct-33.5*
MCV-82 MCH-25.2* MCHC-30.5* RDW-15.1 Plt Ct-525*
[**2206-8-20**] 02:00AM BLOOD WBC-11.9* RBC-3.82* Hgb-9.3* Hct-31.3*
MCV-82 MCH-24.4* MCHC-29.8* RDW-15.2 Plt Ct-470*
[**2206-8-21**] 03:51AM BLOOD WBC-19.3*# RBC-3.31* Hgb-8.3* Hct-26.8*
MCV-81* MCH-25.0* MCHC-30.9* RDW-15.1 Plt Ct-472*
[**2206-8-19**] 08:20PM BLOOD Glucose-100 UreaN-29* Creat-0.8 Na-140
K-4.4 Cl-97 HCO3-30 AnGap-17
[**2206-8-20**] 02:00AM BLOOD Glucose-195* UreaN-29* Creat-0.7 Na-137
K-4.1 Cl-96 HCO3-30 AnGap-15
[**2206-8-21**] 03:51AM BLOOD Glucose-148* UreaN-27* Creat-0.7 Na-140
K-4.2 Cl-103 HCO3-29 AnGap-12
[**2206-8-19**] 08:20PM BLOOD ALT-10 AST-16 CK(CPK)-37 AlkPhos-72
TotBili-0.3
[**2206-8-19**] 08:20PM BLOOD Calcium-10.3* Phos-5.4*# Mg-1.7
[**2206-8-20**] 06:05AM BLOOD Type-ART Temp-36.8 pO2-67* pCO2-63*
pH-7.35 calTCO2-36* Base XS-6 Intubat-NOT INTUBA
CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The
pulmonary arteries are normally opacified without filling
defect. The heart size is normal. The coronary arteries and
thoracic aorta are densely calcified. There is no pleural or
pericardial effusion. Upper lobe predominant centrilobular
emphysema is severe. Patchy opacity in the dependent portions of
the lower lobes is suggestive of atelectasis. There is no
concerning parenchymal opacity. The central lymph nodes are not
enlarged.
The bones show no lesion worrisome for osseous metastasis.
Multiple small
bilateral chronic rib fractures and severe kyphotic angulation
of the thoracic spine with compression deformity of the T5, T6,
T7, T8, and T9 vertebral bodies are unchanged. Limited
evaluation of subdiaphragmatic structures show 2.6cm cyst
arising from the upper pole of the left kidney and dense aortic
atherosclerotic calcifications.
IMPRESSION:
1. No pulmonary embolus.
2. Severe emphysema.
Brief Hospital Course:
COPD Exacerbation:
Ms. [**Known lastname 17327**] was treated in the emergency room with nebs, IV
steroids, and started on azithromycin. She was admitted to the
medical ICU for consideration of bipap support with a full code
status. She did not require mechanical ventilation or bipap, and
had improvement over the next 24 hours. She was switched to oral
steroids starting at prednisone 60mg, with plan for taper over
approximately 3 weeks to a baseline of 10mg of prednisone
continuously. She was started on advair, and continued on her
monteleukast, albuterol and ipratropium. She had a CTA which
ruled out comorbid PE, and showed bronchiectasis and stigmata of
chronic aspiration.
At discharge she remained quite wheezy, but with good air
movement and an overall improvement from when she was admitted.
She will continue to need supportive care for her COPD at rehab.
Given her chronic steroids for COPD exacerbation, we suggested
that she discuss PCP prophylaxis with her outpatient pulmonary
physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**]. We recommended vitamin D and calcium
supplementation.
Coronary Artery Disease:
She did have the complaint of chest tightness on admission,
though this was due to her COPD rather than coronary disease
given absence of ischemic ECG changes and rule-out with two
spaced sets of cardiac biomarkres. Given her history of drug
eluting stent in [**2201**], she was restarted on her clopidogrel.
However, she remained off of aspirin given prior decisions, and
history of perforated ulcer.
Chronic Pain:
The patient was restarted on a fentanyl patch and percocet for
her chronic back pain. She was also continued on nortryptyline.
Medications on Admission:
Acetaminophen 325 mg Tablet
One (1) Tablet by mouth every six (6) hours as needed for pain.
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) neb Inhalation every four (4) hours as needed for
wheezing, dyspnea.
Clopidogrel 75 mg Tablet One (1) Tablet by mouth DAILY (Daily).
Diltiazem HCl 240 mg Capsule, Sustained Release One (1) Capsule,
Sustained Release by mouth DAILY (Daily).
Docusate Sodium 100 mg Capsule Two (2) Capsule by mouth twice a
day.
Fentanyl50 mcg/hr Patch 72 hr One (1) Patch 72 hr Transdermal
every seventy-two (72) hours as needed for pain.
Heparin (Porcine) 5,000 unit/mL Solution
One (1) injection Injection three times a day as needed for
prophylaxis.
Montelukast 10 mg Tablet One (1) Tablet by mouth DAILY (Daily).
Nortriptyline 25 mg Capsule One (1) Capsule by mouth HS (at
bedtime).
Oxycodone-Acetaminophen 5-325 mg Tablet One (1) Tablet by mouth
every six (6) hours as needed for pain.
Paroxetine HCl 20 mg Tablet One (1) Tablet by mouth DAILY
(Daily).
Ranitidine HCl 150 mg Tablet
One (1) Tablet by mouth DAILY (Daily).
Salmeterol 50 mcg/Dose Disk with Device
One (1) Disk with Device Inhalation every twelve (12) hours.
Sennosides [Senna] 8.6 mg Tablet
1-2 Tablets by mouth twice a day as needed for constipation.
Simvastatin 10 mg Tablet One (1) Tablet by mouth DAILY (Daily).
Zolpidem 5 mg Tablet One (1) Tablet by mouth HS (at bedtime) as
needed for insomnia.
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Year (4 digits) **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable [**Year (4 digits) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
Disp:*120 nebulizer* Refills:*2*
5. Clopidogrel 75 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Diltiazem HCl 240 mg Capsule, Sustained Release [**Year (4 digits) **]: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
7. Colace 100 mg Capsule [**Year (4 digits) **]: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
8. Fentanyl 50 mcg/hr Patch 72 hr [**Year (4 digits) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
9. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
10. Montelukast 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Nortriptyline 25 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
12. Oxycodone 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. Paroxetine HCl 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
14. Ranitidine HCl 150 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Humalog 100 unit/mL Solution [**Year (4 digits) **]: as directed per sliding
scale units Subcutaneous four times a day.
16. Simvastatin 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Ipratropium Bromide 0.02 % Solution [**Year (4 digits) **]: One (1)
nebulization Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*120 nebulization* Refills:*2*
18. Advair Diskus 500-50 mcg/Dose Disk with Device [**Year (4 digits) **]: One (1)
IH Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
19. Senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
20. Azithromycin 250 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
21. Prednisone 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day: 6
tablets for 1 day([**8-22**]), then 5 tablets for 3 days([**Date range (1) 17341**]),
then 4 tablets for 3 days ([**Date range (1) 17342**]), 3 tablets for 3 days
([**Date range (1) 17343**]), then 2 tablets for 3 days ([**Date range (1) 17344**]), then 1
tablet daily indefinitely.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
COPD exacerbation
Discharge Condition:
Vital signs stable, satting 97% on 2L
Discharge Instructions:
You were admitted to the [**Hospital1 18**] ICU for shortness of breath. This
was likely due to a COPD exacerbation. We treated you with
steroids and antibiotics. You are being discharged to rehab to
get your lungs stronger.
.
Medications:
We have started you on a slow prednisone taper but at the end of
the taper you should stay on 10mg of prednisone by mouth daily.
You will complete 3 more days of antibiotics.
You will continue on albuterol and ipratropium nebulizers and an
Advair inhaler.
We also started you on calcium and vitamin D.
We have stopped your ambien as it can lead to confusion.
All of your other medications remain unchanged.
.
You will follow up with Dr. [**Last Name (STitle) 575**] and Dr. [**First Name (STitle) **].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2206-9-16**] 11:40
.
When you see Dr. [**Last Name (STitle) 575**], please discuss starting Bactrim for
PCP [**Name Initial (PRE) 1102**].
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2206-11-13**] 9:10
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2206-11-13**] 9:30
Completed by:[**2206-8-21**]
|
[
"401.9",
"414.01",
"272.4",
"V45.82",
"412",
"491.21",
"733.00",
"279.01",
"535.50",
"799.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11690, 11787
|
5316, 7023
|
306, 312
|
11858, 11898
|
3236, 5293
|
12688, 13317
|
2636, 2684
|
8496, 11667
|
11808, 11837
|
7049, 8473
|
11922, 12665
|
2699, 3217
|
247, 268
|
340, 1438
|
1460, 2253
|
2269, 2620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,211
| 137,650
|
37031
|
Discharge summary
|
report
|
Admission Date: [**2143-7-23**] Discharge Date: [**2143-8-27**]
Date of Birth: [**2078-5-25**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Shorntess of breath, nausea/vomiting
Major Surgical or Invasive Procedure:
Intubation
Trach and PEG tube placement
Arterial line placement
Temporary hemodialysis catheter placement
Tunnelled hemodialysis catheter placement
PICC placement
History of Present Illness:
65 year old male without medical history presenting for
evaluation of shortness of breath, nausea and vomiting. He is
visiting his mother and lives in [**Name (NI) 2848**] normally. He has been in
[**Location (un) 86**] for about 10 days. 5-6 days prior to admission he
developed paroxysmal cough. He obtained tessalon perles and an
antibiotic from a local allergist. He did not fill the
antibiotic. His cough was intermittently productive. Over the
weekend, he developed prominent GI symptoms with persistent
nausea, forced dry heaves/wretching and some vomiting. He was
coughing and vomiting up [**First Name8 (NamePattern2) **] [**Location (un) 2452**]-frothy liquid. He noted
shortness of breath and came to the ED for evaluation on [**7-21**].
CXR demonstrated right upper lobe pneumonia with left lower lobe
nodular density and he was discharged on levofloxacin, albuterol
and prednisone 50 mg daily X 4 days.
He went home and took the medication on the day of admission.
His GI symptoms progressed and he had frequent
vomiting/wretching with some hematemesis. He continued to have a
wet cough productive of [**Location (un) 2452**] sputum. He came to the ED for
evaluation.
In the ED, initial vitals were: 102.4 119 206/136 42 89% RA. He
was placed on a NRB and maintained O2 sat 94-96% but would
desaturate to low 80s on room air. Imaging demonstrated
bilateral infiltrates, markedly progressed from [**2143-7-21**]. He was
treated with vancomycin, zosyn, acetaminophen, zofran,
albuterol, compazine, and guaifenasin with codeine.
Upon arrival to the floor, he was sitting up in bed, reporting
shortness of breath and need to urinate. He was unable to speak
in complete sentences and endorsed anxiety.
Past Medical History:
Cataract surgery
Social History:
Married, no children, smokes marijuana
Family History:
Unknown
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.5 BP: 171/95 HR: 120 RR: 37 O2: 90% NRB
Gen: Ill appearing, using accessory muscles, could not speak in
complete sentences, anxious
HEENT: PERRL, OP clear
Neck: Prominence in left neck/supraclavicular area, not a
discrete LN or fluid collection
Car: Tachycardic, regular, no murmur
Resp: Ronchi left, poor air movement right, no
wheeze--anterior/lateral exam
Abd: Soft, distended, not tympanic, + BS
Ext: No LE edema, 2+ DP
Discharge Physical Exam:
General: Trached, awake, making effort to speak
HEENT: PERRL, Normocephalic, trach site intact
Cardiovascular: RRR, S1-S2 nl, no murmurs, rubs, gallops
Respiratory / Chest: Breathing comfortably, intermittently
tachypneic without respiratory distress, coarse breath sounds
bilaterally, no wheezes
Abdominal: Soft, distended, Bowel sounds present, PEG tube in
place
Extremities: Warm and well perfused, trace edema bilaterally
Neurologic: Alert, awake. Follows commands. Moves all
extremities purposefully. Able to speak softly.
Pertinent Results:
CXR [**7-22**]:Infiltrates in both lungs with progression in the right
upper lobe infiltrate. Appearances are suggestive of infection
with superimposed edema. Please ensure followup to clearance.
[**2143-7-24**] renal ultrasound:
1. No hydronephrosis bilaterally, as questioned.
2. Interval development of small perihepatic ascites.
[**2143-7-22**] 09:05PM BLOOD WBC-7.3# RBC-4.96 Hgb-13.1* Hct-39.7*
MCV-80* MCH-26.4* MCHC-33.0 RDW-15.1 Plt Ct-176
[**2143-8-23**] 04:34AM BLOOD WBC-7.2 RBC-2.74* Hgb-7.5* Hct-23.4*
MCV-85 MCH-27.3 MCHC-32.0 RDW-15.4 Plt Ct-246
[**2143-7-22**] 09:05PM BLOOD Neuts-69.8 Lymphs-26.1 Monos-3.4 Eos-0.2
Baso-0.5
[**2143-7-22**] 09:05PM BLOOD PT-12.2 PTT-26.7 INR(PT)-1.0
[**2143-8-23**] 04:34AM BLOOD Plt Ct-246
[**2143-7-22**] 09:05PM BLOOD Glucose-204* UreaN-16 Creat-1.1 Na-131*
K-4.3 Cl-94* HCO3-25 AnGap-16
[**2143-8-23**] 04:34AM BLOOD Glucose-153* UreaN-37* Creat-4.2*# Na-140
K-3.7 Cl-100 HCO3-27 AnGap-17
[**2143-7-23**] 05:04AM BLOOD ALT-45* AST-61* LD(LDH)-361* AlkPhos-214*
Amylase-26 TotBili-0.8
[**2143-8-10**] 10:56PM BLOOD ALT-94* AST-48* AlkPhos-684* Amylase-177*
TotBili-1.4
[**2143-8-23**] 04:34AM BLOOD ALT-54* AST-37 AlkPhos-346* Amylase-338*
TotBili-1.0
[**2143-7-23**] 05:04AM BLOOD Lipase-16
[**2143-8-22**] 03:51AM BLOOD Lipase-601*
[**2143-8-23**] 04:34AM BLOOD Lipase-467*
[**2143-7-23**] 05:04AM BLOOD Albumin-2.6* Calcium-6.0* Phos-3.6
Mg-1.3* Iron-17*
[**2143-8-23**] 04:34AM BLOOD Calcium-7.9* Phos-5.5* Mg-1.9
[**2143-7-23**] 05:04AM BLOOD calTIBC-205* Ferritn-191 TRF-158*
[**2143-8-5**] 05:08AM BLOOD calTIBC-221* VitB12-421 Folate-11.9
Hapto-416* Ferritn-321 TRF-170*
[**2143-8-13**] 03:57PM BLOOD Hapto-392*
[**2143-8-8**] 04:05AM BLOOD Triglyc-1477*
[**2143-8-9**] 11:07PM BLOOD Triglyc-241*
[**2143-7-24**] 06:00AM BLOOD TSH-0.48
[**2143-7-24**] 09:19AM BLOOD Cortsol-25.7*
[**2143-7-26**] 06:03AM BLOOD IgG-476* IgA-98 IgM-362*
[**2143-8-18**] 03:56AM BLOOD Type-ART Temp-39.2 FiO2-40 pO2-155*
pCO2-35 pH-7.48* calTCO2-27 Base XS-3 Intubat-INTUBATED
Aspergillus Galactomannan [**2143-8-3**]: 0.1
Beta-glucan [**2143-8-3**]: 75 (Indeterminate)
Mycoplasma IgM 9 (< 770)
Mycoplasma IgG 1.23 (positive)
[**2143-7-23**] 8:44 am Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2143-7-26**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2143-7-26**]):
Positive for Influenza A viral antigen.
REPORTED BY PHONE TO DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2143-7-23**] AT 1227.
Positive for Swine-like Influenza A (H1N1) virus by RT-PCR
at State
Lab.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2143-7-23**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
.
[**2143-8-27**] 04:56AM BLOOD WBC-6.5 RBC-2.77* Hgb-7.7* Hct-23.3*
MCV-84 MCH-27.8 MCHC-33.0 RDW-16.2* Plt Ct-188
[**2143-8-26**] 04:25AM BLOOD WBC-8.9 RBC-2.44* Hgb-6.7* Hct-20.5*
MCV-84 MCH-27.3 MCHC-32.5 RDW-16.3* Plt Ct-183
[**2143-8-25**] 09:00PM BLOOD Hct-20.7*
[**2143-8-25**] 12:33PM BLOOD Hct-21.7*
[**2143-8-27**] 04:56AM BLOOD Plt Ct-188
[**2143-8-27**] 04:56AM BLOOD PT-14.3* PTT-47.3* INR(PT)-1.2*
[**2143-8-26**] 10:26PM BLOOD PTT-66.8*
[**2143-8-26**] 04:25AM BLOOD Plt Ct-183
[**2143-8-27**] 04:56AM BLOOD Glucose-177* UreaN-35* Creat-4.4*# Na-140
K-3.6 Cl-102 HCO3-26 AnGap-16
[**2143-8-26**] 04:25AM BLOOD Glucose-107* UreaN-73* Creat-7.1*# Na-135
K-3.9 Cl-98 HCO3-21* AnGap-20
[**2143-8-25**] 04:14AM BLOOD Glucose-161* UreaN-52* Creat-5.7*# Na-136
K-3.6 Cl-98 HCO3-25 AnGap-17
[**2143-8-24**] 04:07AM BLOOD Glucose-145* UreaN-28* Creat-3.7* Na-138
K-3.6 Cl-100 HCO3-26 AnGap-16
[**2143-8-27**] 04:56AM BLOOD ALT-46* AST-22 LD(LDH)-180 AlkPhos-428*
Amylase-245* TotBili-0.4
[**2143-8-26**] 04:25AM BLOOD ALT-63* AST-29 AlkPhos-460* Amylase-303*
TotBili-0.5
[**2143-8-25**] 04:14AM BLOOD ALT-75* AST-39 AlkPhos-485* Amylase-328*
TotBili-0.6
[**2143-8-24**] 04:07AM BLOOD ALT-70* AST-54* AlkPhos-428* TotBili-0.7
[**2143-8-27**] 04:56AM BLOOD Lipase-344*
[**2143-8-26**] 04:25AM BLOOD Lipase-626*
[**2143-8-25**] 04:14AM BLOOD Lipase-675*
[**2143-8-23**] 04:34AM BLOOD Lipase-467* GGT-543*
[**2143-8-22**] 03:51AM BLOOD Lipase-601*
[**2143-8-27**] 04:56AM BLOOD Albumin-2.1* Calcium-7.6* Phos-3.6#
Mg-1.6
[**2143-8-26**] 04:25AM BLOOD Calcium-7.7* Phos-5.7* Mg-1.8
[**2143-8-25**] 04:14AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.7
[**2143-8-24**] 04:07AM BLOOD Calcium-7.8* Phos-3.8# Mg-1.7
[**2143-8-23**] 04:34AM BLOOD Calcium-7.9* Phos-5.5* Mg-1.9 Iron-50
[**2143-7-26**] 06:03AM BLOOD IgG-476* IgA-98 IgM-362*
[**2143-8-26**] 04:25AM BLOOD Vanco-27.1*
[**2143-8-19**] 06:28AM BLOOD Vanco-8.7*
[**2143-8-22**] 03:51AM BLOOD HCV Ab-NEGATIVE
[**2143-8-18**] 03:56AM BLOOD Type-ART Temp-39.2 FiO2-40 pO2-155*
pCO2-35 pH-7.48* calTCO2-27 Base XS-3 Intubat-INTUBATED
.
Radiology:
[**8-25**]-CXR-
FINDINGS: In comparison with the study of [**8-23**], the left central
catheter has been repositioned so that the tip lies in the
region of the mid-to-lower portion of the SVC. Tracheostomy tube
and right IJ catheter remain in place. The cardiac silhouette
is again at the upper limits of normal in size. Atelectatic
changes are seen at both bases with continued elevation of the
right hemidiaphragm.
Some ill-defined, primarily reticular opacifications are seen in
the right mid to upper lung zones. These most likely represent
residual fibrous healing from the previous right upper lobe
pneumonia.
.
[**2143-8-22**]-liver or gallbladder u/s-IMPRESSION:
1. Persistent gallbladder sludge without gallbladder wall edema
or
pericholecystic fluid. No intrahepatic or extrahepatic biliary
dilatation.
The study and the report were reviewed by the staff radiologist.
.
EMG [**8-13**]-Abnormal study. The absent sensory response of the left
sural nerve suggests
the possibility of an underlying polyneuropathy. However, in the
absence of abnormalities on motor nerve conduction studies or
signs of ongoing
denervation on needle electromyography, a diagnosis of critical
illness
neuropathy is unlikely.
.
[**8-4**]-CT abd/pelvis-IMPRESSION:
1. Widespread severe multifocal bronchopneumonia.
2. Pulmonary arterial filling defect, not optimally
demonstrated, but
representing a high probability for pulmonary embolism.
3. Fluid throughout the colon, which is abnormal and can be seen
with C. diff. colitis, but which is non-specific.
.
echo [**2143-7-23**]-The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers (cannot definitively exclude).
There is symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The right ventricular free wall
is hypertrophied. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Brief Hospital Course:
Influenza: The patient was admitted with multifocal pneumonia
and some GI symptoms including nausea and vomiting. The patient
had a hypoxemic respiratory failure related to H1:N1 influenza-
he was on tamiflu for this x 10 days. In addition he was
treated with amantadine while awaiting final verification of
H1N1, he was treated with vancomycin and zosyn for possible
bacterial superfinection (however no cultures had grown any
bacterial pathogens). His course was complicated by several
ventilator associated pneumonias and he eventually had a
tracheostomy for respiratory failure, as discussed below.
.
Respiratory failure: Likely secondary H1N1 influenza complicated
by bacterial superinfection. Treated as above. Ability to wean
pt off vent initially limited by fluid overload in the setting
of ARF but gradually able to offload fluid via CVVH. Had
episodes of respiratory distress on [**2143-8-8**] accompanied by vagal
episodes with bradycardia to 30s. ETT with crusted secretions on
bronch; changed out with improvement in respiratory status. Pt
subsequently treated for pansensitive enterobacter pneumonia,
for which he completed an 8-day course of vanc and cefipime on
[**2143-8-19**]. Trach/PEG placed on [**2143-8-14**] and pt tolerating trach mask
with CPAP overnight. Pt restarted on vanc and cefipime on [**8-21**]
for possible new LLL infiltrate in setting of fever. The
cultures did not grow any pathogens at this time. He will
continue vanco and cefipime for 1 more day, course will be
complete on [**8-28**].
.
C diff: The patient had C diff as a complication of his
antibiotic treatment, he was treated with PO vancomycin for
this, to continue for 7 days after completion of antibiotic
course for PNA, to end [**2143-9-4**]
.
Pulmonary embolism: Found to have RLL PE on [**2143-8-4**] CT chest w/
contrast. Started on heparin gtt. Was then started on coumadin,
but coumadin was stopped so he could have a more permanent HD
access placed. He was bridged on heparin gtt. He will be
discharged on a heparin gtt and restarted on coumadin. Heparin
gtt can be stopped when INR is >2.0.
.
Hypertriglyceridemia: TG elevated to 1477 on [**2143-8-8**]. This
resolved with discontinuation of propofol.
.
Elevated LFTs: No evidence of cholecystitis on two abd U/S as
well as HIDA scan. CT abdomen and pelvis without clear
etiology. [**Month (only) 116**] have been related to med effect (?propofol). Does
have subcentimeter post right hepatic lobe hypodensity thought
to be hemangioma on prior imaging. Hep panel negative.
.
Elevated pancreatic enzymes: Acute increase in amylase and
lipase on [**7-10**]. Delayed response to propofol v. passing of stone.
RUQ US did not show any pathology. Continued to be high around
the time of discharge.
.
Fevers: Pt continued to spike nightly fevers despite treatment
of pneumonia and C. diff. Found to have PE on [**2143-8-4**] and
started on heparin gtt. Also grew out aspergillus on [**2143-8-1**]
sputum cx, thought to be colonizer given stable clinical status,
chest infiltrates not classic for fungal infection, and overall
improvement in fever curve along with negative beta glucan and
galactomannan. [**2143-8-3**] and [**2143-8-6**] RUQ u/s done for rising LFTs
showed gallbladder sludge but no evidence of cholecystitis on
these nor [**2143-8-7**] HIDA scan. It is possible that fevers may have
been drug reaction given presence of rash that resolved with
discontinuation of Zosyn; differential negative for eosinophils.
[**2143-8-9**] sputum cx grew aspergillus, thought to be colonizer given
negative beta glucan and galactomannan as well as
noncharacteristic CT chest. [**2143-8-13**] sputum cx subsequently grew
out pansensitive enterobacter, and pt completed an 8-day course
of vanc/cefepime, then was restarted as above. PO vanc to be
continued for several days after IV abx course completed given
C. diff infection.
.
ARF: The patient suffered ATN related to very mild hypotension
which was transient to the 80s systolic. He was briefly on
levophed and given fluid boluses. Renal was consulted and
confirmed ATN and the patient underwent CVVH initially for fluid
removal followed by Hemodialysis. However, fluid status and
electrolytes not optimally controlled on this so changed back to
CVVH with improvement. Eventually was transitioned to HD on MWF
schedule. Tunneled line successfully placed [**2143-8-27**]
Medications on Admission:
None
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for eye dryness.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours): please continue 7 days after IV antibiotics are
stopped.
[**9-4**] last dose.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
sob/wheezing.
14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 1 days: to finish [**8-28**].
17. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
19. heparin
heparin IV per weight dosing protocol. Heparin needed until INR
therapeutic for PE.
20. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 1 days: last dose tomorrow [**8-28**].
21. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
22. insulin sliding scale
please see attached sheet.
23. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
H1N1 influenza (Swine Flu) pneumonia with bacterial
superinfection
Enterobacter ventilator-associated pneumonia
Clostridium difficile colitis
Acute renal failure
Pulmonary embolism
Atrial fibrillation/atrial flutter
Discharge Condition:
sating ~100% on 35% TM
Discharge Instructions:
You were admitted for a severe pneumonia, thought to represent
bacterial pneumonia on top of H1N1 influenza (swine flu). You
required intubation for respiratory failure. You subsequently
developed a ventilator-associated pneumonia. You were treated
for all of these infections. You were also treated for a blood
clot in your lung and a diarrheal infection. Eventually, a trach
and PEG tube were placed to support you during your recovery.
Additionally, you developed kidney failure that required
initiation of dialysis. You will continue on dialysis while
getting rehabilitation.
.
.
Medication changes:
Many new medications have been added and you will need to follow
the attached list.
.
Please call your doctor or return to the hospital if you have
fevers, chills, shortness of breath, chest pain, nausea,
vomiting, diarrhea or other concerns.
Followup Instructions:
Please schedule a follow-up appointment with your PCP [**Name Initial (PRE) 176**] 2
weeks of your discharge from Rehab.
The following appointment has already been scheduled.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-9-16**]
2:00
Please follow up with the kidney doctors, as well. You should
call ([**Telephone/Fax (1) 773**] to make an appointment.
|
[
"415.19",
"276.1",
"584.5",
"008.45",
"427.31",
"427.32",
"785.50",
"487.0",
"782.1",
"507.0",
"285.9",
"349.82",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"96.04",
"38.93",
"38.95",
"43.11",
"31.1",
"38.91",
"96.72",
"33.22",
"39.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17510, 17576
|
10671, 15063
|
304, 469
|
17836, 17861
|
3392, 10648
|
18756, 19181
|
2330, 2339
|
15118, 17487
|
17597, 17815
|
15089, 15095
|
17885, 18469
|
2379, 2818
|
18489, 18733
|
228, 266
|
497, 2218
|
2240, 2258
|
2274, 2314
|
2843, 3373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,234
| 150,220
|
2827
|
Discharge summary
|
report
|
Admission Date: [**2140-2-25**] Discharge Date: [**2140-3-1**]
Date of Birth: [**2096-5-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Increased ICD impedance noted on routine monitoring
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 43 year-old male with history of
cardiomyopathy (EF 45%) s/p ICD found to have ICD lead
dysfunction, transferred for ICD revision.
On routine monitoring of his ICD he was found to have an acute
rise in his ventricular lead impedance from 500 ohms to 1488
ohms. Of note he has a Fidelis 6949 lead which is on advisory.
He was asked present to a hospital and was admitted to [**Hospital **]
Hospital the day prior to transfer. At the OSH his ICD was
turned off and he was monitored without event. He was then
transferred to [**Hospital1 18**] due to concern for lead fracture for ICD
revision.
On presentation he denied any symptoms. He did report having
some dizziness for the last two days but denied any recent
syncope. His last episode of VT/VF was on [**2140-2-2**] for which he
was paced out of the arrhythmia.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: s/p initial ICD in [**2127**] for VT, removed in [**2128**]
for MRI replaced at [**Hospital1 18**] in [**2136**] after cardiac arrest -
[**Company 1543**] ICD, Virtuoso DR D154AWG
3. OTHER PAST MEDICAL HISTORY:
Cardiomyopathy s/p most recent AICD in [**2136**]
History of cardiac arrest in [**2136**]
Hyperlipidemia
Depression
GERD
s/p spinal surgery with cervical fusion C5, C6, and C7 for
bulging disc
Social History:
He lives with his girlfriend. [**Name (NI) **] is currently retired/on
disability but had worked at a mental health hospital
previously.
-Tobacco history: Denies current or previous tobacco use.
-ETOH: Drinks about 3 drinks per week.
-Illicit drugs: Denies drug use.
Family History:
Significant for a father who died in his sleep from a presumed
MI. Mother had diabetes and CAD.
Physical Exam:
(Per Admitting Resident)
GENERAL: Middle-aged, well built male lying in bed in NAD. Alert
and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JVD.
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: + BS, soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2140-2-25**] 02:57PM BLOOD WBC-5.0 RBC-4.97 Hgb-13.4* Hct-40.6
MCV-82 MCH-26.9* MCHC-32.9 RDW-14.3 Plt Ct-192
[**2140-2-25**] 02:57PM BLOOD PT-11.9 PTT-23.3 INR(PT)-1.0
[**2140-2-25**] 02:57PM BLOOD Glucose-123* UreaN-16 Creat-1.3* Na-136
K-4.3 Cl-101 HCO3-25 AnGap-14
[**2140-2-25**] 02:57PM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
[**2140-2-26**] 05:17AM BLOOD %HbA1c-6.4* eAG-137*
[**2140-3-1**] 06:20AM BLOOD WBC-7.2 RBC-4.65 Hgb-12.5* Hct-37.9*
MCV-82 MCH-27.0 MCHC-33.1 RDW-14.2 Plt Ct-176
Discharge Labs
[**2140-3-1**] 06:20AM BLOOD PT-13.2 PTT-25.6 INR(PT)-1.1
[**2140-3-1**] 06:20AM BLOOD Glucose-143* UreaN-11 Creat-1.1 Na-136
K-3.7 Cl-102 HCO3-25 AnGap-13
[**2140-3-1**] 06:20AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.8
Urine Studies
[**2140-2-27**] 08:06AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2140-2-27**] 08:06AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG
[**2140-2-27**] 08:06AM URINE RBC-0 WBC-[**3-4**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2140-2-27**] 08:06AM URINE Mucous-FEW
Microbiology
[**2140-2-28**] - Urine Cx - No growth to date at time of discharge.
Radiology
CXR ([**2140-2-25**]) - FINDINGS: ICD remains in place, with leads
terminating in right atrium and right ventricle. No visible lead
fracture on this portable chest radiograph, which is not optimal
for evaluating subtle lead abnormalities. Note is made of a
slightly curved course of the radiodense coil of the right
atrial lead, which is an apparent change from the prior
radiograph. If warranted clinically, standard PA and lateral
chest radiographs could be performed to more fully evaluate this
region, as discussed with Dr. [**Last Name (STitle) **]. Cardiac silhouette is
mildly enlarged, the aorta is slightly unfolded, and lungs are
clear.
CXR ([**2140-3-1**]) - Transvenous right atrial pacer and right
ventricular pacer defibrillator lead follow their expected
courses from the right axillary pacemaker. No pneumothorax,
pleural effusion or mediastinal widening. Heart size top normal,
improved since [**2-29**].
Brief Hospital Course:
Mr. [**Known lastname **] is a 43 year-old male with cardiomyopathy s/p ICD
found to have ICD lead dysfunction, transferred for ICD
revision.
# ICD lead fracture: The patient was found on routine
monitoring to have increased impedance of his ventricular lead,
suggesting lead fracture. Initial evaluation of leads by CXR did
not show any visible lead fracture. The patient's ICD was turned
off, and there were not events during his ICU stay. The patient
underwent ICD lead extraction/replacement on [**2140-2-29**]. On the
evening following lead placement, he had some nausea and
dyspnea. CXR did not show acute process, and his ABG was
unremarkable. He was given zofran. His symptoms had resolved by
the following morning. His CXR s/p revision showed appropriate
placement of the ICD leads (see above for full report). The
patient was discharged on a 7-day course of Keflex, which he
will complete on [**2140-3-7**].
# Cardiomyopathy: History of idiopathic cardiomyopathy with EF
45% in [**2136**] s/p ICD placement. Pt remained euvolemic during this
hospitalization. Continued to take toprol, lisinopril and
verapamil.
# VT: hx of VT terminated electrically. None this
hospitalization. Plan for f/u with EP/cardiologist/PCP post
hospitalization.
Medications on Admission:
LISINOPRIL 5 mg po daily
TOPROL XL 50 mg po daily
OMEPRAZOLE 20 mg po daily
ZOLOFT
VERAPAMIL 240 mg po daily
ASA 325 mg po daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
6. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 7 days: Please take for a 7-day course, ending on
[**2140-3-7**].
Disp:*27 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Idiopathic cardiomyopathy
ICD lead malfunction status post lead revision
Secondary
Gastroesophageal Reflux
Depression
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital as you were noted to have
increased impedance of your ICD, suggesting fracture of the ICD
leads. You underwent lead revision. You did not have any
complications after this procedure. You are being discharged
home to follow-up with your cardiologist.
CHANGES TO YOUR MEDICATIONS:
- STOP Cymbalta
- START Sertraline (Zoloft) 25 mg daily. You should talk to your
PCP regarding whether he wants to further increase your dose.
- START Cephalexin 500 mg every 6 hours for 7 days
Weigh yourself every morning, [**Name6 (MD) 138**] your MD if your weight goes
up more than 3 lbs.
It was a pleasure taking part in your medical care.
Followup Instructions:
You should keep all of your follow-up appointments. You have an
appointment scheduled at the Device Clinic at [**Hospital1 18**] on [**2140-3-8**]
at 11:00am. If you have any questions, you can call the clinic
at [**Telephone/Fax (1) 62**].
You also have an appointment with Dr. [**Last Name (STitle) 1911**] on [**2140-3-31**]
at 2:40pm. If you have any questions or concerns, you can call
his office at [**Telephone/Fax (1) 62**].
You should also call your cardiologist, Dr [**Last Name (STitle) 13794**], to set up
an appointment with him within 1-2 weeks of discharge. You
should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 656**], as well.
|
[
"425.4",
"311",
"996.04",
"E878.1",
"401.9",
"272.4",
"530.81",
"V45.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
7366, 7372
|
5121, 6374
|
365, 371
|
7543, 7543
|
2991, 2991
|
8378, 9068
|
2145, 2243
|
6553, 7343
|
7393, 7522
|
6400, 6530
|
7691, 7978
|
2258, 2972
|
1364, 1615
|
8007, 8355
|
274, 327
|
399, 1253
|
3007, 5098
|
7558, 7667
|
1646, 1840
|
1275, 1344
|
1856, 2129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,854
| 110,622
|
3636
|
Discharge summary
|
report
|
Admission Date: [**2189-3-31**] Discharge Date: [**2189-4-3**]
Service: MEDICINE
Allergies:
Boric Acid
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
supratherpeutic INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known firstname **] [**Known lastname 16528**] is a [**Age over 90 **] year old female with a history of
afib on coumadin, metastatic GE junction adenocarcinoma, and
dCHF who presents with supratherapeutic INR and anemia. The
patient had been on coumadin for years and this was
discontinued, but subsequently restarted ([**10/2188**]) in the
setting of worsening PVD with arterial cloth in the setting of
metastatic esophageal cancer. She usually gets her INR checked
every 2 weeks but almost a month passed between her last INR
check and the one she had today. Her coumadin dose has remained
relatively stable, however, she has had increased constipation
and decreased appetite and PO intake over the past month. Her
INR check today was > 10 and her PCP advised [**Name9 (PRE) **] evaluation. Over
the past week Mrs. [**Known lastname 16528**] has had darker colored stools,
but has not had any hemetemesis, hematuria, BRBPR, or chest
pain. She has had one episode of epistaxis from her left nostril
and dry heaves for several days.
.
In the ED, initial vs were: Pain 0, T 97.8, HR 97, BP 111/49, RR
18, O2 sat 96% RA. On exam, patient was noted to be guaiac
positive with brown stool. Her labs were notable for an INR > 20
and Hct 22.8, approximately 10 points lower than her recent
baseline. She was given vitamin K 10 mg IV, FFP x 2, and
pantoprazole IV. Blood was also ordered. GI was called and
advised against NGT placement given recent epistaxis. They will
see the patient in the morning.
.
On arrival to the ICU, the patient was comfortable without any
chest pain, shortness of breath, or nausea.
.
Review of sytems:
(+) Per HPI, + intermittant left foot pain, + cough (chronic), +
post-nasal drip (chronic), + vision loss (chronic).
(-) Denies fever, chills. Denies headache, sinus tenderness.
Denied shortness of breath. Denied chest pain or tightness,
palpitations. Denied diarrhea, constipation or abdominal pain.
No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Atrial fibrillation on Coumadin
2. dCHF with EF 60%, Echo in [**11-6**]
3. Constipation alternating with loose stools
4. Hypothyroidism
5. Depression
6. Anemia, iron deficiency
7. Poor vision due to macular degeneration
8. Vertigo - evaluated multiple times in the past by neurology.
9. Metastatic GE junction adenocarcinoma - not on treatment
10. History of PVD with bilateral common femoral occlusions
(10/[**2188**]). Coumadin restarted for palliative reasons for lower
extremity pain.
Social History:
Lives at home. Nephew and boarder also live in the house. Quit
smoking in [**2143**], 30 pack year history. No EtOH. Formerly worked
as an artist.
Family History:
Father died of "heart failure"
Physical Exam:
PE: 99.1F 102 112/76 17 100%RA
Gen: lying in bed, in nad
HEENT: eomi, mmm, NGT in place draining greenish materials
CV: S1S2+
Chest: ctab
Abd: distended, tympanic sound, sluggish bs+, tenderness
diffusely, worse at center of the abdomen, nr, with guarding
Ext: no edema, dp2+
CNS: aox3
Pertinent Results:
[**2189-4-1**] 05:30AM BLOOD WBC-8.6 RBC-2.67* Hgb-7.9* Hct-23.0*
MCV-86 MCH-29.8 MCHC-34.5 RDW-15.7* Plt Ct-364
[**2189-3-31**] 05:55PM BLOOD Neuts-89.0* Lymphs-7.8* Monos-2.8 Eos-0.4
Baso-0.1
[**2189-3-31**] 05:55PM BLOOD PT-150* PTT-49.2* INR(PT)->20.2*
[**2189-4-1**] 05:30AM BLOOD PT-16.2* PTT-26.5 INR(PT)-1.4*
[**2189-3-31**] 05:55PM BLOOD Glucose-148* UreaN-31* Creat-1.2* Na-137
K-3.3 Cl-98 HCO3-39* AnGap-3*
[**2189-4-1**] 05:30AM BLOOD Glucose-95 UreaN-24* Creat-0.8 Na-141
K-3.2* Cl-100 HCO3-30 AnGap-14
[**2189-4-1**] 05:30AM BLOOD CK(CPK)-29
[**2189-3-31**] 05:55PM BLOOD cTropnT-<0.01
[**2189-4-1**] 05:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2189-4-1**] 05:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.9
[**2189-3-31**] 05:55PM BLOOD TSH-2.2
Brief Hospital Course:
This is a [**Age over 90 **] year old female with a PMH of afib on coumadin,
metastatic GE junction cancer, and dCHF who presented with an
INR > 20 and anemia with hematocrit 22.8, markedly decreased
from prior.
# Acute blood loss anemia: Patient with a Hct of 22.8 on
admission and dark guaiac positive stool in the setting of an
INR of 20. She had no evidence of brisk bleeding and remained
hemodynamically stable during her ICU stay. She received 2u of
pRBC's in the ICU with a Hct of 29.3 on discharge. She was
placed on an IV PPI q12H and was monitored on telemetry
throughout her course without incident.
# Supratherapeutic INR: Patient with an INR >20 on admission.
She received vitamin K 10 mg IV and 2 units FFP in the ED. Her
INR was reversed to 1.4 following these measures. Her PCP
recommended that the patient not restart it as an outpatient.
# EKG changes: Patient admitted with new TWI and ST depressions
on EKG without chest pain, though to be from demand ichemia in
the setting of anemia. CE's were negative x 2. A repeat EKG was
improved.
# Acute renal failure: Patient with an admission creatinine of
1.2 up from baseline of 0.6 - 0.9, likely secondary to
hypovolemia from anemia and poor PO intake from cancer. After
fluid repletion with blood products, her Cr dropped to 0.8. Her
Lasix was held in the ICU, but restarted prior to discharge.
# Atrial fibrillation: Patient remained rate-controlled with
home dose of Metoprolol. Her ASA was held due to blood loss and
her physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], was consulted who recommended
stopping her Coumadin permanently.
#. Chronic Diastolic CHF: This was not an active issue during
her stay. She remained stable, but volume status was observed
carefully to prevent fluid overload in the context of receiving
blood products and holding home Lasix. Her ASA was held, but
restarted at 81mg prior to discharge, her Metoprolol was
continued, and her Lasix was restarted prior to discharge.
.
#. Hypothyroidism: TSH was normal and she was continued on her
home dose of levothyroxine.
#. Glaucoma: Home Lumigan was substituted for Latanoprost in
house.
#. Depression: Continued home Sertraline and started patient on
mirtazapine 15mg at bedtime to facilitate sleep and stimulate PO
intake.
#. Chronic post-nasal drip: Patient uses a Rhinocort nasal spray
at home that was substituted with fluticasone. She was also
continued on her home Hyoscamine.
.
Code: Patient remained DNR/DNI throughout this hospitalization.
Medications on Admission:
Bimatoprost [Lumigan] 0.03 % Drops 1 drop OU daily
Budesonide [Rhinocort Aqua] 32 mcg/Actuation Spray, 1 spray NU
daily
Fluticasone 110 mcg/Actuation Aerosol 2 puffs daily
Furosemide 40 mg daily
Levothyroxine 100 mcg daily
Metoprolol Succinate SR 100 mg daily
Prednisolone Acetate 1 % Drops, Suspension 1 drop OU every other
day
Sertraline 25 mg daily
Vit C-Vit E-Copper-ZnOx-Lutein [PreserVision] 226-200-5
mg-unit-mg Capsule PO BID
Warfarin 2 mg daily except takes 3 mg on fridays
Hyoscyamine 0.125 mg SL QHS (not on OMR list)
Recently ordered medications in OMR not on home list
Acetaminophen 325 mg Tablet 1-2 tabs PO Q4-6H prn pain
Aspirin 325 mg daily
Prochlorperazine [Prochlorperazine Maleate] 10 mg daily prn
nausea
Prednisone 2 mg daily
Simvastatin 10 mg daily
Morphine Concentrate 20 mg/mL Solution [**2-3**] ml by mouth Q1h prn
pain or dyspnea 1-5 mg for mild pain, 5-10 mg for moderate pain,
10-20 mg for severe pain
Discharge Medications:
1. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed for cough.
Disp:*120 ML(s)* Refills:*0*
2. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic once a
day: into both eyes.
3. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One
(1) spray Nasal once a day: intranasally.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic every other day: into both eyes.
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QHS (once a day (at bedtime)).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
once a day as needed for nausea.
15. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
16. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Morphine Concentrate 20 mg/mL Solution Sig: as directed mL
PO q1h as needed for pain: [**2-3**] mL for mild pain, [**6-8**] mL for
moderate pain, and [**11-18**] mL for severe pain.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
GI bleed
Atrial Fibrillation
Secondary:
Diastolic Congestive Heart Failure
Hypothyroidism
Glaucoma
Discharge Condition:
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of increased constipation and decreased appetite. It
was found that your Coumadin level was extremely high and that
you had anemia likely due to a bleed in your intestines. You
needed to be admitted to the intensive care unit for close
monitoring. You received 2 units of blood in a transfusion and
your anemia stabilized. Your Coumadin was stopped altogether.
You were also started on a medication called mirtazipine which
helps improve your appetite.
.
The following changes have been made to your home medication
regimen:
1. We started you on a medication for sleep and anxiety, called
Mirtazapine, which you can use at night, as needed, for sleep.
2. We stopped your Coumadin, as your INR was very high on
admission.
3. We restarted you on Aspirin 81 mg daily
4. We started you on a cough syrup, Dextramethorphan, to use as
needed.
Followup Instructions:
Please follow-up with all of your scheduled appointments below:
.
You should contact your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], if
you don't hear from her by early next week.
.
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2189-4-8**] 11:20
.
2. Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-6-8**]
2:30
.
3. Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2189-6-8**] 2:50
|
[
"578.9",
"286.7",
"V58.61",
"428.0",
"427.31",
"362.50",
"E934.2",
"311",
"244.9",
"276.52",
"199.1",
"V10.03",
"428.32",
"584.9",
"285.1",
"V58.65",
"564.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9338, 9416
|
4074, 6606
|
237, 243
|
9569, 9691
|
3303, 4051
|
10643, 11297
|
2949, 2981
|
7587, 9315
|
9437, 9548
|
6632, 7564
|
9715, 10620
|
2996, 3284
|
178, 199
|
1905, 2252
|
271, 1887
|
2274, 2769
|
2785, 2933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,868
| 144,965
|
53822
|
Discharge summary
|
report
|
Admission Date: [**2189-7-8**] Discharge Date: [**2189-7-13**]
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
History of Present Illness:
[**Age over 90 **] yo F who presents from [**Hospital6 3105**] after
mechanical fall and new femoral and humeral fracture.
Patient reports that on morning of presentation she turned too
quickly and tripped and fell to the floor on her left hip when
walking back from the bathroom. She said prior to the fall she
reports she had been felling nauseated and had some diarrhea
over the last few days. She denies any head trauma or LOC. She
called 911 using her MedAlert. She was taken to LGH where she
was found to have a negative CT head, a proximal humeral
fracture, and a distal femoral neck fracture on imaging. She was
given morphine and zofran at the OSH and transferred to [**Hospital1 18**]
for further care.
Per pt's niece, she lives alone at home but has VNA. She has
fallen before - last falls in [**August 2188**], [**February 2189**] (pt sustained rib
fx).
At baseline she reports she is able to walk a few blocks on her
own. She is able to walk up 1 flight of stairs. At night she
uses a walker and wears home oxygen which she says is "for her
heart." She denies any chest pain and denies any shortness of
breath, orthopnea, ankle edema, palpitations, syncope or
presyncope.
In the ED, initial vs were 97.1 97 115/58 16 97% on 3L. She was
noted to have sats in the mid 80s without supplemental O2. Labs
were notable for Cr of 1.6, H/H of 9.8/31.2. She was given 2 mg
of morphine and had a subsequent drop in her blood pressure to
low 90s. She was given a 250 cc bolus with improvement in blood
pressure to 120s/50s. CXR was unremarkable. Ortho was consulted
and recommended medicine admission. She is consented and booked
for OR in AM. Vitals upon transfer were 67 124/54 16 95% on 3L.
On arrival to the floor, pt complaining of pain predominately in
her left arm.
Past Medical History:
PMH: Hypothyroidism, HTN, GERD, HL, Questionable MI
PSH: Appendectomy, Tonsillectomy
Social History:
Retired. former smoker, no EtOH
Family History:
non-contributory
Physical Exam:
ADMISSION:
VS 97.4 105/56 67 14 97% RA
GEN Alert, oriented, in pain
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no LAD
PULM Few crackles at right base anteriorly, otherwise clear. no
wheezes.
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT L. arm in sling. L. hip tender. WWP 2+ pulses palpable
bilaterally, no c/c/e
NEURO CNs2-12 intact, motor exam limited due to fractures and
pain
SKIN no ulcers or lesions
DISCHARGE:
POD#4
Vitals: 97.3/97.8, 150/84 (120s-150s/50s-80s), 102(90s-100s),
95%ra
GEN: elderly women lying in bed, awake, interactive, AAOx3 NAD.
HEENT: NCAT, Dry mucosa, oropharync clear, sceral anicteric
NECK: no JVD appreciated, supple without masses
HEART: Regular rate and rhythm, II/VI systolic murmur LLB. no
rub or [**Location (un) **].
LUNGS: Not labored, full sentences, on RA during my exam without
difficulty.
ABD: thin, soft, NT/ND
LEFT HIP - pulses 2+ b/l. Left leg with full ROM. With bandage
on left hip, I spoke with Ortho they plan to change bandage
today.
LEFT SHOULDER - Left shoulder in sling
Neuro: AAOxself only. CN 2-12 grossly intact, tounge midline,
EOMI, communicating appropriately, right arm and leg sensation
and strength appropriate given POD#4
Pertinent Results:
ADMISSION:
[**2189-7-8**] 09:59PM BLOOD WBC-8.5# RBC-4.91 Hgb-9.8* Hct-31.2*
MCV-64* MCH-19.9* MCHC-31.3 RDW-15.9* Plt Ct-225
[**2189-7-8**] 09:59PM BLOOD Neuts-82.3* Lymphs-13.3* Monos-4.0
Eos-0.3 Baso-0.1
[**2189-7-8**] 09:59PM BLOOD PT-12.2 PTT-35.5 INR(PT)-1.1
[**2189-7-8**] 09:59PM BLOOD Glucose-128* UreaN-41* Creat-1.6* Na-133
K-4.8 Cl-103 HCO3-19* AnGap-16
[**2189-7-8**] 09:59PM BLOOD Calcium-8.9 Phos-4.7* Mg-1.6
STUDIES:
([**2189-7-9**]) CXR - IMPRESSION: No acute chest abnormality.
([**2189-7-8**]) LEFT HIP - Transverse fracture through the left
basicervical femoral neck
([**2189-7-8**]) LEFT KNEE - Transverse fracture through the left
basicervical femoral neck
OSH imaging
XR left shoulder: minimally displaced, surgical neck fracture w/
? of greater troch fx
XR AP Pelvis: Left, displaced, basicervical FNF
DISCHARGE:
[**2189-7-13**] 05:55AM BLOOD WBC-9.5 RBC-4.07* Hgb-8.2* Hct-26.2*
MCV-65* MCH-20.0* MCHC-31.1 RDW-18.7* Plt Ct-230
[**2189-7-10**] 01:55AM BLOOD Neuts-80.7* Lymphs-13.0* Monos-4.4
Eos-1.8 Baso-0.1
[**2189-7-13**] 05:55AM BLOOD Plt Ct-230
[**2189-7-13**] 05:55AM BLOOD Glucose-88 UreaN-32* Creat-1.2* Na-137
K-3.9 Cl-108 HCO3-18* AnGap-15
[**2189-7-13**] 05:55AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.0
[**2189-7-12**] 06:20AM BLOOD calTIBC-120* Ferritn-[**2164**]* TRF-92*
Brief Hospital Course:
[**Age over 90 **] yo F with who presents s/p fall who initially presented to
OSH and found to have nondisplaced proximal humeral fracture and
a distal femoral neck fracture on imaging who was transferred to
[**Hospital1 18**] for further care. Operation on [**2189-7-9**].
.
## FEMORAL FRACTURE - On [**2189-7-9**] Ortho performed Left hip
hemiarthroplasty with [**Doctor Last Name 3389**] components, unipolar, #7 press
fitted stem, 0 mm neck, 42 mm
head. Post operation patient failed extubation and required
intubation and <24 hour stay in ICU. CXR was benign, EKG did not
show any acute changes. After ICU patient was alert and oriented
only to self. Delirium resolved after 48 hours with minimal
intervention, and patient was fully alert and oriented on
discharge. At home patient requires 2L NC Oxygen during sleep
only. Pt placed on prophylactic Heparin SC 5000U [**Hospital1 **] (given her
poor renal function). Pain controlled well with low dose IV
Dilaudid (.125mg q3H:PRN). [**Hospital1 **] by PT who recommends
inpatient rehab. Given patient's multiple recent
hospitalizations she will likely require a long term care
facility. At discharge PT worked with the patient on a daily
basis, their recs are below, see their note for more detail.
.
## ALTERED MENTAL STATUS - Pt was AAOx3 on admission, post-op
patient was AAO to self only. Likely related to sedation, pain
medication, and hospital setting. After ICU discharge, we
minimized noise and interventions, re-oriented the patient
frequently. Delirium resolved within 48 hours and on discharge,
pt was clear/coherent and AAOx3.
.
## PT RECS: L hip ROM, therex program, transfer, gait, and
balance training, IS training Frequency / Duration: 3-5x/wk,
Please encourage all meals OOB, Lock out knees of bed to prevent
knee/hip flexion contracture, Please lay patient flat (as
tolerated ) 30 min/TID
.
## HUMERAL FRACTURE - Communited nondisplaced proximal humeral
fracture on imaging. Non operable at this admission per Ortho.
In sling and pain controlled well. Discuss as outpatient at
follow-up appointment with orthopedics.
.
## HOME SITUATION - Pt's main support is [**Doctor First Name 2894**](her niece), who
can be reached at ): [**Telephone/Fax (3) 110455**]. Currently
patient lives alone with VNA. Due to multiple hospital
admissions in the recent several months, and lack of support
from family, pt will need a 24 hour care facility.
.
## CKD - Patient's Cr was at baseline during this admission
(1.2-1.5). We renally dosed medications, held her Gemfibrozil,
avoided Morphine, and avoided LMWH. Pt had appropriate urine
output during her stay.
.
## LOW BICARB - patient had non anion gap acidosis in the ICU.
Bicarb remained 16-18 on the floors. Patient was asymptomatic
during admission and Lactate 1.1 on [**7-10**]. We encouraged PO
intake and continued IVF as needed.
.
-------
CHRONIC
-------
## hypothyroid - We continued her home dose levothyroxine
50mg/day
.
## GERD - we continued her home dose famotidine 20mg [**Hospital1 **].
.
## HTN - at home on amlodipine 5mg/day, atenolol 50mg/day and
iso mononitrate 60mg/day. BP meds were held due to low BPs in
the ICU, restarted amlodipine and metoprolol at 12.5mg [**Hospital1 **] day
of discharge. Consider increasing beta blocker per BP and HR.
Consider restarting Isosorbide Mononitrate based on her BP and
HR.
.
## Hyperlipidemia - We did not restart gemfibrozil given her
renal function.
.
## TRANSITIONAL
- Consider increasing patient's dose of beta blocker (admitted
on Atenolol 50mg daily, discharged on metoprolol 12.5 mg [**Hospital1 **]) as
appropriate based on HR and BP
- Consider restarting patient on isosorbide mononitrate 60mg
daily once appropriate based on patient's BP and HR
- Consider starting Iron for microcytic anemia
- Continue prophylactic anticoagulation with Heparin SQ 5000U
[**Hospital1 **] until [**2189-7-24**]
- Continued to hold
- Monitor renal function and hydration status, pt has multiple
admissions for poor hydration
- Coordinate plan with orthopedics for left humeral fracture as
outpatient
Medications on Admission:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. isosorbide mononitrate 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
3. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): *Hold until [**3-20**]. Recheck serum creatinine [**3-20**] and
restart if creatinine stable at 1.6 or less.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left lateral chest.
11. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-17**] Sprays Nasal
QID (4 times a day) as needed for congestion.
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
13. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Amlodipine 5 mg PO DAILY
hold for sbp < 100, hr < 60
3. Docusate Sodium 200 mg PO BID
4. Famotidine 20 mg PO Q24H
5. Heparin 5000 UNIT SC BID
last dose [**2189-7-24**]
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
hold for sbp < 100, hr < 60
8. Senna 1 TAB PO BID:PRN constipation
9. Bisacodyl 10 mg PO BID:PRN constipation
10. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for rr<12 or somnolence
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Left proximal femur fracture
Left proximal humerus fracture
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 **],
You were admitted from [**Hospital6 3105**] after a fall.
An X-Ray of your hip and shoulder revealed a broken bone near
your left shoulder and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 110456**] bone in your left hip. The
orthopedic doctors saw and [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **], and decided to perform
surgery on your left hip. The operation was successful and your
left hip was repaired. After surgery you had difficulty
breathing and required a transfer to the ICU. Within 24 hours
you were discharged from the ICU, breathing on your own. You
were [**Name5 (PTitle) 6349**] by physical therapists who recommend inpatient
rehab facility.
You will need to continue blood thinners with heparin injected
three times per day for 14 additional days beyond discharge. You
will need inpatient rehabilitation after this operation. Due to
the multiple hospital admissions in the recent months, you will
also need full nursing home care.
MEDICATION:
STOP Isosorbide mononitrate
STOP Gemfibrozil
START Unfractionated Heparin 5000U injected into skin twice/day
CHANGE Atenolol 50mg once per day to Metoprolol 12.5mg twice per
day
CONTINUE all other medications as you were before
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2189-7-23**] at 2:20 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: THURSDAY [**2189-7-23**] at 2:40 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
Completed by:[**2189-7-13**]
|
[
"530.81",
"820.8",
"244.9",
"518.0",
"585.3",
"812.00",
"280.9",
"E885.9",
"403.90",
"272.4",
"348.31",
"E937.9",
"276.2",
"518.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11040, 11114
|
4877, 8941
|
243, 271
|
11218, 11218
|
3543, 4854
|
12666, 13262
|
2252, 2270
|
10538, 11017
|
11135, 11197
|
8967, 10515
|
11401, 12643
|
2285, 3524
|
190, 205
|
299, 2077
|
11233, 11377
|
2099, 2186
|
2202, 2236
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,380
| 112,188
|
29879
|
Discharge summary
|
report
|
Admission Date: [**2174-4-4**] Discharge Date: [**2174-4-19**]
Date of Birth: [**2096-6-1**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
CHF/Sarcoma
Major Surgical or Invasive Procedure:
Excision of right groin soft tissue sarcoma, gracilis muscle
flap coverage: [**4-13**].
History of Present Illness:
The patient is a 77 year old female with history of
hypertension, hyperlipidemia, and moderate-severe aortic valve
stenosis who was recently diagnosed in [**2174-1-6**] with a
soft-tissue sarcoma in her right groin after developing right
groin pain. She presented on this admission for surgical
excision of the right groin mass.
Past Medical History:
#. Soft tissue right thigh sarcoma - identified [**1-7**] right groin
pain [**2174-1-6**]
- s/p gamma knife
- admitted this admission for wide excisional therapy
#. Aortic Stenosis
- moderate to severe aortic stenosis, [**Location (un) 109**] 0.8cm2; peak 64mmHg,
mean 39mmHg) with mild aortic regurgitation
- echocardiogram at OSH revealed mild concentric LVH with
normal biventricular function
- moderate tricuspid regurgitation and moderate pulmonary
artery systolic hypertension (46mmHg
#. Post-polio syndrome with fusion of right ankle.
#. Hypertension
#. Hyperlipidemia
#. Chronic backpain spinal stenosis
Social History:
The patient is married (first husband died at age 28 [**1-7**]
Hodgkin's lymphoma). The patient lives in a single family home
and was previously a singer.
Tobacco: 1-2ppd x 48 years,
ETOH: None
Illicts: None
Family History:
Mother - passed in the 80's from "old age,"
Father - unknown
5 children
Physical Exam:
Vitals: Afebrile, vital signs stable.
General: Alert and oriented.
Abdomen: Obese, soft. Non-tender, non-distended.
Right Lower Extremity: Incision site clean/dry/intact with some
swelling over incision site. She has a drain intact. She is
neurovascularly intact distally.
Pertinent Results:
[**2174-4-4**] 11:30PM WBC-8.3 RBC-4.03* HGB-10.8* HCT-33.4* MCV-83
MCH-26.7* MCHC-32.2 RDW-17.1*
CPK: 74, 91, Troponin x 2 sets [**Date range (1) 22743**]: <0.01.
[**4-19**]: HCT: 28.9, WBC: 5.6 PLT: 359
Brief Hospital Course:
The patient was admitted to the vascular surgery service on
[**2174-4-4**] for pre-operative planning. In anticipation of the
surgery, the patient underwent diagnostic abdominal aortogram
with pelvic arteriogram with pre and post hydration with
discontinuation of patient's home lasix. The following morning,
on the day of planned surgical resection, the patient was noted
to be tachypnic, hypertensive, hypoxic and agitated with rales
[**12-7**] way up her lung fields, consistent with pulmonary edema. The
surgery was cancelled given decompensated CHF requiring a
non-rebreather. The patient received 20mg IV lasix x 2, was
transferred to the PACU with improvement in O2 requirements to >
95% on 2L NC. The patient was then transferred to the medical
service for management of CHF and medical optimization prior to
possible repeat attempt for surgery. Pain service was consulted
and a tunneled epidural catheter was placed for pain control.
She was optimized medically for one week and on [**4-13**], she
underwent resection of her right groin sarcoma without
complications. Vascular surgery was not needed as the tumor was
resected off the femoral vessels without the need for bypass.
Plastic surgery applied a gracilis flap over the femoral
vessels. Post-operatively, internal medicine was consulted to
help manage her fluid status. She did extremely well
post-operatively. Her epidural was discontinued a few days
after the procedure and she had good pain control on oral pain
medications. Her foley catheter was removed on post-operative
day number five. She worked with physical and occupational
therapy. She was discharged in stable condition to rehab on
post-operative day number six.
Due to the drain output of 20 cc over 24 hours, plastic surgery
service decided to keep the drain in place at the time of
discharge for plan to record drain amounts at rehab then return
to plastic surgery (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in 1 week for removal of
the drain. It was also decided by them to keep her on oral
keflex to prevent infection while the drain is in place.
Medications on Admission:
Medications on transfer:
ISS
Lidocaine 5% Patch 2 PTCH TD Q 24 HRS
Atenolol 25 mg PO DAILY
Nifedipine CR 30 mg PO DAILY
Lorazepam 0.5-1 mg PO Q4-6H:PRN
Citalopram Hydrobromide 40 mg PO DAILY
Nicotine Patch 14 mg TD DAILY
Furosemide 40 mg PO DAILY (holding)
OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Gabapentin 600 mg PO TID
Simvastatin 10 mg PO DAILY
Haloperidol 2.5 mg IV Q4H:PRN
Lasix 20mg IV x 2
.
Medications, outpatient
Atenolol 25mg daily
Nifedipine XL 30mg qd
Simvastatin 20mg qd
Lasix 40mg qd
Neurontin 300mg [**Hospital1 **]
Celexa 40mg qd
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24 HRS ().
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6-8H
(every 6 to 8 hours) as needed.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
TID (3 times a day) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
14. Insulin Regular Human Subcutaneous
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed. Tablet(s)
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
19. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] center
Discharge Diagnosis:
Primary:
1. Congestive heart failure secondary to aortic stenosis and
fluid overload
2. Sarcoma, right thigh
3. Delirium secondary to hypoxia and oversedation with
underlying dementia.
4. Anxiety
5. Elevated blood sugar
6. Moderate-Severe aortic stenosis
7. Hypertension
.
Secondary:
1. Hyperlipidemia
2. Post Polio Syndrome
Discharge Condition:
Good: No shortness of breath, no supplemental oxygen
requirement, good pain control.
Discharge Instructions:
You were admitted for the surgical removal of the soft tissue
sarcoma in your right groin. Pre-operatively, you experienced
an episode of CHF secondary to fluid overload in the setting of
aortic stenosis. You underwent surgical excision of the mass.
.
Please call your doctor or return to the emergency room if you
develop fevers/chills, chest pain, lightheadedness/dizziness,
faiting, shortness of breath, worsening back/leg pain, inability
to tolerate food/fluid or any other symptoms that concern you.
Please record the daily drain output. Continue with oral keflex
while the drain is in place. Return in 1 week to see Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of plastic surgery for removal of the drain.
Followup Instructions:
Please follow up with your primary care provider within one week
of your discharge from rehab. Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 71433**].
.
Follow-up with Dr. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] in 3
weeks.
.
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in plastic surgery in 1 week
for removal of your drain.
Completed by:[**2174-4-19**]
|
[
"292.81",
"424.1",
"401.0",
"416.9",
"724.2",
"272.4",
"294.8",
"440.0",
"799.02",
"138",
"E937.8",
"440.20",
"250.00",
"428.0",
"171.3",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"83.82",
"88.48",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
6662, 6712
|
2276, 4400
|
329, 419
|
7090, 7177
|
2044, 2253
|
7967, 8449
|
1661, 1734
|
5046, 6639
|
6733, 7069
|
4426, 4426
|
7201, 7944
|
1749, 2025
|
278, 291
|
447, 778
|
4451, 5023
|
800, 1419
|
1435, 1645
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,534
| 183,762
|
8983
|
Discharge summary
|
report
|
Admission Date: [**2133-3-1**] Discharge Date: [**2133-3-10**]
Date of Birth: [**2055-11-6**] Sex: F
Service: MEDICINE
Allergies:
Cortisone
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
trochanteric fixation nail repair
cardiac catheteization
PICC line placement and removal
History of Present Illness:
The patient is a 77-year-old woman with a history of Type 1
diabetes, systolic heart failure, coronary artery disease s/p
MIs and CABG who presented to the Emergency Department after
falling down the 4 steps of her house while trying to get to her
car. According to interviewers in the ED, the patient had no
loss of consciousness and the narrative was one of mechanical
fall. Following the fall, the patient had hip pain and
deformity.
In the ED, the patient was waiting in triage when she became
hypoxic to 80s despite supplemental oxygen and her lungs had
crackles throughout. The patient has a history of systolic CHF
requiring diuresis. The patient's chest X-ray was consistent
with pulmonary edema (likely flashed) with RA saturation in the
70s and low 90s on non-rebreather. The physicians in the ED
decided to intubate the patient, which was completed without
complication. The patient was originally on nitroglycerin gtt,
Versed/Fentanyl, but the compbination of the sedatives and the
nitroglycerin made her hypotensive so the nitroglycerin was
stopped. The patient still gets hyypotensive with boluses for
[**Last Name (LF) 31158**], [**First Name3 (LF) **] she was started on dopamine. Also in the ED, the
patient was pan-CT scanned, and her only injury is a left femur
fracture. Orthopedics would like to surgically correct but want
medical clearance first. Her vitals upon leaving the ED were Hr
76, BP 110/48, 100% saturation on ventilation.
.
On arrival to the MICU, the patient was sedated and intubated
but responsive. She was motuhing words but could not be
understood secondary to the endotracheal tube.
Past Medical History:
1. Myocardial infarction [**Numeric Identifier 13971**]
2. Diabetes
3. Type III monoclonal ammopathy
4. Hypertension
5. Congestive heart failure (ejection fraction 20%)
6. ventricular tachycardia status post ICD
Past surgical history:
-4 vessel Coronary artery bypass graft, PTCA
Social History:
Occupation: Retired
Drugs:
Tobacco: Remote, quit 15 yrs ago
Alcohol: Denies
Patient is single without children. She lives alone.
Family History:
no hx of heart disease
Physical Exam:
Admission-
General: Alert, responsive to commands, intubated
HEENT: Sclera anicteric, EOMI, PERRL
Neck: Supple, JVP not apprehended secondary to C-spine collar
CV: S1, S2, 2/6 systolic murmur
Lungs: Crackles at bases of lungs bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: Foley in place, patient producing urine
Ext: cool, pulses Dopplerable but not palpable on feet, no
pitting edema
Neuro: CNIII-XII intact, moving all four extremities.
Discharge-
Vitals - Tm/Tc: 98.1/97.4 HR:74-78 BP: 102-109/51-78 RR:18-24 02
sat: 100% RA
In/Out:
Last 24H: [**Telephone/Fax (1) 31159**]
Last 8H: 300/250
Weight: 50.2(54.2)
.
Tele: SR, no VEA
.
FS: 199/88
.
GENERAL: 77 yo F, sitting in bed, breathing comfortably
HEENT: mucous membs moist, no lymphadenopathy, JVD at 10
CHEST: Crackles 1/2 up on left, basilar on right
CV: S1 S2, no S3, RRR,
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+
NEURO: 4/5 strength in U/L extremities.
SKIN: left thigh lateral staple site with no drainage, erythema
and mild TTP.
PSYCH: A/O, aware of diagnosis and discussing possible rehabs.
Pertinent Results:
[**2133-3-1**] 08:05PM BLOOD WBC-7.4 RBC-3.76* Hgb-11.9* Hct-38.5
MCV-103* MCH-31.6 MCHC-30.9* RDW-13.1 Plt Ct-306
[**2133-3-1**] 08:05PM BLOOD Neuts-61.0 Lymphs-31.9 Monos-5.8 Eos-0.6
Baso-0.6
[**2133-3-1**] 08:05PM BLOOD PT-10.3 PTT-31.2 INR(PT)-0.9
[**2133-3-1**] 08:05PM BLOOD Glucose-182* UreaN-20 Creat-0.7 Na-133
K-4.9 Cl-99 HCO3-26 AnGap-13
[**2133-3-1**] 08:05PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.1
[**2133-3-1**] 11:00PM BLOOD Type-ART Rates-14/4 Tidal V-400 PEEP-10
FiO2-60 pO2-125* pCO2-50* pH-7.30* calTCO2-26 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2133-3-1**] 08:14PM BLOOD Lactate-1.9
.
CXR [**3-1**]:Single supine portable view of the chest was obtained.
The
endotracheal tube terminates approximately 3 cm above the level
of the carina. Nasogastric tube is seen coursing below the level
of the diaphragm, with the side port at the GE junction and
distal tip likely terminating within the stomach, suggest
advancement so that the side port is well within the stomach.
Extensive bilateral perihilar opacities likely relate to edema,
although underlying consolidation may also be present. No large
pleural effusion or pneumothorax is seen. The patient is status
post median sternotomy and CABG. Left-sided AICD is stable in
position.
.
CT spine [**3-1**]:
1. No fracture or subluxation.
2. Bilateral lung apices opacifications better evaluated on the
concurrent CT of the chest.
.
CT head [**3-1**]:
1. No acute intracranial process.
2. Chronic right parietal infarct.
3. Moderate-to-severe small vessel disease and atherosclerotic
calcifications
of the carotid arteries
.
CT A/P [**3-1**]:
1. Acute left intertrochanteric femoral fracture with adjacent
hematoma
2. Diffuse ground-glass opacities in both lungs consistent with
pulmonary
edema and bilateral posterior lung opacifications likely
representing
atelectatic changes, less likely aspiration or contusion.
3. No acute vascular or visceral injury. No evidence of aortic
injury and no pulmonary embolism.
4. Left lateral 7th rib fracture seen on radiograph from this
same date
([**2133-3-1**]) is not visualized on CT, however this might be
related to technical reasons
.
Hip XR [**3-1**]: IMPRESSION: Left intertrochanteric fracture.
.
Echo [**3-2**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 5-10 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the sepum, inferior, and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). The
estimated cardiac index is normal (>=2.5L/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 aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. 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 moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction suggestive of
multivessel CAD (LAD and PDA distribution). Mild mitral
regurgitation. Pulmonary artery hypertension. Incresaed PCWP.
Compared with the report of the prior study (images unavailable
for review) of [**2125-4-23**], left ventricular systolic function is
now improved and the estimated PA systolic pressure is now
lower.
Brief Hospital Course:
76 yo woman with h/o DM1, CAD, CHF admitted for left hip
fracture and acute congestive heart failure requiring
intubation.
.
# Ischemic cardiomyopathy: Acute on chronic systolic and
diastolic heart failure.
-Patient was diuresed, and her symptoms improved. She briefly
required intubation. The patient spent time on several services
while in-house, and at one point there was concern for an acute
ST elevation on EKGs, so she was taken to the cardiac cath lab.
At that time, chronic total occlusion of her LAD was diagnosed,
and no intervention was performed. The patient will need her
heart failure regimen titrated while at rehab, including ACE-I,
beta-blocker and diuretics. She needs additional diuresis
acutely, which should be performed at rehab. Additionally,
given her chronic angina and CAD, she may benefit from renexa as
an outpatient, and her imdur should be increased as tolerated.
.
# Femur fx-s/p internal fixation:
-Occured in setting of mechanical fall. The patient underwent
uncomplicated repair with placement of nail by orthopaedics.
Due to intra-operative blood loss, she required transfusion of
blood products. She was discharged to an acute rehab facility
for additional physical therapy.
.
# Hyponatremia:
-Most likely secondary to pain induced SIADH, coupled with
hypervolemic hyponatremia. This improved with pain medication
and diuresis. In the future, she may benefit from a vaptan
.
# Type I DM:
-Her insulin regimen was titrated in house based on finger
sticks and changing PO intake.
.
======
Transitional issues:
-Renexa should be considered as anti-anginal
-Titrate ACE-I, beta-blocker, and diuretic (torsemide)
-Restart aldactone as tolerated
-Dry weight is 108 pounds, weight at discharge is 112 pounds.
Medications on Admission:
HOME MEDICATIONS: confirmed with pharmacy
asa 325mg daily
plavix 75mg daily
Metoprolol 100mg daily
lisinopril 10mg daily
imdur 30mg daily
aldactone 25mg daily
furosemide 40mg daily
atorvastatin 40mg daily
NTG PRN
insulin
actonel 35mg weekly
Ca/D
B12 ER 1000mcg daily
ferrous sulfate
Silver sulfadiazine cream 1% x 14 days (finished
Discharge Medications:
1. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
Hold SBP < 90.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every four (4)
hours as needed for pain .
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for diarrhea.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily) for 3 weeks.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
15. insulin glargine 100 unit/mL Solution Sig: Seven (7) units
Subcutaneous at bedtime.
16. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold SBP <100.
17. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day:
Hols SBP < 90.
18. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
19. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
20. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
21. furosemide 10 mg/mL Syringe Sig: Sixty (60) mg Injection
once a day as needed for for SOB or weight gaiin more than 2
pounds in 1 day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left femoral neck fracture
Acute on Chronic Systolic congestive heart failure
ST elevation myocardial infarction
Anemia
Hyponatremia
Diabetes Mellitus type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had a left hip fracture and needed an operation to fix the
fracture. After the operation, you had a small heart attack and
an emergency cardiac catheterization showed that you had a lot
of old blockages in your heart arteries but we were unable to
open them. We have adjusted your medicines to help to prevent
your angina episodes. It is very important that you stay at your
dry weight of 112 pounds. Weigh yourself every morning, call Dr.
[**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days.
.
We made the following changes to your medicines:
1. Start tylenol and oxycodone as needed for hip pain
2. Start colace, senna and dulcolox suppository as needed for
constipation
3. Start lovenox for 4 weeks to prevent a blood clot.
4. Decrease metoprolol to 25 mg daily as your blood pressure is
low
5. Decrease imdur to 15 mg daily, this may be increased if you
have chest pain
6. Decrease insulin to 7Units daily at bedtime
7. Decrease lisinopril to 2.5 mg daily as your blood pressure is
low
8. Decrease aldactone to 12.5mg daily until your blood pressure
is better.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital1 **] [**Hospital **] MEDICAL CARE CTR
[**Location (un) 2788**]
Address: [**Location (un) **], [**Location (un) 2788**],[**Numeric Identifier 13479**]
Phone: [**Telephone/Fax (1) 2789**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2133-3-18**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2133-3-26**] at 10:40 AM
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
|
[
"733.00",
"564.00",
"V45.02",
"428.0",
"410.91",
"414.8",
"413.9",
"V58.67",
"288.50",
"E878.1",
"273.1",
"287.5",
"401.9",
"E935.2",
"997.1",
"518.81",
"E939.4",
"820.21",
"414.01",
"414.02",
"428.43",
"250.03",
"E942.4",
"280.9",
"E880.9",
"458.29",
"414.2",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15",
"38.97",
"96.71",
"37.22",
"00.40",
"88.56",
"00.66",
"96.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11420, 11492
|
7360, 8891
|
277, 368
|
11694, 11694
|
3688, 7337
|
13002, 13989
|
2496, 2520
|
9489, 11397
|
11513, 11673
|
9133, 9133
|
11870, 12979
|
2286, 2332
|
2535, 3669
|
9151, 9466
|
8912, 9107
|
229, 239
|
396, 2022
|
11709, 11846
|
2044, 2263
|
2348, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,359
| 142,610
|
24381
|
Discharge summary
|
report
|
Admission Date: [**2122-1-30**] Discharge Date: [**2122-2-3**]
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transferred to [**Hospital1 18**] for Pulmonary stent
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
HPI: 86 year old male with CAD s/p CABG, AS s/p AVR and CRI
presenting with a lung mass for a bronchoscopy at an OSH. The
patient is intubated at this time and history is obtained from
the records. The patient was in his usual state of health until
[**11-25**] when he developed progressive dyspnea on exertion. He had
a mechanical fall in [**Month (only) 404**] or [**2121-12-19**] and a CXR was
performed to evaluate for a rib fracture. Xray demonstrated a
right lung mass. CT chest done on [**2122-1-13**] demonstrated a
spiculated, ill-defined mass in the RUL, 6 cm, surrounding the
RUL bronchus and marked narrowing of the bronchus with
lymphadenopathy. He underwent a scheduled bronchoscopy on
[**2122-1-28**] which demonstrated marked airway tumor in the right
upper lobe extending into the right bronchus intermidius. The
airways were not completely obstructed, but there was reported
marked narrowing with significant secretions. Bronchial
washings, brushings and biopsies of the lesion were done. He was
transferred to [**Hospital1 18**] for further management given the airway
involvement. He remained intubated for transfer. Cytology from
the OSH demonstrated Squamous cell carcinoma.
.
Upon arrival at [**Hospital1 18**], the patient was evaluated by the
interventional pulmonary team. He had a repeat bronchoscopy
performed which demonstrated right upper lobe mucosal thickening
and friability as well as a probably neoplasm with endobronchial
involvement. The airways were considered safe for extubation.
Biopsies, brushings and washings were repeated and the patient
was prepared for extubation.
Past Medical History:
CAD - s/p CABGX4(LIMA->LAD, SVG->D1, OM, and PDA) [**2109**]
Aortic stenosis
HTN
Chronic anemia
Osteoarthritis
Gout
Hypothyroidism
Hyperchol.
BPH
Asbestosis
COPD
CRI
Social History:
Lives alone, wife is in nursing home.
Cigs: long history and now smokes [**1-20**] cigarettes/day
ETOH: 2-3 beers/day
Family History:
unremarkable
Physical Exam:
vitals: 96.0, 140/60, 68, 17, 95%/RA
Gen: AOx3
HEENT: unremarkable
Car: Reg
Resp: CTAB, decreased BS on right side
Abd:s/nt/nd/nabs
Ext: trace LE edema, 2+ DP pulses
Pertinent Results:
[**2122-2-1**] 07:10AM BLOOD WBC-8.5# RBC-3.64* Hgb-10.7* Hct-33.9*
MCV-93 MCH-29.5 MCHC-31.6 RDW-16.3* Plt Ct-219
[**2122-2-1**] 07:10AM BLOOD Glucose-85 UreaN-75* Creat-2.6* Na-142
K-4.2 Cl-106 HCO3-24 AnGap-16
[**2122-2-1**] 07:10AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
[**2122-1-30**] 11:27AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-508* pCO2-38
pH-7.44 calTCO2-27 Base XS-2 Intubat-INTUBATED Comment-SPECIMEN
I
.
Chest XRAY [**2122-1-30**]
1. Endotracheal tube and orogastric tube in standard position.
2. Large right perihilar mass, reportedly a known finding, and
concerning for lung neoplasm.
3. Persistent small pleural effusions versus pleural thickening.
.
CT HEAD W/O CONTRAST [**2122-2-1**]
1. No evidence of metastatic disease on non-contrast CT scan,
although MRI remains more sensitive for this indication.
2. Mild opacification of the right sphenoid sinus.
Brief Hospital Course:
A/P: 86 year old male with CAD, AS, CRI, COPD, Asbestos exposure
with new squamous cell carcinoma of the right upper lobe.
.
#. Lung cancer: Squamous cell cytology from OSH. All
washings/brushings/biopsies repeated on bronchoscopy. Airways
patent based on Interventional Pulmonolgy evaluation. Patient
satting at 95%/RA postextubation. He will get further oncology
evaluation at [**Hospital1 18**] including a PET-CT scan for staging. He also
has an IP appointment.
.
#. Coronary artery disease: continue outpatient regimen of beta
blocker, statin and can restart 81 mg aspirin.
.
#. Anemia: at baseline; we did not continue his Procrit as it
can sometimes engance tumor growth. Continuation of this
medication to be discussed with oncologist.
.
#. Prophylaxis: Venodynes given history of thrombocytopenia
related to heparin
.
# Dispo: discharged to rehab
Medications on Admission:
Synthroid 137 mg daily
Folate 1 mg daily
Lexapro 10 mg daily
Allopurinol 100 mg [**Hospital1 **]
Colace 100 mg daily
Aspirin 81 mg daily
Metoprolol 25 mg [**Hospital1 **]
Hytrin 5 mg daily
Bumex 1 mg [**Hospital1 **]
Senokot 1 mg po bid
Lipitor 40 mg po daily
Ambien 10 mg daily
Spiriva 1 inhh daily
Alphagan
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Lifecare [**Location (un) 5165**]
Discharge Diagnosis:
Lung Malignancy (Squamous Cell Cancer)
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to evaluate a mass in your lung. You did not
require a stent. You did not have any oxygen requirement during
your hospital course at [**Hospital1 18**].
.
Please follow up with all your appointments and take all your
medications. Please do not use Procrit until your oncology
appointment. You can discuss about Procrit with your oncologist.
Followup Instructions:
PET-CT (for initial staging) has been scheduled on [**2122-2-10**] at
10:30AM. Please call ([**Telephone/Fax (1) 9595**] about your appointment.
Please follow the instructions from the instruction sheet and
drink the contrast before the study. You have been given this
sheet and contrast bottle.
.
Oncology appointment: Thoracic Oncology Program: [**0-0-**].
Please call 1 day after your discharge to check the date or
appointment.
.
Interventional Pulmonary: Please call [**Telephone/Fax (1) 7769**] one day after
discharge to check the date/time of appointment.
.
Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **]
2 weeks.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2122-2-3**]
|
[
"V45.81",
"197.0",
"501",
"403.90",
"519.19",
"244.9",
"496",
"274.9",
"585.4",
"V42.2",
"272.0",
"428.0",
"285.21",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"33.27"
] |
icd9pcs
|
[
[
[]
]
] |
5799, 5859
|
3399, 4257
|
288, 303
|
5942, 5961
|
2508, 3376
|
6368, 7197
|
2292, 2306
|
4616, 5776
|
5880, 5921
|
4283, 4593
|
5985, 6345
|
2321, 2489
|
195, 250
|
331, 1950
|
1972, 2140
|
2156, 2276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,335
| 128,950
|
32447
|
Discharge summary
|
report
|
Admission Date: [**2176-11-3**] Discharge Date: [**2176-11-21**]
Date of Birth: [**2124-4-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
FALL
Major Surgical or Invasive Procedure:
ANGIOGRAMS
History of Present Illness:
HPI: 52yF with h/o EtOH related cirrhosis and hepatic
encephalopathy who is s/p fall with trauma to right posterior
head and was transfered from OSH with ICH. [**Hospital1 18**] ED review of
scan noted a large SAH with mass effect. Patient was noted to
have a focal seizure at OSH, further detail unknown. EtOH level
at 9am found to be 113. Upon arrival to ED, patient was
intubated
secondary to fear of respiratory decompensation.
Past Medical History:
PMHx: EtOH encephalopathy, cirrhosis, depression
Social History:
Social Hx: +EtOH
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 97.6 BP: 130/88 HR: 99 R: 17 O2Sats: 93% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 2 to 1 EOMs left lateral gaze impaired
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Asleep easily aroused and alert, cooperative with
exam, normal affect. Opens eyes to name
Orientation: Oriented to person, place, and date.
Recall: Not assessed
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 1 mm
bilaterally.
III, IV, VI: Extraocular movements intact to right gaze without
nystagmus. EOM impaired to left gaze
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Pronator drift not assessed. LUE and LLE with
+withdrawal to stimuli but voluntary movement weak with grip
[**12-15**].
RUE and RLE antigravity
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: Untested
Pertinent Results:
CT/MRI:
CTH: Extensive right intraparenchymal hemorrhage with minimal
midline shift. Extensive SAH. Possible IVH
[**2176-11-3**] 12:05PM ALBUMIN-4.7 CALCIUM-8.7 PHOSPHATE-3.9
MAGNESIUM-1.7
[**2176-11-3**] 12:05PM ASA-NEG ETHANOL-46* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-11-3**] 12:05PM PT-11.8 PTT-20.8* INR(PT)-1.0
[**2176-11-3**] 12:05PM GLUCOSE-111* UREA N-9 CREAT-0.6 SODIUM-135
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-23 ANION GAP-20
[**2176-11-3**] 12:31PM WBC-5.6 RBC-3.27* HGB-10.9* HCT-32.5* MCV-99*
MCH-33.3* MCHC-33.5 RDW-14.5
Brief Hospital Course:
[**Known firstname 8771**] [**Known lastname **] was admitted to the SICU for close
neurological monitoring. She underwent cerebral arteriography
for a right sylvian fissure hemorrhage with extension into the
basal cisterns. This did not reveal an arteriovenous
malformations, aneurysms, or AV fistulas which could explain the
source of the hemorrhage on [**11-3**].
She was started on nimodipine [**11-4**] for prophylaxis of vasospams
given unclear source of blood. She was able to be extubated and
was transferred to stepdown unit [**11-6**]. The patient had a repeat
angio on [**11-11**] which showed vasospasm. She was given papaverin
with no effect. Her groin site healed well with no hematoma. The
patient's INR was increased on [**11-13**] to 1.5. She was monitored
closely in the ICU to watch for any sequela of the vasospasm.
She had been hyponatremic and was given sodium tablets for
several days. She was improving neurologically so she was
transferred to the floor on [**2176-11-16**] she continued to have a
pronounced left sided drift.
It was discovered that she had scabies on [**11-18**] so she was
started on Lindane because the hospital does not stock
premetherin. She was also found to have roseasa. Physical and
Occupational therapy evaluated the patient and recommended that
she could go home with 24 hour supervision. Her boyfriend [**Name (NI) **]
has agreed to do 24 hour supervision.
On discharge she was awake, alert and orietated x3, she had no
focal motor or sensory deficits. She followed commands but was
impulsive at time. She was tolerating a regular diet and
voiding without problems.
Medications on Admission:
Medications prior to admission:
Dilantin, Gapapentin, Lipitor, fioreset, trazadone, ativan
(dosages all unknown)
Discharge Medications:
1. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily) as needed for pruritis.
Disp:*60 grams* Refills:*3*
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Low back pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
4. Metronidazole 1 % Gel Sig: One (1) Appl Topical DAILY (Daily)
as needed for rosacea on face: apply daily to face, rosacea.
Disp:*1 tube* Refills:*1*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for prn itch.
Disp:*30 Tablet(s)* Refills:*1*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while taking Percocet.
Disp:*40 Capsule(s)* Refills:*0*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **] -[**Location (un) **]
Discharge Diagnosis:
Traumatic SAH
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**First Name (STitle) **] TO BE SEEN IN 4 weeks with a CTA..
YOU WILL NEED TO BE SEEN BY A DERMATOLOGIST FOR YOUR
ROSACEA/Scabies PLEASE CALL ([**Telephone/Fax (1) 8132**] TO MAKE AN
APPOINTMENT.
Completed by:[**2176-11-21**]
|
[
"V11.3",
"724.2",
"571.2",
"852.00",
"E888.9",
"276.1",
"852.20",
"787.21",
"695.3",
"133.0",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5785, 5852
|
3003, 4631
|
312, 324
|
5910, 5934
|
2409, 2980
|
6981, 7283
|
913, 917
|
4795, 5762
|
5873, 5889
|
4657, 4657
|
5958, 6958
|
947, 1215
|
4689, 4772
|
268, 274
|
352, 789
|
1523, 2390
|
1230, 1507
|
811, 862
|
878, 897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,238
| 152,694
|
36946
|
Discharge summary
|
report
|
Admission Date: [**2189-10-6**] Discharge Date: [**2189-10-16**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Altered mental status, respiratory distress, mitral
regurgitation
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
86 yo female with history of paroxysmal atrial fibrillation,
moderately severe mitral regurgitation, moderate pulmonary
hypertension, diastolic dysfunction and mild aortic stenosis
presented to [**Hospital3 **] on [**2189-9-29**] for palpitations.
According to the patient's family she complained of fatigue,
worsening dyspnea on exertion and cough for the three days prior
to admission. She denied fevers, chills, orthopnea, PND, and
chest pain.
.
At [**Location (un) **], she was found to be in A fib with rapid ventricular
response. In the ED, she was treated with DC cardioversion and
IV amiodarone. Following DC cardioversion, the patient
developed respiratory arrest requiring intubation. She was
found to have questionable infiltrate on CXR that was present
from admission. Subsequently she developed sinus bradycardia
and hypotension, and was started on dopamine for pressor
support. On [**2189-9-30**], she developed a junctional rhythm and the
amiodarone was discontinued. At that time she was weaned off
propofol, however failed SBT. Multiple attempts at weaning were
tried from that point on, but were unsuccessful. She was
digoxin loaded on the 11th. On the 12th, she went back into A
fib however without rapid ventricular response. She was
extubated this AM and started on PO amiodarone. She is being
transferred here for surgical evaluation of severe symptomatic
mitral regurgitation.
.
On review of systems, according to the patient's family she has
a prior history of stroke, she denies any prior history of TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, 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 absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
.
On presentation, the patient is in atrial fibrillation with
rapid ventricular response, hypotensive to the 60s systolic, and
unresponsive to verbal commands.
Past Medical History:
1. CARDIAC RISK FACTORS: none
.
2. CARDIAC HISTORY:
-CABG: quadruple bypass in [**2169**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
.
Atrial Fibrillation
Moderate severe mitral regurgitation
Mild Aortic stenosis - peak gradient 28mmHg
Moderate pulmonary hypertension - pressure of 46mmHg
Diastolic heart failure
.
3. OTHER PAST MEDICAL HISTORY:
Crohn's disease, s/p partial colectomy in [**2181**],
Gastroesophageal reflux disease,
Right hemispheric stroke in [**2186**] with negative head MRA and
temporal artery biopsies, s/p right carotid endarterectomy in
[**2179**]
Wet macular degeneration
Hypothyroidism
COPD
Social History:
She was very active, independent at baseline. Supportive
husband and sons. Previously lived in [**State **], now resides in
FL, visiting the [**Location (un) 86**] area recently.
-Tobacco history: She smoked in the distant past quitting 60
years
ago
-ETOH: She drinks two glasses of wine with supper
-Illicit drugs: denies
Family History:
No cardiac hx
Physical Exam:
GEN: NAD, alert, interactive, disoriented
HEENT: Bleeding at IJ site resolved
CV: RRR, GIII/VI murmur at RUSB and apex, dynamic precordium
with RV heave
PULM: CTAB anteriorly
ABD: soft, NT/ND
EXTR: no pedal edema, no breakdown
Pertinent Results:
On Admission:
[**2189-10-6**] 05:40PM BLOOD Neuts-67.1 Lymphs-17.2* Monos-9.8
Eos-5.5* Baso-0.4
[**2189-10-7**] 04:18AM BLOOD PT-12.9 PTT-55.7* INR(PT)-1.1
[**2189-10-6**] 05:40PM BLOOD ALT-50* AST-41* CK(CPK)-75 AlkPhos-305*
TotBili-0.8
[**2189-10-7**] 04:18AM BLOOD GGT-291*
[**2189-10-6**] 05:40PM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2189-10-7**] 04:18AM BLOOD CK-MB-5
[**2189-10-7**] 01:33PM BLOOD CK-MB-9
[**2189-10-6**] 05:40PM BLOOD Albumin-3.1* Calcium-9.1 Phos-4.2 Mg-1.8
[**2189-10-6**] 05:40PM BLOOD Type-ART pO2-306* pCO2-40 pH-7.46*
calTCO2-29 Base XS-5
CXR [**10-6**]
Heart is mildly enlarged. Pulmonary interstitium is abnormal,
which could be
due to residual edema. Followup advised. No pleural effusion or
pneumothorax. ET tube and left internal jugular line are in
standard
placements. A nasogastric tube passes into the stomach and out
of view. No
pneumothorax. Upper most two sternal wires are fractured, but
not widely
displaced. I suggest the clinical inspection of the sternotomy
to exclude
instability or other complication.
Head CT [**10-7**]
1. No acute hemorrhage, mass effect, or territorial vascular
infarction.
2. Region of encephalomalacia within the right occipital lobe
consistent with prior infarct.
3. Scattered punctate calcifications throughout the right
hemisphere
consistent with prior granulomatous disease.
4. Scattered calcifications within the basal ganglia
bilaterally.
Cardiac ECHO [**10-12**]
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. The right atrium is dilated. Mild spontaneous echo
contrast is seen in the body of the right atrium. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
The right ventricular cavity is dilated with moderate global
free wall hypokinesis. 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. No masses or
vegetations are seen on the aortic valve. There is mild to
moderate aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Moderate to severe (3+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate-severe mitral regurgitation. Mild-moderate
tricuspid regurgitation. Probably mild/moderate aortic stenosis
([**Location (un) 109**] 1.2 cm2). Depressed left and right ventricular function (EF
40%). Complex atheroma in the descending aorta.
[**10-8**] Abd US
Limited study. Tiny right-sided pleural effusion. Otherwise,
unremarkable abdominal ultrasound.
[**10-12**] Unilateral UE US
Small nonocclusive thrombus seen within the right IJ at the
level
of the recent puncture. There is no pseudoaneurysm. No AV
fistula and no
hematoma identified.
[**10-15**] CXR:
NG tube tip is out of view below the diaphragm. Mild
cardiomegaly is stable. The sternal wires are aligned with
rupture of the first two wires as before, right peripheral
catheter tip is in unchanged position. There is no pneumothorax.
Bilateral increased interstitial marking is unchanged. No
evidence of new lung abnormalities.
Brief Hospital Course:
86 yo female with severe mitral regurgitation, severe tricuspid
regurgitation, diastolic heart failure, atrial fibrillation
transferred from [**Location (un) **] for evaluation of respiratory arrest
and severe mitral regurg. She was treated during this
hospitalization for her arrhythmia, respiratory failure and
mental status changes.
.
# Respiratory Distress: Pt was admitted with respiratory
distress thought to be secondary to over-sedation and also had
sputum growing GNR and CXR [**10-8**] shows evidence of LLL PNA. On
arrival, her blood gas was WNL however she was unable to
maintain her airway due to her mental status changes, therefore
she was urgently intubated, and successfully extubated on day 5
of the admission. She was treated with 7-day course of
vanc-zosyn (completed on [**10-12**]) out of concern for pneumonia,
and provided with nebs and chest PT for supportive care. She
was also diuresed out of concern for fluid overload. She will
need baseline PFT's now that she is on Amiodarone.
.
# Altered Mental Status: Likely [**1-26**] oversedation given 5+ day
course of propofol at the outside hospital. With
discontinuation of the propofol, her mental status significantly
improved and she was alert and interactive currently. Head CT
was performed and showed no acute changes. There may also have
been a component of ICU/infecious delerium and pt continued to
have some confusion on discharge, however was oriented to person
and time.
.
# Atrial Fibrillation: The patient has history of rapid A fib
at the outside hospital s/p DC/CV and amiodarone/digoxin loading
with subsequent bradycardia and junctional rhythm. On arrival,
patient was in A fib with RVR and hypotensive. After
cardioversion on arrival to this hospital, she remained in NSR
until [**10-11**] when patient went back into a fib with RVR. She was
continued on amiodarone for rate control and was in atrial
fibrillation on discharge. She was also treated with Warfarin
(decreased from home dose because of amiodarone) with a Heparin
drip bridge. Her INR at discharge was 1.3. Please check INR on
Monday [**10-19**], heparin can be discontinued with INR > 2.0.
.
# Mitral Regurgitation/Tricuspid Regurgitation: Mod-severe
MR/mild-moderate TR on TTE in-house. Blood pressure was kept at
systolic <120 with lisinopril for afterload reduction to prevent
flash pulmonary edema with MR. Valve replacement surgery was
deferred given her tenuous state.
.
# Acute Kidney Injury: Patient??????s baseline Cr 1.1. Initially
this was presumed to be pre-renal however FeUrea was elevated
suggesting intrinsic renal disease, likely AIN [**1-26**] lisinopril
given elevated urine eosinophils. Her creatinine and UOP were
monitored, additional fluids held given her heart failure and MR
and concern for inducing pulmonary edema. Creatinine at
discharge is 1.2.
.
# Leukocytosis: On admission, there was concern for PNA,
therefore she was treated with a 7 day course of vanc/zosyn.
She was then afebrile, negative c. diff, s/p 7 day abx course,
blood cxs negative, therefore low concern for infectious
etiology at discharge. Patient has increasing leukocytosis, but
normal PMNs with elevated relative eosinophils, therefore may
have leukocytosis secondary to AIN. Completed Vancomycin course
for PNA so this should not be contributing to leukocytosis; all
cultures negative to date except rare yeast on sputum culture.
Her WBC had decreased on discharge to 16.
.
# Acute on chronic Diastolic congestive heart failure: The
patient has diastolic heart failure on most recent echo, but
preserved systolic function, TTE in-house showed EF 40%.
Lisinopril continues at increased dose. She was treated with
blood-pressure control. Metoprolol was discontinued because of
AV block on amiodarone IV initially. Pt has been well rate
controlled on current dose of amiodarone. Lasix was decreased to
20 mg daily, currently appears euvolemic with weight 49 kg
today.
.
# Coronary Artery Disease: History of quadruple CABG in [**2169**],
has not been reevaluated since. No evidence of acute ischemia.
No ASA given history of PUD. She was continued on plavix,
pravastatin and captopril.
.
# Decreased Hct/Bleeding from R Neck: Pt had continuous oozing
from her IJ site which did not cease with compression. Her
anticoagulation goals were slightly decreased and an US was
obtained to evaluate for hematoma, however only a small
non-obstructive thrombus was visualized. She was given one unit
of PRBCs and her hematocrit stabilized. The line was pulled and
oozing ceased.
.
# Hypotension: She temporarily required pressures on admission
however improved with tx of infection and stabilization of
cardiac rhythm.
.
# Cool LUE: Dopplers of LUE showed normal flow, warmth improved
with heating pad and decreased discoloration. She has no
numbness and good cappillary refill.
.
# Hypothyroidism: TSH WNL, continue levothyroxine at home doses.
Monitor thyroid function, given now on amiodarone.
.
# Crohn's Disease: No acute issues, continue to monitor. Pt will
need assistance with frequent feeding to ensure adequate caloric
intake.
.
# Diarrhea: c.diff negative x2, no abdominal pain; believed most
likely to be due to tube feeds, now d/c'ed.
.
# Macular Degeneration: Continue brimonidine eye drops and
PreserVision vitamin supplementation.
.
# History of CVA: Affected her right eye and is s/p left sided
CEA. Continue plavix and pravastatin. No aspirin secondary to
PUD.
.
# PUD: Continue home PPI
.
# Osteoporosis: Continue actonel weekly
Medications on Admission:
Coumadin 4-mg/day
furosemide 40-mg/day
lisinopril 1.25-mg/[**Hospital1 **]
Plavix 75-mg/day
levothyroxine 0.05-mg/day
pravastatin 40-mg/day
metoprolol 12.5-mg [**Hospital1 **]
Omega 3 fatty acids
Actonel 35-mg/week
brimonidine eye drops
PreserVision one tab daily
Omeprazole 20mg [**Hospital1 **]
Calcium 500mg one tab daily
Discharge Medications:
1. 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.
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
4. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
12. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO once a day.
13. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
16. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
17. Outpatient Lab Work
Please check CBC, Chem-7, and INR on Monday [**2098-10-18**]. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
19. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
twice a day.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: Hold
for k > 4.0.
21. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per sliding scale units Intravenous continuous.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Atrial Fibrillation with rapid ventricular response
Acute on Chronic Systolic and Diastolic Congestive Heart Failure
Pneumonia
Hypoactive Delerium
Mitral Regurgitation
Leukocytosis
coronary Artery disease
Discharge Condition:
stable
blood culture x2 and urine cxo n [**10-15**] pnd
Foley was d/c'ed on [**10-16**]
Discharge Instructions:
You had atrial fibrillation with rapid ventricular response. You
were started on amiodarone to control your heart rhythm and
rate. You also had trouble breathing and required a breathing
tube. You were slow to wake up from sedatives and will need a
lot of physical therapy before you return home.
.
Weigh yourself every morning, call provider if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days
Adhere to 2 gm sodium diet
Fluid restriction: 1500cc
.
Medication changes:
1. START Amiodarone to control your heart rate and rhythm.
2. INCREASE your Lisinopril to 20 mg.
3. STOP Metoprolol, you cannot continue this with amiodarone
because of low heart rates.
4. START Heparin IV until your INR is > 2.0.
.
Please call your doctor or return to the hospital if you develop
fever, chest pain, shortness of breath, palpitations, confusion,
or other symptoms that concern you.
Followup Instructions:
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 11767**] Date/time: [**11-3**] at 10:40 am.
.
Primary Care:
[**Last Name (LF) 11375**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 11376**] Please call after you
leave rehabilitation to make an appt
Completed by:[**2189-10-16**]
|
[
"362.50",
"486",
"293.0",
"787.91",
"733.00",
"V45.81",
"518.81",
"244.9",
"V12.54",
"424.0",
"V12.79",
"416.8",
"428.43",
"428.0",
"584.5",
"397.0",
"414.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.62",
"96.72",
"96.04",
"96.07",
"38.91",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15057, 15127
|
7245, 8268
|
282, 294
|
15376, 15467
|
3787, 3787
|
16397, 16725
|
3503, 3518
|
13148, 15034
|
15148, 15355
|
12799, 13125
|
15491, 15954
|
3533, 3768
|
2533, 2827
|
15974, 16374
|
177, 244
|
322, 2456
|
3802, 7222
|
8284, 12773
|
2859, 3137
|
2478, 2512
|
3153, 3487
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,727
| 168,295
|
16136
|
Discharge summary
|
report
|
Admission Date: [**2199-1-26**] Discharge Date: [**2199-2-15**]
Date of Birth: [**2113-3-25**] Sex: F
Service: MEDICINE
Allergies:
Altace / Levofloxacin
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Weakness, cough
Major Surgical or Invasive Procedure:
1) Thoracentesis
2) VATS /Decortication
3) 2 left sided chest tubes placed/removed
4) PICC line placement
History of Present Illness:
Ms. [**Known lastname 10940**] is a pleasant 85 year old female with past medical
history significant for
HTN, atrial flutter, mitral regurgitation and prior hemorrhagic
CVA in [**2191**] leaving her with some residual right hemiparesis who
was initially admitted on [**1-26**] with complaints of generalized
weakness, malaise, cough and fevers. She explained she had been
too weak on the morning of her ED presentation to even stand up
with her walker. Also complained of some minimal associated
nausea at times.
In the ED on [**1-26**] her initial vital signs were: Temp 98F and
Tmax 100.8F, BP 160/70, HR 81, RR 16 and 93% on room air. CXR
revealed a LLL pneumonia and she was started on Levofloxacin.
While on levofloxacin she continued to have sluggish clinical
improvement and her WBC rose from 12 range to 19-20k on [**1-27**]
and then on [**1-28**] her repeat CXR was worse with increasing
pleural effusion in the left mid-lung with worsening infection
in that location so a chest CT was ordered and her antibiotics
changed to vanco/cefepime at that juncture. CT chest done [**1-29**]
showed moderate, partially loculated left pleural effusion,
anterior LUL consolidation consistent with pneumonia as well as
a 5cm aneurysmal dilation of the ascending aorta.
.
Thoracic surgery consult was called and performed thoracentesis
that was notable for pH 7.10 and patient failed further
interventional pulmonology directed drainage attempt of her
loculated parapneumonic LLL pneumonia/effusion. Thus, she was
then set up for a VATS decortication on [**2199-1-31**] with chest
tube placement.
.
Per thoracics surgery, patient tolerated VATS decortication
procedure very well with exception of mild non-sustained episode
of NSVT ectopy upon leaning her on her side briefly but this
resolved in about 15 seconds per report. She had approximately
300-400cc semi-solid (gelatinous-like material) removed and sent
for additional cultures. She had 2 chest tubes placed to -20 cm
of water suction (posterior on the skin-> apical; anterior on
the skin-> basilar) and her lung expanded nicely. There was also
an area of some small nodularity over pleura noted and these
were biopsied for ruling out malignancy. BAL also sent for
cultures. Post-op vital signs in PACU were HR 60s, BP 112/60s
and she was still intubated at time of surgical sign out.
Estimated blood loss 75cc and given 1.5L IVFs.
.
Patient arrived to the floor and appeared to be in no acute
distress but was still with slurred speech at times and seemed
mildly sedated from recent drugs in surgery but would answer
direct questions and became attentive quickly with redirection.
Arrival vital signs were: T 97.5F, BP 110/60, HR 70, RR 16 and
she arrived on shovel mask @35% O2 with oxygen saturations of
93-96% range. Denies any pain. Patient has two small dressings
along left lateral rib cage that appear clean and non-bloody
with two protruding chest tubes.
Past Medical History:
--Hypertension
--Atrial flutter/fib
--Mitral regurgitation
--Left thalamic CVA (hemmorhagic) in [**2191**] with right hemiparesis
--Breast CA s/p excision [**2191**]
--h/o E.Coli UTIs
--diabetes mellitus type II
--Thyroid nodules
--Chronic unstable gait
--Galucoma and macular degeneration
--Hyperlipidemia
Social History:
She lives in an [**Hospital3 **] and uses a walker at baseline.
Fair independence with ADLs. No tobacco or alcohol.
.
Family History:
Family History is largely unknown; mother died in [**Name (NI) 651**] and her
father died in [**Name (NI) 6607**].
Physical Exam:
[**1-26**] ADMISSION EXAM:
Vitals - T96.3, BP 173/98, HR 84, 98% on 2 liters
General - Well appearing (smiling occasionally) in no distress.
Eyes - No pallor; EOMI
HEENT - Moist MM; no neck masses
Pulm - Decreased sounds 1/2 up on left
CV - Regular; systolic murmur heard at base
Abdomen - Soft but distended; tympanic; non-tender; no masses
Ext - Warm; no edema
Neuro - Right facial droop; able to raise eyebrows but smile
uneven. Deltoid strength slightly less on right than left;
otherwise has even strength in upper and lower extremities;
sensation grossly intact
Psych - Calm; appropriate
Skin - Warm; no rashes
.
[**1-31**] TRANSFER EXAM:
Physical Exam:
Vitals: T 97.5F, BP 110/60, HR 70, RR 16 and she arrived on
shovel mask @35% O2 with oxygen saturations of 93-96% range
General: Alert and oriented x 2, no acute distress, slow speech
and appears lethargic at times but easily aroused and able to
answer direct questions with full attention and good eye
contact. Noted slight R facial droop (previously documented)
HEENT: PERRL but sluggish bilaterally with small pupils
bilaterally. Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Two left lateral chest tubes emerging from thoracic
dressings and draining 100cc serosanguinous fluid. Left lung
mild crackles at base, no wheeze and no anterior rhonchi.
CV: Regular rate and rhythm. Normal S1 + S2. 3/6 systolic murmur
at base area, no other rubs, no gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS [**1-26**]:
WBC-12.9*# RBC-4.30 Hgb-13.6 Hct-39.6 MCV-92 MCH-31.6 MCHC-34.3
RDW-12.9 Plt Ct-335# (Neuts-93.1* Lymphs-3.2* Monos-2.5 Eos-0.2
Baso-1.1)
Glucose-203* UreaN-9 Creat-0.6 Na-134 K-3.6 Cl-94* HCO3-30
AnGap-14
Lactate-1.8
.
Renal Fx and Na sample trend:
[**2199-1-26**] 12:00PM BLOOD Glucose-203* UreaN-9 Creat-0.6 Na-134
K-3.6 Cl-94* HCO3-30 AnGap-14
[**2199-1-29**] 07:20AM BLOOD Glucose-150* UreaN-8 Creat-0.5 Na-127*
K-3.2* Cl-90* HCO3-29 AnGap-11
[**2199-1-31**] 07:40AM BLOOD Glucose-159* UreaN-6 Creat-0.4 Na-130*
K-3.4 Cl-93* HCO3-29 AnGap-11
[**2199-2-1**] 07:50AM BLOOD Glucose-216* UreaN-9 Creat-0.5 Na-127*
K-4.1 Cl-92* HCO3-29 AnGap-10
[**2199-2-3**] 09:10AM BLOOD Glucose-239* UreaN-5* Creat-0.5 Na-132*
K-3.3 Cl-96 HCO3-31 AnGap-8
[**2199-2-3**] 06:40PM BLOOD Na-134 K-4.2 Cl-98
[**2199-2-7**] 07:45AM BLOOD Glucose-170* UreaN-19 Creat-1.4* Na-137
K-4.1 Cl-100 HCO3-27 AnGap-14
[**2199-2-10**] 07:25AM BLOOD Glucose-184* UreaN-24* Creat-1.4* Na-139
K-3.6 Cl-103 HCO3-25 AnGap-15
[**2199-2-11**] 08:00AM BLOOD Glucose-140* UreaN-20 Creat-1.2* Na-135
K-3.2* Cl-101 HCO3-26 AnGap-11
[**2199-2-12**] 05:15AM BLOOD Glucose-129* UreaN-22* Creat-1.2* Na-139
K-3.8 Cl-106 HCO3-24 AnGap-13
[**2199-2-13**] 08:45AM BLOOD Glucose-213* UreaN-17 Creat-1.0 Na-140
K-3.0* Cl-104 HCO3-29 AnGap-10
White count sample trend.
[**2199-1-26**] 12:00PM BLOOD WBC-12.9*# RBC-4.30 Hgb-13.6 Hct-39.6
MCV-92 MCH-31.6 MCHC-34.3 RDW-12.9 Plt Ct-335#
[**2199-1-27**] 07:00AM BLOOD WBC-20.3*# RBC-3.89* Hgb-12.2 Hct-35.8*
MCV-92 MCH-31.4 MCHC-34.1 RDW-12.4 Plt Ct-271
[**2199-1-31**] 07:40AM BLOOD WBC-12.9* RBC-3.82* Hgb-12.1 Hct-35.5*
MCV-93 MCH-31.8 MCHC-34.2 RDW-12.6 Plt Ct-299
[**2199-2-1**] 07:50AM BLOOD WBC-17.3* RBC-3.88* Hgb-12.1 Hct-35.8*
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.1 Plt Ct-334
[**2199-2-2**] 07:30AM BLOOD WBC-13.9* RBC-3.91* Hgb-12.3 Hct-36.4
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.2 Plt Ct-375
[**2199-2-3**] 09:10AM BLOOD WBC-10.2 RBC-3.58* Hgb-11.1* Hct-33.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.2 Plt Ct-386
[**2199-2-5**] 07:35AM BLOOD WBC-11.2* RBC-3.80* Hgb-11.8* Hct-34.7*
MCV-91 MCH-31.0 MCHC-33.9 RDW-13.4 Plt Ct-397
[**2199-2-6**] 05:15AM BLOOD WBC-15.2* RBC-3.73* Hgb-11.4* Hct-34.2*
MCV-92 MCH-30.5 MCHC-33.2 RDW-13.4 Plt Ct-393
[**2199-2-7**] 07:45AM BLOOD WBC-20.9* RBC-3.69* Hgb-11.5* Hct-33.4*
MCV-91 MCH-31.2 MCHC-34.5 RDW-13.5 Plt Ct-334
[**2199-2-8**] 08:00AM BLOOD WBC-17.7* RBC-3.44* Hgb-10.5* Hct-31.9*
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.5 Plt Ct-346
[**2199-2-9**] 04:26AM BLOOD WBC-16.8* RBC-3.32* Hgb-10.2* Hct-30.6*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.5 Plt Ct-339
[**2199-2-11**] 08:00AM BLOOD WBC-17.1* RBC-3.40* Hgb-10.2* Hct-31.0*
MCV-91 MCH-29.9 MCHC-32.9 RDW-13.4 Plt Ct-316
[**2199-2-11**] 07:33PM BLOOD WBC-25.0* RBC-3.31* Hgb-10.0* Hct-30.1*
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.6 Plt Ct-270
[**2199-2-12**] 05:15AM BLOOD WBC-16.4* RBC-2.95* Hgb-9.3* Hct-27.6*
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.9 Plt Ct-271
[**2199-2-13**] 08:45AM BLOOD WBC-15.4* RBC-3.42* Hgb-10.5* Hct-31.0*
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.9 Plt Ct-330
.
Other labs:
[**2199-1-26**] 12:00PM BLOOD PT-13.5* PTT-33.0 INR(PT)-1.2*
[**2199-2-13**] 08:45AM BLOOD PT-15.6* PTT-39.4* INR(PT)-1.4*
[**2199-2-11**] 07:33PM BLOOD ALT-29 AST-33 CK(CPK)-34 AlkPhos-69
TotBili-0.6
[**2199-2-1**] 11:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2199-2-1**] 06:20PM BLOOD CK-MB-3 cTropnT-<0.01
[**2199-2-1**] 11:33PM BLOOD CK-MB-3 cTropnT-<0.01
[**2199-2-1**] 11:00AM BLOOD CK(CPK)-72
[**2199-2-1**] 06:20PM BLOOD CK(CPK)-59
[**2199-2-1**] 11:33PM BLOOD CK(CPK)-51
[**2199-2-4**] 08:00AM BLOOD %HbA1c-6.9* eAG-151*
[**2199-2-1**] 11:00AM BLOOD Osmolal-271*
[**2199-2-12**] 05:15AM BLOOD TSH-3.9
[**2199-2-9**] 04:26AM BLOOD Vanco-20.0
[**2199-2-1**] 10:05AM BLOOD Type-ART pO2-81* pCO2-49* pH-7.38
calTCO2-30 Base XS-2
Labs on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2199-2-15**] 10:35 11.7* 3.30* 10.1* 30.3* 92 30.4 33.2 14.2
386
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2199-2-15**] 10:35 164*1 17 0.8 137 3.2* 102 29 9
ANTIBIOTICS Vanco
[**2199-2-9**] 04:26 20.0
Microbiology:
MICROBIOLOGY:
[**2199-2-8**], [**2199-2-11**], [**2199-2-12**] blood cx pending
[**2199-1-26**], [**2199-2-7**], [**2199-2-11**] URINE CULTURE neg
[**2199-2-8**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative
[**2199-1-26**] blood cx neg
12/30/1 blood cx neg x2
[**2199-1-29**] 5:00 pm PLEURAL FLUID
GRAM STAIN (Final [**2199-1-29**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2199-2-1**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-2-4**]): NO GROWTH.
[**2199-1-31**] 1:37 pm PLEURAL FLUID L PLEURAL FLUID.
GRAM STAIN (Final [**2199-1-31**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2199-2-3**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-2-6**]): NO GROWTH.
[**2199-1-31**] 1:56 pm TISSUE
GRAM STAIN (Final [**2199-1-31**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2199-2-3**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-2-6**]): NO GROWTH.
ACID FAST SMEAR (Final [**2199-2-1**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2199-2-4**]):
NO FUNGAL ELEMENTS SEEN.
[**2199-1-31**] 1:45 pm TISSUE PLEURAL RIND.
GRAM STAIN (Final [**2199-1-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2199-2-3**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-2-6**]): NO GROWTH.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2199-2-4**]):
NO FUNGAL ELEMENTS SEEN.
ACID FAST SMEAR (Final [**2199-2-1**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2199-1-31**] 2:32 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2199-1-31**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2199-2-2**]): NO GROWTH, <1000
CFU/ml.
[**2199-1-31**] Pleural biopsies:
1. Acute and chronic inflammation, granulation tissue,
fibrinopurulent exudate.
2. Multiple levels are examined
[**2199-1-31**] Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, neutrophils, and histiocytes.
IMAGING STUDIES:
.
CT HEAD (final read): No acute intracranial pathologic process.
Unchanged
periventricular white matter hypodensities compatible with
chronic
microvascular ischemic disease. Seen on image 14, series 2, are
what are likely two contiguous, punctate chronic lacunar
infarcts in the left lentiform nucleus.
.
[**2199-1-30**] CXR - pt rotated to the right; large L pleural effusion
w/ underlying atelectasis or infection - stable to slight
increase from [**2199-1-29**].
.
[**2199-1-29**] CT CHEST: Moderate, partially loculated left pleural
effusion. Anterior left upper lobe consolidation consistent with
pneumonia. 5cm aneurysmal dilation of the ascending aorta.
Vascular surgery consultation is recommended.
.
[**2199-2-5**] PICC under fluoro:
IMPRESSION: Uncomplicated fluoroscopically guided PICC line
exchange for a
new single-lumen PICC line. Final internal length is 45 cm, with
the tip
positioned in the SVC. The line is ready to use.
.
[**2199-2-6**] CXR PA/lat:
IMPRESSION: Improving left lower lobe opacity, likely
atelectasis. No new
areas of consolidation to suggest a new source of infection.
.
[**2199-2-7**] Chest ultrasound:
FINDINGS: Transverse and sagittal images of the left chest were
obtained.
There is complex fluid at the base of the left thorax.
Superiorly, there is
more fluid type material visualized.
IMPRESSION: Complex fluid in left chest, with organized material
dependantly and more simple fluid superiorly. No septations are
visualized.
.
[**2199-2-7**] Renal ultrasound:
FINDINGS:
The right kidney measures 10.7 cm. There is mild increased
cortical
echogenicity noted. There is no hydronephrosis, mass, or
calculus identified.
The left kidney measures 10.2 cm. There is mildly increased
cortical
echogenicity noted. There is no hydronephrosis, mass, or
calculus identified.
Imaging of the bladder demonstrates patent bilateral ureteral
jets. The
bladder is otherwise unremarkable.
IMPRESSION:
1. Mildly increased cortical echogenicity in both kidneys,
findings
suggestive of a chronic medical renal disease.
2. No evidence of hydronephrosis.
.
[**2199-2-7**] echo:
The left atrium is normal in size. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**2-10**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Moderately dilated ascending aorta. Normal left
ventricular cavity size and wall thickness with low normal
global left ventricular systolic function. Mild to moderate
aortic regurgitation. Mild mitral and tricuspid regurgitation.
Mild pulmonary artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2196-3-15**], the ascending aortic aneurysm has
increased in size from 4.8 cm to 5.1 cm. The previously
mentioned left ventricular wall motion abnormalities
(hypokinesis of the distal septal and anterior segments) are no
longer seen.
.
[**2199-2-9**] CXR:
There is a right-sided central venous catheter with distal lead
tip projecting over the axilla likely within the axillary vein.
Previously, there was a single loop and the distal tip was
pointing into a distal branch of the axillary vein. The cardiac
silhouette is unchanged and enlarged. There is a left
retrocardiac opacity and some atelectasis at the left mid lung
field, which is stable. Small right-sided pleural effusion is
also seen. There is calcification of thoracic aorta. There are
no pneumothoraces.
.
[**2199-2-11**] chest image under fluoro:
IMPRESSION:
Unsuccessful attempt at repositioning of right-sided PICC
catheter due to a
short episode of aspiration and clinical instability during the
procedure due to which the procedure had to be abandoned.
However, a new PICC line is left midline in the right cephalic
vein.
.
[**2199-2-11**] CXR:
FINDINGS: Stable appearance of left lower lobe atelectasis with
subsequent
retrocardiac opacities and small bilateral pleural effusions. No
pneumothorax, no other focal consolidation. Unchanged position
of the
right-sided PICC line in the axillary vein.
.
[**2199-2-13**] Video Swallow:
FINDINGS: A video oropharyngeal swallow study was performed in
conjunction
with the speech and swallow division. Multiple consistencies of
barium were
administered under intermittent fluoroscopic surveillance.
Minimal
penetration was seen with both thin and nectar thick
consistencies of barium.
There was no aspiration. There was prolonged mastication and
delayed
oropharyngeal transit time. Please see the speech pathology
report in OMR for full details.
IMPRESSION: Minimal penetration of thin and nectar thick
consistencies.
.
[**2199-2-13**] Upper extremity ultrasound:
LEFT UPPER EXTREMITY ULTRASOUND
No priors are available.
[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left subclavian,
internal jugular,
axillary, brachial, basilic, and cephalic veins were performed.
Around the
site of IV insertion in the left antecubital fossa within the
cephalic vein is
some occlusive thrombus with the remaining portion of cephalic
vein and other
vessels displaying normal compressibility, flow, augmentation,
and waveforms.
IMPRESSION:
Focal region of left cephalic thrombus within the antecubital
fossa in the
immediate vicinity of the indwelling peripheral IV. Remaining
vessels
including the deep vessels are patent.
D/w Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 2:30 p.m. via phone.
.
[**2199-1-26**] EKG: rate 80, normal sinus rhythm with borderline A-V
conduction delay. Non-specific ST-T wave abnormalities.
Occasional atrial premature beats. Compared to the previous
tracing of [**2197-9-23**] no diagnostic interval change.
.
Brief Hospital Course:
In summary, Ms. [**Known lastname 10940**] is an 85 year old female with history of
HTN, hemorrhagic CVA ([**2191**]), breast cancer resected in [**2191**],
paroxysmal atrial flutter /fibrillation, mitral regurgitation,
and recent diagnosis of PNA with complicated parapneumonic
effusion s/p thoracentesis and s/p s/p VATS decortication done
[**1-31**]. Please see below for more detailed hospital course:
.
# Pneumonia: Initial presentation on [**1-26**] notable for
leukocytosis (peak 20k), weakness and fevers and CXR
confirmation of LLL pneumonia which evolved into a loculated
pleural effusion. She was transitioned from Levaquin to
Vanco/Cefipime on [**1-28**] for broader coverage after CT showed
worsening infiltrate and effusion. She had a thoracentesis that
was notable for pH 7.10. She failed further interventional
pulmonology directed drainage attempts so she underwent VATS
decortication procedure on [**1-31**] with 2 chest tubes placed over
left lateral chest for further drainage. Chest tubes
successfully removed on [**2-3**] and [**2-4**] with follow-up
PA/Lateral CXR showing no complicating pneumothorax and mild
resolution of her effusions. Her white count returned to the
normal range and her fevers resolved. She had been on
Cefipime/Vancomycin coverage and ID was consulted on [**2-4**] and
her coverage was narrowed to IV vanco and po levaquin. Her
white count again began to rise and she was started on po flagyl
on [**2-7**] as she had been observed to have aspirated earlier in
her hospitalization. Her white count rose to 20 and she was
switched back to cefepime on [**2199-2-9**] and her levaquin was
discontinue given concern for AIN in the setting of new renal
failure, unremarkable renal ultrasound, and presence of
eosinophils in urine sediments. Blood cx, urine cx, c diff, and
repeat CXR were all negative. The current plan is for 3 weeks
total of abx treatement IV vancomycin, cefepime, and flagyl with
day 1 being [**2199-1-31**], date of empyema drainage, tx until [**2-22**], [**2199**]). She needs weekly surveillance labs every Friday
(CBC with differential, chem, Vanco trough goal 15-20). Final
BAL/pleural fluid cultures were unremarkable. Blood culture data
remained unremarkable with no growth at time of discharge. Final
biopsy/pathology results from pleural nodule tissue samples
showed chronic inflammation, granulation tissue, fibrinopurulent
exudate.
On [**2199-2-11**], she was sent to IR for repositiong of PICC. While
there, patient started coughing followed by a brief episode of
unresponsiveness in which she became dusky. Pt then noted to be
in afib with RVR, HTN with BP in 200s, and hypoxic with SaO2 in
80s. Patient was nasally suctioned, given IV lopressor 3.5mg,
40mg IV labetolol with minimal improvement in hemodynamics. She
was transferred to the ICU, where hemodynamics improved with
supportive care. It was thought that this might be an
aspiration event as she has a similar unresponsive episode
earlier in her hospitalization. On [**2-12**], the patient was stable
on 3L by NC, and was transferred to the floor. She continued to
do well post ICU and her WBC count was trending downwards. The
patient should follow up in thoracic clinic 2 weeks after
discharge for repeat CXR. She was discharged without requiring
supplemental oxygen.
.
#Aspiration concerns: Patient had a notable episode the day
after her VATS procedure on [**2-1**] when she began coughing
immediately following drinking fluid at breakfast. She also had
some worse dyspnea acutely. No associated chest pains,
dizziness. Cardiac enzymes cycled and were unremarkable. EKG
with rapid atrial fibrillation which responded to IV metoprolol
and HRs returned to 60-70s range. Event felt to be related to
brief aspiration, although only minimal changes on STAT CXR to
corroborate this suspicion. She was left on aspiration
precautions and evaluated formally by speech and swallow team
who felt she had no active aspiration events during study but
did recommend ongoing aspiration precautions, ground solids
diet, and nectar prethickened liquids. There was a likely 2nd
aspiration event on [**2199-2-11**] as detailed above. She was
re-evaluated by speech and swallow and diet recommendations are:
1. Suggest PO diet of thin liquids and ground solids.
2. Meds crushed or whole with applesauce.
3. 1:1 supervision to assist with feeding and maintain standard
aspiration precautions.
4. TID oral care.
.
#Hypertension: In the beginning of her hospitalization she
remained predominantly normotensive to low range SBPs in
100s-130s ranges. Her metoprolol had been uptitrated during her
admission due to her a fib/a tach. She became mildly
hypertensive to the 160s-170s on [**2198-2-11**] and diltiazem was added
to serve as a dual BP and HR control [**Doctor Last Name 360**]. Her home anti-HTN
HCTZ medication was discontinued in the setting of her
hyponatremia. At time of discharge this medication continued to
be held.
.
# Hyponatremia: Ms. [**Known lastname 10940**] had normal sodium levels on admission
but Na dropped to 127 soon thereafter and overall trend slowly
improved (134--> 127--> now 130s range again prior to
discharge). Etiology felt to be secondary to SIADH effects given
urine sodium pattern and known acute severe lung process that
she is recovering from. Given effects of blocked Na
reabsorption at distal tubule, her HCTZ medication was
discontinued.
.
#Atrial Fibrillation /Cardiac Ectopy: Ms. [**Known lastname 10940**] has a known
history of paroxysmal atrial fibrillation and atrial flutter.
She had a brief run of 15 seconds NSVT on telemetry
intra-operatively per thoracic surgery reports which resolved on
its own without intervention. No complaints of chest pain,
subjective palpitations during hospital course despite having
transition to persistent atrial fibrillation/a tach on post-op
day 1. She required several IV metoprolol doses to control
outbursts of afib with RVR and team slowly uptitrated her PO
metoprolol for better heart rate control and diltiazem was also
added. However during her episode of unresponsiveness on [**2-11**] she
was noted to be in a fib with RVR, with rates in the 120s-140s.
In the MICU, she was continued on home metoprolol and diltiazem,
and given IV diltiazem PRN. By the time of transfer to the
floor her HR was stable in the 70s and had converted back into
sinus rhythm. She was discharged on diltiazem 60mg qid.
Despite CHADS score of 3 she was not anticoagulated given recent
surgery, fall risks, and history of hemorrhagic stroke.
.
#ARF: She developed ARF while in the hospital. Her creatinine
peaked at 1.4 from 0.5. She did have rare eos in her urine but
no peripheral eosinophilia. There was concern for possible AIN
secondary to Levaquin and the antibiotic was changed back to
cefepime as detailed above. Her FENA was 1. She was kept well
hydrated with gentle 1L fluid boluses each day given that she is
on a thickened liquid diet earlier in the admission. Her renal
ultrasound showed only chronic changes likely consistent with
her diabetes. Her creatinine trended down to 0.8 at the time of
her discharge.
.
#Fall: On the day of her discharge, the patient suffered a
witnessed fall where she hit her right occiput against a drywall
wall. There was no evidence of contusion, bleeding or pain at
the site of the head strike. Neurological exam was intact and
the patient's mental status was at baseline.
.
# Ascending Aortic Aneurysm. CT chest done on [**1-29**] discovered a
5cm aneurysmal dilation of the ascending aorta which was
discussed with primary hospitalist and information passed to PCP
who will continue to monitor this issue on an outpatient basis.
PCP has been aware of this issue for several years and has been
following in outpatient setting.
.
#h/o hemorrhagic CVA: Patient had left thalamic hemorrhagic CVA
back in [**2191**] and has some known right sided weakness as residual
effect. Neurological exam has been at usual baseline since
admission which included a mild right facial droop/asymmetry,
right sided 4/5 weakness in upper and lower extremities. She was
continued on [**Hospital1 **] neurologic exam checks post-operatively with no
new focal deficits discovered.
.
#Glaucoma and macular degeneration: She was continued on usual
home doses of brimonidine 0.15 % drops to left eye twice a day
and home levobunolol 0.5 % Drops 1 drop to left eye twice a day.
.
#Diabetes mellitus: Last HgbA1c was <5% range in [**2198-8-9**] and
repeat here was 6.9% on [**2-4**]. DM was diagnosed several years
ago when she was near 7% HgbA1c. No known complications of
neuropathy or proteinuria. Fair control in recent years. Glucose
was treated in the hospital with an ISS which was uptitrated
during her admission. She was started on insulin glargine for
better control of her sugars during her acute hospitalization
and at discharge was requiring 14U daily. This will need to be
re-evaluated and likely need to be decreased once her acute
illness is over.
.
#Hyperlipidemia: She was continued on home dose of 20mg
atorvastatin daily.
.
#Mild thrush: Noted on exam and patient was placed on oral
Nystatin therapy for 1 week duration.
.
# Thyroid nodule: To be followed up as an outpatient, PCP [**Name Initial (PRE) 12309**].
TSH 3.9 on [**2198-2-12**].
.
# Code: DNR per longtime preference by Mrs. [**Known lastname 10940**]. Her health care
proxy is her son [**Name (NI) 3924**]. [**Name2 (NI) **] discussion with [**Doctor Last Name 3924**] on [**2198-2-12**],
Mrs. [**Known lastname 10940**] should be resuscitated should aspiration recur.
Medications on Admission:
HOME MEDICATION LIST:
1. Atorvastatin 20 mg daily
2. Metoprolol 75 mg daily
3. Hydrochlorothiazide 12.5 mg daily
4. Brimonidine 0.15 % Drops 1 drop to left eye twice a day
5. Escitalopram 20 mg
6. Levobunolol 0.5 % Drops 1 drop to left eye every twelve (12)
hours
7. Alendronate 70 mg weekly
8. Senna [**Hospital1 **]
9. Vitamin D 1000 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care
Discharge Diagnosis:
Primary:
Pneumonia, bacterial
Pleural effusion, parapneumonic
Hyponatremia
Atrial fibrillation
.
Secondary:
Aortic Aneurysm ; stable and followed as outpatient
Diabetes mellitus
Hypertension
Thyroid nodules
History of breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Code Status: Full
Discharge Instructions:
You were admitted to the hospital with shortness of breath,
weakness and fevers and found to have a pneumonia based on chest
x-rays. After a few days your infection worsened and a follow-up
CT scan of your chest was concerning for a complication of
pneumonia called a complex pleural/lung effusion (or empyema).
Therefore, you were transferred across the street to the [**Hospital Ward Name 12837**] of [**Hospital1 18**] so that the thoracic surgery team could do a
procedure called a decortication pleural surgery and place chest
tubes around your lungs to drain out your infection. You
tolerated this procedure very well and both chest tubes were
removed within 4 days time. You were also given IV antibiotics.
You need to take these antibiotics until your follow up
appointment with infectious disease.
.
During your hospital stay you also had a flare-up of your known
abnormal heart rhythm called atrial fibrillation. You were
treated with both IV and oral rate control medications to
improve your heart rates. You were started on a medication
called diltiazem.
You had episodes of unresponsiveness which might have been
related to aspiration. You were seen by speech and swallow and
you can drink thin liquids but you need to be on a ground solids
diets.
.
You also had new renal failure while you were in the hospital
which might have been due to taking the medication levaquin also
called levofloxacin. This had gotten entirely better by
discharge.
.
It is very important that you follow-up with all of your
outpatient specialists and your primary care in the coming weeks
as outlined below.
Followup Instructions:
You have the following follow-up appointments:
Department: INFECTIOUS DISEASE
When: THURSDAY [**2199-2-21**] at 3:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2199-2-26**] at 9:00 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
Completed by:[**2199-2-15**]
|
[
"486",
"112.0",
"424.0",
"401.9",
"996.1",
"362.50",
"250.00",
"E930.8",
"365.9",
"V10.3",
"438.20",
"253.6",
"799.02",
"427.89",
"692.9",
"427.31",
"E879.8",
"427.32",
"241.0",
"584.9",
"272.4",
"V49.86",
"276.8",
"780.09",
"580.9",
"781.2",
"510.9",
"511.89",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.73",
"34.20",
"34.52",
"34.91",
"34.09",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
28829, 28908
|
18847, 19237
|
299, 407
|
29184, 29184
|
5627, 8701
|
31013, 31036
|
3838, 3954
|
28929, 29163
|
28460, 28806
|
19254, 28434
|
29385, 30990
|
4629, 5608
|
11811, 11841
|
11874, 12597
|
31061, 31862
|
244, 261
|
9461, 11271
|
435, 3356
|
29199, 29361
|
3378, 3686
|
3702, 3822
|
8713, 9442
|
12614, 18824
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,758
| 193,989
|
35860
|
Discharge summary
|
report
|
Admission Date: [**2169-4-26**] Discharge Date: [**2169-5-15**]
Date of Birth: [**2121-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Mr. [**Known lastname 81496**] is a 48-year-old gentleman who has had recurrent
pneumonias. He was found to have a near-obstructing anatomic
obstruction due to a cartilaginous defect at the takeoff of the
left main stem bronchus.
Major Surgical or Invasive Procedure:
[**2169-4-26**] Resection of left bronchial stenosis through
right thoracotomy, carinal reconstruction, bronchoscopy with
aspiration and lavage, intercostal muscle flap buttress, and
pericardial fat pad buttress. Flexible bronchoscopy with
therapeutic aspiration for mucous plug.
[**2169-4-29**] Flexible bronchoscopy with therapeutic aspiration for
mucous plug.
[**2169-5-1**] Therapeutic bronchoscopy with aspiration and
bronchoalveolar lavage for Secretions and pneumonia following
left carinal reconstruction for bronchial stenosis.
[**2169-5-2**] Mucous plugging,Flexible bronchoscopy with
bronchoalveolar
lavage.
[**2169-5-3**] Retained secretions and pneumonia a Flexible
bronchoscopy with bronchoalveolar lavage.
[**2169-5-4**] Flexible bronchoscopy with therapeutic aspiration of
secretions.
[**2169-5-5**] Flexible bronchoscopy with therapeutic aspiration of
secretions. Bronchoalveolar lavage right middle lobe.
[**2169-5-7**] Flexible bronchoscopy with bronchoalveolar lavage.
[**2169-5-8**] Flexible bronchoscopy with bronchoalveolar lavage.
[**2169-5-9**] BEDSIDE SWALLOWING EVALUATION-
History of Present Illness:
Mr. [**Known lastname 81496**] is a 48-year-oldgentleman who has had recurrent
pneumonias. He was found to have a near-obstructing anatomic
obstruction due to a cartilaginous defect at the takeoff of the
left main stem bronchus.
Past Medical History:
PMH includes:
. mild mental retardation
. HTN
. heavy tobacco exposure
. recurrent respiratory infection and severe pneumonia requiring
hospitalization in the past two years, one of them requiring
mechanical ventilation and prolonged ICU stay
. s/p R knee surgery
. frequent EtOH use
Social History:
Lives with his mother who is blind
long term hx smoking, approximately [**12-16**] pack/per day
+ ETOH ? 3 beers/day up to a case a day.
Family History:
NC
Physical Exam:
Upon discharge
A and O NAD
AVSS
Hypotelorism, anicteric, no JVD
RRR no m/r/g
CTA b/l
soft NT/ND
no c/c/e
neuro grossly intact
Pertinent Results:
[**2169-5-12**] 06:35AM BLOOD WBC-17.1* RBC-2.99* Hgb-9.1* Hct-24.9*
MCV-83 MCH-30.4 MCHC-36.5* RDW-14.1 Plt Ct-715*
[**2169-5-11**] 04:21AM BLOOD WBC-18.9* RBC-3.00* Hgb-9.0* Hct-25.4*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.6 Plt Ct-589*
[**2169-5-10**] 04:13AM BLOOD WBC-17.5* RBC-3.17* Hgb-9.5* Hct-27.7*
MCV-88 MCH-29.9 MCHC-34.2 RDW-13.5 Plt Ct-545*
[**2169-5-9**] 02:44AM BLOOD WBC-18.8* RBC-3.26* Hgb-9.9* Hct-28.6*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.8 Plt Ct-495*
[**2169-5-8**] 02:48AM BLOOD WBC-18.6* RBC-3.26* Hgb-9.9* Hct-29.2*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.8 Plt Ct-431
[**2169-5-6**] 02:06AM BLOOD WBC-20.0* RBC-3.58* Hgb-10.8* Hct-32.2*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.9 Plt Ct-484*
[**2169-5-4**] 03:24AM BLOOD WBC-18.0* RBC-3.56* Hgb-10.8* Hct-32.5*
MCV-91 MCH-30.4 MCHC-33.2 RDW-13.7 Plt Ct-551*
[**2169-4-26**] 04:38PM BLOOD WBC-34.4*# RBC-4.21* Hgb-12.9* Hct-38.3*
MCV-91 MCH-30.6 MCHC-33.7 RDW-14.0 Plt Ct-334
[**2169-5-12**] 06:35AM BLOOD Glucose-106* UreaN-26* Creat-0.8 Na-137
K-3.8 Cl-96 HCO3-28 AnGap-17
[**2169-5-10**] 04:13AM BLOOD Glucose-143* UreaN-26* Creat-0.8 Na-136
K-4.3 Cl-98 HCO3-28 AnGap-14
[**2169-5-8**] 02:48AM BLOOD Glucose-117* UreaN-31* Creat-0.7 Na-136
K-4.4 Cl-99 HCO3-26 AnGap-15
[**2169-5-6**] 02:06AM BLOOD Glucose-166* UreaN-33* Creat-0.8 Na-134
K-4.6 Cl-96 HCO3-27 AnGap-16
[**2169-4-27**] 02:07AM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-28 AnGap-12
[**2169-4-26**] 04:38PM BLOOD Glucose-130* UreaN-15 Creat-0.7 Na-142
K-4.2 Cl-108 HCO3-26 AnGap-12
[**2169-5-12**] 06:35AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.3
[**2169-4-30**] 04:22AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.9
[**2169-5-10**] 06:23AM BLOOD Vanco-24.4*
[**2169-5-9**] 05:54AM BLOOD Vanco-13.3
[**2169-5-5**] 07:46AM BLOOD Vanco-13.8
[**2169-5-9**] 02:56AM BLOOD Type-ART pO2-116* pCO2-45 pH-7.44
calTCO2-32* Base XS-6
[**2169-5-5**] 02:59AM BLOOD Type-ART pO2-123* pCO2-38 pH-7.47*
calTCO2-28 Base XS-4
[**2169-4-29**] 04:06AM BLOOD Type-ART pO2-70* pCO2-57* pH-7.34*
calTCO2-32* Base XS-2
[**2169-4-26**] 12:04PM BLOOD Type-ART pO2-104 pCO2-55* pH-7.32*
calTCO2-30 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2169-5-9**] 02:56AM BLOOD freeCa-1.20
Brief Hospital Course:
OPERATIONS DURING ADMISSION
[**4-26**] R thoracotomy & L mainstem bronchoplasty
CONSULTATIONS DURING ADMISSION
SICU
OTOLARYNGOLOGY
BRIEF HOSPITAL COURSE
Mr. [**Known lastname 81496**] is a 48-year-old gentleman with mild mental
retardation who has had recurrent pneumonias in the setting of
long term history of smoking. He was found to have a
near-obstructing anatomic obstruction due to a cartilaginous
defect at the take off of the left main stem bronchus. His
hospital course has been characterized primarily by a prolonged
ICU course secondary to need for reintubation, difficulty
weaning off the ventilator secondary to frequent mucus plugging
with the need for multiple bronchoscopies, and possible
pneumonia.
Brief course:
[**2169-4-26**] - he underwent a resection of left bronchial stenosis
through right thoracotomy, carinal reconstruction, bronchoscopy
with aspiration and lavage, intercostal muscle flap buttress,
and pericardial fat pad buttress; He was admitted ti the ICU
with a epidural infusion for pain control a right chest tube to
suction with minimal air leak. Started Vanco/zosyn/cipro.
[**4-27**] Chest tube to water seal O2 via 50% face mask and 4 liters
NC with o2 sats 96% intermittent de-sats to 80% pulmonary toilet
help improve o2 sats.
[**2169-4-28**] low grade fevers 100.2 labile O2 sats on 60% and 4liters
NC with sats 89%; given lasix, underwent bronch
[**4-29**] , acute desat to 60s , improved w/suction; but patient
developed increased work of breathing re-intubated and
bronchoscopy performed for secretions and mucous plug;
reintubated due to poor secretion clearance required another
bronch for mucous plug.
[**2169-4-30**] bronch -> secretions, started TF, KVO, diurese, tighten
RISS
[**2169-5-1**] Repeat bronch again for thick plugs; replaced A-line,
episodic desats requiring suction/chest PT, d/c'd prop, Nystatin
S&S, advanced NGT, d/c'd Lopressor
[**2169-5-2**] Bronchoscopy again for thick plugs; heme stable
[**2169-5-3**] bronch-thick secretions, tightened RISS, started
aldactone
[**2169-5-4**] bronch - thick secretions; lasix drip for CXR with pulm
edema; spironolactone increased [**2169-5-4**] bronch-thick secretions
[**5-5**]: d/c'd Lasix/Aldactone, tightened RISS, bronch
[**5-6**]: changed TF to Nutren Pulm
[**5-7**]: bronch -> reduced secretions
[**2169-5-8**] Bronch then extubated
[**2169-5-9**] CT pulled, pt w/small apical R ptx, passed swallow
study for softs/thin liquids, diuresed w/goal 1L negative,
started chest PT, got OOB to chair
[**2169-5-10**] stayed in ICU for incr secretions, chestPT etc, PICC
placed, TF dc'd, FOley dc'd, PICC placed for abx
[**2169-5-11**] tx to floor, abx dc;d (x2 wks), straight cath'd for
urinary retention , straight cath'd for urinary retention
[**2169-5-12**] Agressive pulmonary toilet, nebs, mucomyst
[**2169-5-13**]: developed diarrhea with increased leukocytosis, C dif
sent, started on empiric PO vanco
[**2169-5-14**] PO vanco changed to PO flagyl, C dif sample sent,
patient c/o hoarse voice different from preop, ORL consulted
[**2169-5-15**] ORL came to see patient felt there was no further
intervention needed
Medications on Admission:
Accupril
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q6H (every 6 hours).
Disp:*1 bottle* Refills:*2*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 bottle* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2
times a day).
Disp:*QS 1 month supply* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Left main stem bronchial stenosis.
Discharge Condition:
stable require aggressive pulmonary toilet
Discharge Instructions:
1. Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
2. Continue aggressive pulmonary toilet and nebulizers with
mucomyst to keep secretions loose.
3. Diet: thin liquids, soft solids only, take your meds with
thin liquids, and always eat sitting up
4. Activity: regular walking encouraged, no heavy lifting
5. Take your medicines as prescribed
6. If your diarrhea worsens or does not improve, and/or you
develop abdominal pain, please call Dr.[**Name (NI) 2347**] office or
come to the Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2169-5-23**] 11:00am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I
Chest Disease Center. Report to the [**Hospital Ward Name 517**] Clinical Center
[**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes
before your appointment.
Please also call as soon as possible to make an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for that day as well to have a possible
bronchoscopy. The phone number is [**Telephone/Fax (1) 3020**].
|
[
"519.19",
"401.9",
"518.81",
"788.29",
"787.91",
"997.39",
"507.0",
"317"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"96.72",
"32.09",
"33.48"
] |
icd9pcs
|
[
[
[]
]
] |
8929, 8984
|
4758, 7890
|
552, 1655
|
9063, 9108
|
2559, 4735
|
9778, 10398
|
2394, 2398
|
7949, 8906
|
9005, 9042
|
7916, 7926
|
9132, 9755
|
2413, 2540
|
282, 514
|
1683, 1914
|
1936, 2222
|
2238, 2378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,296
| 138,016
|
33568
|
Discharge summary
|
report
|
Admission Date: [**2174-5-10**] Discharge Date: [**2174-5-14**]
Date of Birth: [**2112-12-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
fever, cough , shortness of breath at home after discharge
[**2174-4-13**].
Major Surgical or Invasive Procedure:
s/p MV repair (#30 annuloplasty band) [**2174-4-8**].
History of Present Illness:
Mr [**Known lastname 77804**] is a 61yo male s/p MVrepair done on [**2174-4-8**]. He
progressed well from his surgery and was discharged to home with
servives on [**2174-4-13**]. He reports over the past 48-72 hours he
began experiencing a cough with dyspnea. [**5-9**] he became febrile
temp=101 and he vomited x 2. He also reports episodes of
increased heart rate and blood pressure associated with
coughing. Coughing was relieved with robitussin. Dr.[**Name (NI) 27809**]
office was called and Mr [**Known lastname 77804**] was told recommended to go to
the ED.
Past Medical History:
s/p MVrepair (#30 annuloplasty band [**2174-4-8**]), and gortex neo
band
HTN
GERD
Obesity
post op AFib
high cholesterol
Social History:
Denies tobacco use. Admits to several ETOH drinks with dinner.
Family History:
NC
Physical Exam:
Physical exam prior to discharge
VS: T=98.5', 94/57,78 SR, rr:18,Wt.=111.7, 96% R/A
General: A&O x3, NAD
CVS:RRR
Lungs:CTA
ABD: benign
EXT:no C/C/E
sternum stable.
Pertinent Results:
[**2174-5-13**] 06:00AM BLOOD WBC-5.5 RBC-3.05* Hgb-9.2* Hct-27.1*
MCV-89 MCH-30.0 MCHC-33.8 RDW-14.4 Plt Ct-177
[**2174-5-12**] 02:54AM BLOOD WBC-6.0 RBC-3.18* Hgb-9.4* Hct-28.2*
MCV-89 MCH-29.6 MCHC-33.3 RDW-14.5 Plt Ct-179
[**2174-5-12**] 02:54AM BLOOD Glucose-103 UreaN-18 Creat-1.0 Na-138
K-4.0 Cl-106 HCO3-21* AnGap-15
[**2174-5-11**] 02:12PM BLOOD Glucose-118* UreaN-15 Creat-1.0 Na-138
K-4.3 Cl-106 HCO3-23 AnGap-13
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77805**]Portable TTE
(Complete) Done [**2174-5-11**] at 12:18:52 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2112-12-28**]
Age (years): 61 M Hgt (in): 69
BP (mm Hg): 111/74 Wgt (lb): 244
HR (bpm): 78 BSA (m2): 2.25 m2
Indication: Endocarditis.
ICD-9 Codes: 424.0, 424.90, 424.1, 424.2
Test Information
Date/Time: [**2174-5-11**] at 12:18 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) **] L.
[**Hospital1 **], RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.6 cm <= 5.0 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: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 4.25
Mitral Valve - E Wave deceleration time: 202 ms 140-250 ms
Findings
LEFT ATRIUM: LA volume markedly increased (>32ml/m2).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Well-seated mitral annular ring with
normal gradient. No mass or vegetation on mitral valve. Mild
mitral annular calcification. No MS. Trivial MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrial volume is markedly increased (>32ml/m2). The
right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened 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. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No obvious vegetation or abscess seen. There is a
small, linear echodensity on the ventricular side of the
anterior mitral valve leaflet. It is probably the synthetic
mitral chord. This appears to be causing some turbulent flow
directed towards the posterior leaflet during systole. There is
trivial mitral regurgitation (may be underestimated due to
shadowing). Overall LV systolic function appears intact.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-5-11**] 16:17
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2174-5-11**] 1:57 PM
CHEST (PORTABLE AP)
Reason: ? infiltrate
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with s/p mv repair readmit for fever
REASON FOR THIS EXAMINATION:
? infiltrate
CHEST RADIOGRAPH
INDICATION: Readmission for fever.
FINDINGS: As compared to the previous radiograph of [**2174-5-10**], there is unchanged subtle cardiomegaly. Status post mitral
valve replacement. Unchanged minimal fluid overload, no focal
parenchymal opacity suggestive of pneumonia. No pleural
effusions.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: WED [**2174-5-11**] 4:42 PM
Brief Hospital Course:
[**5-10**] Mr [**Known lastname 77804**] was admitted for observation and further workup
for fever-cough and dyspnea; likely from volume overload. TTE
performed, blood cultures sent, beta-blocker reduced and
diuresis increased. Antibiotic therapy for a positive UTI was
completed with Bactrim. All remaining cultures were negative. No
futher events of fever and dyspnea. On [**2174-5-13**] Mr [**Known lastname 77804**] was
felt to be fully recovered after adequate diuresis and ABX
therapy for his UTI. He was discharged to home and recommended
to keep followup visits with his PCP, [**Name10 (NameIs) **], and
DrKhabbaz.
Medications on Admission:
ASA 81(1)
Toprol XL 50(1)
Amiodarone 200(1)
Lasix 40(2)
KCL 10(1)
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Discharge Condition:
Good.
Discharge Instructions:
Return to the emergency room if you develop fever, shortness of
breath,
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 77806**] 1 week
Already scheduled appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2174-6-16**] 1:00
Provider: [**Name10 (NameIs) 27270**] [**Name11 (NameIs) **] TESTING Phone:[**Telephone/Fax (1) 11767**]
Date/Time:[**2174-5-18**] 9:00
Completed by:[**2174-5-16**]
|
[
"401.9",
"278.00",
"599.0",
"530.81",
"780.2",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8643, 8649
|
7328, 7952
|
398, 453
|
8697, 8705
|
1490, 6747
|
8825, 9278
|
1287, 1291
|
8069, 8620
|
6784, 6837
|
8670, 8676
|
7978, 8046
|
8729, 8802
|
1306, 1471
|
283, 360
|
6866, 7305
|
481, 1047
|
1069, 1190
|
1206, 1271
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,318
| 113,918
|
15146
|
Discharge summary
|
report
|
Admission Date: [**2137-8-8**] Discharge Date: [**2137-8-16**]
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
female with a past medical history of atrial fibrillation,
supraventricular tachycardia, bradycardia and an episode of
ventricular tachycardia in [**2119**], who presented to her primary
exertion. The patient had been previously managed on beta
blockers and calcium channel blockers, but her symptoms were
worsening. She was given a Holter Monitor and returned to
her primary care physician's office where she was complaining
of increased palpitations. At her primary care physician's
office, her blood pressure was found to be somewhat low and a
subsequently EKG revealed ventricular tachycardia. She was
work-up.
At [**Last Name (un) 1724**], she was stable in monomorphic ventricular tachycardia
and essentially asymptomatic. Attempted cardioversion with
amiodarone was unsuccessful and her ventricular tachycardia
persisted with some increased shortness of breath. She was
therefore DC cardioverted and transferred to [**Hospital1 346**] for an Electrophysiology study and
potential ventricular tachycardia ablation.
At [**Hospital1 69**], she was taken to the
Electrophysiology Laboratory for attempted ventricular
tachycardia ablation. The procedure was complicated by
decreased blood pressures to the 80s systolic. Subsequent
cardiac echocardiogram revealed a 1.5 cm hemodynamically
significant pericardial effusion with right atrial pressures
of around 25 by pulmonary artery catheterization. She also
had recurrent ventricular tachycardia in the Electrophysiology
Laboratory and was given a Lidocaine drip. Pericardiocentesis was
performed in which we drained approximately 250 cc of blood with
subsequent normalization of blood pressures.
The patient was therefore transferred to the Cardiac Care
Unit where again she experienced a decrease in blood pressures.
An additional amount of fluid was drained. Her blood pressures
subsequently normalized. In addition, the patient had an elevated
CPK, MB and troponin. Lidocaine was eventually discontinued and
she was switched to amiodarone plus Mexitil and aggressively
diuresed secondary to congestive heart
failure.
She was eventually cardioverted on [**2137-8-13**] from atrial
fibrillation back to normal sinus rhythm. Today, she was
transferred to the [**Hospital Unit Name 196**] Service for further evaluation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of atrial fibrillation.
3. History of supraventricular tachycardia.
4. History of paroxysmal ventricular tachycardia.
5. Hypercholesterolemia.
6. Bradycardia status post permanent pacemaker.
7. Chronic lower extremity edema.
8. Degenerative joint disease.
9. Increased urinary frequency.
10. Fibrocystic breast disease.
ALLERGIES: Bactrim.
MEDICATIONS ON TRANSFER FROM CARDIAC CARE UNIT:
[**Unit Number **]. Aspirin 325 mg p.o. q. daily.
2. Lasix 20 mg p.o. q. daily.
3. Lipitor 10 mg p.o. q. daily.
4. Amiodarone 400 mg p.o. three times a day.
5. Protonix 40 mg p.o. q. daily.
6. Colace 100 mg twice a day.
7. Mexiletine 150 mg three times a day.
8. Captopril 75 mg p.o. three times a day.
9. Metoprolol 100 mg p.o. twice a day.
10. Norvasc 10 mg p.o. q. daily.
11. Carvedilol 25 mg twice a day.
PHYSICAL EXAMINATION: Vital signs revealed 97.4 F.
Temperature; blood pressure 193/90; heart rate paced sinus
rhythm at 74; respiratory rate of 18. She is [**Age over 90 **]% on two
liters nasal cannula. In general, she is pleasant, lying in
bed and in no acute distress. HEENT examination revealed
neck supple; sclerae anicteric. Increased jugular venous
distention to the ear at 45 degrees. Cardiovascular
examination revealed an S1 and an S2; regular rate and
rhythm. I/VI systolic ejection murmur heard mostly at the
left upper sternal border; occasional premature ventricular
contractions. Distal pulses and radial pulses two plus and
regular. Lungs with decreased breath sounds at the bases;
otherwise clear to auscultation bilaterally. Abdomen soft,
nontender, and present bowel sounds. Extremities: Markedly
swollen bilaterally. One to two plus pitting lower extremity
edema; one to two plus pulses bilaterally. Warm and well
perfused.
LABORATORY: On transfer, white blood cell count was 8.0,
hematocrit 31.8, platelets 241. Sodium 139, potassium 3.8,
chloride 101, bicarbonate 28, BUN 14, creatinine 0.8 with
blood glucose of 93.
While in the Cardiac Care Unit, her CK peaked at 336 on
[**8-9**], with a peak MB of 54 and a peak troponin of 40, both
on [**8-8**]. Her current cardiac enzymes are overall down
trending with her last CPK of 53 and her last troponin of
10.7 on [**8-10**].
A previous echocardiogram performed on [**2137-8-9**], showed an
ejection fraction of 40% with mild left atrial enlargement
and right atrial enlargement. Symmetric mild left
ventricular hypertrophy. One plus mitral regurgitation and a
trivial pericardial effusion.
HOSPITAL COURSE: The patient was brought into the [**Hospital Unit Name 196**]
Service for further evaluation. Because of her elevated
cardiac enzymes, it was decided to perform stress imaging to
determine if the patient had any significant cardiac
ischemia. A Persantine Sestamibi stress test was performed
on [**2137-8-14**], which was significant for an appropriate heart
rate and blood pressure response, no angina, uninterpretable
EKG; the MIBI portion was significant for no perfusion
defects, no wall motion abnormalities and an ejection
fraction of 60%.
Given the results of the negative stress test, it was
therefore only necessary to better control the patient's
blood pressure. She was discontinued from her Carvedilol and
her Norvasc was increased from 5 mg p.o. q. daily to 10 mg
p.o. q. daily. Her blood pressure the next day subsequently
stabilized into the 110s over 70s, and she was overall doing
quite well, ambulating well without any difficulty.
A Physical Therapy consultation was obtained and felt that
she was safe to return home with some occasional Physical
Therapy services.
She will slowly decrease her amiodarone with a new dose on
[**2137-8-16**], of 400 mg p.o. daily. She will take this for a
total of three weeks and then switch to 200 mg p.o. daily of
amiodarone. She will also be discharged on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
Monitor and follow-up with Dr. [**Last Name (STitle) 284**] in
Electrophysiology Service Clinic in approximately four weeks.
She will also follow-up with her primary care physician in
approximately one week for any adjustment of her blood
pressure medications.
CONDITION AT DISCHARGE: The patient is ambulating well and
overall is doing quite well. She was felt to be safe for
discharge.
DISCHARGE STATUS: To home with Physical Therapy services.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) 4949**], her primary
care physician, [**Name10 (NameIs) **] [**8-23**], at 10:45 a.m.
2. She will also follow-up with Dr. [**Last Name (STitle) 284**] in
approximately four weeks on the results of her [**Doctor Last Name **] of Hearts
Monitor which she will be discharged home on today.
3. In addition she will follow up with Dr. [**Last Name (STitle) 44150**] of
cardiology at [**Last Name (un) 1724**].
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. daily.
2. Lisinopril 40 mg p.o. q. daily.
3. Lipitor 10 mg p.o. q. daily.
4. Ranitidine 150 mg p.o. q. daily.
5. Aspirin 325 mg p.o. q. daily.
6. Metoprolol 100 mg p.o. three times a day.
7. Amiodarone 400 mg p.o. q. daily for three weeks; then 200
mg p.o. q. daily starting on [**2137-9-6**].
8. Mexiletine 150 mg p.o. three times a day.
9. Norvasc 10 mg p.o. q. daily.
DISCHARGE DIAGNOSES:
1. Recurrent paroxysmal ventricular tachycardia status post
unsuccessful ventricular tachycardia ablation.
2. Paroxysmal atrial fibrillation.
3. Hypertension.
4. Hypercholesterolemia.
5. Bradycardia status post permanent pacemaker.
6. Chronic lower extremity edema.
7. Degenerative joint disease.
8. Pericardial tamponade complicating EPS, treated with
pericardiocentesis.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 44151**]
MEDQUIST36
D: [**2137-8-20**] 20:55
T: [**2137-8-26**] 15:05
JOB#: [**Job Number 44152**]
|
[
"428.0",
"997.1",
"401.9",
"427.31",
"427.1",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.26",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
7780, 8429
|
7355, 7759
|
4992, 6657
|
6862, 7332
|
3312, 4974
|
6673, 6838
|
101, 2419
|
2441, 3289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,471
| 106,942
|
10513+10514
|
Discharge summary
|
report+report
|
Admission Date: [**2116-4-11**] Discharge Date: [**2116-4-13**]
Date of Birth: [**2082-3-28**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old
morbidly obese female with a history of sleep apnea requiring
assist control ventilation and now presenting with fevers,
chills and headache since [**2116-4-10**]. She complains of nausea,
low back pain likely chronic and mild photophobia.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea.
2. Asthma for which she was intubated and tracheostomy.
ALLERGIES: The patient is allergic to Percocet and Vicodin
for which she gets a rash.
MEDICATIONS: She is on Fluticasone inhaler, Fioricet,
Heparin subcutaneous, Salmeterol, Venlafaxine and Albuterol.
HOSPITAL COURSE:
1. Headache - The patient had symptoms consistent with
meningitis versus subarachnoid versus sinusitis. In terms of
meningitis, she is being treated empirically with Ceftriaxone
and Vancomycin due to inability to do a lumbar puncture given
her size. She has a low grade temperature but no elevated
white blood cell count throughout her hospital stay.
2. In terms of subarachnoid, it is unlikely. Neurologic
checks q4hours did not show any focal deficit.
3. In terms of sinusitis, she has symptoms of maxillary
tenderness, though x-ray did not show any fluid levels in her
sinuses. However, she was given Pseudoephedrine throughout
the course to alleviate it. Her headache did go down from
ten out of ten to five out of ten and continues to get
better.
4. In terms of her fever, she has an unclear etiology,
likely infectious, but urinalysis was clear. Chest x-ray was
clear. Blood cultures are pending. Given that temperature
is coming down, it is reassuring.
5. Depression - She continued her Effexor.
6. Pulmonary - She continued on her ventilation at home for
obstructive sleep apnea.
In terms of her discharge, she received a PICC line in her
arm to receive her antibiotics for meningitis and she will
continue a ten day course.
DISCHARGE DIAGNOSES:
1. Question rule out meningitis.
2. Obstructive sleep apnea.
3. Depression.
MEDICATIONS ON DISCHARGE:
1. Pseudoephedrine.
2. Ceftriaxone two grams intravenously q12hours.
3. Vancomycin one gram q12hours.
4. Salmeterol one puff twice a day.
5. Fluticasone 110 mcg two puffs twice a day.
[**Name6 (MD) 34651**] [**Name8 (MD) 34652**], M.D. [**MD Number(1) 34653**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2116-4-13**] 17:17
T: [**2116-4-13**] 17:55
JOB#: [**Job Number 34654**] and [**Numeric Identifier 34655**]
Admission Date: [**2116-4-11**] Discharge Date: [**2116-4-13**]
Date of Birth: [**2082-3-28**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old
female with past medical history of obstructive sleep apnea,
asthma, obesity, ovarian cyst, HIV and history of
tracheostomy in [**2114-3-1**], presenting with fevers,
chills, lower back pain, myalgia, denies any nausea,
vomiting, diarrhea, has headache, as well as some diarrhea
without any chest pain or shortness of breath. The patient
complained of [**11-6**] frontal headache associated with fevers.
ALLERGIES: The patient is allergic to Percocet and Vicodin.
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg.
2. Effexor.
3. [**Doctor First Name **].
4. Ambien.
5. Multivitamins.
6. Ventolin.
7. Serevent.
SOCIAL HISTORY: The patient denies alcohol, drugs or
tobacco. She lives alone and works as a medical insurance
company employee.
PHYSICAL EXAMINATION: On presentation, the patient had a
temperature of 102.1, heart rate 96, respiratory rate 18, and
blood pressure 92/22. In general, the patient is obese. The
pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. The heart
is regular rate and rhythm, II/VI systolic ejection murmur
heard best at the left upper sternal border. The lungs are
clear to auscultation bilateral. No crackles. The abdomen
is soft, nontender, nondistended, positive bowel sounds.
Extremities - no cyanosis, clubbing or edema. No nuchal
rigidity. Neurologic examination reveals no focal deficits.
LABORATORY DATA: On presentation, white blood cell count was
9.6 with 23% bands. Chem7 was unremarkable. Chest x-ray was
difficult to interpret due to body habitus.
HOSPITAL COURSE: The patient's issues in the Intensive Care
Unit therefore were:
1. Headache - It was worrisome for infectious etiology or
subarachnoid. Attempts at lumbar puncture were unsuccessful
in the Emergency Department. CT as well as x-ray was not
performed given that the patient's weight was 550 pounds
exceeding the limits of the CAT scan table as well as could
not be done under fluoroscopy. The patient refused to lie on
stomach for the procedure which required thirty minutes in
that position. Given the situation, her headache was still
thought to be either a tension headache, migraine, meningitis
or subarachnoid. In terms of subarachnoid, q4hour neurologic
checks were performed to insure that there was no
neurological findings though the diagnosis is low in the
differential.
2. Meningitis - The patient was started on two grams
Ceftriaxone empirically to treat this given that lumbar
puncture could not be performed. She was also given Tylenol
for treatment of the headache. In terms of infection, again
chest x-ray was difficult to interpret. The patient denied
any upper respiratory infection symptoms. Urine was negative
and blood cultures were negative.
3. Obstructive sleep apnea - In terms of her obstructive
sleep apnea, she has a tracheostomy in place and she uses
mechanical ventilation pressor support at home. She continues
her mechanical ventilation support in the hospital at the
settings that she uses at home.
4. Neuropsychiatric - depression - Her Effexor was
continued.
5. Obesity - The patient's body mass index is 89.
Unfortunately, this was the [**Last Name **] problem with inability to
image her head. During the hospital course, it was
complicated by she had erythema, redness in her left lower
extremity consistent with cellulitis and she was started on
Keflex to treat the cellulitis.
During hospital course, the patient also had a PICC line
placed for intravenous antibiotic.
CONDITION ON DISCHARGE: On discharge, the patient was in
good condition with the same diagnoses and was discharged in
good condition.
[**Name6 (MD) 34651**] [**Name8 (MD) 34652**], M.D. [**MD Number(1) 34656**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2116-5-21**] 16:02
T: [**2116-5-24**] 12:02
JOB#: [**Job Number 34657**]
|
[
"780.6",
"276.1",
"599.7",
"473.8",
"322.9",
"682.6",
"V44.0",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2045, 2125
|
2151, 2765
|
3317, 3437
|
4405, 6333
|
3592, 4387
|
2794, 3291
|
459, 752
|
3454, 3569
|
6358, 6723
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,274
| 115,195
|
38673
|
Discharge summary
|
report
|
Admission Date: [**2141-4-11**] Discharge Date: [**2141-4-18**]
Date of Birth: [**2063-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
T6 burst fracture
Major Surgical or Invasive Procedure:
[**2141-4-11**]: T3-T9 posterior instrumented fusion
History of Present Illness:
78 y/o female with PMHx Parkinsons disease, COPD on home O2 2L,
4.2cm thoracic aortic aneurysm, CHF, depression,
hypercholesterolemia, hx L5-S1 discectomy, R TKA years ago,
peripheral neuropathy who is POD #3 s/p T3-T9 arthrodesis and
instrumentation. The patient has had multiple visits to OSH EDs
for low back pain starting in mid [**Month (only) **] and was initially
treated with rehabilitation. At the rehab facility, she
developed progressive weakness of her lower extremity and bowel
and bladder incontinence. She was transfered back to the ED of
[**Hospital **] hospital where CXR done showed burst fracture of T6 with
retropulsed fragment causing narrowing of the canal in that
area. She was then transfered to [**Hospital1 **] on [**2141-4-11**]. There was
marked blood loss in surgery but she was hemodynamically stable
the entire long surgery. She was transfused 2 PBRCs for oozing
from surgical site. (No hct drop). She self extubated the
morning after surgery. Ortho felt that surgery was done too
late. She has intact sensation but toes are upgoing B/L, and
she is now paralyzed from waist down.
.
Other complicating factors since she has been in the TICU
include UTI, A fib, and hypoxia. She is being treated with
Augmentin for the UTI. The patient had an episode of Afib last
night (first known episode). This was thought to be secondary
to overdiuresis. The patient's heart rate never got above
105bpm. The ICU team gave intermittent lopressor 5 mg IV, then
started lopressor 12.5 mg tid PO. Currently more hypoxic than
baseline felt to be [**2-21**] to volume overload (on 4L). She
diuresed 1L to 20 IV lasix. She received an IVC filter today
prophylactically (no DVTs). The patient was to be called out of
the unit yesterday, however had an episode of hypotension,
unclear etiology, possibly not correlating non-invasive to
invasive monitoring. Hypotension has resolved and the patient
is being transferred to medicine for continued care.
.
On transfer vs were 97.2 82 103/56 17 98% on 3L. Patient
complains of some back pain, but is otherwise feeling well.
Very frustrated about her current situation. Feels bloated and
gassy as well.
Past Medical History:
1) S/p reduction of fracture dislocation T5-6 and T6-7,
posterior arthrodesis T3-4, T4-5, T5-6, T6-7, T7-8 and T8-9,
posterior instrumentation T3 to T9, and arthroplasty in same
region.
2) Parkinsons disease
3) COPD on home O2
4) 4.2cm thoracic aortic aneurysm
5) Depression
6) hypercholesterol
7) hx L5-S1 discectomy
8) R TKA years ago
9) peripheral neuropathy
10) CHF
Social History:
Was at [**Hospital 5682**] Rehab for a week prior to this admission, but
was previously living at [**Location (un) 583**] [**Hospital3 400**]. Denies any
current tobacco or ETOH use. Smoked for 35 yrs and quit [**2126**].
Son [**Name (NI) **] lives in the [**Location (un) **] area and is quite involved in the
care of the mother.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Vitals - 97.2, 82, 103/56, 17, 98% on 3L.
GEN: elderly female, lying still, in mild discomfort
HEENT: EOMI, PERRLA, MMM, no LAD, neck supple
CV: S1S2, RRR, no m/r/g
RESP: CTA b/l, no w/r/r
ABD: soft, distended, NT, + BS, no guarding/rebound
GU: catheter in place
Back: dressing dry and intact
SKIN : no rash, no ulceration, no erythema in decubiti
NEURO: CNII-XII grossly intact, 5/5 strength in UE, 0/5 strength
in LE's. Sensation intact in LE's.
Pertinent Results:
CT C/T/L spine ([**2141-4-11**])
IMPRESSION:
1. Severe compression fracture of T6 vertebral body with
retropulsion causing narrowing of the spinal canal.
2. Bilateral sixth rib fractures at the costovertebral
junctions.
3. Right sacral fracture. Recommend a pelvis CT to assess for
associated fractures. This was discussed with Dr. [**First Name (STitle) **] in the
MICU at 8:50 am on [**2141-4-11**].
4. Lumbar spondylosis with moderate multilevel neural foraminal
narrowing. Grade I anterolisthesis at L3-4 is likely related to
facet arthropathy. Grade I anterolisthesis at L5-S1 secondary to
bilateral L5 pars defects.
5. Left renal cystic lesion is incompletely evaluated. If there
are no previous studies to confirm its stability, then further
characterization with an ultrasound is suggested.
.
MRI T-spine ([**2141-4-10**])
IMPRESSION: Burst fracture at T6 with greater than 50% loss of
height and involvement of the anterior, middle and posterior
columns as well as retropulsion and spinal canal compromise.
.
CBC
[**2141-4-15**] 05:45AM BLOOD WBC-7.8 RBC-3.02* Hgb-8.7* Hct-26.6*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.2* Plt Ct-304
[**2141-4-14**] 01:48AM BLOOD WBC-9.1 RBC-3.21* Hgb-8.8* Hct-27.7*
MCV-86 MCH-27.3 MCHC-31.7 RDW-15.3 Plt Ct-218
[**2141-4-13**] 01:53PM BLOOD WBC-10.9 RBC-3.58* Hgb-9.7* Hct-30.6*
MCV-86 MCH-27.0 MCHC-31.6 RDW-15.6* Plt Ct-235
[**2141-4-13**] 02:44AM BLOOD WBC-9.3 RBC-3.38* Hgb-9.6* Hct-29.5*
MCV-87 MCH-28.5 MCHC-32.6 RDW-16.0* Plt Ct-246
[**2141-4-12**] 03:04AM BLOOD WBC-9.4 RBC-3.35* Hgb-9.7* Hct-29.1*
MCV-87 MCH-28.8 MCHC-33.2 RDW-16.3* Plt Ct-260
[**2141-4-11**] 10:50PM BLOOD WBC-9.1 RBC-3.71* Hgb-10.3* Hct-32.4*
MCV-87 MCH-27.7 MCHC-31.7 RDW-16.0* Plt Ct-285
[**2141-4-11**] 10:13AM BLOOD WBC-10.9 RBC-3.87* Hgb-10.3* Hct-33.1*
MCV-86 MCH-26.7* MCHC-31.2 RDW-15.9* Plt Ct-296
[**2141-4-10**] 05:25PM BLOOD WBC-11.1* RBC-4.26 Hgb-11.7* Hct-36.7
MCV-86 MCH-27.6 MCHC-31.9 RDW-15.8* Plt Ct-299
.
Coag
[**2141-4-15**] 05:45AM BLOOD PT-11.0 PTT-28.4 INR(PT)-0.9
[**2141-4-13**] 02:44AM BLOOD PT-10.5 PTT-25.9 INR(PT)-0.9
[**2141-4-11**] 10:50PM BLOOD PT-11.2 PTT-23.1 INR(PT)-0.9
[**2141-4-11**] 08:00PM BLOOD PT-11.4 PTT-22.0 INR(PT)-0.9
[**2141-4-11**] 05:10PM BLOOD PT-11.2 PTT-23.4 INR(PT)-0.9
[**2141-4-11**] 12:10PM BLOOD PT-10.6 PTT-23.3 INR(PT)-0.9
.
Chemistry
[**2141-4-15**] 05:45AM BLOOD Glucose-91 UreaN-9 Creat-0.4 Na-143 K-3.7
Cl-105 HCO3-32 AnGap-10
[**2141-4-14**] 01:48AM BLOOD Glucose-92 UreaN-12 Creat-0.4 Na-140
K-4.2 Cl-103 HCO3-35* AnGap-6*
[**2141-4-13**] 01:53PM BLOOD Glucose-139* UreaN-10 Creat-0.5 Na-141
K-4.0 Cl-101 HCO3-34* AnGap-10
[**2141-4-13**] 02:44AM BLOOD Glucose-122* UreaN-11 Creat-0.5 Na-141
K-3.6 Cl-104 HCO3-30 AnGap-11
[**2141-4-12**] 03:04AM BLOOD Glucose-133* UreaN-21* Creat-0.6 Na-142
K-4.0 Cl-108 HCO3-28 AnGap-10
[**2141-4-11**] 10:50PM BLOOD Glucose-124* Creat-0.7 Na-143 K-4.1
Cl-108 HCO3-28 AnGap-11
[**2141-4-11**] 10:13AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-143
K-4.2 Cl-105 HCO3-29 AnGap-13
[**2141-4-10**] 05:25PM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-142
K-4.1 Cl-97 HCO3-36* AnGap-13
[**2141-4-14**] 01:48AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2141-4-13**] 02:44AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.9
[**2141-4-12**] 03:04AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.3 Mg-1.9
[**2141-4-11**] 10:50PM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0
[**2141-4-11**] 10:13AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.3
Brief Hospital Course:
This is a 78 year old female with PMH of Parkinson's, COPD, CHF,
h/o L5-S1 discectomy presents with progressive LE weakness and
bowel and bladder incontinence, found to have a nontraumatic T6
burst fracture with retropulsed fragment. Now s/p T3-T9
arthrodesis but with paralysis of bilateral lower extremities.
.
#. T6 burst fracture - nontraumatic compression fracture now s/p
emergent T5-7 posterior decompression and T3-9 fusion on
[**2141-4-11**]. Patient is now paralyzed from the waist down,
although sensation in her legs remains intact. She seems to not
have sensation of her abdomen and has developed some abrasions
there, likely from her scratching the area. Uncertain what
precipitated the fracture, T6 vertebral body was sent to
pathology to evaluate for pathologic fracture and only showed
fragments of trabecular bone with focal remodelling and
fibrocartilage with degenerative changes. Ortho does not
recommend bracing her spine following this procedure. Patient
has pain well managed with oxycodone 5 mg q6h standing.
.
#. Anemia - Patient had significant blood loss during surgical
procedure and also oozing from wound. She was transfused 2
units of pRBCs, but was never documented to have a drop in
hematocrit. No current signs of bleeding and hematocrit has
remained stable around 27.
.
#. Neurogenic bladder - PM&R recommends d/c foley catheter and
start intermittent catheterization every 4-6 hours. However,
having to reposition her legs for straight cath every 4-6 hours
is very painful for patient, and so foley was left in for the
time being. Foley can be discontinued in rehab.
.
#. Neurogenic bowel - Patient was started on an aggressive bowel
regimen of colace, senna, bisacodyl suppository, miralax, and
lactulose. During this admission, patient was also given enemas
to help with passing bowel movements. On discharge, patient's
abdomen still remains distended. She should get enemas as
needed to ensure that she has a bowel movement everyday.
.
#. UTI - urine culture shows E.coli sensitive to Augmentin.
Patient was started on Augmentin on [**4-12**] for a planned 7 day
course for treatment of UTI.
.
#. Decubitus ulcer prophylaxis - patient was turned q2hrs for
prevention of decubitus ulcer formation.
.
#. DVT prophylaxis - had an IVC filter placed on [**4-13**]
prophylactically. PM&R recommends anticoagulation with Lovenox
30 mg [**Hospital1 **] for 12 weeks despite having IVC filter placed as
patient has just had orthopedic surgery.
.
# Stress ulcer prophylaxis - Patient was started on a PPI while
in perioperative period. Can be discontinued 4 weeks out from
surgery.
.
#. Parkinson's - patient was continued on sinemet, requip, and
comtan
.
#. Depression - patient was continued on Cymbalta and Remeron
.
#. COPD - patient uses 2L of O2 at home at baseline. Patient
was continued on spiriva, ipratropium, albuterol
Medications on Admission:
Sinemet 25/100 one tab PO BID (0530 and 1030)
Sinemet 25/100 PO 0.5 tabs [**Hospital1 **] (1400 and 1900)
Sinemet CR 25/100 one tab QID (0530, 0730, 1400, 1900)
Comtan 200mg PO one tab FIVE Times per day (0530, 0730, 1030,
1400, 1900)
Requip 8 mg, 2 tabs daily
Furosemide 40mh\g PO daily
MOM 30ml PRN
Dulcolox PR PRN
Tylenol 650 mg Q6 PRN
Fleets EAnema PRNSimvastatin 40mg daily
Cymbalta 60mg daily
ASA 81 mg daily
KCL 10 Meq daily
Clonazepam 0.5 mg [**Hospital1 **]:PRN
MVI one tab daily
Prilosec 20mg [**Hospital1 **]
Remeron 15mg qHS
Naprosyn 500mg [**Hospital1 **]:PRN
Vicodin one tab [**Hospital1 **]:PRN
Spiriva 18mcg daily
Flovent 110mg 2 puffs daily
Albuterol IH 1 puff Q4 PRN
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig: One
(1) nebulizer Inhalation every four (4) hours as needed for
shortness of breath, wheezing.
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day): Take at 05:30AM, 07:30AM, 2:00PM, 7:00PM .
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): take at 2PM and 7PM.
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day): take at 5:30AM and 10:30AM.
9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO FIVE TIMES
PER DAY ().
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Ropinirole 1 mg Tablet Sig: Sixteen (16) Tablet PO QAM (once
a day (in the morning)).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness breath.
16. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
18. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 12 weeks.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): please hold for oversedation or RR<10. Patient may
refuse
.
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
22. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
23. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
24. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
25. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
26. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
27. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety.
28. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Flaccid paralysis
T6 burst fracture
.
Secondary Diagnosis:
1) S/p reduction of fracture dislocation T5-6 and T6-7,
posterior arthrodesis T3-4, T4-5, T5-6, T6-7, T7-8 and T8-9,
posterior instrumentation T3 to T9, and arthroplasty in same
region.
2) Parkinsons disease
3) COPD on home O2
4) 4.2cm thoracic aortic aneurysm
5) Depression
6) hypercholesterol
7) hx L5-S1 discectomy
8) R TKA years ago
9) peripheral neuropathy
10) CHF
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Bedbound
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
leg weakness and inability to hold urine and stool. You were
found to have a T6 fracture for which you had spine surgery and
had your T3-T9 vertebrae were fused. Unfortunately even after
the surgery, you have not been able to move your legs. You are
being discharged to a rehabilitation facility to see if there is
a chance at regaining some motor function in your legs.
.
Your new medication list has been forwarded to [**Hospital3 **]
center.
Followup Instructions:
Please keep all of your outpatient follow-up appointments listed
below:
.
1. Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 711**], NP at your primary
care doctor's office on [**4-28**] at 2PM.
.
2. Department: ORTHOPEDICS
When: MONDAY [**2141-5-1**] at 9:00 AM
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
.
3. Department: SPINE CENTER
When: MONDAY [**2141-5-1**] at 9:20 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
o At this follow-up visit your incision will be checked and
baseline X-rays and questions will be answered.
|
[
"336.1",
"344.1",
"V43.65",
"596.54",
"599.0",
"041.4",
"733.00",
"496",
"781.0",
"458.29",
"285.1",
"427.31",
"428.0",
"356.9",
"799.02",
"564.81",
"441.2",
"733.13",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"81.63",
"77.49",
"84.52",
"03.53",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
13606, 13676
|
7285, 10163
|
333, 388
|
14168, 14168
|
3861, 7262
|
14816, 15752
|
3357, 3361
|
10898, 13583
|
13697, 13697
|
10189, 10875
|
14300, 14793
|
3391, 3842
|
276, 295
|
416, 2598
|
13775, 14147
|
13716, 13754
|
14183, 14276
|
2620, 2992
|
3008, 3341
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,487
| 110,744
|
5483
|
Discharge summary
|
report
|
Admission Date: [**2173-7-14**] Discharge Date: [**2173-7-24**]
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
gentleman, well known to the vascular service, who was
recently discharged after evaluation of a right foot ulcer.
He returned on [**2173-7-14**] with an episode of a fall early
that morning. The patient felt dizzy and fell on the floor.
He had some pain in both eyes. The patient does have a
history of a cerebrovascular accident and transient ischemic
attacks and was scheduled for a right carotid endarterectomy.
The patient denies any changes in speech, numbness, tingling
or loss of sensation anywhere in his body. His symptoms
disappeared in a few minutes.
PAST MEDICAL HISTORY: 1. Coronary artery disease, old Q
wave myocardial infarction in [**2172-3-12**]. 2. Congestive
heart failure, left ventricular ejection fraction 25% to 30%.
3. Diabetes mellitus. 4. Chronic obstructive pulmonary
disease. 5. End-stage renal disease, on hemodialysis on
Monday, Wednesday and Friday. 6. Gout. 7. Anemia. 8.
Pneumonia in [**2173-3-12**]. 9. Epididymitis. 10. Right foot
gangrene.
PAST SURGICAL HISTORY: 1. Percutaneous transluminal
coronary angioplasty in [**2173-6-12**] (left anterior descending
artery plus stent, left coronary artery plus stent). 2.
Left femoral-peroneal bypass graft in [**2172-3-12**]. 3. Left
arteriovenous fistula. 4. Left transmetatarsal amputation.
5. Left inguinal hernia repair in [**2114**]. 6. Radiocephalic
fistula in [**2172-12-12**]. 7. Left brachiocephalic fistula
in [**2173-1-12**].
MEDICATIONS ON ADMISSION: Glucotrol 2.5 mg p.o.q.d.,
Lopressor 12.5 mg p.o.b.i.d., Lipitor 10 mg p.o.q.d., Zestril
5 mg p.o.q.d., allopurinol 100 mg p.o.q.d., Tums 500 mg
p.o.t.i.d., aspirin 325 mg p.o.q.d., Flomax 0.4 mg
p.o.q.h.s., Protonix 40 mg p.o.q.d., Atrovent one to two
puffs q.12h., albuterol one to two puffs q.4-6h.p.r.n.,
Flovent one to two puffs b.i.d., Epogen 4,000 units with
hemodialysis, Plavix 75 mg p.o.q.d., levofloxacin 250 mg
p.o.q.48h., Flagyl 500 mg p.o.t.i.d.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 97.3, pulse 72, blood
pressure 100/60, respiratory rate 16 and oxygen saturation
94% in room air. Head, eyes, ears, nose and throat: Pupils
equal, round, and reactive to light, no erythema, no
exudates. Cardiovascular: Regular rate and rhythm. Lungs:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended. Extremities: Right dry gangrene
over lateral aspect of right foot, gangrenous toes #2 and 3
on the right foot, left transmetatarsal amputation, incision
site clean, dry and intact, 1+ ankle edema bilaterally.
Pulses: Carotids 1+ with bruits heard on right, femoral 2+
bilaterally, popliteal not palpable, dorsalis pedis
Dopplerable right and left, and posterior tibialis
Dopplerable on left, nonpalpable and non-Dopplerable on
right. Neurologic examination: Alert and oriented times
three, cranial nerves II through XII intact, sensory intact,
motor intact, deep tendon reflexes 1+ bilaterally.
LABORATORY DATA: Admission hematocrit was 32.9, sodium 139,
potassium 4.5, chloride 99, bicarbonate 27, BUN 54,
creatinine 3.6 and blood sugar 82.
HOSPITAL COURSE: The patient was admitted to the vascular
service and placed on a heparin drip for anticoagulation. A
cardiology consult was obtained and a recommendation was made
for the patient to remain on Plavix due to his recent cardiac
procedure.
On [**2173-7-18**], on recommendation from cardiology, the
Plavix was stopped because it was felt that the patient had
had an adequate amount of time on this medication. The
patient remained asymptomatic until [**2173-7-21**], when he
was taken to the Operating Room for a right carotid
endarterectomy.
At the end of the case, during suturing, the patient
developed severe hypotension with a systolic blood pressure
dropping down to 50 and heart rate in the 40s and 50s. The
patient was supported on epinephrine. A Swan-Ganz catheter
was placed showing a central venous pressure of 14, pulmonary
artery pressure of 60/22, cardiac output 3.4. A
transesophageal echocardiogram was performed in the Operating
Room, which showed a left ventricular ejection fraction of
35%, distal anterior septal hypokinesis, and mild tricuspid
regurgitation.
The patient responded well to pressors and was transported to
the Post Anesthesia Care Unit with a blood pressure of 120/70
and electrocardiogram showing no significant changes at that
time. The patient was transferred to the Surgical Intensive
Care Unit, where he remained completely asymptomatic. He was
ruled out for a myocardial infarction by cardiac enzymes and
electrocardiograms. The patient was transferred to a regular
floor on [**2173-7-23**].
Laboratory data on discharge: Hematocrit 27, white blood
cell count 8.2, platelet count 199,000, sodium 140, potassium
3.8, chloride 105, bicarbonate 23, BUN 35, creatinine 3.8,
blood sugar 135, prothrombin time 12.7, partial
thromboplastin time 29.5, INR 1.1, calcium 7.3, magnesium
1.6, phosphorous 4.3.
DISPOSITION: The patient continued to be asymptomatic and
was discharged home on [**2173-7-24**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home with
VNA services.
DISCHARGE MEDICATIONS:
Glucotrol 2.5 mg p.o.q.d.
Lopressor 12.5 mg p.o.b.i.d.
Lipitor 10 mg p.o.q.d.
Zestril 5 mg p.o.q.d.
Allopurinol 100 mg p.o.q.d.
Tums 500 mg p.o.t.i.d.
Aspirin 325 mg p.o.q.d.
Flomax 0.4 mg p.o.q.h.s.
Protonix 40 mg p.o.q.d.
Atrovent one to two puffs q.12h.
Albuterol one to two puffs q.4-6h.p.r.n.
Flovent one to two puffs t.i.d.
Epogen 4,000 units with hemodialysis.
Levofloxacin 250 mg p.o.q.48h. times ten days.
Flagyl 500 mg p.o.t.i.d. times ten days.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Dakin's solution one-quarter strength for dressing changes
b.i.d.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 1391**] in ten to 14 days, at which time staples will be
removed. At that time, the patient can discuss further
management of his right foot ulcer with Dr. [**Last Name (STitle) 1391**].
DISCHARGE DIAGNOSES:
1. Right carotid stenosis, status post right carotid
endarterectomy.
2. Episode of hypotension, ruled out for myocardial
infarction, etiology unknown.
SECONDARY DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure.
3. Diabetes mellitus.
4. Chronic obstructive pulmonary disease.
5. End-stage renal disease, on hemodialysis.
6. Gout.
7. Anemia.
8. Epididymitis.
9. Right foot ulcer.
10. Right leg ischemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 22171**]
MEDQUIST36
D: [**2173-7-25**] 16:02
T: [**2173-7-25**] 16:26
JOB#: [**Job Number 22172**]
|
[
"250.40",
"496",
"458.2",
"583.81",
"440.24",
"707.15",
"428.0",
"433.10",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
6240, 6394
|
5378, 6219
|
1641, 2102
|
3297, 4855
|
1186, 1614
|
6415, 6949
|
2125, 2967
|
4870, 5247
|
131, 728
|
2992, 3279
|
751, 1162
|
5272, 5355
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,571
| 114,546
|
33470
|
Discharge summary
|
report
|
Admission Date: [**2114-5-24**] Discharge Date: [**2114-6-6**]
Date of Birth: [**2050-7-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hepatocellular carcinoma and two pulmonary nodules found on PET
scan
(FDG avidity in the right upper lobe nodule)
To undergo resection with Dr [**First Name (STitle) **] and Dr [**Last Name (STitle) 77624**]
Major Surgical or Invasive Procedure:
[**2114-5-24**] Exploratory laparotomy, resection segment 4B, Flexible
bronchoscopy, VATS right upper lobectomy, mediastinal lymph node
dissection.
[**2114-5-28**] cardiac catheterization with stenting of RCA
History of Present Illness:
Mr. [**Known lastname 77625**] was involved in a motor vehicle accident [**2-20**] and
on a CT scan an incidental 3-cm lesion involving the left lobe
of the segment 4B was found. He had further workup including a
chest CT which demonstrated 2 small lung nodules. He was seen
by thoracic surgery and underwent a flexible bronchoscopy with
biopsy and cervical mediastinoscopy which was unremarkable. A
PET scan showed + right upper lobe nodule. It was decided to
proceed with right upper lung lobectomy and liver resection for
removal of the lesion.
Past Medical History:
type 2 diabetes mellitus, history of alcohol abuse, duodenal
ulcer
Social History:
50-pack-year tobacco use, history of alcohol abuse. He works as
a floor sander.
Family History:
Mother had myocardial infarction in her 70s.
Father had myocardial infarction in his 70s and had an unknown
type of cancer.
Physical Exam:
VS: 98.3, 105, 89/45, 8, 100%
Gen: A+O, MAE
Card: Reg rhythm, tachy
Resp: CTA bilaterally
Abd: Soft, non-tender, non-distended, + BS
Extr: No edema
Dressings C/D/I
Pertinent Results:
[**2114-5-24**] 06:34PM BLOOD WBC-19.0* RBC-3.17*# Hgb-9.8*# Hct-29.1*#
MCV-92 MCH-31.1 MCHC-33.8 RDW-13.7 Plt Ct-348
[**2114-5-24**] 06:34PM BLOOD PT-14.4* PTT-34.6 INR(PT)-1.3*
[**2114-5-24**] 06:34PM BLOOD Glucose-173* UreaN-29* Creat-0.9 Na-141
K-5.2* Cl-112* HCO3-21* AnGap-13
[**2114-5-24**] 06:34PM BLOOD ALT-67* AST-96* LD(LDH)-185 AlkPhos-61
Amylase-116* TotBili-0.6
[**2114-5-24**] 06:34PM BLOOD Albumin-3.2* Calcium-8.8 Phos-4.1 Mg-1.1*
[**2114-5-27**] 10:05PM BLOOD CK-MB-8 cTropnT-0.16*
[**2114-5-28**] 02:27AM BLOOD CK-MB-9 cTropnT-0.39*
[**2114-5-28**] 10:05AM BLOOD CK-MB-33* MB Indx-10.0* cTropnT-1.12*
[**2114-5-28**] 03:41PM BLOOD CK-MB-29* MB Indx-10.3* cTropnT-1.07*
[**2114-5-28**] 09:47PM BLOOD CK-MB-14* MB Indx-7.9* cTropnT-1.01*
[**2114-5-29**] 04:12AM BLOOD CK-MB-10 MB Indx-7.8*
[**2114-5-29**] 04:12AM BLOOD cTropnT-0.93*
Pathology:
[**2114-5-24**]
Lung, right upper lobe, lobectomy (G-P):
a. Moderately differentiated adenocarcinoma; see synoptic
report #1.
b. Immunostains of the tumor cells are positive for cytokeratin
7 and TTF-1, and negative for cytokeratin 20 and HepPar1, with
satisfactory controls. This immunophenotype supports a pulmonary
origin.
Gallbladder, cholecystectomy (Q):
a. Mild chronic cholecystitis.
b. No calculi present.
Liver, segment 4A, resection (R-U):
a. Hepatocellular carcinoma, well-differentiated; see synoptic
report #2.
b. Immunostains of the tumor cells are diffusely and strongly
positive for HepPar1, with satisfactory controls, supporting the
diagnosis
Imaging:
[**2114-5-24**] echo: The left atrium is normal in size. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.
[**2114-5-28**] Cardiac cath: Selective coronary angiogrpahy in this
right dominant system revealed one vessel coronary disease. The
LMCA was free of angiographically apparent CAD. The LAD had
minimal luminal irregularities. The LCX had a 30% proximal
lesion. The RCA had a 99% mid vessel stenosis and an aneuysm of
the ostium which was present at baseline.
2. Resting hemodynamics revealed nromal systemic blood pressure.
3. Successful stenting of a a heavily calcified mid RCA lesion
with a
2.5 X 8 mm Driver and a 2.5 X 12 mm Vision bare metal stents
(see PTCA
comments for detail).
[**2114-5-28**] echo: 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 mild to
moderate regional left ventricular systolic dysfunction with
basal to mid inferior akinesis and inferoseptal and
inferolateral hypokinesis. Overall EF 40-45%. The estimated
cardiac index is normal (>=2.5L/min/m2). The right ventricular
cavity is mildly dilated There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The ascending aorta is mildly dilated. 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. The estimated pulmonary artery
systolic pressure is mildly elevated. There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild to moderate focal left ventricular dysfunction
consistent with CAD. Mild right ventricular dilation with
preservation of apical motion (base less well seen), mild
pulmonary hypertension, and septal flattening. Cannot rule out
pulmonary embolism.
Compared with the prior study (images reviewed) of [**2114-4-4**],
the focal wall motion abnormalities and right ventricular
findings are new. \
Brief Hospital Course:
Mr. [**Known lastname 77625**] was admitted to the hepatobiliary surgery service
and was followed closely by the thoracic surgery service after
his surgeries on [**5-24**]. For details of the surgeries, please
refer to the operative notes. He was kept in the PACU for close
monitoring post op. He had an epidural in place which was held
due hypotension. He had 2 chest tubes in place as well as an
abdominal JP drain. On POD 1 ([**5-25**]) his chest tubes were placed
to water seal, the epidural was continued and he was stable for
transfer to the floor. On POD 2 ([**5-26**]), he was doing well and
his pain was well controlled with the epidural/PCA and chest
tube #1 was removed and the 2nd chest tube was placed to bulb
suction.
On POD 3 ([**5-27**]) he was started on clear liquid diet. Overnight
he had acute mental status changes with increased O2
requirements and respiratory distress. EKG showed new Afib and
Lopressor was given with no change. ABG showed decreased PaO2.
CXR demonstrated increased left lung opacity. He was
transferred to the SICU for further management. He was
intubated and diltiazem IV drip for afib was started. Cardiac
enzymes revealed increased troponins with new ischemia on EKG. A
Heparin drip and pressors were started. IV antibiotics were
started for possible sepsis.
Cardiology was consulted and he was taken emergently to the cath
lab for a PTCA and stenting (bare metal)of RCA on the morning of
POD 4 ([**5-28**]). He was started on aspirin, plavix and was
maintained on integrelin x 18 hours post procedure. Lower
extremity US which were negative for DVT and a bronchoscopy
which was clear. He remained intubated on POD 5 ([**5-29**]). The
epidural was d/c'd on POD 6 ([**5-30**]).
Overnight he had a acute change in neurological exam where he
was only moving his LUE to sternal rub and not moving his RUE
and had R pupil > L pupil. Sedation (versed & propofol)was
turned off. A stat head CT was done which showed no evidence of
acute intracranial pathology. Two units of PRBC were transfused
for a hct of 25.8. Neuro exam improved. He was slowly weaned off
of pressors and given lasix for volume overload. CXR showed
Asymmetrical interstitial edema affecting the left lung to a
greater degree than the right. Nebs were given. A low dose
propofol drip was used for agitation. He was weaned off the vent
on [**6-2**].
On [**6-2**], he was transferred out of the SICU to the [**Hospital Ward Name 121**] 10
(med-[**Doctor First Name **] unit) where he continued to improve. The CT was d/c'd
without incident. CXR on [**6-3**] showed persistent right-sided
moderate-to-large pneumothorax, unchanged and left-sided
effusion and left basilar atelectasis persisted. Breath sounds
were diminished on the left. O2 was weaned off. He was assisted
OOB. The foley was removed and diet was advanced. Vicodin was
used for pain with break thru dilaudid. It was noted that he had
periods of forgetfulness. PT declared him safe for discharge
home as he was ambulatory and able to do stairs.
On [**6-6**], the JP drain was removed. Vital signs and labs were
stable. He was ambulatory and tolerating a regular diet. Follow
up appointments with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 5795**] were made as
well as with Dr. [**Last Name (STitle) **] (Oncology). A follow up appointment with
Cardiology was to be made.
Medications on Admission:
metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Outpatient Physical Therapy
Cardiac rehab post MI (STEMI)
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatoma
Right upper lobe carcinoma
s/p STEMI with RCA stent placement [**2114-5-28**]
Discharge Condition:
Stable/good
Discharge Instructions:
Please call Dr[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] if you have
fevers > 101, chills, nausea, vomiting, diarrhea, yellowing of
skin or eyes, shortness of breath, chest pain,inability to eat
or take medications.
Monitor incision for redness, drainage or bleeding
No heavy lifting. No driving or alcohol while taking pain
medication
Followup Instructions:
-Follow up with Oncology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/Dr. [**Last Name (STitle) **] on
Tuesday, [**6-12**] at 3pm, [**Hospital Ward Name 23**] building, [**Location (un) **], phone
[**Telephone/Fax (1) 77626**].
-CXR at [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **] [**2114-6-21**] at 3:30 then go
to -[**Location (un) **] for follow up with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) 77627**]
(Thoracic)at 4pm 5/8([**Telephone/Fax (1) 1504**]
Follow up with Cardiology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] .
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-6-14**] 1:10
Completed by:[**2114-6-6**]
|
[
"997.1",
"575.11",
"427.31",
"250.00",
"155.0",
"518.81",
"512.1",
"E878.6",
"410.91",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"96.04",
"99.20",
"00.40",
"36.06",
"88.55",
"37.22",
"33.22",
"50.22",
"88.52",
"51.22",
"96.72",
"32.41",
"40.3",
"00.46",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10146, 10152
|
5882, 9259
|
521, 732
|
10283, 10297
|
1841, 5859
|
10696, 11504
|
1516, 1642
|
9343, 10123
|
10173, 10262
|
9285, 9320
|
10321, 10673
|
1657, 1822
|
273, 483
|
760, 1312
|
1334, 1402
|
1418, 1500
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,511
| 167,536
|
24536
|
Discharge summary
|
report
|
Admission Date: [**2134-7-5**] Discharge Date: [**2134-7-24**]
Date of Birth: [**2081-1-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
super obesity (BMI=66)
Major Surgical or Invasive Procedure:
[**7-7**]: Open Roux-en-Y gastric bypass
[**7-16**]: Exploratory laparotomy, Cholecystectomy (open),
Debridement of fascial wound
History of Present Illness:
53 year-old man with a history of obesity, BMI of 66. He was
initially evaluated for gastric restrictive surgery through the
[**Hospital 18**] [**Hospital 33018**] clinic on [**10-7**] and [**2132-11-10**] with
follow-up visits in the Weight Winners Program on 7 visits from
[**11-27**] to [**2133-2-6**]. His initial presentation weight
was 495.9 lbs on [**2132-10-7**], height of 73.75 inches and BMI of
64.2. [**Known firstname 62002**] was evaluated in the surgical clinic on [**2133-2-18**] at
weight of 476.4 lbs and BMI of 61.7. He was approved for the
Roux-en-Y gastric bypass procedure and scheduled for surgery,
however during Pre-op Admission Testing he was noted to be in
new-onset atrial fibrillation with hypertension. Surgery was
cancelled and he was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] of
Cardiology for management of his blood pressure and evaluation
of atrial fibrillation, for which he was placed on Coumadin. He
returned to PAT on [**2133-8-11**] with surgery date set for [**2133-8-18**]. At
this time it was noted that he had developed a left lower
extremity cellulitis
with a history of recurrent cellulitis, which had been treated
with IV antibiotics daily at [**Hospital3 2358**]. Surgery was again
postponed until the cellulitis resolved. Prior to scheduled
surgery, [**Known firstname 62002**] was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62003**] and
dietitian [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], RD for dietary counseling and initiation
of Xenical prior to surgery. He was admitted on [**2134-7-5**] to
undergo open Roux-en-Y gastric bypass.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Atrial fibrillation, on coumadin
Obstructive Sleep Apnea (on CPAP of 10 with 2 liters of
oxygen)Lower extremity venous stasis with recurrent cellulitis
Osteoarthritis of back and lower extremity joints
Social History:
He is married living with his wife. [**Name (NI) **] has a business involved
in medical transportation. He is former Olympic-style wrestler
in the old Soviet [**Hospital1 1281**]. He was former one pack cigarettes daily
stopping in [**9-/2131**], no recreational drugs, occasional alcohol
on weekends.
Family History:
Family history is noted for father deceased age 68 of MI and
obesity and mother deceased age 72 from stroke. His son
underwent [**Name2 (NI) 33554**] gastric bypass for morbid obesity through
[**Hospital1 18**] Program in [**2132**].
Physical Exam:
Gen: No acute distress.
HEENT: Sclerae were anicteric, conjunctiva clear, pupils equal,
round and
reactive to light, mucous membranes moist, oropharynx without
exudates
Neck: Trachea midline. Neck supple with no adenopathy
Pulm: Occasional expiratory wheeze, otherwise clear to
auscultation bilaterally.
CV: Irregular rhythm, regular rate, normal S1 and S2, no
murmurs/rubs/gallops
Abd: Soft, non-tender, obese, with normal bowel sounds. Open
areas of abdominal wound on superior and inferior aspects, with
wound VAC in place.
Ext: +1 edema, lower extremities, bilaterally. No joint swelling
Neuro: no focal deficits
Pertinent Results:
[**2134-7-5**] 01:00PM PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2134-7-5**] 10:00PM CALCIUM-8.6 PHOSPHATE-4.2# MAGNESIUM-1.7
[**2134-7-5**] 10:00PM POTASSIUM-4.5
[**2134-7-5**] 11:04PM WBC-14.9*# RBC-4.89 HGB-15.7 HCT-44.6 MCV-91
MCH-32.1* MCHC-35.2* RDW-14.3
[**2134-7-5**] 11:04PM PLT COUNT-189
[**7-6**] CXR: The lung volumes are significantly decreased with the
bibasilar
linear opacitiessis. The bilateral perihilar vessel crowdness
most likely related to poor inspiration effort but underlying
pulmonary edema cannot be excluded.
[**7-7**] CXR: Question early developing opacity in the lingular
segment
[**7-8**] CXR: Worsening left lower lobe/lingular consolidation
suggesting developing infection, pulmonary engorgement
[**7-9**] CXR: Left lower lobe opacities have improved consistent
with improving atelectasis
[**7-9**] US-guided PICC placement: Uncomplicated ultrasound-guided
single lumen PICC line placement via the right cephalic venous
approach. Final internal length is 47 cm, with the tip
positioned in the SVC
[**7-11**] Pathology (gallbladder): Chronic cholecystitis, Hyperplasia
of cholecystic duct lymph node, No calculi in this specimen
[**7-11**] CXR: Low lung volumes, left basilar opacity noted on the
prior examination has resolved in the interim. The lungs are
grossly clear. There is some perihilar fullness of the
pulmonary bronchovasculature.
[**7-11**] Ultrasound of gallbladder: No evidence of gallstone or
pericholecystic fluid or edema identified in the visualized
portion of the gallbladder. Fatty liver.
[**7-11**] Doppler U/S of LE: Normal flow, compressibility, and
augmentations are seen in both common femoral, superficial
femoral, and popliteal veins. No evidence of DVT.
[**7-11**] CXR: Cardiac size is slightly increased accompanied by
increasing vascular engorgement and perihilar haziness, likely
due to worsening edema from volume overload. Small bilateral
pleural effusions.
[**7-11**] ECG: Atrial fibrillation. Possible prior anterior
myocardial infarction based on Q waves in leads V1-V3. Compared
to prior tracing of [**2134-6-21**] ventricular response rate has
increased.
[**7-12**] CXR: No obvious infiltrate or failure, possible small areas
of left
lower lobe atelectasis not excluded.
Brief Hospital Course:
Admitted on [**2134-7-5**] and underwent open Roux-en-Y gastric bypass.
He tolerated the procedure well with no complications. While in
the PACU the patient went into rapid AFib, became hypertensive
(200/100) with heartrate in the 100s. He was subsequently placed
on nitro gtt and lopressor gtt, SBP titrated to 150 systolic.
Vital signs were otherwise stable. He denied chest pain and
shortness of breath. He was placed on dilaudid PCA for pain
management, in addition to thoracic epidural which was placed by
anesthesia in the OR. On POD2, NG tube removed, and patient
started on Stage I bariatric diet following negative Methylene
blue test. Around mid-day on POD2, patient began tachycardic (HR
140s) with O2 sats 87% on room air and was transferred to SICU
for hemodynamic monitoring, heartrate control, and respiratory
monitoring. He received Lopressor 10mg IV with stabilization of
blood pressure and rate control (HR 110s in AFib). He was placed
on 4L oxygen via nasal cannula with improvement in oxygen
saturation to 95%. CXR revealed linear atelectasis in the right
perihilar and left retrocardiac regions, with increased opacity
in the lingular segment, suspicious for developing infiltrate.
No effusion or pneumothorax, although mild tortuosity of the
thoracic aorta. He was placed NPO with IVF at 100cc/hr.
Overnight, heartrate was maintained 99-135 in AFib with
labetolol and lopressor IV. Blood pressure stabilized in
120-150s systolic. On POD3, the patient developed a low grade
temperature, for which blood and urine cultures were sent, and
prophylactic vancomycin and cefepime were started for suspected
pneumonia. He was placed on Stage I diet and coumadin was
re-started for prophylactic AFib management. On POD4, he was
transitioned to Stage II diet, which he tolerated well. On POD5,
he was transferred from the SICU to [**Hospital Ward Name 121**] 9. AFib was stabilized
with heartrate in the 70s-90s on po diltiazem and lopressor. He
was tolerating Stage II diet, with maintainence fluids at
100cc/hr. On POD6, patient developed right sided abdominal pain,
temperature to 101.4, rigors, shortness of breath, and
tachycardia (AFib) to 120-130s. He was immediately transferred
to the SICU. At this time, he was also noted to have wound
erythema, which prompted opening the wound at bedside, with
resulting purulent, brown, foul-smelling fluid expelled. Patient
was unable to undergo CT scan due to weight = 519 pounds. He
received a RUQ ultrasound to evaluate the gallbladder and a
doppler ultrasound of the lower extremities to rule out DVT.
Findings revealed no evidence of gallstone or pericholecystic
fluid or edema identified in the visualized portion of the
gallbladder, and normal flow, compressibility, and augmentations
in both common femoral, superficial femoral, and popliteal
veins, with no evidence of DVT. He was subsequently taken to the
operating room for exploration to washout wound and rule out
possible leak. Intraoperatively, exploratory laparotomy, open
cholecystectomy, and debridement of fascial wound were performed
with no leak found. He was brought back to the SICU
post-operatively intubated and sedated. He was resuscitated,
placed on zosyn and hemodynamics were closely monitored. On
POD7/1, the patient was weaned off propofol and subsequently
extubated with accompanying NG tube removal. Wound cultures
revealed gram negative rods (E.Coli and Enterococcus), for which
zosyn was continued. On POD8/2, temperature was 100.5 and wound
appeared erythematous at the staple line, with serous drainage
at superior and inferior edges. The wound was opened around
these seromas and packed with wet-dry gauze. In addition to
zosyn, vancomycin was added for wound erythema. He was placed on
Stage I diet, and transitioned to Stage II as tolerated. The
patient continued to be in AFib with heartrates in 100-150s. He
was maintained on diltiazem, lopressor, and eventually esmolol
gtt with improvement in HR to 70-90s. On POD [**7-26**] he was
transitioned to Stage III diet. Antibiotics were continued and
aggressive pulmonary toilet was encouraged. Diuresis with Lasix
IV was administered, as appropriate. On POD [**8-26**], the patient's
foley was discontinued and wound erythema was noted to decrease.
On POD [**9-27**], the patient was transferred from SICU to [**Hospital Ward Name 121**] 9 on
telemetry, remained in AFib well-controlled on po diltiazem and
lopressor. On POD [**10-28**] until 15/9, the patient remained on Stage
III diet which he tolerated well, ambulated with the assistance
of physical therapists and nurses, urinated without difficulty,
and reported adequate pain control. He received dressing changes
3x per day with wet-dry gauze in superior and inferior portions
of open wound, covered with dry gauze. JP drain output
progressively decreased, quality was serosanginous. He was
started on his home medications (Lisinopril, Atenolol,
Multivitamin, HCTZ, Coumadin), which he tolerated well. Labs
were checked daily and electrolytes were repleted as
appropriate. Atenolol was changed to Metoprolol 75mg po TID for
elevated heart rate (100s), which since decreased to 80s. A
wound VAC was placed on POD 18/12. Home nursing was arranged
prior to discharge to assist with VAC changes every 3 days and
evaluate for physical therapy. Coumadin was 7.5 mg po daily on
discharge. He will followup with Dr [**Last Name (STitle) 73**] and Dr [**Last Name (STitle) 13983**], in
addition to Dr [**Last Name (STitle) **] following discharge.
Medications on Admission:
Atenolol 100mg po daily
HCTZ 25mg po daily
Coumadin 5mg po qhs
Lisinopril 20mg po daily
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): crush medication.
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
3. Zantac 15 mg/mL Syrup Sig: Ten (10) mL PO twice a day.
Disp:*250 150* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*250 ML(s)* Refills:*1*
5. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
Have INR checked on Monday.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*250 Tablet(s)* Refills:*2*
7. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 caplets* Refills:*2*
8. Outpatient Lab Work
INR, PTT, PT on [**8-1**], [**7-30**]
Follow up with Dr. [**Last Name (STitle) 73**] and Dr. [**Last Name (STitle) 13983**] concerning your INR
and coumadin dosing
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Super obesity with BMI of 62
2. Obstructive sleep apnea
3. Hypertension
4. Atrial fibrillation, chronic
5. Chronic back pain
6. Wound and intradominal abscesses
7. Wound dehiscence
8. Cholecystitis s/p cholecystectomy
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of
breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet:
Stay in Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You will be given a prescription for pain medication, which
may make you drowsy. Do not drive while taking pain medication.
2. You should begin taking a Flintstones chewable complete
ultivitamin. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**9-6**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming. Home nursing will
perform dressing changes daily.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2134-7-28**] 3:15
[**Doctor Last Name **] [**Doctor Last Name 28352**], RD,LDN Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2134-7-28**] 3:30
|
[
"272.4",
"562.10",
"V85.4",
"724.5",
"401.9",
"998.13",
"427.89",
"575.11",
"998.59",
"486",
"278.01",
"998.31",
"427.31",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"93.59",
"96.59",
"93.90",
"51.22",
"44.31",
"86.04",
"83.39"
] |
icd9pcs
|
[
[
[]
]
] |
12567, 12625
|
5940, 11438
|
334, 466
|
12890, 12899
|
3666, 5917
|
14334, 14603
|
2779, 3014
|
11576, 12544
|
12646, 12869
|
11464, 11553
|
12923, 13489
|
3029, 3647
|
272, 296
|
14218, 14311
|
494, 2186
|
13514, 14206
|
2208, 2444
|
2460, 2763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,139
| 196,603
|
429
|
Discharge summary
|
report
|
Admission Date: [**2115-7-2**] Discharge Date: [**2115-7-15**]
Date of Birth: [**2052-5-19**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
back pain, buttock pain and exacerbated leg pain
Major Surgical or Invasive Procedure:
1. Bilateral L3 laminotomies, medial facetectomies and
foraminotomies of the L4 nerve root.
2. Bilateral laminectomy of L5 with medial facetectomy of L4-L5
and foraminotomies bilaterally at the L5 nerve roots.
3. Complex repair and allograft placement of a dural tear.
4. Placement of lumbar drain L1-2.
History of Present Illness:
Mrs. [**Known lastname 1391**] was having anterior quads symptoms and leg
symptoms that were on top of her acute chronic back pain. She
is currently on MS Contin and Neurontin. She is [**8-28**] at rest,
[**9-27**] with activity. However, she is almost 90% back pain and
this is what stops her and not leg pain. She has had
significant benefit from mild ablation in her back previously.
Her thigh pain has certainly settled down on the Neurontin.
Past Medical History:
Asthma
COPD
hypothryroidism
Depression
hyperlipidemia
Social History:
Currently married, smokes cigarettes
Family History:
Colon CA
Physical Exam:
On Discharge:
A+Ox3
NAD
Tmax: 99.2 BP:120/70 P:58 O2:93%
Heart: RRR
Lungs: slight crackles at bases
Abd: soft non-tender
CN 2-12 intact
Extremities:
B/UE is [**4-22**] throughout, SILT, distal pulses intact
B/LE: 5/5 strength, SILT, distal pulses intact
Pertinent Results:
[**2115-7-6**] 02:30AM BLOOD WBC-7.4 RBC-3.05* Hgb-9.6* Hct-29.3*
MCV-96 MCH-31.5 MCHC-32.9 RDW-12.8 Plt Ct-207
[**2115-7-7**] 02:19AM BLOOD WBC-5.8 RBC-3.10* Hgb-9.8* Hct-29.3*
MCV-94 MCH-31.5 MCHC-33.4 RDW-13.1 Plt Ct-207
[**2115-7-8**] 01:25AM BLOOD WBC-7.7 RBC-3.23* Hgb-10.5* Hct-30.6*
MCV-95 MCH-32.6* MCHC-34.3 RDW-12.5 Plt Ct-232
[**2115-7-9**] 02:27AM BLOOD WBC-9.1 RBC-3.23* Hgb-10.3* Hct-30.5*
MCV-94 MCH-31.8 MCHC-33.7 RDW-12.4 Plt Ct-237
[**2115-7-9**] 08:00PM BLOOD WBC-7.9 RBC-3.24* Hgb-10.4* Hct-30.6*
MCV-94 MCH-32.1* MCHC-34.0 RDW-12.4 Plt Ct-233
[**2115-7-10**] 04:30AM BLOOD WBC-7.0 RBC-3.21* Hgb-10.2* Hct-30.5*
MCV-95 MCH-31.8 MCHC-33.5 RDW-12.9 Plt Ct-254
[**2115-7-11**] 04:30AM BLOOD WBC-6.3 RBC-3.43* Hgb-10.8* Hct-31.8*
MCV-93 MCH-31.4 MCHC-33.8 RDW-12.8 Plt Ct-286
[**2115-7-3**] 11:25PM BLOOD CK(CPK)-1588*
[**2115-7-4**] 08:10AM BLOOD CK(CPK)-866*
[**2115-7-3**] 11:25PM BLOOD CK-MB-25* MB Indx-1.6 cTropnT-<0.01
[**2115-7-4**] 08:10AM BLOOD CK-MB-14* MB Indx-1.6 cTropnT-<0.01
[**2115-7-11**] 04:30AM BLOOD TSH-1.5
[**2115-7-11**] 04:30AM BLOOD VitB12-597 Folate-8.7
[**2115-7-7**] 3:04 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2115-7-9**]**
MRSA SCREEN (Final [**2115-7-9**]): No MRSA isolated.
[**2115-7-7**] 3:04 am MRSA SCREEN Source: Rectal swab.
**FINAL REPORT [**2115-7-9**]**
MRSA SCREEN (Final [**2115-7-9**]): No MRSA isolated.
[**2115-7-8**] 8:58 am MRSA SCREEN Source: Rectal swab.
**FINAL REPORT [**2115-7-10**]**
MRSA SCREEN (Final [**2115-7-10**]): No MRSA isolated.
[**2115-7-8**] 8:58 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2115-7-10**]**
MRSA SCREEN (Final [**2115-7-10**]): No MRSA isolated.
[**2115-7-10**] 10:53 am URINE Source: Catheter.
**FINAL REPORT [**2115-7-11**]**
URINE CULTURE (Final [**2115-7-11**]): NO GROWTH.
ECHO [**2115-7-11**]
The left atrium is mildly dilated. There is asymmetric left
ventricular hypertrophy (basal septal wall thickness 2.0 cm).
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is no resting LVOT
obstruction, but with the Valsalva manuever, a small (12 mmHg)
gradient is elicited. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Asymmetric septal left ventricular hypertrophy with
preserved biventricular systolic function. Mild LVOT gradient
with Valsalva maneuver. Moderate pulmonary hypertension.
CT scan head [**2115-7-11**]
1. No acute intracranial pathology.
2. Apparent effacement of the right parietal and temporal sulci
are likely
due to motion and artifact, particularly in light of the
patient's resolving
delirium and lack of focal neurologic deficits. These findings
were discussed
with Dr. [**First Name (STitle) 3646**] [**Name (STitle) 3647**] at 9 p.m. on [**2115-7-10**].
Brief Hospital Course:
Mrs. [**Known lastname 1391**] was admitted for her elective lumbar spine surgery
for spinal stenosis. She was indentified in the holding area
and brought back to the OR for her lumbar decompression. The
procedure was complicated by a large dural tear. She did
tolerate the procedure well. She was then brought to the PACU
and then brought to the general floor. Once on the floor, she
had O2 saturation into the 70-80s with hypercarbic blood gas and
lethergy secondary to her morphine pain meds. Chest radiographs
and symptoms were consistant with CHF. She was given narcan and
transfered to the TSICU and intubated. She remaind in the TSICU
were she was kept intubated for five days. There were no event
in the TSICU and she remained hemodynamically stable. Once
extubated, she was brought to the floor. Once to the floor
medicine was consulted to workup her CHF vs COPD symptoms. She
was d/c'd from morphine and her mental status improved. She did
work with physical therapy. The rest of her hospital course was
unremarkable.
1. CHF- Echo showed asymmetric septal left ventricular
hypertrophy consistant with cardiomyopathy with sinus pause
secondary to sleep apnea.
2. menatl status changes- there was concern for meningitis
concerning her intra-op dural tear and intracranial pathology.
CT was negative for pathology and her status did return once out
of the TSICU and off morphine.
Medications on Admission:
xalatan 2.5ml qhs
advair 250/50
albuterol PRN
gabapentin 300mg TID
morphine 30mg q6hrs
levothyroxine 0.125mcg daily
paroxetine 40mg daily
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Continue till ambulatory.
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Severe lumbar stenosis, L4-L5.
2. Moderate left lateral recess stenosis, L2-L3.
3. Severe back and leg pain.
4. She had dural adhesions to the bone and dural defect found
and identified at the time of surgery.
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Physical Therapy:
Activity as tolerated
Treatments Frequency:
Please change dressing daily. Staples will be removed at post
op visit on [**2115-7-30**]
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3648**] PA-C. You have an
appointment scheduled for [**2115-7-30**] at 09:00am. If you have
questions, please call [**Telephone/Fax (1) **].
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**]
at the next available appointment. You can make this
appointment by calling ([**Telephone/Fax (1) 3650**].
Completed by:[**2115-7-15**]
|
[
"997.09",
"E878.8",
"293.9",
"724.02",
"244.9",
"327.23",
"493.20",
"428.0",
"997.1",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.59",
"96.71",
"03.09",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7687, 7757
|
4857, 6260
|
321, 627
|
8014, 8023
|
1556, 4834
|
9063, 9583
|
1254, 1264
|
6448, 7664
|
7778, 7993
|
6286, 6425
|
8047, 8886
|
1279, 1279
|
8904, 8926
|
8948, 9040
|
1293, 1537
|
233, 283
|
655, 1107
|
1129, 1184
|
1200, 1238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,338
| 103,944
|
45224
|
Discharge summary
|
report
|
Admission Date: [**2208-4-27**] Discharge Date: [**2208-4-30**]
Date of Birth: [**2147-7-28**] Sex: M
Service: MEDICINE
Allergies:
Abacavir / ritonavir / Lyrica
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Chief Complaint: AMS, fever, hypoxia, renal failure
Reason for MICU transfer: AMS requiring intubation
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 60 year old gentleman with a history of HIV last cd4
in [**1-25**] was 783 and VL undetectable who arrives with respiratory
distress, fevers x1day. Also having myoclonic jerks similar to
those seen on two previous admissions, for which no etiology was
found but presumed to be [**12-17**] metabolic derangements. Initial
hypoxic to 60-70's on RA, febrile to 101.8 (R). Labs show new
renal failure. During ED stay, patient remains febrile and
becomes increasingly altered/combative.
.
Of note, patient was most recently admitted for myoclonic jerks
and altered mental status from [**Date range (1) 96656**]. He was found to be
in renal failure, positive opioid tox screen. Renal hypothesized
ritonavir-induced nephrotoxicity was initial insult (ritonavir
crystals in urine), worsened by lisinopril and prerenal azotemia
in setting of insufficient PO intake and diarrhea. On discharge
all HAART was discontinued, as was Lyrica. Morphine and Lyrica
also held during hospitalization. Per OMR, Lyrica and Morphine
were re-prescribed on [**2208-4-7**]. There are no recent notes in OMR
documenting recent healthcare, and his wife could not be reached
by phone in the MICU.
.
In the ED, initial VS were: 101.0 124 124/63 16 74% RA. Initial
physical exam was significant for tremulousness and combative
behavior. Initial labs were signficant for cr 4.9 (baseline
1.2), K+ 4.2, CK 4619, MB 58 and MBI 1.3. LFTs were mildly
elevated with a normal t.bili and lipase. A serum tox screen was
negative and urine tox screen positive for opiates. A lactate
was 1.7. A UA was negative. An EKG demonstrated sinus
tachycardia. Given his elevated CK, MB and troponin (despite
flat MBI and presence of [**Last Name (un) **]), a heparin gtt was started for
empiric management of ACS. Cards recommends continuing to trend
enzymes. His oxygen saturations on arrival were in the 70s which
improved with a non-rebreather. A PE was entertained but could
not be addressed with a CTA [**12-17**] [**Last Name (un) **], thus heparin was further
pursued. A CXR revealed evidence of a pneumonia and given
hypoxia and h/o COPD, he was started on vancomycin and cefepime
for management of a pna and IV solumedrol and albuterol and
ipratropium nebs for a copd exacerbation. He became more
combative over time and the patient was ultimately intubated for
safety after ativan and haldol did not improve his mental
status. An initial ABG demonstrated 7.24/70/93 and subsequent
was 7.24/62/99. Vent settings on transfer were: Fio2 100% PEEP
5, TV 550. An LP was performed and results were pending at the
time of transfer. A CT head demosntrated no findings. He
received 4 L NS prior to transfer. Vitals on transfer: 134/97,
64, 22
.
On arrival to the MICU, vitals are: 98.0 144/105 22 100% (vent
settings: FiO2 50% PEEP 5 TV 550). Patient was agitated and
attempting to self-extubate so was bolused with fentanyl and
midazolam.
.
Review of systems: unable to obtain, patient intubated
Past Medical History:
- COPD: workup on [**11-23**] at [**Hospital1 **] with PFTs, which demonstrated
obstructive deficit with partial reversibility during
bronchodilator testing. FEV1 67% predicted value.
- HIV: diagnosed in [**2194**], no AIDS related complications (CD4 783
and VL undetectable in [**1-24**])
- Hepatitis C (viral load 6,270,000 IU/mL on [**2207-8-12**])
- History of IV drug use.
- Herpes zoster infection with postherpetic neuralgia, on
Morphine and Pregabalin.
- HTN
- Similar episode of myoclonic jerking in fall [**2205**], admitted to
[**Hospital 1263**] Hospital (etiology & treatment unknown), completely
resolved
Social History:
- Tobacco: active smoked w/ 30 pyh - now [**11-17**] cigg/day
- Alcohol: 1 40oz beer on weekends
- Illicits: remote history of polysubstance abuse including
heroin,
cocaine, marijuana, and alcohol
- Housing: lives w/ wife in [**Location (un) 686**]
- Employment: unemployed, preiovusly in contruction - no
asbestos exposure
Family History:
father and sister with asthma
Physical Exam:
On admission:
Vitals: 98.0 144/105 77 22 100% (vent settings: FiO2 50% PEEP 5
TV 550)
General: intubated, sedated, not responsive to painful stimuli
HEENT: Sclera slightly icteric, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Pupils pinpoint, reactive bilaterally. Does not respond
to pain.
Pertinent Results:
On admission:
.
[**2208-4-27**] 12:20PM BLOOD WBC-7.8 RBC-4.49* Hgb-14.0 Hct-44.5
MCV-99* MCH-31.2 MCHC-31.5 RDW-12.7 Plt Ct-128*
[**2208-4-27**] 12:20PM BLOOD PT-10.9 PTT-28.6 INR(PT)-1.0
[**2208-4-27**] 12:20PM BLOOD Glucose-123* UreaN-28* Creat-4.2*# Na-133
K-4.2 Cl-96 HCO3-27 AnGap-14
[**2208-4-27**] 12:20PM BLOOD ALT-63* AST-212* CK(CPK)-4619* AlkPhos-54
TotBili-0.6
[**2208-4-27**] 12:20PM BLOOD CK-MB-58* MB Indx-1.3
[**2208-4-28**] 03:07AM BLOOD CK-MB-31* MB Indx-1.2 cTropnT-0.01
[**2208-4-27**] 12:20PM BLOOD Albumin-4.3 Calcium-7.9* Phos-4.5 Mg-2.1
[**2208-4-27**] 05:20PM BLOOD Type-ART pO2-93 pCO2-70* pH-7.24*
calTCO2-31* Base XS-0
.
lumbar puncture: unremarkable, hsv pcr negative
.
CXR:
IMPRESSION: Patchy new right basilar opacification, which would
perhaps be
compatible with atelectasis associated with persistent elevation
of the right
hemidiaphragm, but pneumonia could also be considered in the
appropriate
setting.
.
CT Head:
IMPRESSION: No acute intracranial process. Prominent mucosal
thickening of the
ethmoidal cells
.
EKG:
EKG ([**4-28**], 0005): sinus tach, no ST changes
EKG ([**4-28**], 0138): sinus rhythm, rate 73, no ST changes
.
Brief Hospital Course:
Hospitalization Summary:
60 year old gentleman with a history of HIV last cd4 in [**1-25**] was
783 and VL undetectable who arrives with respiratory distress
and altered mental status
.
# ALTERED MENTAL STATUS - Patient presented to the ER very
agitated. His wife explained that he had been confused for the
past day. He was intubated for safety after his agitation was
not affected by ativan/haldol administration. On HD#2, he was
extubated and as his renal function improved, he became more
oriented and conversant. His confusion was thought to be
secondary to morphine, lyrica, and other medications
accumulating in his acute renal failure. His Utox was + for
morphine. He had had a similar presentation over the past year.
LP was negative, Head CT negative, and HSV PCR negative.
.
# HYPOXIC HYPERCARBIC RESPIRATORY FAILURE: Patient was hypoxic
on arrival to the ER with O2 sats in the 60s-70s on RA. Initial
ABG (likely on significant O2 nc) showed 7.24/70/93 making
hypercarbic respiratory failure from accumulation of narcotics
in renal failure most likely. He was intubated in the ER for
safety and his hypercarbia and hypoxia improved. He was
extubated on HD#2 and weaned to 2L nc prior to being called-out.
Steroids and antibiotics were intiallly started for possible
COPD exacerbation but these were later discontinued. Home
nebulizers were continued.
.
# ACUTE RENAL FAILURE: Cr was 4.2 on arrival. Acute renal
failure was thought to be pre-renal and it improved dramatically
over 2 days with IVF to his baseline of 1.1. Other causes such
as tenofovir toxicity were also entertained. HAART medications
were initially held but were restarted as Cr returned to
baseline.
.
# TRANSAMINITIS: [**Month (only) 116**] be secondary to his known HCV with high
viral load. [**Month (only) 116**] be med-related: in particular, Raltegravir can
cause elevated LFTs (especially in patients with comorbid
HBV/HCV).
.
# CARDIAC ENZYME ELEVATIONS: Trop was initially elevated to 0.09
w/ MB of 58. These trended down. No concerning EKG changes were
seen.
.
# HTN: The patient was hypertensive on the day he was called out
of the ICU. Labetalol was uptitrated.
.
# HIV: ARVs were restarted as renal function improved - truvada,
raltegravir, and etravirine.
.
DVT prophylaxis was with subcutaneous heparin. Communication
with Wife [**Name (NI) **] [**Name (NI) 96657**] (HCP). [**Telephone/Fax (1) 96658**] or [**Telephone/Fax (1) 96659**].
Code status was Full Code.
Medications on Admission:
-Albuterol 90mcg HFA inhaler 1-2 puffs q4-6 hrs PRN wheeze
-Budesonide-formoterol 160mcg-4.5mcg inh 1 puff [**Hospital1 **]
-Emtricitabine-tenofovir (Truvada) 200mg-300mg tab PO daily
-Etravirine (Intelence) 200mg PO BID
-Isoniazid 300mg PO qHS
-Morphine 100mg PO BID
-Pregabalin (Lyrica) 150mg PO BID
-Raltegravir (Isentress) 400mg PO BID
-Pyridoxine 100mg PO daily
-Lisinopril (dose unknown)
-Cyclobenzaprine (dose unknown)
Discharge Medications:
1. Raltegravir 400 mg PO BID
2. Pyridoxine 100 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
hold for sbp < 100 or map <60
RX *lisinopril 10 mg 1 Tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
4. Isoniazid 300 mg PO HS
5. Etravirine 200 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Morphine SR (MS Contin) 100 mg PO Q12H
hold for sedation or rr < 10
8. Albuterol Inhaler [**11-16**] PUFF IH Q6H:PRN cough/wheeze
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
10. Labetalol 300 mg PO BID
hold for SBP < 120
RX *labetalol 300 mg 1 Tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
Acute renal failure
SECONDARY:
HIV
Hypertension
COPD
HIV neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 96657**],
You presented because of some jerking movements that you have
had in the past. You were admitted to the ICU with respiratory
and renal failure. You were intubated, stabilized, and then
extubated from the breathing machine. After you were given IV
fluids, your kidney fuction improved back to your baseline.
The cause of your jerking movements is not entirely clear; it is
possible that due to the kidney injury there was a buildup of
medications in your blood causing these symptoms. Currently,
this has resolved.
It is very important that you refrain from using unprescribed
medications and illicit drugs, as these can lead to serious
medical issues.
Note that while you were here you had very elevated blood
pressures; your blood pressure regimen was increased.
The following changes were made to your medications:
STOP LYRICA (pregabalin)
STOP CYCLOBENZAPRINE (flexeril)
INCREASE Labetalol to 300 mg twice daily for blood pressure
RESTART Lisinopril 10 mg once daily for blood pressure
Followup Instructions:
Please call Dr.[**Name (NI) 6767**] office at ([**Telephone/Fax (1) 6732**] to schedule an
appointment for within 1 week of discharge. At that visit, you
should have labs checked to ensure that your kidney function is
still fine.
Completed by:[**2208-5-6**]
|
[
"518.81",
"349.82",
"333.2",
"790.4",
"275.3",
"070.70",
"491.21",
"584.9",
"276.2",
"305.90",
"E947.9",
"401.9",
"275.41",
"V08"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9922, 9928
|
6304, 8766
|
393, 418
|
10082, 10082
|
5113, 5113
|
11292, 11553
|
4418, 4450
|
9243, 9899
|
9949, 10061
|
8792, 9220
|
10233, 11269
|
4465, 4465
|
3375, 3413
|
266, 355
|
447, 3356
|
6065, 6281
|
5127, 6056
|
10097, 10209
|
3435, 4057
|
4073, 4402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,333
| 105,358
|
37243
|
Discharge summary
|
report
|
Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-16**]
Date of Birth: [**2125-3-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Neosporin Scar Solution / Bacitracin
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior thoracolumbar fusion with instrumentation
History of Present Illness:
Ms. [**Known lastname 49985**] has a long history of back pain. She has
attempted conervative therapy and surgical therapy but has
developed a flat back syndrome. She is electing to proceed with
surgical correction.
Past Medical History:
PMHx:
hx of afib (currently in sinus rhythm)
TIA X 3, no neuro deficit
spinal stenosis
hx skin cancer
ankle fracture [**3-13**]
PSHx:
anterior portion of surgery yesterday [**2193-5-6**]
D&C
colonoscopy
ear lobe surgery
Social History:
Denies tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2194-6-14**] 05:20AM BLOOD WBC-7.9 RBC-3.38* Hgb-11.1* Hct-30.9*
MCV-92 MCH-32.7* MCHC-35.7* RDW-16.4* Plt Ct-147*
[**2194-6-13**] 05:10AM BLOOD WBC-8.4 RBC-2.77* Hgb-9.2* Hct-25.4*
MCV-92 MCH-33.4* MCHC-36.5* RDW-16.7* Plt Ct-143*
[**2194-6-12**] 12:51AM BLOOD WBC-7.5 RBC-3.27* Hgb-10.6* Hct-29.3*
MCV-90 MCH-32.5* MCHC-36.3* RDW-17.6* Plt Ct-105*
[**2194-6-11**] 04:00PM BLOOD WBC-6.1 RBC-3.21* Hgb-10.7* Hct-29.8*
MCV-93 MCH-33.3* MCHC-35.9* RDW-17.2* Plt Ct-134*
[**2194-6-10**] 05:20AM BLOOD WBC-7.2 RBC-2.63*# Hgb-9.3* Hct-25.9*
MCV-99*# MCH-35.3*# MCHC-35.8* RDW-12.9 Plt Ct-160
[**2194-6-13**] 05:10AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
[**2194-6-12**] 12:51AM BLOOD Glucose-241* UreaN-21* Creat-0.8 Na-139
K-4.6 Cl-107 HCO3-24 AnGap-13
[**2194-6-10**] 05:20AM BLOOD Glucose-186* UreaN-23* Creat-1.0 Na-139
K-5.0 Cl-104 HCO3-28 AnGap-12
[**2194-6-13**] 05:10AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.6
Brief Hospital Course:
Ms. [**Known lastname 49985**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2194-6-9**] and taken to the Operating Room for L5-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T9-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the SICU in a
stable condition. Postoperative HCT was low and she was
transfused PRBCs with good effect. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery remained in
place until postop day one. She was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#3 from the second procedure.
She was fitted with a TLSO brace. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
HCTZ
quinapril
simvastatin
escitalopram
metoprolol
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] of [**Location (un) 1821**]
Discharge Diagnosis:
Thoracic kyphosis
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are out of bed. You may take it off while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: as tolerated
Thoracic lumbar spine: when OOB
Must have TLSO brace when out of bed.
Treatment Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2194-6-16**]
|
[
"V12.54",
"E878.1",
"738.5",
"737.19",
"427.31",
"285.1",
"722.52",
"996.49",
"733.13",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.64",
"84.52",
"03.90",
"84.51",
"81.62",
"80.99",
"81.35",
"81.06"
] |
icd9pcs
|
[
[
[]
]
] |
4881, 5005
|
2437, 3971
|
324, 386
|
5098, 5104
|
1466, 2414
|
7249, 7328
|
926, 931
|
4072, 4858
|
5026, 5077
|
3997, 4049
|
5128, 5234
|
946, 1447
|
7060, 7158
|
5270, 5463
|
275, 286
|
5499, 5930
|
5942, 7042
|
414, 633
|
7179, 7226
|
655, 877
|
893, 910
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,028
| 181,142
|
4362
|
Discharge summary
|
report
|
Admission Date: [**2144-10-26**] Discharge Date: [**2144-10-30**]
Date of Birth: [**2093-7-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 51-year-old male with
history of diabetes and gastroesophageal reflux disease and
metastatic renal cell cancer who underwent a thoracotomy with
biopsy in [**2144-2-23**]. He was treated with a vaccine for
renal cell carcinoma at that time. The patient now presents
with a large left hilar mass.
PAST MEDICAL HISTORY: Significant for right nephrectomy in
[**2125**] for renal cell cancer, he is diabetic, gastroesophageal
reflux disease as well as depression.
SOCIAL HISTORY: Tonsillectomy, right knee surgery in [**2136**],
right nephrectomy in [**2135**] and a right flank mass excision in
[**2137**].
MEDICATIONS ON ADMISSION:
1. Paxil 20 mg p.o. q day.
2. Prilosec 20 mg p.o. q day.
3. Amaril 2 mg half tab p.o. q Am.
4. Ambien 5 mg p.o. q h.s.
ALLERGIES: Contrast dye.
PHYSICAL EXAMINATION: On presentation was noted for neck
supple, there was no lymphadenopathy. His lungs were clear
to auscultation bilaterally. His heart was regular rate and
rhythm. Abdomen soft, nontender, nondistended. He had an
old right nephrectomy incision subcostal margin that was well
healed. Extremities showed no evidence of edema.
He had admission labs with white count 7,000, hematocrit of
25.8, platelet count 619, coagulation profile 12. PT/INR
1.1, PTT 28, albumin 3.4. Chemistries within normal limits
with a normal BUN and creatinine.
He was therefore, taken to the operating room on [**2144-10-26**]
where he underwent a radical pneumonectomy with an
inter-pericardial approach. After that time the patient was
sent to the Intensive Care Unit for postoperative care. On
postoperative day 0 the patient was doing well, his
cardiovascular profile was being supported with
Neo-Synephrine drip. His urine output was noted to be
somewhat decreased, he was started on Digoxin for atrial
fibrillation prophylaxis. His postop hematocrit was 25 and
he was therefore transfused a unit of blood with low urine
output although his preoperative crit was also 25. Post
transfusion crit subsequently came back at 32 and he did have
inappropriate response to urine output. Preoperative heart
rate was noted to be 104 and sinus tach with no ischemic
changes. No strain pattern.
Postoperatively he was persistently tachy between 104 to 117.
All of the parameters for pain, anxiety, hypoxia, hypercarbia
were all optimized to eliminate the possible underlying
[**Doctor Last Name 360**].
The patient was maintained on epidural as well as had a Foley
catheter to gravity. By postop day one he was doing well,
Neo-Synephrine was weaned, Digoxin was maintained for
prophylaxis for atrial fibrillation. He was given chest
physical therapy, incentive spirometry and his chest tube was
to suction. He was transferred to the floor subsequent to
that and put on Protonics for gastrointestinal prophylaxis.
He was started on a sliding scale, Amaril as started on
postoperative day two, his creatinine was noted to rise to
about 1.4 from a baseline of 1. Urine output was marginal
however, given an intermittent bolus of normal saline he
responded appropriately.
By postoperative day two the patient had a chest tube
removed, he had no pneumothorax by postop chest x-ray. There
was no air fluid level on the left chest. The right chest
was well expanded with no pneumo as previously stated, there
was some basilar atelectasis noted however, no effusion.
The patient continued aggressive pulmonary toilet including
incentive spirometry, coughing and deep breathing and
nebulizer treatments p.r.n. with the respiratory therapy
service and early mobilization with good pain control.
By postop day three the patient had his epidural removed,
Foley catheter taken out, he was started on oral analgesics
with Percocet as needed. He was ambulatory and afebrile.
On postop day four the patient's post transfusion crit was
recorded as 28 and stable, therefore, he was deemed
appropriate for discharge at this time. He will be sent home
on the following discharge medications: He will resume all
of his preop meds as well as addition of Percocet 5/325 mg
one to two tabs p.o. q 4 hours as needed. Lopressor 12.5 mg
q b.i.d., He will also be on a stool softener, Colace 100 mg
b.i.d. as well as Percocet. He will continue his Amaril,
Ambien an Paxil as well as Prilosec as previously stated.
CONDITION ON DISCHARGE: Stable. Afebrile. Sating at 96%
His exam is noted for a well approximated incision with no
staples, no erythema or exudate across the left hemithorax.
The right chest was clear to auscultation with occasional
crackles at the base. Heart was regular and his extremities
had no edema, warm and well perfused.
DISCHARGE STATUS: To go to home.
DISCHARGE DIAGNOSIS:
1. History of metastatic renal cell carcinoma.
2. Status post radical left pneumonectomy with
inter-pericardial approach for a large left hilar
mass. Final pathology is pending at time of discharge.
The patient will see Dr. [**Last Name (STitle) 175**] in the clinic one week from
discharge.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2144-10-30**] 10:31
T: [**2144-10-30**] 10:47
JOB#: [**Job Number 18816**]
|
[
"197.0",
"V10.52",
"311",
"997.1",
"530.81",
"250.00",
"427.89",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.5",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4149, 4466
|
4857, 5446
|
808, 959
|
982, 4125
|
162, 470
|
493, 636
|
653, 782
|
4491, 4836
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.