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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
19,585
| 118,860
|
16488+56772
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-12-21**] Discharge Date: [**2116-12-29**]
Date of Birth: [**2047-7-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old
gentleman transferred from [**Hospital 46855**] Hospital secondary to
decrease in level consciousness at a nursing home. The
patient was found by his sister on [**12-3**] with decrease
responsiveness. He had been previously moving on his own at
baseline taking care of himself. He was admitted to [**Hospital2 **]
[**Hospital3 6783**] Hospital in [**Last Name (un) 45671**] and diagnosis was unclear
whether he had a glioblastoma versus a stroke. An MRI and a
CT with contrast there, but the diagnosis was unclear.
Diagnostic workup. The patient was to follow up as an
outpatient with a repeat scan in a few weeks. The patient
was also treated with steroids, but they were discontinued on
arrival to the nursing home. Over the last several days the
patient's mental status decreased and he became less
responsive. He was intubated at [**Hospital 46855**] Hospital and
transferred to [**Hospital1 69**] for
further evaluation.
On arrival te patient's blood pressure was 123/72. Pulse 76.
Respiratory rate 14. Sat 98%. He was intubated and
breathing spontaneously on the ventilator. He did not follow
commands. He withdrew all extremities to stimulation. He
had positive dolls eyes with decreased corneals bilaterally.
Pupil on the right was 1.5 to 1, on the left was 2 to 1.5 and
sluggish. Deep tendon reflexes were 2 out of 4. His toes
were up going bilaterally.
PAST MEDICAL HISTORY: Peripheral vascular disease status
post femoral popliteal bypass graft, diabetes, hypertension,
atrial fibrillation, and chronic obstructive pulmonary
disease.
CT from the outside hospital showed large amount of mass
effect and edema on the left side with question of early
herniation.
HOSPITAL COURSE: The patient was seen by Dr. [**First Name (STitle) **] on
[**2116-12-22**]. He had an MRI with gadolinium, which showed
evidence of a left frontal irregular enhancing lesion with
mass effect involving the basal ganglion and asymmetric
ventricles. The patient will be going to the Operating Room
for evacuation of this tumor. On [**2116-12-23**] underwent a left
frontal parietal craniotomy for resection of what looked like
a glioblastoma. Postoperative vital signs were stable. He
was intubated and opening his eyes to voice. His right eye
he uses. His left he has a ptosis. Pupils down to 1.5 on
the right, 2 down to 1.5 on the left. He does not follow
commands. He has a left ptosis. He has increased tone in
the left upper extremity, flaccid right upper extremity. He
moves bilateral lower extremities spontaneously. He is
actually purposeful in the left upper extremity and
hemiplegic on the right side and his neurological examination
has been stable postop. He is seen by physical therapy and
occupational therapy and found to require a rehab stay.
The patient is stable. He will be weaned down to 4 q 6 of
Decadron over a two to three day period. His vital signs
remained stable. His other medications include Dilantin 100
mg intravenous q 8 hours, which will be changed to po and
Protonix 40 mg po q day along with Decadron 6 mg po q 6 hours
for two days and then down to 4 q 6 and stay at that dose.
He will follow up with Dr. [**First Name (STitle) **] in one to two weeks for follow
up. The staples should be removed on postop day number ten.
His condition was stable at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2116-12-29**] 09:37
T: [**2116-12-29**] 09:43
JOB#: [**Job Number 46856**]
Name: [**Known lastname 8647**], [**Known firstname 33**] Unit No: [**Numeric Identifier 8648**]
Admission Date: [**2116-12-21**] Discharge Date: [**2116-12-31**]
Date of Birth: [**2047-7-14**] Sex: M
Service:
ADDENDUM: Discharge summary was originally dictated on
[**2116-12-29**]. The patient's discharge was delayed until [**2116-12-31**]
due to lack of rehabilitation bed. The patient's condition
remained stable and he was neurologically at his baseline
with a right hemiparesis. He was transferred to
rehabilitation to have follow up with Dr. [**First Name (STitle) 24**] in one to two
weeks's time.
[**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern4) 920**], M.D. [**MD Number(1) 921**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2117-2-11**] 12:37
T: [**2117-2-11**] 12:55
JOB#: [**Job Number 8649**]
|
[
"191.1",
"401.9",
"427.31",
"438.20",
"250.00",
"374.31",
"496",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"01.59",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1901, 4737
|
162, 1572
|
1595, 1883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,652
| 173,654
|
39303
|
Discharge summary
|
report
|
Admission Date: [**2172-11-18**] Discharge Date: [**2172-11-27**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Evaluation for IR procedure for LGIB of unknown etiology
Major Surgical or Invasive Procedure:
1. Upper endoscopy
2. Colonoscopy
3. CT Angiography
4. Tagged RBC Scan
5. Bilateral lower extremity ultrasound
6. Infrarenal IVC filter placement
History of Present Illness:
Ms. [**Known lastname 13144**] is a 87-year old woman with history of CAD CHF and
previous history of internal hemorrhoids transferred from OSH
for 3 days of LGIB. She initially presented on [**11-15**] from an
[**Hospital3 **] facility with an episode of BRBPR in her
bathroom to [**Hospital **] hospital, with an initial Hct of 31.9. Ms.
[**Known lastname 13144**] was hemodynamically stable and admitted to the floor
where she sustained a gradual drop in her Hct (naidr 22.9) and
platelets (89K) and subsequently transfused and. She received a
colonoscopy that demonstrated old/fresh blood throughout colon
with diverticular disease most pronounced on the left. The
bleeding source could not be identified. She continued to bleed
and was then transferred to the ICU.
.
On the morning [**2172-11-17**], Ms. [**Known lastname 13144**] received a tagged RBC scan
that demonstrated no active bleeding. Later that day, she began
to bleed again and a repeated tagged RBC scan (11hrs post
contrast) showed diffuse activity throughout the colon with the
most likely origin near the hepatic flexure. (Poor localization
of bleeding by tagged RBC scan is noted). Concerned about the
risks major surgery, GI and surgery at [**Location (un) **] thought IR might
a good therapeutic option.
.
Ms. [**Known lastname 13144**] was therefore tranfered to the [**Hospital1 **] for evaluation
for possible IR. At the time of transfer, SBP ranged 110s-120s,
HR 80s, O2 Sat 98-100% 2L NC. She had one episode of tachycardia
for which she received a single dose of a beta blocker (her home
beta blocker had been held up to this point).
.
<strong> Summary of events and interventions at OSH: 6 units
PRBCs, 1 unit plts, intermittent episodes of BRBPR (~300cc in
total) during transfer. Cause of bleeding unclear. OSH Hct 22 ->
27 </strong>
.
On [**2172-11-18**], at arrival at [**Hospital1 18**] she was calm and in no acute
distress. MICU ([**2172-11-18**] - [**2172-11-21**]) interventions events: 2 units
PRBC, intermittent episodes of bloody BMs, imaging studies (EGD,
colonoscopy, angiography) inconclusive.
.
# [**2172-11-18**]
- 1 unit PRBCs (Hct 28.1 --> 28.5 --> 28)
.
# [**2172-11-19**]
- Tachycardic to 120s, treated with diltiazem 5mg, HR decreased
to 60s but pt remained in Afib
- NG lavage w/traumatic epistaxis (Pt became tachycardic to
120s, treated with diltiazem 5mg, HR decreased to 100)
- EGD: Erythema in the pre-pyloric region. Otherwise normal EGD
to third part of the duodenum.
- Colonscopy: 2 large sigmoid nonbleeding diverticuli, sigmoid
1.4cm flat polyp. More blood in left colon than right colon. No
source of bleeding within the colon was identified
- Maroon BM w/stable Hct (26-28)
.
# [**2172-11-20**]:
- Hct AM 24.4 in setting of bloody BM -> 1uPRBC -> Hct 29.9; Hct
remained stable
- Angiography: No sign of active bleeding
- Stools: 3 bloody BL prior
.
Prior to transfer from the ICU, vital signs were Tmx: 98.9 Tcur:
98.2
HR 77 BP 115/52 (110-144/42-106) RR 21 (14-28) O2 Sat 97% on RA.
.
Upon arrival to the floor, Ms. [**Known lastname 13144**] reports no acute
distress, however, she does report feeling somewhat lightheaded.
Her mental status has been stable. She had 1x bloody bowel
movement approximately <150 ml. Her Hct has remained stable at
27.6. Since her initial presentation at [**Location (un) **] and arrival to
the floor, she has received a total of 10 units PRBCs.
.
Past Medical History:
- Coronary artery disease
- GERD
- Internal hemorrhoids
- ? CHF (baseline EF unknown)
- Interstitial lung disease
- Hypertension
- Benign positional vertigo (recurrent)
- Left bundle branch block
- Urinary urgency with incontinence
- Panic attacks
- Essential tremor
- Osteoarthritis
- Sinusitis
Social History:
Widowed. Moved from [**State 108**] recently.
- Tobacco: None
- Caffeine: 2 cups of coffee per day
- Alcohol: None currently, drank 1 drink per day prior to [**6-/2172**]
hospitalization
- Illicits: Denies illicit drug use
Family History:
Noncontributory
Physical Exam:
ON ADMISSION:
Vitals: afebrile 125/50 81 18 100/3L
General: Alert, oriented, c/o mild abdominal pain, acutely aware
of bowel movements, no acute distress
HEENT: Sclera anicteric, dry MM
Neck: no JVP elevation, collapsable on U/S exam
Lungs: Sparse scattered crackles but otherwise clear
CV: RRR, II/VI SEM
Abdomen: soft, mildly diffusely tender, non-distended, +BS, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: cold but with palpable pulses, no edema
Skin: dry, pale
Rectal: ~[**1-18**] cup of maroon liquid stool
AT DISCHARGE:
97.1 afebrile 136/60 (90-136/60s) 75 (65-86) 20 95% RA
General Appearance: Well nourished, no acute distress, wrapped
up in a blanket
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mmm
Neck: No JVP elevation
Lungs: CTAB, wheezing much improved (just had an ipratropium neb
per pt), good inspiration no accessory muscle use, no rhonchi,
or rales
CV: RRR (not tachy or irreg sounding this AM), II/VI SEM, no
carotid bruits appreciated.
Abdomen: Soft, non tender, non-distended, +BS, no rebound
tenderness or guarding
Ext: WWP; +1 edema, some discomfort with squeezing but otherwise
improvd
Skin: Dry, pale. Limited skin exam.
Pertinent Results:
On admission:
[**2172-11-18**] 04:30AM BLOOD WBC-7.7 RBC-3.12* Hgb-9.8* Hct-26.9*
MCV-86 MCH-31.4 MCHC-36.3* RDW-17.2* Plt Ct-114*
[**2172-11-18**] 04:30AM BLOOD Neuts-76.8* Lymphs-18.0 Monos-4.0 Eos-0.8
Baso-0.4
[**2172-11-18**] 04:30AM BLOOD PT-12.9 PTT-27.2 INR(PT)-1.1
[**2172-11-18**] 04:30AM BLOOD Fibrino-174
[**2172-11-18**] 04:30AM BLOOD Glucose-113* UreaN-18 Creat-0.3* Na-140
K-3.9 Cl-109* HCO3-29 AnGap-6*
[**2172-11-18**] 10:28AM BLOOD CK-MB-3 cTropnT-<0.01
[**2172-11-18**] 04:30AM BLOOD Calcium-7.2* Phos-1.8* Mg-2.0
[**2172-11-18**] 08:33AM BLOOD Type-MIX pH-7.28* Comment-GREEN TOP
[**2172-11-18**] 08:33AM BLOOD Lactate-1.4
[**2172-11-18**] 08:33AM BLOOD freeCa-1.05*
.
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2172-11-27**] 06:12 6.4 3.34* 10.4* 30.1* 90 31.0 34.4 17.4*
130*
.
STUDIES:
# ECG [**2172-11-18**]:
Normal sinus rhythm. Complete left bundle-branch block. Low
voltage in the
lateral precordial leads. Frontal plane axis at minus 25
degrees. No previous tracing available for comparison.
.
# TTE [**2172-11-18**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal biventricular systolic function. Moderate tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
.
# CT Abdomen/pelvis [**2172-11-18**]:
<I>CT Abdomen w/ & w/o Intravenous Contrast</I>
There is dependent atelectasis at the lung bases, without
nodule, mass,
consolidation, or pleural/pericardial effusion. There is a
moderate hiatus
hernia.
.
The liver is normal in size and attenuation. There are no focal
liver lesions identified. The hepatic vasculature is widely
patent. Incidental note is made of a replaced right hepatic
artery, arising from the SMA. There is no intra- or
extra-hepatic biliary ductal dilation. The gallbladder is
unremarkable.
.
The spleen is normal in size. Pancreas enhances homogeneously.
The main
pancreatic duct is mildly prominent, measuring 3 mm, but there
are no
obstructing mass lesions identified. There are no adrenal
nodules or masses. Kidneys enhance symmetrically. Punctate
hypodensities, cortically based are noted within the right
kidney, too small to characterize though likely representing
cysts. There are no enhancing renal mass lesions. There is no
nephrolithiasis or hydronephrosis.
.
Accounting for hiatus hernia, the stomach, duodenum, and
intra-abdominal loops of small bowel are normal. There is no
bowel distention, and there is no bowel wall thickening. The
colon is similarly unremarkable. Scattered sigmoid diverticula
are noted, without evidence of acute diverticulitis. There is no
active extravasation identified within the gastrointestinal
tract to localize the patient's source of bleeding.
.
The aorta is atherosclerotic, but normal in caliber. There is
narrowing at
the origin of the celiac axis, though the celiac artery remains
patent, and there is no post-stenotic dilation. The SMA and [**Female First Name (un) 899**]
are well opacified. Single renal arteries are patent
bilaterally. The common, external, and internal iliac arteries
are patent, as are the visualized portions of the common,
superficial, and deep femoral arteries. Visualized deep veins
are similarly normal.
.
There is no free fluid or free air in the abdomen. There is no
mesenteric or retroperitoneal adenopathy.
.
<I>CT Pelvis w/ & w/o Intravenous Contrast</I>
Bladder is decompressed by a Foley catheter. Uterus is
unremarkable, and
there are no adnexal masses. Multiple phleboliths are noted.
There is no
free fluid in the pelvis, and there is no pelvic or inguinal
adenopathy.
.
BONE WINDOWS: Extensive degenerative change is identified in the
visualized thoracolumbar spine. A non-aggressive lucent lesion
in noted in the L4 vertebral body, without suspicious lytic or
sclerotic osseous lesion
.
IMPRESSION:
1. No active extravasation identified within the
gastrointestinal tract.
Sigmoid diverticulosis is noted, but there is no definite source
of
gastrointestinal hemorrhage is identified.
2. Small hiatus hernia.
3. Replaced right hepatic artery, arising from the SMA.
4. Moderate stenosis at the origin of the celiac artery.
.
# Chest (Portable AP) [**2172-11-18**]:
Heart size top normal. Elevation of right hemidiaphragm probably
due to
eventration. Lungs grossly clear. No pleural effusion. Healed
fracture
posterior left middle rib should not be mistaken for a lung
nodule.
.
# Colonoscopy [**2172-11-19**]:
Findings:
- Contents: Red blood was seen in the entire colon, more in the
left colon than in the right. There was no blood in the terminal
ileum.
- Protruding Lesions: A single sessile 14 mm polyp was found in
the descending colon. This was not removed given current
bleeding. A single sessile 5 mm polyp was found in the sigmoid
colon. This was not removed given current bleeding.
- Excavated Lesions: A few diverticula with large openings were
seen in the sigmoid colon.
.
Impression: Blood in the colon
Diverticulosis of the sigmoid colon
Polyp in the descending colon
Polyp in the sigmoid colon
Otherwise normal colonoscopy to terminal ileum
.
Recommendations: No source of bleeding within the colon was
identified.
If recurrent bleeding immediate angiography.
.
# Upper endoscopy [**2172-11-19**]:
Findings: Esophagus: Normal esophagus.
Stomach: Mucosa - Erythema of the mucosa was noted in the
pre-pyloric region.
Duodenum: Normal duodenum.
.
Impression: Erythema in the pre-pyloric region
Otherwise normal EGD to third part of the duodenum
.
Recommendations: No upper GI source of bleeding found
.
# Chest XRay [**2172-11-22**]
FINDINGS: Thoracolumbar levoscoliosis, mild cardiomegaly,
tortuosity of the descending thoracic aorta are unchanged since
[**2172-11-18**]. Lung volumes are decreased. There is no evidence of new
consolidation or effusion.
.
IMPRESSION:
1. No evidence of pneumonia.
2. Decreased lung volumes.
.
# EKG [**2172-11-22**]
Probable atrial fibrillation with rapid ventricular response.
Left
bundle-branch block. Since the previous tracing of [**2172-11-20**] sinus
rhythm has been replaced by probable atrial fibrillation.
.
# TAGGED RED BLOOD CELL: GI Bleeding Study [**2172-11-24**]
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen were obtained for 2 hours. A left lateral view of the
pelvis was also obtained. Blood flow images show no evidence of
GI bleeding. Dynamic images show no evidence for active
gastrointestinal bleeding two hours after injection. The study
was terminated at this point due to patient request.
.
# Bilateral Lower Extremity Ultrasound
Grayscale and Doppler examination of the right and left common
femoral, superficial femoral, popliteal and calf veins were
performed. There is occlusive thrombus within the right peroneal
vein and non-occlusive thrombus within the right posterior
tibial vein. The right popliteal, superficial femoral and common
femoral veins are patent with normal compressibility and
respiratory variation in flow. There is also a
large 5.6 x 3.1 x 1.9 cm [**Hospital Ward Name 4675**] cyst in the right popliteal
fossa.
.
Within the left leg, there is non-occlusive thrombus within one
of the deep intramuscular veins of the posterior calf, possibly
the gastrocnemius vein. The other deep veins including the left
common femoral, superficial femoral, popliteal, peroneal and
posterior tibial veins are patent with normal compressibility
and respiratory variation and flow.
.
Brief Hospital Course:
87 year old woman with history of [**Hospital **] transferred from OSH for
evaluation for IR procedure for LGIB of unclear exact source. No
fevers, leukocytosis.
.
# LGIB: Pt presented to OSH with LGIB and Hct lowest at 22.9.
She was transfused 6units PRBCs at OSH. Colonoscopy and imaging
there had suggested colonic origin. She was transferred to
[**Hospital1 18**] where CT abdomen/pelvis revealed sigmoid diverticulosis
but no active extravasation. She underwent colonoscopy under
anesthesia that revealed diverticulosis of sigmoid colon and
polyps in descending and sigmoid colon but did not identify site
of bleeding. NG lavage returned bright red blood. Endoscopy
was performed that again did not identify bleeding. She
required 4 additional units of PRBCs during ICU course for Hct
below 25. She continued to have multiple episodes of dark
maroon colored output from rectum. She was taken for CT
angiography that was also negative for active extravasation.
After all these procedures and her last unit of transfused
PRBCs, Hct remained stable at 27-29 and she was transferred to
the floor at that point. Surgery consult team was made aware of
the patient how given inability to localize bleeding no surgical
intervention was recommended. Pt continued to ooze initially
while on the floor and require additional unit of blood for a
total of 11units during her stay. Tagged red blood cell scan
failed to localize the bleeding. Pt's bleeding improved and
stool changed from maroon to brown w/out evidence of frank
blood. HCT stablized and was 30-32 at time of discharge. GI
follow-up is planned as outpt.
.
# DVT: On the floor, pt complained of leg pain. On exam was
tender to palpation and legs showed +1 edema. LENIS was performe
and demonstraed b/l dvts. Because of continued bleed, the pt
could not receive anticoagulation so a IVC filter was placed
w/out complications.
.
# CAD: Pt's history of CAD was unclear. She had known LBBB, Q
waves on EKG. Pt does not believe any past AMI. Denies any chest
pain or new onset SOB. Metoprolol and aspirin were initially
held in setting of GIB. Metoprolol was eventually restarted
along with diltazem (see below) given afib. Isosorbide
mononitrate continued to be held given concern over bleeding and
risk of hypotension.
.
# CHF: TTE performed at admission showed preserved EF > 55% and
mild symmetric left ventricular hypertrophy with normal
biventricular systolic function, moderate tricuspid
regurgitation, and moderate pulmonary artery systolic
hypertension. Home triamterene and HCTZ were held during ICU
stay due to LGIB. These need for restarting these [**Hospital1 4085**]
will need to be re-evaluated as an outpt as the pt recovers.
Currently blood pressure is stable on metoprolol 25mg TID and
diltizem 30mg QID.
.
# Rapid afib: In the ICU, HR increased to 120s on HD2; she was
given one time dose of diltiazem 5mg which decreased HR to 60s
but pt remained in afib. She was given low dose beta blocker and
converted back to sinus rhythm. On the floor, pt had 2 episodes
of afib w/RVR which required pushing of IV diltiazem and support
with IV fluids given low blood pressure. Rates were in the 160s
and pt was becoming hypotensive; on heart rate measure showed
rate of 207 but repeat was in the lower 100s. Pt broke and
returned to sinus with IV diltazem. Pt was eventually placed on
a regimen of 25mg metoprolol TID and 30mg Diltiazem QID; this
may need to be adjusted and she recovers.
.
# ?Sleep apnea: Oxygen saturation in high 90s on room air but
fell to 80s while asleep. She preferred to sleep w/O2 at night
which improved sats. She should be assessed with sleep study as
outpatient.
.
# Interstitial lung disease: Pt had unclear history of
interstitial lung disease and had been on low dose prednisone at
home. This was held during ICU course and continued to be held
on the floor due to bleeding concerns. Pt also had some wheezing
and coarse lung sound whihc improved w/nebulizer treatments.
Howver, albuteol could not be used b/c of afib so ipratropium
was used. Will need to reassess as outpt the need for
prednisone.
.
# Urinary retention: Patient is being treated for urinary
urgency with incontinence. She had an episode of urinary
retention for ~8hrs in which she was found to have 750 mL of
urine in her bladder. This resolved without intervention with a
post-void volume of ~300 mL.
.
Pt has GI follow-up planned.
Pt is going to rehab facility to complete recovery and then will
return to her [**Hospital3 **] facility.
.
Medications on Admission:
HOME MEDS:
- Metoprolol succinate, 25 mg SR, 1 tablet daily
- omeprazole, 20mg EC 1 capsule PO daily
- prednisone, 5 mg tab PO daily
- isosorbide mononitrate, 30 mg tab SR 24 hr QHS
- sertraline, 50 mg tab 1 tab PO daily
- tolterodine, 4 mg Capsule SR 1 PO daily
- triamterene-hydrochlorothiazide, 37.5 mg-25 mg, 1 tablet PO
MWF
- ibandronate, 150 mg tablet monthly
- fluticasone, 50 mcg Spray, suspension, 2 sprays nasal daily
- pyridoxine 100 mg tab PO daily
- ascorbic acid, 500 mg SR daily
- calcium carb-D3-mag cmb11-zinc 333 mg-200 unit-[**Unit Number **] mg-5 mg 1
tab daily
- cholecalciferol (vitamin D3), 400 unit daily
- cyanocobalamin (vitamin B-12), 1,000 mcg tablet SR daily
- ginger (zingiber officinalis), 500 mg capsule daily
- naproxen 250 mg tablets, unknown dose
- omega-3 fish 1 tablet PO QAM
- omega-3 fatty acids-vitamin E 1,000 mg (120 mg-180 mg) capsule
daily
.
MEDICATIONS At TRANSFER TO [**Hospital1 18**]
- Nexium 40mg IV BID
- Lopressor 2.5mg Q4H prn HR > 110
- Flonase 2 sprays [**Hospital1 **]
.
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days: 6 day course to be completed on [**11-28**] (last day of abx).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing, SOB.
9. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
10. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
lower GI bleed from unknonw source
hypotension
anemia due to acute blood loss
atrial fibrillation w/rapid ventricular rate
.
Secondary:
bilateral DVT requiring placement of an IVC filter
UTI
GERD
Interstitial lung disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you were having
bleeding from your lower gastrointestinal track. You needed to
be admitted to the ICU because of the extent of your bleeding
and the need for significant blood transfusions and blood
pressure support. Multiple attempts were made to determine the
source of the bleeding including a colonoscopy and a special
imaging scan. Unfortunately, we could not identify the source of
your bleeding. However, you were given multiple units of blood
and were stablized in the ICU. Your condition improved and you
were able to be moved out of the ICU to the regular medicine
floor. Your bleeding slowed and finally stopped. However, while
on the medicine floor, you had several episodes of a fast
irregular heart beat called atrial fibrillation which resulted
in low blood pressure. Medications were given to control your
heart rate so that it would go at normal rate and your blood
pressure improved. In addition, you had lower leg pain. A
special ultrasound was performed which showed that your had
clots in both of your legs. Ususually this would be treated with
anticoagulation [**Location (un) 4085**]; however, you could not receive these
medications while you were in the hospital because of your
bleeding. To prevent the clots from moving into your heart and
lung, a special filter was placed in the vein leading to your
heart. You were also found to have a urinary tract infection and
were treated with antibiotics. Your condition improved and you
were able to be discharge to a rehabiliation facility to
complete your recovery.
.
The following changes were made to your medications:
- Please START taking metoprolol succinate 75mg daily.
- Please START taking diltaziam XR 120mg daily.
- Please START taking pantoprazole 40mg daily instead of
omeprazole
- Please complete a 6 day course of Ciprofloxacin 500 mg daily
to be finished on [**2172-11-28**].
- Please continue using Ipratropium nebulizers to help with your
wheezing every 6hrs.
- Please STOP taking your prednisone. You will need to speak to
your doctors regarding this [**Name5 (PTitle) 4085**] change and whether or not
you should restart or stop this [**Name5 (PTitle) 4085**].
- Please STOP taking isosorbide mononitrate. You will need to
speak to your doctors regarding this [**Name5 (PTitle) 4085**] change and
whether or not you should restart or stop this [**Name5 (PTitle) 4085**].
- Please STOP taking triamterene-hydrochlorothiazide. You will
need to speak to your doctors regarding this [**Name5 (PTitle) 4085**] change
and whether or not you should restart or stop this [**Name5 (PTitle) 4085**].
- Please STOP taking naproxen, aspirin, ibuprofen or any other
NSAIDS you may take over the counter (you can take tylenol for
pain).
- Please continue to take all of your other home medications as
prescribed.
Please be sure to take all [**Name5 (PTitle) 4085**] as prescribed.
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **], cardiologist and other health care
providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
.
Followup Instructions:
You will need to speak to your doctors regarding this [**Name5 (PTitle) 4085**]
change and whether or not you should restart or stop this
[**Name5 (PTitle) 4085**].
.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2172-12-9**] at 1:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2172-12-25**] at 1:40 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2173-1-17**]
|
[
"788.31",
"458.9",
"275.41",
"788.20",
"414.01",
"041.4",
"599.0",
"515",
"276.52",
"562.10",
"453.42",
"311",
"333.1",
"428.0",
"578.9",
"530.81",
"287.5",
"285.1",
"211.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.7",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
20748, 20850
|
14003, 18520
|
309, 456
|
21125, 21125
|
5717, 5717
|
24443, 25428
|
4459, 4476
|
19596, 20725
|
20871, 21104
|
18546, 19573
|
21308, 24420
|
4491, 4491
|
5050, 5698
|
213, 271
|
6424, 13980
|
484, 3883
|
5731, 6405
|
21140, 21284
|
3905, 4203
|
4219, 4443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,828
| 120,301
|
23993
|
Discharge summary
|
report
|
Admission Date: [**2108-8-7**] Discharge Date: [**2108-10-15**]
Date of Birth: [**2035-11-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Hypopharyngeal Mass, concern for proximal airway compression.
Major Surgical or Invasive Procedure:
[**2108-8-7**] Hypopharyngeal tumor biopsy.
[**2108-8-7**] G-tube placement.
[**2108-8-7**] Port placement.
[**2108-9-10**] Tracheostomy.
History of Present Illness:
72 M was admitted for expedited workup of hypopharyngeal lesion
and biopsy that was compressing the proximal airway as seen on
PET/CT. After biopsy was performed with ENT service, patient was
admitted to the ENT service for further observation. Right
venous access port was placed as well as G-tube in preparation
for induction chemotherapy. Once patient was stable from
procedures, he was transferred to the oncology service for
preparation of starting chemotherapy.
He reports no acute complaints on admission to the ENT service.
Past Medical History:
NIDDM.
HTN.
BPH.
Cataracts.
CVA.
Pancreatitis.
Bilateral inguinal hernia repair.
Bilateral knee surgery.
Hypopharyngeal squamous cell cancer dx 7/[**2108**].
Social History:
He used to work as a brick layer, but is currently not working.
He lives alone and has never been married. He does not smoke
and never smoked. He used to drink, but quit six years ago
after having been quite a heavy drinker.
Family History:
No history of cancer in his family.
Physical Exam:
Exam on admission to [**Hospital Unit Name 153**]:
General: Lethargic, oriented x 2 (person, place), no acute
distress
HEENT: Sclera anicteric, MM dry, oropharynx clear without noted
lesions, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant heart sounds, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, rhonchi
Abdomen: soft, non-distended, bowel sounds present but
hypoactive, G-tube in place with minimal yellow bilious
drainage, no tenderness to palpation, no rebound or guarding
GU: Foley in place, scrotal erythema noted, no penile lesions
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx2, moving all four extremities
Pertinent Results:
ADMISSION LABS:
[**2108-8-8**] WBC 10.4, Hb 11.5, HCT 33.1, PLT 100.
[**2108-8-8**] PT 11.6, INR 1.1, PTT 28.1
[**2108-8-8**] Na 134, K 4.4, CL 98, CO2 30, BUN 24, creat 0.9, glucose
223.
[**2108-8-8**] Albumin 3.6, Ca 9.1, Phos 2.7, Mg 2.1.
[**2108-8-8**] ALT 16, AST 22, ALK 70, T BILI 0.6.
.
[**2108-7-19**] CT NECK: IMPRESSION:
1. Exophytic polypoid, hyperenhancing mucosal mass lesion in the
posterior hypopharynx protruding into the airway lumen at the
level of the piriform sinuses without obstruction. This, in
combination with enlarged left level II and level V lymph nodes,
one of which is necrotic, is concerning for malignancy. Direct
visualization is recommended.
2. Nonenhancing, cystic-appearing lesion is noted on the right
retropharyngeal and right masticator space, causing mild mass
effect in the right carotid space, correlation with MRI of the
neck with and without contrast is recommended for further
characterication.
3. Hyperdense secretions in the left maxillary sinus may
represent fungal or inspissated secretions, incompletely
evaluated on this study.
4. Patulous upper esophagus.
.
[**2108-8-3**] PET/CT: IMPRESSION:
1. FDG-avid hypopharyngeal mass and cervical lymphadenopathy.
2. FDG-avid right 7th rib sclerotic focus, concerning for
metastasis.
3. Airway narrowing. This finding was discussed by Dr. [**Last Name (STitle) 11925**]
with the clinical team at the time of completion of the study.
4. Tree in [**Male First Name (un) 239**] and ground glass opacities in the right middle
lobe, which are non-specific but concerning for aspiration in
the setting of pharyngeal obstruction.
5. Ascending aortic dilation.
6. Calcified splenic artery aneurysm.
7. Tiny lung nodules. Follow up is recommended within one year.
.
[**2108-8-8**] RIGHT RIB X-RAY: IMPRESSION:
1. Large amount of free air underneath the hemidiaphragms.
Subcutaneous air. This should be correlated with the recent
surgery and if it cannot be explained by the surgery, further
evaluation with CT can be performed to assess for perforation.
2. Sclerotic right seventh lateral rib lesion concerning for
metastasis is best evaluated on the PET-CT examination.
.
[**2108-8-9**] MRI BRAIN: IMPRESSION:
1. Unchanged bilateral retropharyngeal and masticator space
lesions, with cystic/necrotic changes on the right side,
previously demonstrated by neck CT on [**2108-7-19**], likely
related with a history of hypopharyngeal cancer.
2. Intracranially there is no evidence of abnormal enhancement
to suggest metastasis or leptomeningeal disease.
3. Chronic lacunar ischemic changes are demonstrated in the
cerebellar hemispheres. Subcortical and periventricular areas of
chronic small vessel disease. No acute or subacute ischemic
changes are identified.
.
[**2108-8-9**] VIDEO SWALLOW: IMPRESSION: Aspiration of thin and nectar
thick liquids after the swallow in patient with hypopharyngeal
mass.
.
[**2108-8-20**] CXR: CONCLUSION: There is a pneumonia at the left lung
base.
.
[**2108-8-20**] KUB: IMPRESSION: No obvious signs of free air. Exam
somewhat limited by image quality.
.
[**2108-8-21**] CXR FINDINGS: CONCLUSION: Progression of the pneumonia
at the left lung base.
.
[**2108-8-23**] Wound Cx: [**2108-8-23**] 11:34 am SWAB Source: G-tube
site.
GRAM STAIN (Final [**2108-8-23**]): mixed bacterial types (>=3).
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
[**2108-8-26**] CXR: COMPARISON: Chest radiograph from [**8-20**] and [**8-21**], [**2108**]. There is gradual progression of multifocal
consolidations, currently extensively involving left lower lobe,
left upper lobe and right lower lobe. In addition, there is
interval development of pulmonary edema and bilateral pleural
effusions. No pneumothorax is seen.
.
[**2108-8-28**] CT HEAD: IMPRESSION:
1. No definite acute intracranial process.
2. No major vascular territorial infarct. If clinical
suspicion is high, MRI could be considered.
3. Left basal ganglia lacunes, age-related involution and mild
small vessel ischemic disease.
4. Re-demonstration of cystic mass in the right retropharynx.
5. Longstanding left maxillary sinus disease with atelectatic
appearance of the sinus and bony sclerosis.
.
[**2108-8-28**] MRI/MRA BRAIN: IMPRESSION:
1. Multiple small acute infarcts in bilateral cerebral
hemispheres, right pons, and bilateral cerebellar hemispheres,
suggesting a central embolic source. This was discussed with
Dr. [**Last Name (STitle) **] from neurology between 4:30 and 4:45 pm on [**2108-8-28**].
2. No evidence of intracranial metastatic disease.
3. Partially visualized bilateral retropharyngeal and right
masticator space masses, related to the patient's known
hypopharyngeal cancer.
4. Unremarkable head MRA.
.
[**2108-8-29**] ECHO: IMPRESSION: LIMITED VIEWS. Suboptimal image
quality. Preserved global left ventricular systolic function.
Cannot assess right ventricular function, aortic valve
structure/function, or tricuspid valve structure/function.
.
[**2108-9-2**] CXR: IMPRESSION: There are bilateral layering pleural
effusions and residual patchy airspace opacity in the left upper
lobe, left middle lung and at both bases. These findings may
reflect pneumonia. There is likely a superimposed component of
mild interstitial edema as well. Right Port-A-Cath is unchanged
in position. No pneumothorax is seen. Overall, cardiac and
mediastinal contours are likely stable, although the left heart
border is somewhat obscured by the overlying effusion.
.
[**2108-9-3**] ECHO: No thrombus/mass. Compared with the prior study
(images reviewed) of [**2108-8-29**], a PFO is now detected.
.
[**2108-9-3**] LE DOPPLER U/S: IMPRESSION:
1. Non-occlusive deep venous thrombosis within a short segment
of the right peroneal vein.
2. No deep venous thrombosis within the left lower extremity.
.
[**2108-9-10**] CXR: IMPRESSION: No change from 9:54 a.m. in
pneumomediastinum and bibasilar opacities.
.
[**2108-9-15**] RUE DOPPLER U/S: IMPRESSION: No right upper extremity
deep venous thrombosis.
.
[**2108-9-20**] CTA NECK IMPRESSION:
1. Status post tracheostomy placement with tip terminating
within the intrathoracic proximal trachea. Thickening of the
pretracheal soft tissues at the level of the tracheostomy entry
likely post-surgical in nature. No evidence of erosions into
adjacent vessels by the tumor or active bleeding. interval
decreased size of level 5 abnormal lymph node and right
parapharyngeal cystic mass.
2. Hypopharyngeal mass as described, smaller since the prior
examination.
3. Blurring of the fat planes of the anterior neck as it could
be seen with radiation.
4. Enlarged lymph nodes in the AP window and pretracheal
spaces.
5. Worsening pleural effusions and parenchymal opacities that
could be seen with volume overload. .
.
[**2108-9-27**] pCXR FINDINGS: As compared to the previous radiograph,
there is an unchanged right basilar opacity. The extent and
severity of the parenchymal opacity is similar to the previous
examination. Tracheostomy and right-sided Port-A-Cath are
unchanged. Unchanged mild retrocardiac atelectasis. No
pneumothorax.
.
[**2108-9-25**] CXR FINDINGS:Analysis is performed in direct comparison
with the next preceding similar study of [**2108-9-10**]. The
tracheal cannula is in midline position, seen to terminate in
the trachea. Termination point is similar as it was before.
The on previous examination identified paratracheal air and
subcutaneous air in the left lower neck region, indicative of
pneumomediastinum at that time, cannot be seen anymore. No
pneumothoraces present. Heart size unchanged. The previously
existing pulmonary congestive pattern and bilateral basal
parenchymal infiltrates have regressed markedly. No new
abnormalities are seen. A remaining diffuse haze on the left
base is indicative for some pleural effusion layering
posteriorly. IMPRESSION: Stable position of tracheostomy
cannula, previously identified pneumomediastinum has
disappeared. No pneumothorax.
.
[**2108-10-2**] pCXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Tracheostomy tube in constant
position, right pectoral Port-A-Cath. Constant elevation of the
right hemidiaphragm with minimal blunting of the costophrenic
sinuses. Borderline size of the cardiac silhouette. No newly
appeared parenchymal opacities. No pulmonary edema.
.
[**2108-10-12**] CXR: IMPRESSION: Tracheostomy tube is in standard
position. Right subclavian infusion port ends in the mid to low
SVC. No mediastinal widening or pneumothorax. Lungs are
essentially clear. Small right pleural effusion unchanged.
.
DISCHARGE LABS:
[**2108-10-15**] 06:30AM BLOOD WBC-4.1 RBC-2.63* Hgb-9.1* Hct-25.1*
MCV-96 MCH-34.8* MCHC-36.4* RDW-17.3* Plt Ct-108*
[**2108-10-10**] 09:23AM BLOOD Neuts-71.4* Lymphs-11.4* Monos-8.5
Eos-8.5* Baso-0.3
[**2108-9-22**] 06:00AM BLOOD PT-11.0 PTT-30.8 INR(PT)-1.0
[**2108-10-15**] 06:30AM BLOOD Glucose-158* UreaN-27* Creat-0.7 Na-131*
K-4.5 Cl-94* HCO3-35* AnGap-7*
[**2108-10-10**] 09:23AM BLOOD ALT-20 AST-19 LD(LDH)-163 AlkPhos-82
TotBili-0.2
[**2108-10-6**] 06:00AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.8 Mg-2.0
[**2108-10-13**] 06:00AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.9
[**2108-8-9**] 05:45AM BLOOD %HbA1c-7.0* eAG-154*
[**2108-8-28**] 05:32AM BLOOD Triglyc-52 HDL-16 CHOL/HD-2.8 LDLcalc-19
[**2108-9-10**] 10:21AM BLOOD Osmolal-324*
[**2108-9-15**] 03:54AM BLOOD TSH-3.7
[**2108-8-16**] 06:00AM BLOOD 25VitD-26*
Brief Hospital Course:
72yo man with h/o EtOH abuse, DM, recently diagnosed
hypopharyngeal SCC admitted [**2108-8-7**] to ENT service for biopsy of
pharyngeal mass, G-tube and port placement. Then transferred to
the oncology service on [**8-8**] for initiation of chemotherapy. His
hospital course was significant for initiation of tube feeds
after failing a swallow evaluation. Chemotherapy with
docetaxel, cisplatin, 5FU was initiated [**2108-8-11**], complicated by
diarrhea, severe cytopenias, ? leaking G tube, severe
nausea/vomiting. On [**2108-8-19**], he received 10mg olanzapine for
nausea and subsequently became very lethargic and developed
fever, hypotension, acute kidney injury, and ultimately
transfered to the ICU [**2108-8-20**] for sepsis and neutropenic fever.
His ICU course was significant for diagnosis of LLL pneumonia,
hypotension attributed to hypovolemia [**3-8**] limited PO
intake/diarrhea vs. sepsis, improvement in acute renal failure,
hypernatremia. He has had frequent atrial ectopy and PVCs and
electrolyte abnormalities. ENT planned for tracheostomy [**2108-8-28**]
for airway protection during therapy, but on [**2108-8-28**] early AM,
he was found to have left facial droop. MRI confirmed CVA
suggestive of thromboembolism. TTE showed no evidence of clot.
Neuro recommended starting heparin ggt, which was started
[**2108-8-29**]. TEE could not be done given size/location of
hypopharyngeal mass. Repeat TTE with bubble study revealed a
PFO and LE doppler U/S showed a RLE DVT. The tracheostomy was
eventually placed [**2108-9-10**]. However, this was complicated by
bleeding over one week. Anticoagulation was stopped as a
result. A rechallenge with anticoagulation failed a second time
due to bleeding from his tumor and trach site. He has
subsequently been managed with venodynes and prophylactic
heparin 5,000 units SC TID. On [**2108-9-24**] he coughed out his
tracheostomy cannula. Replacement was complicated by bleeding
and hemoptysis requiring ENT evaluation. Bleeding/hemoptysis
resolved gradually over next 4 days. He again developed
aspiration pneumonia [**2108-9-28**] and was started on cefepime and
vancomycin. His respiratory status was stable and actually
improved rather quickly. Antibiotics were stopped [**2108-10-3**].
Combination XRT and cetuximab was planned. A loading dose
(400mg/m2) of cetuximab was given [**2108-10-3**] and radiation started
[**2108-10-10**] and will continue for 6 weeks total.
.
MICU COURSE:
Mr. O' [**Known lastname **] was admitted to MICU For airway monitoring after
trach placement. Trach placement was uncomplicated. On
admission, he was breathing comfortably and in no distress.
Post-op CXR was performed, which showed pneumomediastinum; this
was not unexpected given recent open procedure. Repeat CXR
showed no change in pneumomediastinum. Post-op trach care was
administered including airway suctioning as needed. Tube feeds
were re-initiated with additional boluses of free water given
hypernatremia. Enoxaparin was held overnight on day 1 of MICU
course because of bleeding from suction. However, bleeding was
limited, so enoxaparin was restarted in the morning of MICU day
2. Ophthalmology was consulted for continuing care of VZV; they
recommended continuing acyclovir. He remained hemodynamically
stable and returned to the primary team.
.
OTHER DETAILS:
# Cough: CXR negative. Cough may be due to XRT. Continued
suction and humidified air via trach.
.
# Recurrent aspiration pneumonia/sepsis: Resolved. Episode
[**2108-8-20**] required transfer to ICU with relative hypotension,
tachycardia, fever, hypoxia, and tachypnea. LLL pneumonia on
CXR treated initially with vancomycin, cefepime, and
metronidazole due to concern for aspiration. CXR [**2108-8-21**] and
[**2108-8-26**] showed worsening infiltrate, so abx changed to meropenem
with vancomycin [**2108-8-26**], finished [**2108-9-3**]. Concern for another
episode of PNA prompted use of vanco and cefepime [**2108-9-28**] -
[**2108-10-3**]. Continued to have secretions and rhonchi. Guaifenesin
PRN cough. Aspiration precautions. AVOID sedating meds.
.
# Eye pain: Due to post-herpetic neuralgia +/- stye.
Ophthalmology consulted. Started on lubrigel to maintain
hydration to eye surface. Tramadol and acetaminophen PRN.
.
# Left eye lens implant (for ?glaucoma): Outpatient
bacitracin/polymyxin B used initially; stopped per
Ophthalmology.
.
# Zoster: VZV culture positive. Started on acyclovir treatment
dose x10d, then changed to prophylaxis dose. Ophthalmology
consulted; no ocular involvement initially, then filamentary
keratopathy seen [**2108-10-4**]. Pain initially controlled with
gabapentin, titrated off [**2108-9-15**] to avoid somnolence. Restarted
gabapentin given increased pain; will titrate up dose.
Acetaminophen and tramadol PRN.
.
# S/P trach [**2108-9-10**]: Complicated by bleeding, resolved off
anticoagulation, now on heparin SC. Cuff deflated [**2108-9-14**].
Routine trach change to uncuffed trach [**2108-9-17**]. CTA [**2108-9-20**]
showed soft-tissue swelling around the trach, but no active
bleed. Coughed out trach tube [**2108-9-24**], re-bled then, now
resolved. Airway suctioning PRN. Continued telemetry for
continuous O2 monitoring (hospital policy for trach patients).
.
# Hemoptysis: As above. ENT consulted. No bleeding from tumor,
likely source is mild trauma from trach replacement. Resolved.
- Change trach tube as needed or recommended by ENT/resp care
team.
.
# Hypopharyngeal squamous cell CA: T1N2bMx stage [**Doctor First Name **]. Started
cycle #1 TCF chemo [**2108-8-11**] complicated by N/V, severe cytopenias,
sepsis, and CVA. Per ENT, the mass initially was filling the
hypopharynx and likely affecting his ability to handle
secretions though the airway was open. Trach postponed due to
acute CVA, initially planned for [**2108-8-28**]. Per ENT (via
laryngoscopy), excellent response to chemotherapy with a ~90%
reduction in tumor size. Unable to continue with TCF given
life-threatening complications, his treatment was changed to XRT
with concurrent cetuximab as a radio-sensitizer. Loading dose
cetuximab 400mg/m2 given [**2108-10-3**]. 2nd weekly dose delayed due
to insurance issues; given 250mg/m2 [**2108-10-12**]. Anti-emetics PRN.
Caphasol, Maalox/diphenhydramine/lidocaine PRN mouth pain.
Continue daily XRT with weekly cetuximab for six weeks total.
.
# CVA/PFO: Left face drooping seen [**2108-8-28**]; MRI positive for
CVA, likely embolic. Neurology consulted and heparin gtt
started. Aspirin started [**2108-8-28**], but stopped when heparin
started. MRA brain unremarkable. TTE negative for clot. No
TEE given location of tumor. Repeat TTE with bubble study
showed a PFO. LE doppler U/S showed a RLE DVT, possible source
of CVA and [**Last Name (un) **] (paradoxical emboli). Heparin gtt changed to
enoxaparin. Then stopped for post-trach bleeding complications.
Restarted heparin gtt [**2108-9-19**] and stopped [**2108-9-20**] due to
recurrent trach bleed. Continue heparin 5000U SC TID. PT/OT.
.
# RLE DVT: Anticoagulation stopped due to trach bleeding. IVC
filter considered, but decided against. Continued heparin SC
PPx and venodynes.
.
# Acute renal failure: Baseline creatinine 0.7, peak 1.6, now
back to baseline. Furosemide/metolazone given for anasarca, now
euvolemic. Maintain adequate hydration with tube feeds/flushes.
.
# Paraphimosis: Urology successfully reduced it [**2108-9-14**].
.
# Diarrhea: Intermittent. C. diff negative x2. Loperamide PRN.
.
# Thrombocytopenia: Chronic. Suspected due to alcoholic liver
disease/hypersplenism. Severe post-chemo, now back to baseline.
.
# Anemia: Chronic anemia but sub-acute drop due to chemo, then
post-trach bleeding. Transfused 1U RBC [**2108-8-31**], [**2108-9-3**],
[**2108-9-10**], 2U [**2108-9-12**], 1U [**2108-9-14**], [**2108-9-18**], [**2108-10-1**], [**2108-10-9**].
.
# Hx Anasarca: Resolved. Due to hypoalbuminemia. Albumin
infusions with furosemide/metolazone effectively diuresed.
.
# NIDDM: HbA1c 7.0 on [**2108-8-9**]. Endocrine following. Insulin
glargine dose at 6U daily. Cover with insulin sliding scale.
.
# Hypertension: Decreased amlodipine 10 to 5mg daily [**2108-8-30**] and
discontinued [**2108-9-13**] to change to metoprolol given ectopy.
Metoprolol dose increased from 12.5 to 25mg [**Hospital1 **]. Added back
amlodipine 5mg daily [**2108-9-20**]. Trigger for hypertensive urgency
[**2108-9-21**], so amlodipine increased to 10mg daily. Started
lisinopril 5 mg daily [**2108-9-30**] for SBPs in 160s for several days.
Increased lisinopril to 10mg daily [**2108-10-12**] for continued
uncontrolled HTN.
.
# Non-sustained ventricular tachycardia: Frequent PVCs, atrial
ectopy. Resolved with addition of metoprolol 12.5mg PO BID.
.
# Hyperlipidemia: Stable. Continued statin.
.
# Anxiety/PTSD/depression: New depression. Increased outpatient
citalopram from 20 to 30 mg on [**2108-10-7**].
.
# Nasal congestion: Saline nasal spray.
.
# Scrotal erythema: Miconazole powder to skin.
.
# Pain (Port site, G-tube site, left forehead zoster): Restarted
gabapentin for left forehead zoster pain. Acetaminophen PRN.
- TITRATE UP GABAPENTIN FOR ZOSTER PAIN.
.
# Hypernatremia: Improved after stopping furosemide and
increasing tube feed flushes. Decreased tube feed flushes as
sodium levels declined.
.
# Hyponatremia: Mild. SIADH vs recent HCTZ/hypovol (hctz dc'd
[**2108-9-28**]). Decreased free water intake. Salt tablets PRN.
.
# Severe weakness/lethargy: Severe deconditioning. TSH normal.
Stopped gabapentin [**2108-9-15**] to avoid sedation. Slowly improving.
PT reconsulted.
.
# FEN: NPO and continuous tube feeds with water flushes.
Repleted hypokalemia. Repleting low vitamin D. Improved
alkalosis after gentle IVFs and blood transfusion.
.
# GI PPx: Lansoprazole via G-tube. Bowel regimen restarted for
constipation.
.
# DVT PPx: Heparin SC 5,000U TID.
.
# IV access: Port placed [**2108-8-7**].
.
# Precautions: Fall, MRSA (positive screen), aspiration.
.
# CODE STATUS: FULL.
Medications on Admission:
bacitracin polymixin
citalopram 20mg daily
glimepiride 1 mg daily
lisinopril 5 mg daily
omeprazole 20 mg daily
oxycodone 5mg Q4H prn pain
simvistatin 20 mg daily
asa 81 mg daily
colace 100 mg [**Hospital1 **]
MVI one daily
Glucerna 8oz three times daily
NaCl nasal spray 2 sprays ea nostril prn
Discharge Medications:
1. lansoprazole 30 mg Rapid Dissolve, DR [**Last Name (STitle) **] DAILY.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
2. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO q6HR
PRN nausea.
Disp:*20 Tablet(s)* Refills:*2*
3. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO q8HR PRN
nausea.
Disp:*20 Tablet(s)* Refills:*2*
4. amlodipine 10 mg PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID.
6. simvastatin 10 mg tablet Sig: Two (2) tablet PO DAILY.
7. fluticasone 50 mcg/actuation Spray Sig: Two (2) Spray Nasal
DAILY.
8. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: 5ML PO
Q6H PRN cough.
9. bisacodyl 10mg tablet,delayed release (DR/EC) PO DAILY PRN
constipation.
10. miconazole nitrate 2 % Powder Sig: Appl Topical [**Hospital1 **] PRN
scrotal irritation.
11. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Fifteen (15) mL Mucous membrane QID PRN pain.
12. loperamide 2 mg PO QID PRN loose stool.
13. folic acid 1 mg PO DAILY.
14. cholecalciferol (vitamin D3) 400 unit tablet Sig: Two (2)
tablet PO DAILY.
15. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **].
16. ipratropium bromide 0.02 % Solution Sig: One (1) Neb Inh Q6H
PRN wheezes.
17. acyclovir 400 mg tablet Sig: One (1) tablet PO Q8H.
18. heparin (porcine) 5,000 unit/mL Solution Sig: 1mL Injection
TID.
19. acetaminophen 325 mg tablet Sig: 1-2 tablets PO Q6H PRN
pain.
20. metoprolol tartrate 25 mg tablet Sig: 0.5 tablet PO BID.
21. white petrolatum-mineral oil 56.8-42.5% Ointment Sig: Appl
Ophthalmic Q2-3HR.
22. tramadol 50 mg PO BID PRN left eye pain.
23. citalopram 20 mg tablet Sig: 1.5 tablets PO DAILY.
24. lisinopril 10 mg tablet Sig: One (1) tablet PO DAILY.
25. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO BID.
26. magnesium hydroxide 400 mg/5 mL Sig: 30ML PO Q6H PRN
Constipation.
27. gabapentin 100 mg capsule Sig: Two (2) capsule PO TID.
28. docusate sodium 50 mg/5 mL Liquid Sig: 10mL PO TID.
29. polyethylene glycol 3350 17 gram Powder in Packet PO DAILY.
30. acetaminophen 650mg PO: Give 30 minutes prior to cetuximab.
31. diphenhydramine HCl 50 mg/mL Sig: 1mL Injection: Give 30
minutes prior to cetuximab.
32. insulin glargine 100 unit/mL Solution Sig: 6U SC qHS.
33. insulin regular human 100 unit/mL Solution Sig: As directed
Units Injection QID: Per sliding scale.
34. cetuximab 100mg/50mL Solution Sig: 250mg/m2 IV once a week
for 4 weeks: Continue until radiation is complete.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] HOSPITAL [**Hospital1 **]
Discharge Diagnosis:
1. Hypopharyngeal squamous cell carcinoma (throat cancer).
2. Cycle #1 TCF (docetaxel, cisplatin, 5FU) chemotherapy.
3. Aspiration.
4. Hypertension (high blood pressure).
5. Thrombocytopenia (low platelet count).
6. Hypokalemia (low potassium level).
7. Diarrhea.
8. Arrhythmia.
9. Mucositis.
10. Pneumonia.
11. Neutropenia (low white blood count).
12. Anemia (low red blood cell count).
13. Diabetes.
14. Stroke.
15. Acute kidney failure.
16. DVT (deep vein thrombosis, blood clot in right leg).
17. Patent foramen ovale (hole in heart).
18. Hemorrhage from tracheostomy.
19. Zoster (shingles).
20. Arrhythmia.
21. Generalized weakness.
22. Radiation therapy and cetuximab chemotherapy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for a biopsy of a tumor in
your throat (hypopharynx). A G-tube for tube feeding and a port
for chemotherapy were placed. The tumor biopsy confirmed
squamous cell carcinoma (cancer) and you were transferred to the
Oncology floor to start chemotherapy. MRI of the brain did not
show any cancer in the brain. Video swallow evaluation showed
severe aspiration of food and liquids. You cannot eat or drink
until this is re-evaluated. All of your nutrition must come
through tube feeds. Tube feeds were started and you developed
high blood sugars managed with insulin.
.
Chemotherapy was difficult to tolerate. You needed several
different types of anti-nausea medications. All of your blood
counts became very low from the chemotherapy. You developed
fevers and pneumonia that were treated in the Intensive Care
Unit with IV antibiotics. You also developed a stroke with
left-sided weakness. The stroke likely originated from a blood
clot in the right leg that traveled in the blood stream and
passed through a hole in the heart (patent foramen ovale) and
then into the brain and kidney also causing some kidney damage.
You were started on a blood thinner for this. To prevent
difficulty breathing from future radiation therapy, a
tracheostomy was placed. However, this was complicated by
bleeding and the blood thinner was not able to be restarted.
You also developed a rash on your left forehead. Culture
confirmed this was shingles. You were treated with an
anti-viral drug acyclovir and a pain medicine gabapentin for it.
.
You developed recurrent pneumonia and were started on IV
antibiotics. You coughed out your trach tube, but this was
replaced. You started daily radiation treatment [**10-10**],
Monday through Friday for 6 weeks. You will also be treated
with weekly cetuximab immunotherapy during your radiation. Your
first dose was on [**2108-10-3**]. As radiation therapy continues, your
cough may worsen and require more suctioning.
TRANSITION ISSUES:
1. You will return to [**Hospital1 18**] for daily radiation therapy, Monday
to Friday, for 6 weeks.
2. You will receive weekly cetuximab infusion therapy weekly
until radiation therapy is completed.
3. You will be going to a rehab center for physical therapy.
Followup Instructions:
YOU WILL NEED TO FOLLOW-UP WITH YOUR ONCOLOGIST DR. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3150**] IN 1 MONTH. We are working on a follow up appt with
Dr. [**Last Name (STitle) **] in 30 days. You will be called at home with the
appointment. If you have not heard or have questions, please
call ([**Telephone/Fax (1) 45687**].
|
[
"453.42",
"997.02",
"198.89",
"780.61",
"E878.3",
"401.9",
"284.11",
"052.7",
"434.11",
"V43.65",
"530.81",
"276.0",
"995.92",
"272.4",
"427.1",
"V15.52",
"528.01",
"263.9",
"E933.1",
"536.2",
"584.9",
"507.0",
"148.8",
"250.02",
"276.69",
"787.91",
"288.03",
"519.09",
"V12.54",
"038.9",
"V85.1",
"745.5",
"053.19",
"V15.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"96.6",
"31.42",
"97.23",
"99.25",
"29.12",
"31.1",
"43.19",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
25005, 25073
|
12003, 22078
|
367, 506
|
25804, 25804
|
2340, 2340
|
28281, 28636
|
1509, 1546
|
22424, 24982
|
25094, 25783
|
22104, 22401
|
25979, 28258
|
11161, 11980
|
1561, 2321
|
266, 329
|
534, 1068
|
6306, 11145
|
2356, 6297
|
25819, 25955
|
1090, 1249
|
1265, 1493
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,143
| 194,626
|
46655
|
Discharge summary
|
report
|
Admission Date: [**2181-4-3**] Discharge Date: [**2181-4-16**]
Date of Birth: [**2118-3-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
aortic valve endocarditis
Major Surgical or Invasive Procedure:
[**2181-4-11**] Aortic valve replacement with a size 21 St. [**Male First Name (un) 923**] Regent
mechanical valve for aortic valve endocarditis
History of Present Illness:
Mrs. [**Known lastname 32496**] is a 62 yo female who reports 2 months of not
feeling well. She states that she stopped driving 2 months ago
and nearly 1 month ago began feeling poorly with decreased
appetite, decreased mobility and really
started feeling badly about 1-2 weeks prior to admission with
very limited mobility and a 30 pound weight loss in 1 month.
She has been dizzy and short of breath. She was found to be in
acute renal failure with a creatinine of 6.6 and anemic with
hematocrit of 23. She was hydrated and transfused 3 units PRBC.
Her renal failure was thought to be due to acute interstitial
nephritis.
She had blood cultures positive for entercoccus on [**3-23**] and
[**3-25**], with negative blood cultures since. The source of
enterococcus has not been found. She has developed worsening LE
edema, and recurrent rapid atrial fibrillation and a repeat
echocardiogram [**4-3**] showed worsening AI. She is transfered for
surgical
evaulation.
Past Medical History:
Past Medical History
diabetes-followed by [**Last Name (un) 387**]
chronic diastolic heart failure
fibromyalgia
gerd
obesity
asthma
pneumonia
Past Surgical History
appendectomy
tonsillectomy
stomach surgery as a child
arthroscopic knee surgery
Social History:
The patient lives in [**Location 5110**], MA with her family. She does not
currently smoke or drink alcohol. No illicit drug use. She has a
distant smoking history (over 30 years ago). She has no tattoos.
She has one dog and has not recently
traveled.
Family History:
Father and mother had diabetes and one sister had
cervical cancer and the other sister has ovarian cancer.
Physical Exam:
PHYSICAL EXAM:
VS: Tc 98.5, BP 124-145/48-60, HR 65-75, RR 18, 98% RA
GEN: pleasant, nad
HEENT: PERRL, EOMI, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush, pale conjunctiva
CV: RRR, audible S1 with diastolic murmur best heard at the left
lower sternal border
PULM: CTA bilat with few crackles at the bases
BACK: no focal tenderness, no CVAT
GI: normoactive BS, soft, non-tender, non-distended
MSK: no joint swelling or erythema. Slight left upper back pain
to palpation. This is not over the bone, but over the muscle.
There is no point tenderness over the spine.
EXT: warm and well perfused, 2+ edema in both feet, faint DP
pulses palpable bilaterally. Slight R plantar erythema.
LYMPH: no cervical lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: AAOx3, CN 2-12 intact, normal sensitivity in the feet.
PSYCH: non-anxious, normal affect
Pertinent Results:
[**2181-4-15**] 05:54AM BLOOD WBC-12.8* RBC-2.92* Hgb-8.3* Hct-25.0*
MCV-86 MCH-28.3 MCHC-33.1 RDW-17.4* Plt Ct-254
[**2181-4-14**] 05:16AM BLOOD WBC-15.7* RBC-3.07* Hgb-8.9* Hct-26.1*
MCV-85 MCH-28.9 MCHC-34.1 RDW-17.6* Plt Ct-239
[**2181-4-16**] 06:18AM BLOOD PT-23.7* INR(PT)-2.3*
[**2181-4-15**] 05:54AM BLOOD PT-21.2* PTT-46.9* INR(PT)-2.0*
[**2181-4-14**] 05:16AM BLOOD PT-18.1* INR(PT)-1.6*
[**2181-4-13**] 03:50AM BLOOD PT-15.5* INR(PT)-1.4*
[**2181-4-12**] 02:10AM BLOOD PT-15.5* PTT-38.3* INR(PT)-1.4*
[**2181-4-11**] 05:20PM BLOOD PT-15.2* PTT-32.9 INR(PT)-1.3*
[**2181-4-11**] 03:54PM BLOOD PT-16.7* PTT-46.1* INR(PT)-1.5*
[**2181-4-11**] 03:55AM BLOOD PT-15.6* PTT-79.8* INR(PT)-1.4*
[**2181-4-10**] 05:46AM BLOOD PT-15.8* PTT-74.2* INR(PT)-1.4*
[**2181-4-9**] 05:30PM BLOOD PT-16.6* PTT-55.9* INR(PT)-1.5*
[**2181-4-16**] 06:18AM BLOOD Glucose-88 UreaN-31* Creat-2.3* Na-139
K-4.4 Cl-100 HCO3-26 AnGap-17
[**2181-4-15**] 05:54AM BLOOD Glucose-125* UreaN-33* Creat-2.4* Na-136
K-3.9 Cl-100 HCO3-29 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 4092**] [**Hospital1 18**] [**Numeric Identifier 99057**]
(Complete) Done [**2181-4-11**] at 2:26:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2118-3-29**]
Age (years): 63 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Congestive heart failure. Left
ventricular function. Mitral valve disease. Prosthetic valve
function.
ICD-9 Codes: 424.90, V43.3, 424.1, 424.0
Test Information
Date/Time: [**2181-4-11**] at 14:26 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) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
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: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. Moderate to severe spontaneous
echo contrast in the body of the LA. Depressed LAA emptying
velocity (<0.2m/s) All four pulmonary veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV cavity size. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Normal ascending aorta
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Large vegetation on
aortic valve. No aortic valve abscess. No AS. Moderate to severe
(3+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS.
Mild to moderate ([**2-4**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The 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 mildly 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 atrial septal defect is seen by 2D or color
Doppler. 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 aortic root is mildly dilated at the sinus level. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is a large vegetation on the
aortic valve. No aortic valve abscess is seen. There is no
aortic valve stenosis. Moderate to severe (3+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild to moderate ([**2-4**]+) mitral regurgitation is seen.
There is no pericardial effusion.
POST CPB:
1. Unchanged LV and RV function. LVEF = 55%
2. Bileaflet mechanical valve in aortic position. Well seated
and stable with good leaflet excursion. Trace aortic
regurgitation and no discernible gradient across the valve.
3. No other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2181-4-11**] 16:46
?????? [**2173**] CareGroup IS. All rights reserved.
Brief Hospital Course:
This 63-year-old patient with a recent onset of cardiac symptoms
was investigated and found to have aortic valve endocarditis
with large vegetations and severe aortic regurgitation. [**4-4**]
Infectious disease was consulted for antibiotic recommendations.
Preoperative workup included a Dental consult that was done and
teeth #12,20,21 were extracted. Pulmonary was consulted for
recommendations regarding possible sleep apnea. Initially she
was managed with medically for the Enterococcus which was grown
in the blood, but the aortic incompetence was getting worse
along with worsening acute renal failure and she was taken for
urgent aortic valve replacement.
On [**4-11**] Ms.[**Known lastname 32496**] was taken to the operating room and underwent
an urgent Aortic valve replacement with a size 21 St. [**Male First Name (un) 923**]
Regent mechanical valve for aortic valve endocarditis with
Dr.[**First Name (STitle) **]. Please refer to operative report for further surgical
details. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated in critical but stable
condition. She awoke neurologically intact and was extubated
without difficulty. All lines and drains were discontinued in a
timely fashion. She was weaned off pressors and
Beta-blocker/Statin/ aspirin and diuresis were initiated. Renal
continued to follow postoperatively. Anticoagulation with
Coumadin was initiated for her mechanical aortic valve. She was
transferred to the step down unit on POD#1 for further
monitoring. Physical Therapy was consulted for evaluation of
strength and mobility.
ID was consulted for bacteremia: Sensitive enterococcal NVE
would warrant therapy
with both ampicillin + aminoglycoside to utilize synergy to
improve treatment outcomes.
The patient with recent severe renal insufficiency,
aminoglycoside was held because of this.
Renal Consult was obtained for ATN. At its worst, her renal
function was marked by a creatinine of 6.6 on [**3-20**] from a
baseline of 1.1-1.4. Since then her renal function has improved
to a creatinine of 2.3 to 2.7. Because of her renal function
consistant in the mid 2 range the recommendation of holding the
aminoglycoside therapy was adhered to.
The remainder of her hospital course was essentially uneventful.
On POD 5 she was cleared for discharge to NE [**Hospital1 **], [**Location (un) 701**].
All follow up appointments were advised.
Medications on Admission:
avapro 150mg daily, aspirin 81mg daily, glucophage 500mg twice
daily, hydrochlorothiazide 25mg daily, insulin sliding scale,
lasix 40mg daily, lopressor 50mg twice daily, multivitamin,
prilosec 20 mg twice daily, savella 50 mg twice daily, ultram
50mg twice daily
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
10. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 1 months: Untill [**5-28**].
11. Insulin
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast
Glargine 10 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 3 Units 3 Units 3 Units 0 Units
160-199 mg/dL 6 Units 6 Units 6 Units 3 Units
200-239 mg/dL 9 Units 9 Units 9 Units 6 Units
240-280 mg/dL 12 Units 12 Units 12 Units 9 Units
> 280 mg/dL Notify M.D.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. PICC care
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
15. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: MD to dose daily for goal INR 2.5-3 for mechanical aortic
valve.
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: [**2-4**]
Tablet, Chewables PO QID (4 times a day) as needed for gi upset.
18. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
19. Furosemide 40 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Endocarditis, Aortic Insufficiency s/p Aortic Valve Replacement
Past medical history:
Acute renal failure
Diabetes-followed by [**Last Name (un) **]
Chronic diastolic heart failure
Fibromyalgia
Gastroesophageal reflux disease
Obesity
Asthma
Pneumonia
Past Surgical History
Appendectomy
Tonsillectomy
Stomach surgery as a child
Arthroscopic knee surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: 2+ bilateral LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**Telephone/Fax (1) 170**] Date/Time:[**2181-5-7**] 2:30
PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) **] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35275**] [**Telephone/Fax (1) 35276**] [**5-8**] at
1:30pm
Dr. [**Last Name (STitle) 35275**] will recommend cardiologist
Dr. [**Last Name (STitle) 35275**] will follow coumadin/INR on discharge from
rehab (confirmed with [**Doctor First Name **])
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBC, Bun, Crea, LFTs, ESR and CRP
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
FOLLOW UP APPOINTMENTS SCHEDULED:
[**2181-5-14**] 10:30a ID,[**Doctor Last Name **] [**Doctor First Name 2482**]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
[**2181-4-30**] 09:30a ID,[**Doctor Last Name **],[**Doctor First Name **]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
Sleep medicine: Dr. [**First Name (STitle) 3441**] and [**Doctor Last Name **] on [**2181-5-3**] at 2PM [**Hospital Ward Name 23**]
Building [**Location (un) 436**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-4-16**]
|
[
"729.1",
"278.00",
"428.0",
"285.9",
"530.81",
"250.00",
"E935.9",
"715.90",
"525.3",
"427.31",
"276.51",
"521.81",
"790.7",
"041.04",
"428.32",
"493.90",
"V58.67",
"525.50",
"V15.82",
"584.5",
"V85.41",
"521.09",
"V45.89",
"421.0",
"525.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"23.19",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
13707, 13779
|
8589, 11005
|
304, 451
|
14176, 14405
|
3008, 7007
|
15328, 16832
|
2006, 2115
|
11319, 13684
|
13800, 13864
|
11031, 11296
|
14429, 15305
|
7056, 8092
|
2145, 2989
|
238, 266
|
479, 1452
|
13886, 14155
|
1736, 1990
|
8102, 8566
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,497
| 107,073
|
33981
|
Discharge summary
|
report
|
Admission Date: [**2154-5-27**] Discharge Date: [**2154-6-3**]
Date of Birth: [**2085-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin / Lopressor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2154-5-29**] AVR (23mm CE Magna porcine)/ MVR ([**Street Address(2) 12523**]. [**Male First Name (un) 923**]
porcine valve)/ Maze procedure/ligation left atrial appendage
History of Present Illness:
69 yo male with history of RHD/Afib, found to have valvular
stenosis in [**2146**].Recently experiencing DOE and had a recent
admission for lung biopsy for BOOP. Coumadin was recently
stopped and he had a CVA in [**3-16**].Recent echo showed severe
MR/MS/AS.
Past Medical History:
rheumatic heart disease
A fib
MR/MS/AS
depresseion
CVA
interstitial lung disease
prior amiodarone toxicity
BOOP
depression
OA
elev. chol.
BPH
PNA
pneumothorax
hypothyroidism
diverticulosis
GERD
Social History:
retired
lives with wife
social ETOH
quit 30 years ago, 35 pack/yr hx
Family History:
father died at 49
Physical Exam:
98 T 104/53 HR 80 RR 18 96% RA sat
alert and oriented x3, moments of short term memory loss evident
[**Last Name (un) **], EOMI, 2+ carotids, no bruits, no JVD
4/6 SEM, no r/g
right basilar faint inspiratory wheezes
abd benign
trace pretibial edema, no c/c
5'8" 155#
Pertinent Results:
[**2154-5-31**] 06:00AM BLOOD WBC-11.9* RBC-3.14* Hgb-9.9* Hct-28.7*
MCV-91 MCH-31.6 MCHC-34.7 RDW-15.0 Plt Ct-145*
[**2154-5-31**] 06:00AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-135
K-3.7 Cl-98 HCO3-29 AnGap-12
[**2154-5-27**] 05:29PM BLOOD %HbA1c-6.1*
PRE CPB The left atrium is moderately dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. Moderate to severe spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No
definitive thrombus is seen in the left atrial appendage. 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%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. 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 moderately thickened. There is moderate to severe
aortic valve stenosis (area 1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. The mitral valve shows characteristic rheumatic
deformity. There is moderate to severe valvular mitral stenosis
(area 1.0 cm2). Mild to moderate ([**1-9**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild tricuspid regurgitation. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST CPB Patient is being atrially paced. Normal biventricular
systolic function. Bioprosthesis in the mitral position is
oriented towards the left ventricular outflow tract but is well
seated. Leaflet motion is normal. There is trace valvular mitral
regurgitation. The maximum pressure gradient across the mitral
valve is 13 mm Hg with a mean pressure gradient of 4 mm Hg at a
cardiac output of 6.5 l/m. There is a bioprosthesis located in
the aortic position. It is not well seen but it does appear well
seated with normal leaflet function. There is at least trace
valvular aortic regurgitation but shadowing and poor echo
windows prevent full assessment of the regurgitation. The
maximum pressure gradient across the aortic valve is 14 mm Hg.
The left atrial appendage has been resected. The thoracic aorta
appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2154-5-29**] 14:26
Brief Hospital Course:
Admitte [**5-27**] for IV heparin bridge off coumadin. PAT w/u
completed. Underwent surgery [**5-29**] with Dr. [**Last Name (STitle) 914**]. Transferred
to the CVICU in stable condition on titrated propofol and
phenylephrine drips. Extubated that evening. Beta blockade
titrated and transferred to the floor on POD #1. Chest tubes and
pacing wires removed on POD #2. Coumadin restarted on POD #2.
CXR stable post CT removal. Pt consult / pt cleared for home.
Diuresis continued. This was carried on. On Dc INR is 1.2. Pt is
a chronic afibber. Dr [**First Name (STitle) **] will follow in the usual manner.
Coumadin has been discussed thouroughly with the patient. he
agrres with the paln.
Medications on Admission:
lasix 10 mg daily
Kcl 20 mEq daily
aldactone 25 mg daily
digoxin 0.25 mg daily
levothyroxine 75 mcg daily
verapamil 180 mg daily
celexa 20 mg [**Hospital1 **]
risperdal 0.25 mg [**Hospital1 **]
Ca++ 500 mg + D [**Hospital1 **]
coumadin 4 mg M,W,F (LD [**4-24**])
coumadin 3 mg T, [**Last Name (un) **], SAT, SUN
prednisone 5mg (LD [**5-21**])
claritin 10 mg daily
ASA 81 mg daily
MVI daily
pravachol 40 mg daily
selenium 200 mg daily
prilosec 20 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(MO,WE,FR).
Disp:*180 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
Disp:*360 Tablet(s)* Refills:*2*
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: prn.
Disp:*30 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
Disp:*0 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Lasix 20 mg Tablet Sig: [**1-9**] tab Tablet PO once a day: start
after you complete the 40 mg daily dose.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] care
Discharge Diagnosis:
AS/MR s/p AVR/MVR/ Maze/ligation LAA
interstitial lung disease
rheumatic heart disease
A fib
CVA
BOOP/amiodarone toxicity
s/p thoracoscopic wedge resecton [**2-15**]
depression
OA
elev. chol.
BPH
PNA
pneumothorax [**1-15**]
hypothyroidism
diverticulosis
GERD
Discharge Condition:
stable
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
You came in on coumadin, have your INR followed in the usual
manner.
Followup Instructions:
see Dr. [**Last Name (STitle) 914**] in [**2-10**] weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 55499**] in 4 weeks
INR:
See Dr. [**Last Name (STitle) 78476**] [**Name (STitle) 13434**] on DC. Your coumadin has not
changed.Keep on the same dose. Go to the lab you go to in
[**Location (un) **] and have your INR drawn NLT [**6-5**]. You are already tied
into the lab. Just in case I aven gven you a prescription for
INR draw. Take this withyou. I hav also set up VNA to draw your
INR. For some reason they cqnnot do,it is your responibiity to
have your INR drawn.
Completed by:[**2154-6-2**]
|
[
"715.90",
"311",
"244.9",
"515",
"396.8",
"530.81",
"V15.82",
"438.0",
"427.31",
"398.91",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.27",
"37.34",
"35.23",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7564, 7616
|
4208, 4899
|
287, 463
|
7919, 7928
|
1400, 4185
|
8252, 8867
|
1071, 1090
|
5407, 7541
|
7637, 7898
|
4925, 5384
|
7952, 8229
|
1105, 1381
|
243, 248
|
491, 751
|
773, 969
|
985, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,003
| 108,797
|
5159
|
Discharge summary
|
report
|
Admission Date: [**2119-5-17**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2067-9-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 21114**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Central venous line placement, PICC placement, Intubation, NG
tube, Lumbar puncture
History of Present Illness:
(History per patient's domestic partner and HCP): 51 y.o. male
with HIV (CD4 of 559 and VL undetectable in [**Month (only) 547**]), ESRD [**1-7**] IgA
nephropathy s/p DDRT in '[**14**], DM, CAD who initially presented to
an OSH with a chief complaint of SOB. Patient was recently
discharged from [**Hospital1 18**] with presumed CAP after extensive work-up
was otherwise negative for TB (by AFB and Quanteferon Gold) and
PCP. [**Name10 (NameIs) **] was initially treated with Levofloxacin, followed by
Ceftriaxone and Azithromycin, then finally Cefpodoxime for 7
days on discharge to complete a total of 2 weeks of antibiotics.
He returned home and was in his normal state of health until
approximately 3 days ago when he began experiencing shortness of
breath and a cough, intermittently productive of clear sputum.
Reportedly, he had no F/C, N/V during this time. He has chronic
diarrhea in the setting of HAART. On the day of admission,
patient woke up feeling profoundly short of breath and also
complaining of neck pain and stiffness without headache. His
partner then notes that he vomited a very large amount of brown
emesis with no blood. Approximately 2 hours later, the patient
was lightheaded and unsteady on his feet and his partner, a
dialysis tech, took his blood pressure and recorded an SBP of
70. Temperature was also noted to be elevated to 102. EMS was
then notified and patient was taken to [**Hospital6 5016**].
.
At [**Hospital3 **], patient continued to be hypotensive in the 70s
and hypoxic to 86% on RA. He was given 3 L NS and a CXR was
ordered, which showed a RLL infiltrate. He was then given
Levofloxacin and transferred to [**Hospital1 **] for further management.
.
In the [**Hospital1 18**] ED, patient was noted to be hypotensive to SBP 72
and relatively hypoxic with O2 sat of 93% on 4L NC. A repeat CXR
showed a right lung infiltrate and a probable effusion on the
left. Given continued O2 requirement and hypotension, patient
was intubated and started on Levophed then subsequently admitted
to the MICU for further management.
Past Medical History:
DM I
Diabetic retinopathy
Nephropathy, s/p CRT [**2114**], on HIV-transplant protocol
Hyperlipidemia
Neuropathy, c/b ulcers
Charcot foot with R calcaneal injury and collapse/fracture
Necrobiosis lipoidica diabeticorum
Osteoporosis
Depression
Hypertension
Anemia
Syphilis in [**2094**], treated with penicillin
Toxoplasmosis seropositivity
h/o perianal condyloma
h/o c. diff colitis s/p hospitalization in [**2109**]
Social History:
Mr. [**Known lastname **] was born in [**State 350**]. He works for the IRS in
[**Location (un) 2268**]. Lives with long-time partner in monogamous
relationship. No h/o asbestos. Remote h/o tobacco 15yrs x [**12-7**]
ppd. Denies current alcohol use, but has a history of abuse.
Family History:
His mother is deceased, she had breast cancer and CAD. His
father died of a perforated gastric ulcer with peritonitis. He
has one older brother with hepatitis, and a younger brother with
cerebral palsy. No other disorders that he is aware of run in
his family.
Physical Exam:
VS: T - 98.4, BP - 118/54 (.03 Levophed), HR - 78, RR - 16, O2 -
99% AC 500/14/5/100%
GEN: Sedated, intubated, appears comfortable
HEENT: NC/AT, PERRLA, EOMI, no conjuctival injection, anicteric,
OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: Heart sounds difficult to appreciate given loud, coarse BS
PULM: Diffusely roncherous. No appreciable wheezes
ABD: Markedly distended, tympanic to percussion, no wincing on
palpation, decreased BS
EXT: warm, dry, no c/c; 2+ pitting edema b/l in [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: Multiple areas of chronic skin breakdown with necrotic
centers that do not appear super-infected
Pertinent Results:
[**2119-5-29**] CXR Portable: Mild pulmonary edema has resolved. There
is linear atelectasis in the right mid and lower lung zones.
There are no pleural effusions. Appropriate position of
right-sided PICC line with tip in the mid SVC.
.
[**2119-5-25**] CXR Portable: Increasing mild pulmonary edema. Improving
left basilar atelectasis.
.
[**2119-5-24**] Echo: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. The right atrial
pressure is indeterminate. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
.
[**2119-5-24**] CXR Portable: The right middle lobe consolidation,
stable since the [**2119-5-23**] examination, has clearly improved
since the [**2119-5-18**] examination. The left lower lobe opacity
has worsened. The small left pleural effusion is stable. There
is no right pleural effusion. The endotracheal tube is 2 cm from
the carina. The right internal jugular line tip is at the
caval/brachiocephalic junction.
.
[**2119-5-23**] CXR Portable: Mild pulmonary edema is noted demonstrated
by increased prominence of peripheral septal lines. Component of
right middle lobe opacity has improved with minimal improvement
of left lower lobe opacity. Moderate left pleural effusion and
associated atelectasis remain. The upper lungs remain clear. No
appreciable right pleural effusion is noted.
.
[**2119-5-21**] CXR Portable: Comparison is made with prior chest x-ray
of [**5-20**]. A perihilar edema persists, left hemidiaphragm
remains obscured indicating collapse consolidation in the left
lower lobe and the right heart border is also obscured
indicating a right lower lobe infiltrate.
.
[**2119-5-20**] Abdomen Portable:
.
[**2119-5-17**] CT head w/o contrast: There is no hemorrhage, edema,
mass, mass effect, or evidence of acute vascular territorial
infarction. Ventricles and sulci are unchanged in size and
configuration. Dense atherosclerotic calcifications are noted on
the carotid siphons and vertebral arteries. Left phthisis bulbi
is unchanged.
IMPRESSION: No acute intracranial process. No change from
[**2119-4-19**].
[**2119-5-17**] CXR Portable: 1. Right IJ catheter terminating in the
contralateral brachiocephalic vein and directed laterally. 2.
Interstitial edema with more focal right middle lobe opacity may
reflect either "atypical" edema or pneumonia.
[**2119-6-1**] 05:56AM BLOOD WBC-5.6 RBC-2.62* Hgb-9.4* Hct-27.7*
MCV-106* MCH-35.9* MCHC-34.1 RDW-18.0* Plt Ct-742*
[**2119-5-29**] 05:15AM BLOOD Neuts-56.3 Lymphs-31.0 Monos-6.2 Eos-5.6*
Baso-1.0
[**2119-5-24**] 05:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+
[**2119-5-29**] 05:15AM BLOOD PT-13.5* PTT-29.4 INR(PT)-1.2*
[**2119-6-1**] 05:56AM BLOOD Glucose-193* UreaN-13 Creat-0.8 Na-141
K-3.7 Cl-108 HCO3-21* AnGap-16
[**2119-5-31**] 05:01AM BLOOD ALT-62* AST-38 LD(LDH)-320* AlkPhos-134*
TotBili-0.3
[**2119-5-30**] 06:13AM BLOOD CK-MB-6 cTropnT-0.06*
[**2119-5-30**] 01:49AM BLOOD CK-MB-7 cTropnT-0.08*
[**2119-5-27**] 07:28PM BLOOD CK-MB-15* MB Indx-0.9 cTropnT-<0.01
[**2119-5-27**] 03:04AM BLOOD CK-MB-18* MB Indx-0.7
[**2119-6-1**] 05:56AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9
[**2119-6-1**] 05:56AM BLOOD VitB12-1070* Folate-16.4
[**2119-5-18**] 07:43AM BLOOD Cortsol-18.5
[**2119-5-18**] 07:42AM BLOOD Cortsol-15.9
[**2119-5-18**] 07:42AM BLOOD Cortsol-9.9
[**2119-5-18**] 05:08AM BLOOD IgG-897 IgA-189 IgM-66
[**2119-5-26**] 06:07PM BLOOD B-GLUCAN-Test
[**2119-5-23**] 12:52PM BLOOD MISCELLANEOUS TESTING-Test Name
[**2119-5-23**] 12:52PM BLOOD MISCELLANEOUS TESTING-Test Name
[**2119-5-18**] 04:33PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2119-5-18**] 04:33PM BLOOD B-GLUCAN-Test
[**2119-5-17**] 10:23PM BLOOD COCCIDIOIDES ANTIBODY,
IMMUNODIFFUSION-Test
[**2119-5-17**] 10:23PM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test Name
[**2119-5-17**] 10:23PM BLOOD BLASTOMYCOSIS ANTIBODY (BY CF AND
ID)-Test Name
Brief Hospital Course:
[**Hospital **] hospital course was as follows, by problem:
.
# Hospital aquired pneumonia s/p hypoxic respiratory failure: At
admissions, considerations included HAP given recent
hospitalization and "failed" course of abx for CAP (although
initially improved clinically) and aspiration given lack of gag
and BAL showing OP flora and prominent infiltrate RML. Patient
had been recently treated for pneumonia, which was felt to be
CAP given negative Quanteferon Gold, PCP and Legionella [**Name9 (PRE) 8019**]
and current work-up had been unrevealing for possible organisms.
Patient's immunocomprised status was certainly of concern,
though negative workup as above made the more atypical
considerations less likely. Patient was intubated (note
difficult intubation) and treated with a 14 day course of zosyn
and vancomycin and 5 day course of azithromycin. Patient was
successfully extubated, transitioned to the floor on 2L to
complete the antibiotic course, and at discharge was satting
>96% on room air. Cultures never produced a clear pathogen. A
sputum sample on [**5-19**] did show sparse growth of [**Female First Name (un) 564**]
glabrata, for which he was temporarily treated with fluconazole.
Patient improved considerably outside of the ICU. Patient was
unable to provide a repeat sputum sample, and given his clinical
improvement and the lack of efficacy of fluconazole for [**Female First Name (un) 564**]
glabrata, the medication was stopped at discharge.
.
# Hypertension: The patient's initial hypotension was attributed
to hypovolemia given response to fluids. Sepsis was considered
initially, but no source was identified. Following transfer from
the MICU, the patient was found to be hypertensive for much of
the remainder of his hospital course. His beta-blocker and [**Last Name (un) **]
were increased and a calcium-channel blocker added; at discharge
his BP was better controlled.
.
# NSTEMI: The patient had an NSTEMI while in the ICU, and a
second episode of elevated troponins (without EKG changes) after
transfer to the floor. In the first episode, the patient was
briefly put on heparin gtt. Cards consulted and felt most likely
demand in setting of respiratory distress and thus no
intervention was planned. The second episode was associated with
chest pain thought to be more MSK in nature and related to his
frequent coughing. He was maintained on his beta-blocker and his
aspirin was increased to 325mg daily. At discharge, he was free
of chest pain, SOB, and palpitations. Outpatient follow-up for
further evaluation and stress test was arranged with his
cardiologist.
.
# C. difficile: Positive stool study this admission. Started on
metronidazole on [**5-23**] with some slowing of his diarrhea. Loose
stools improved during course of stay outside of MICU. On
discharge (ie last day of antibiotics), patient was sent out
with additional 14 day course of metronidazole. As patient has
history of chronic diarrhea, his home regimen of tincture of
opium was also started.
.
# Positive coccidoides: Serum test positive, although patient
was also on Bactrim for PCP [**Name Initial (PRE) 1102**] (risk of
false-positive). Given history of HIV and on immunosuppression
for renal transplant, patient was initially treated on
fluconazole as above. On day of discharge, fluconazole
discontinued.
.
# ARF/ESRD s/p transplant: Patient had elevated creatinine at
presentation - likely secondary to hypovolemia/underperfusion
which hypotensive - which resolved through the hospital stay.
Calcitriol and nephrocaps were continued at home dose.
Tacrolimus dosing was temporarily cut in half secondary to
interaction with fluconazole, and increased to home dose once
fluconazole was discontinued. Tacrolimus trough was checked
daily. Prednisone was continued at home dose, and Bactrim SS for
PCP [**Name Initial (PRE) 1102**]. At discharge, creatinine was well in normal
range.
.
# HIV: No active issues; on HAART. Continued medications for
neuropathy, and treated for chronic diarrhea as above.
.
# DM: Developed AG met acidosis with positive ketones in MICU;
was placed back on insulin gtt. Gap closed and placed back on
home dose of Lantus and insulin SS. Patient was then changed
from Lantus to NPH for easy of titration. Patient's blood
glucose remained elevated for much of hospital course, with
daily adjustments of NPH. On discharge, patient was restarted on
his home regimen of Lantus and sliding scale insulin.
.
# Anemia: At admission, hematocrit was >37. For remainder of
hospital course, hct remained in upper 20s. Given elevated MCV,
patient appeared to have a macrocytic anemia. Vitamin B12 was
found to be elevated, and folate was within normal range.
.
# Depression: Continued Effexor
.
# Hyperlipidemia: Pravastatin held given mild transaminitis, up
from baseline, and elevated CK not attributable to cardiac
source.
.
#COMMUNICATION: Patient's domestic Partner, [**Name (NI) **]: [**Telephone/Fax (1) 21115**]
(cell), [**Telephone/Fax (1) 21116**] (home)
Medications on Admission:
Ambien 10 mg PO QD
Amitriptyline 10 mg PO QHS
Androgel 1%
Aspirin 81 mg PO QD
Bactrim SS 1 tab QMWF(?)
Calcitriol .25 mcg QTues/Sat
Combivir 1 tab [**Hospital1 **]
Creon 20 sa [**Male First Name (un) **] 3 tablets w/ meals 1 w/ snacks
Diovan 160mg QAM/80 mg QPM
Effexor XR 150 mg PO QD
Flomax 0.4 mg PO QHS
Fosamax 70 mg Q Sunday
Furosemide 80 mg [**Hospital1 **]
Lantus 33 U QHS w/ Humalog according to carb counting
Lomotil PRN
Lorazepam 1 mg PO QHS
Metoprolol 150 mg PO BID
Nephrocaps 1 cap PO QD
Neurontin 300 mg QID (1 tablet at 8AM, 2PM, 5PM, 2 tablets QHS)
Pravastatin 10 mg PO QD
Pred Forte 1% gtt
Prednisone 5 mg PO QD
Prilosec 40 mg PO QD
Prograf 1 mg PO BID
Viramune 1 tab PO BID
Dilaudid PRN for pain
Opium Tincture PRN for diarrhea
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
3. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Prednisolone Acetate 1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic DAILY (Daily).
5. Tacrolimus 0.5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 2X/WEEK
(TU,SA).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMWF.
11. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
14. Opium Tincture 10 mg/mL Tincture Sig: Fifteen (15) Drop PO
BID (2 times a day).
15. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
20. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
21. Lantus 100 unit/mL Solution Sig: 33 units Subcutaneous at
bedtime.
22. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: for a
total of 300 mg daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
23. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: for a
total of 300 mg daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
1. Hospital acquired pneumonia
2. Hypoxic respiratory failure, now resolved
3. Colitis secondary to clostridium dificle
4. Elevated troponins, now resolved
5. Acute renal failure/End-stage renal disease s/p transplant
([**2115**])
Secondary:
1. HIV, on HAART
2. Diabetes mellitus
3. Hyperlipidemia
4. Hypertension
Discharge Condition:
Hemodynamically stable. Ambulatory. Patient to work with
physical therapy at home.
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**5-17**] for treatment of a severe
pneumonia. At admission, you were intubated and taken to the
intensive care unit. The pneumonia was treated with a 14 day
course of antibiotics. While in the hospital were also found to
have an infection of your colon; you will continue treatment for
this at home for an additional 14 days. In the hospital, you had
2 episodes of increased work of your heart. As an outpatient,
you should followup with your cardiologist to undergo a stress
test.
Physical therapy will work with you at home to help you regain
your strength.
The following changes have been made to your home medication
regimen. You will now take Diovan 160mg twice daily, and
metoprolol extended release once daily. You should stop taking
Pravastatin. We have also added one additional medication:
Flagyl 500mg PO three times daily for 14 days.
Contact your medical provider for any fever, shortness of
breath, worsening of productive cough, or for any other
concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2119-6-6**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2119-6-7**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-6-13**] 11:00
[**Hospital **] [**Hospital 982**] Clinic, [**2119-8-1**] 2:30. You will be contact[**Name (NI) **] if
an earlier appointment becomes available.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21117**] MD, [**MD Number(3) 21118**]
Completed by:[**2119-6-3**]
|
[
"276.52",
"410.71",
"584.9",
"250.61",
"785.50",
"V45.82",
"480.9",
"250.51",
"518.81",
"272.4",
"311",
"276.4",
"281.9",
"362.01",
"933.1",
"038.9",
"427.31",
"414.01",
"E928.8",
"995.92",
"507.0",
"913.0",
"008.45",
"V08",
"357.2",
"V42.0",
"E931.7",
"787.91",
"733.00",
"E915"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.24",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
16588, 16671
|
8571, 13569
|
289, 374
|
17037, 17122
|
4169, 8548
|
18189, 18975
|
3216, 3478
|
14366, 16565
|
16692, 17016
|
13595, 14343
|
17146, 18166
|
3493, 4150
|
230, 251
|
402, 2466
|
2488, 2905
|
2921, 3200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,427
| 146,278
|
23964
|
Discharge summary
|
report
|
Admission Date: [**2182-6-27**] Discharge Date: [**2182-7-8**]
Date of Birth: [**2125-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2182-6-27**] Five Vessel CABG(LIMA to LAD, vein graft to diagonal,
vein graft sequential to ramus and obutse marginal, vein graft
to PDA)
History of Present Illness:
This is a 57 year old male with known history of coronary artery
disease. He underwent previous PCI of his LAD in [**2173**] and most
recently PCI of his obutse marginal in [**2181-1-30**]. He presents
now with exertional angina and dyspnea on exertion. A recent
Myoview imaging study was notable for ischemia. Subsequent
cardiac catheterization revealed 80% LAD lesion after the stent;
90% stenosis of the first obtuse marginal and a totally occluded
mid right coronary artery. Based on the above results, he was
referred for surgical revascularization. Prior to surgery, an
echocardiogram was performed which showed an LVEF of 30%. There
was only 1+ mitral regurgitation and trace aortic insufficiency.
The ascending aorta and aortic root were mildly dilated,
measuring 3.9 cm and 3.7 cm respectively.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes
Mellitus Type II, GERD, Hiatal Hernia, Hypothyroidism, Chronic
back pain, History of Kidney Stones, s/p Rotator Cuff Surgery,
s/p Polypectomy, s/p Tonsillectomy
Social History:
90 pack year history of tobacco, quit [**2173**]. Admits to rare ETOH.
Currently lives with his wife and works for [**Name (NI) 22957**].
Family History:
Denies premature CAD.
Physical Exam:
Vitals: BP 120/70, HR 76, RR 16
General: obese male in no acute distress, macular rash noted on
abdomen, chest and legs
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2182-7-6**] 05:00AM BLOOD WBC-10.0 RBC-3.49* Hgb-10.8* Hct-30.8*
MCV-88 MCH-31.0 MCHC-35.1* RDW-13.9 Plt Ct-396
[**2182-7-6**] 05:00AM BLOOD UreaN-14 Creat-0.9 Na-132*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. The operation was uneventful and
he was transferred to the CSRU for invasive monitoring. Within
24 hours, he awoke neurologically intact and was extubated. He
maintained stable hemodynamics and transferred to the SDU on
postoperative day two. Heart failure therapy which included
Coreg, ace-inhibition and diuretics were started. He remained
fluid overloaded and initially required aggressive diuresis with
intravenous Lasix. The [**Last Name (un) **] Center was consulted to assist in
the managment of his diabetes mellitus. Given his poorly
controlled blood sugars, insulin therapy was eventually
initiated. He maintained stable hemodynamics but was noted to
have occasional non-sustained ventricular tachycardia. He
remained asymptomatic. Given his low ejection fraction, the EP
service was consulted to evaluate the need for an AICD. A
postoperative echocardiogram on [**7-1**] showed slightly worsening
LVEF of 25% with slightly worsening MR. It was recommended to
optimize his CHF regimen and reassees his LVEF in [**2-4**] months. An
AICD was not recommended at this time. Over several days,
medical therapy was optimized. He experienced less ventricular
ectopy and continued to make clinical improvements with
diuresis. He was noted to have moderate amount of sternal
drainage which was treated with intravenous Vancomycin and
betadine dressing changes. By discharge, his sternal drainage
resolved but he will continue oral antibiotics and additional
dressing changes given risk for sternal wound infection(diabetes
mellitus). The remaineder of his hospital course was uneventful
and he was medically cleared for discharge on postoperative day
11.
Medications on Admission:
Aspirin 325 qd, MVI, Nambumetone 750 [**Hospital1 **], Metformin 1000 [**Hospital1 **],
Plavix 75 qd, Levoxyl 0.175 qd, Omeprazole 20 qd, Quinapril 10
qd, Actos 15 qd, Glipizide 7.5 [**Hospital1 **], Lopressor 25 [**Hospital1 **], Lipitor 30
qd, Imdur 30 qd, Lasix 40 qd, Advair, Tramadol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
13. Quinapril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 40 mg [**Hospital1 **] x 1 week, then 40 mg QD ongoing.
Disp:*60 Tablet(s)* Refills:*0*
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 1 weeks.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
16. Insulin Glargine 100 unit/mL Cartridge Sig: Twelve (12)
units Subcutaneous at bedtime.
Disp:*QS 1 month* Refills:*0*
17. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: per
sliding scale units Subcutaneous four times a day.
Disp:*QS 1 month* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva ([**Location (un) 3320**] Branch)
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG, Congestive Heart Failure,
Postop Sternal Drainage, Postop NSVT, Hpertension, Diabetes
Mellitus Type II, GERD, Hypothyroidism
Discharge Condition:
Good.
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 914**] in [**3-6**] weeks - call for appt.
Local PCP and cardiologist in [**1-4**] weeks - call for appt.
Completed by:[**2182-7-8**]
|
[
"244.9",
"428.0",
"250.00",
"530.81",
"V58.67",
"401.9",
"724.2",
"272.4",
"427.89",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.14",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6655, 6727
|
2382, 4201
|
365, 508
|
6932, 6940
|
2187, 2359
|
7258, 7438
|
1760, 1783
|
4544, 6632
|
6748, 6911
|
4227, 4521
|
6964, 7235
|
1798, 2168
|
280, 327
|
536, 1341
|
1363, 1589
|
1605, 1744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,047
| 197,419
|
24853
|
Discharge summary
|
report
|
Admission Date: [**2136-7-26**] Discharge Date: [**2136-9-20**]
Date of Birth: [**2108-5-30**] Sex: M
Service: MEDICINE
Allergies:
Ambisome
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Recurrent AML
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A 28-year-old gentleman with a history of AML status post
recurrence after a third allogeneic transplant from an unrelated
donor. The patient most recently received decitabine followed
by DLI on [**2136-6-12**], decitabine on day 13 and DLI which was on
[**7-10**]. He subsequently received donor lymphocyte infusion on
[**7-23**]. He subsequently had bone marrow biopsy which revealed
persistent involvement of patient's known acute leukemia. He's
therefore admitted for further chemotherapy. On presentation
tonight he continues to feel well without complaints except for
some mild dyspnea on exertion. Denies fever, chill or rigor. No
easy bruising or bleeding.
Past Medical History:
PAST ONCOLOGIC HISTORY
- [**10-29**]: Diagnosed with AML (p/w fevers and myalgias, found to
have Influenza A. WBC of 3 with 74% blasts. Started 7+3
consolidation therapy. Had residual disease after completion
requiring HIDAC.
- [**3-2**]: Nom-myeloablative allo-transplant from matched sibling.
relapsed shortly thereafter.
- [**2134-4-12**]: Completed a course of clofarabine and ARA-C
- [**2134-5-7**] Full myeloablative allo transplant from the same
matched
sibling . Transplant was c/b prolonged neutropenia, fevers, high
transfusion requirement secondary to ABO mismatched graft.
- [**2135-11-1**]: p/w progressive fatigue. Found to have 54% blasts in
his peripheral blood without evidence of tumor lysis or DIC.
- Underwent ARA-C (1g/m2) on days [**1-30**] and clofarabine (40 mg/m2)
on days [**3-2**]. He received all 6 days as an outpatient.
- Chronic GVH of the liver, manifesting as liver
function test abnormalities. He had a Liver Bx in [**7-31**]: findings
consistent with GVH, but also increased ferritin consistent with
iron overload. He has received therapeutic phlebotomy for this.
-now s/p ALLO MUD, Day 25 on day of admission
<br>
OTHER PAST MEDICAL HISTORY
-HTN - treated prior on metoprolol and more recent on
nifedipine - pt does not immediately recall prior dose - but
states noted pressures have been up and down a bit just recently
- has been off meds since transplant
-Pituitary adenoma: followed by Dr. [**Last Name (STitle) 62546**] at [**Hospital1 2025**]. Recent
MRI did not show any change in adenoma size
-Splenic rupture [**2-27**] MVA in [**2125**], no splenectomy required
-h/o VRE bacteremia in [**4-30**].
Social History:
Currently unemployed and living with his parents. Previous to
his recent admission he had worked as an MRI tech. He has 2
younger brothers, one of whom was his stem cell donor. He has
never smoked and drinks alcohol occasionally.
Family History:
Patient had a cousin who passed away from leukemia at the age of
9. His aunt had polycythemia. His grandfather has DM2, and his
father has multiple kidney stones. He also notes that multiple
relatives on his father's side have had MIs and CAD.
Physical Exam:
Vital signs stable, afebrile
GEN: NAD
HEENT: MMM, OP clear
CV: RRR, normal S1 S2, no murmurs, rubs, or gallops
PULM: CTAB
ABD: soft, NT/ND, BS+, no HSM
EXT: no c/c/e
Pertinent Results:
[**2136-7-25**] 11:25AM ALT(SGPT)-68* AST(SGOT)-39 LD(LDH)-139 ALK
PHOS-198* TOT BILI-0.4 DIR BILI-0.1 INDIR BIL-0.3
[**2136-7-25**] 11:25AM GRAN CT-108*
[**2136-7-25**] 11:25AM NEUTS-5* BANDS-0 LYMPHS-77* MONOS-1* EOS-14*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-3*
[**2136-8-8**] 11:40 am BLOOD CULTURE Source: Line-picc white
port.
**FINAL REPORT [**2136-8-11**]**
Blood Culture, Routine (Final [**2136-8-11**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = Sensitive , MIC OF 1.5 MCG/ML Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Aerobic Bottle Gram Stain (Final [**2136-8-9**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. OLCECSKY ON [**2136-8-9**] AT 0600.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2136-8-9**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Brief Hospital Course:
This is a 28 year old male with AML s/p 3rd allo SCT (2 sibling
donors, 1 MUD) ~6 months ago who was admitted after a bone
marrow biopsy was indicative for recurrent AML in order to
receive chemotherapy.
.
# AML: He received 5 days of chemotherapy on a regimen that
included cytarabine, mitoxantrone, and Mylotarg which he
tolerated well except for some rigors with Mylotarg which
responded to demerol and some fevers after cytarabine infusions.
Otherwise, he had mild nausea and headaches that responded to
lorazepam and oxycodone. He had fevers which were believed to
be due to the cytarabine since the fevers only occurred
following the chemo and cultures were negative. He received
tumor lysis and DIC labs frequently during chemo, none of which
were positive. He was prophylaxed with D5w-bicarb and
allopurinol. Bone marrow biopsy was done of [**8-17**]. The patient
received a stem cell boost on [**8-28**]. This caused him to have
fevers and rigors, but this resolved by the next day. His cell
counts began to rise after 6 days, and he no longer required
transfusions of red cells or platelets.
.
# Febrile neutropenia/ID: He was put on cefepime prophylaxis
while neutropenic and vancomycin was added when he spiked
through cefepime. He was also maintained on acyclovir,
ursodiol, and voriconazole prophylaxis. The patient became
febrile up to 103 on [**8-3**] and have continued. The patient had
VRE bacteremia and the patient was started on linezolid and
vancomycin was d/c'ed. The fevers persisted and due to rising
LFT voriconazole was switched to micafungin and cefepime was
changed to meropenem as fevers continued. As LFT's normalized
the pt continued to have fevers, tachycardia and developed sharp
[**Month/Year (2) 5283**] abdominal pain and mica was changed to vori again, and an
extensive work up including [**Month/Year (2) 5283**] US, CT A/P, MRI of liver, HIDA
scan, surface ECHO, CTA of chest, CT non-con of chest was
pursued to evaluate the cause of the pt's persistent
hyperdynamic state and severe pleuritic pain. Pulm was consulted
on [**8-14**] and pt underwent a bronch on [**8-15**] that he seemed to
tolerated well. On the evening of [**8-15**], pt developped acute
respiratory distress with hypoxia and tachycardia. He was placed
on a NRB with improvement in sats to 100% but a large A-a
gradient with ABG 7.44/45/79, lactate of 1.0. Pt was tachycardic
to 170s and tachypneic. The patient was discharged from
voriconazole and started on ambisome and posaconazole for
increased aspergillus as well as atypical fungal coverage. The
patient continued to spike fevers, however, clinically appeared
much better. His pain also decreased significantly. He was
transferred back from the ICU on [**8-17**]. He continued to spike
fevers while on the floor and was cultured repeatedly, but was
never positive except for the single VRE positive blood culture.
.
On [**8-26**], the patient was switched to daptomycin in preparation
for his stem cell boost on [**8-28**], however, this caused a rise in
the patients LFTs and bilirubin. It was stopped on [**9-8**]. The
patient remained clinically stable, and the ambisome and
meropenem were also discontinued. The patient's bilirubin
subsequently decreased after stopping the daptomycin. ID was
consulted, who felt that given that he had already received one
month's worth of treatment between the daptomycin and linezolid,
it was reasonable to simply stop the drug and watch for fever.
.
#Rib pain - After returning to the floor from the ICU, the
patient continued to complain of severe lateral thoracic pain,
R>L that required treatment with q4h IV dilaudid. Per the
patient, this was different from the pleuritic chest pain that
he had experienced previously. A CT scan of the chest done on
[**9-15**] showed no acute process or etiology of his pain. He was
switched to MS contin and was subsequently weaned over the
course of several days off of the narcotics.
.
#Elevated bilirubin - The patient had an elevation of his
bilirubins from [**Date range (1) 62547**]. Initially, the etiology was unclear,
and [**Name (NI) 5283**] u/s and liver MRI showed no evidence of [**Last Name (un) **]-occlusive
disease, cholecystis or biliary duct destruction consistent with
GVHD. His daptomycin was stopped and his bilirubins returned
close to baseline.
.
#Nutrition - The patient had poor PO intake due to nausea and
lack of appetite. He was placed on TPN, which was stopped on
[**9-15**] when his appetite and nausea improved.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet TID
FOLIC ACID - 1 mg Tablet DAILY
LEVOFLOXACIN 500MG DAILY
LORAZEPAM 0.5 mg Tablet - [**1-27**] Tablet Q8H PRN
PENTAMIDINE 300 mg Recon Soln INH qmonth last dose was [**7-6**].
PROCHLORPERAZINE EDISYLATE 10 mg TabletQ8H PRN
URSODIOL - 300 mg Capsule [**Hospital1 **]
VORICONAZOLE 200 mg Tablet [**Hospital1 **]
MULTIVITAMIN DAILY
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*180 Capsule(s)* Refills:*2*
4. Posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Five (5)
mL PO QID (4 times a day).
Disp:*600 mL* Refills:*2*
5. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours): Do not substitute.
Disp:*120 Capsule(s)* Refills:*2*
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Pentamidine 300 mg Recon Soln Sig: One (1) 300mg Inhalation
once a month: last administration [**9-6**].
10. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) vial Inhalation once a month: prior to pentamidine
inhalation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety or nausea.
Disp:*60 Tablet(s)* Refills:*0*
14. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute myelogenous leukemia
Discharge Condition:
stable, afebrile, ambulatory
Discharge Instructions:
Your were admitted to [**Hospital1 **] Hospital for
chemotherapy after a bone marrow biopsy showed recurrence of
your AML. You received chemotherapy for this and a stem cell
boost on [**8-28**]. After this, your cell counts recovered and
were stable at the time of your discharge.
.
During your admission, you also developed fevers and severe
right sided chest pain. For this you underwent a bronchoscopy.
We found that you had an infection with a bacteria known as
vancomycin resistant enterococcus, and you were treated with
antibiotics for this. We were also concerned that you had a
fungal infection in your chest, for which you were also treated
with several medications known as posaconazole and ambisome.
Because this occurred while you were on voriconazole, we changed
your fungus prophylaxis to posaconazole. For your pain, you
were initially treated with dilaudid. As your pain improved we
switched you to oral morphine, which you have also been given a
prescription to go home with.
.
There have been several changes to your medications. The list
included with these instructions is the most up-to-date and
complete list of your medications. Please take these
medications as prescribed.
.
Please keep all of your outpatient follow-up appointments listed
below.
.
Please seek medical care for any concerning symptoms such as
fevers >100.4, chills, abdominal pain, vomiting, diarrhea, or
shortness of breath.
.
For your diet, please ensure that you are always eating well
cooked foods. Avoid uncooked food such as salads, fresh fruit
or sushi.
Followup Instructions:
Please keep all of your follow-up appointments listed below:
.
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2136-9-21**] 10:00
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2136-9-22**] 10:00
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2136-9-23**] 10:00
.
[**2136-9-24**] 02:30p [**Last Name (LF) **],[**First Name3 (LF) **] H.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
[**2136-9-24**] 02:30p [**Last Name (LF) **],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
.
[**2137-2-18**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
[**2137-2-18**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **] H.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Completed by:[**2136-9-21**]
|
[
"288.00",
"284.1",
"117.3",
"486",
"789.59",
"999.31",
"518.82",
"996.85",
"287.5",
"790.7",
"782.4",
"041.04",
"511.9",
"V02.59",
"205.00",
"V09.81",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.05",
"00.14",
"38.93",
"33.24",
"99.25",
"41.31",
"00.92",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
11744, 11750
|
5071, 9584
|
283, 290
|
11821, 11852
|
3372, 5048
|
13462, 14554
|
2920, 3169
|
9991, 11721
|
11771, 11800
|
9610, 9968
|
11876, 13439
|
3184, 3353
|
230, 245
|
318, 986
|
1008, 2656
|
2672, 2904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,302
| 113,254
|
33800
|
Discharge summary
|
report
|
Admission Date: [**2110-3-31**] Discharge Date: [**2110-4-6**]
Date of Birth: [**2035-5-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Elective cardiac surgery
Major Surgical or Invasive Procedure:
3/1008 - CABGx2(Vein->Obtuse marginal, Vein->Posterior Left
Ventricular Branch); PFO Closure; AVR(21mm St. [**Male First Name (un) 923**] Epic Porcine
Valve)
History of Present Illness:
74 year old female who is currently asymptomatic who has been
followed the last 2 years for aortic stenosis. Her most recent
echo showed severe AS with an aortic valve area of 0.5cm2. She
is now admitted for surgical management.
Past Medical History:
AS
PFO
CAD
Hyperlipidemia
HTN
CVD
Social History:
Retired microbiologist. Never smoked. Denies drinking alcohol.
Lives with Husband and oldest son.
Family History:
Father died of stroke.
Physical Exam:
Admission
VS: HR 78 BP 162/77 RR 14 HT 62" WT 175lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally
HEART: RRR, III-IV/VI holsystolic murmur
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities, no
peripheral edema, pulses [**1-22**]+ peripherally. No carotid bruit
appreciated.
NEURO: No focal deficits.
Discharge
Pertinent Results:
[**2110-4-1**] CXR
The ET tube tip is 5.3 cm above the carina. The NG tube tip is
in the stomach. The Swan-Ganz catheter tip currently terminates
in right interlobar pulmonary artery. The patient is after
removal of chest tube and mediastinal drains. There is no
pneumothorax or increasing pleural effusion is identified.
Bibasilar left more than right atelectasis is unchanged.
[**2110-3-31**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium. No spontaneous echo contrast or thrombus is seen in the
body of the right atrium or the right atrial appendage.
2. A patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal for the patient's body
size. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade III/IV (severe) LV diastolic dysfunction.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
7. Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened.
8. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of phenylephrine. Well-seated
bioprosthetic valve in the aortic position. Mild residual
stenosis, no paravalvular leak. Atrial septum intact without
visible shunt. Biventricular systolic function is preserved.
Aortic contour is normal post decannulation.
[**2110-3-31**] 01:28PM UREA N-8 CREAT-0.3* CHLORIDE-119* TOTAL
CO2-20*
[**2110-3-31**] 01:28PM WBC-28.1*# RBC-3.52*# HGB-9.8* HCT-29.3*#
MCV-83 MCH-28.0 MCHC-33.6 RDW-14.2
[**2110-3-31**] 01:28PM PLT COUNT-195
[**2110-3-31**] 01:28PM PT-15.7* PTT-37.7* INR(PT)-1.4*
[**2110-3-31**] 12:57PM FIBRINOGE-197
[**2110-4-6**] 06:45AM BLOOD WBC-19.2* RBC-3.03* Hgb-8.8* Hct-26.7*
MCV-88 MCH-28.9 MCHC-32.9 RDW-16.1* Plt Ct-428
[**2110-4-6**] 06:45AM BLOOD PT-32.2* INR(PT)-3.3*
[**2110-4-5**] 06:10AM BLOOD PT-34.6* INR(PT)-3.6*
[**2110-4-4**] 05:00AM BLOOD PT-17.3* PTT-26.0 INR(PT)-1.6*
[**2110-4-5**] 06:10AM BLOOD UreaN-22* Creat-0.8 K-4.0
CHEST (PA & LAT) [**2110-4-4**] 10:04 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman s/p AVR/CABG/PFO closure
REASON FOR THIS EXAMINATION:
eval for pleural effusions
REASON FOR EXAMINATION: Followup of a patient after aortic valve
replacement, CABG and patent foramen ovale closure.
PA and lateral upright chest radiograph compared to [**2110-4-1**].
Patient was extubated in the meantime interval with removal of
the NG tube and Swan-Ganz catheter. The moderate cardiomegaly is
stable. The bibasal opacities are consistent with post-surgical
atelectasis, improved. Small amount of pleural effusion is
demonstrated, bilateral. There is no evidence of failure. There
is no pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname 78151**] was admitted to the [**Hospital1 18**] on [**2110-3-31**] for
surgical management of her aortic valve and coronary artery
disease. She was taken directly to the operating room where she
underwent coronary artery bypass grafting to two vessels, and
aortic valve replacement with a 21mm St. [**Male First Name (un) 923**] Epic Porcine valve
and a PFO closure. Please see operative note for details.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mrs.
[**Known lastname 78151**] awoke neurologically intact and was extubated. She
awoke mildly confused but slowly cleared mentally. She was
transfused with two units of packed red blood cells for
postoperative anemia. Mrs. [**Known lastname 78151**] developed atrial
fibrillation for which amioadrone and coumadin was started. On
postoperative day two, she was transferred to the step down unit
for further recovery. Beta blockade, aspirin and a statin were
resumed. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted to assist
with her postoperative strength and mobility. She became
confused and was pancultured given her WBC of 20. Her INR rose
quickly to 3.6. Her confusion improved and her INR stabilized
and she was ready for discharge home on POD #6.
Medications on Admission:
Vasotec 5mg [**Hospital1 **]
Aspirin 81mg QD
Lipitor 10mg QD
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
for 7 days, then decrease to 200 mg daily until d/c'd by
cardiologist.
Disp:*90 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: then as directed by Dr. [**Last Name (STitle) 58623**].
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
CAD/AS/ASD s/p AVR(21mm Porcine), PFO closure, CABGx2 [**2110-3-31**]
HTN
Hyperlipidemia
PVD
AF
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 40149**] in 2 weeks. ([**Telephone/Fax (1) 78152**]
Follow-up with Dr. [**Last Name (STitle) 58623**] in 1 week. [**Telephone/Fax (1) 58624**]. Coumadin
will be followed by the office of Dr. [**Last Name (STitle) 58623**] and INR should be
drawn on Monday [**2110-4-7**] and then called to her office. Plan
confirmed with Dr. [**Last Name (STitle) 58623**].
Please call all providers for appointments.
Completed by:[**2110-4-8**]
|
[
"791.9",
"424.1",
"285.9",
"272.4",
"745.5",
"E878.2",
"998.0",
"427.31",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"35.21",
"39.61",
"35.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7863, 7934
|
4948, 6303
|
307, 467
|
8073, 8082
|
1418, 4265
|
8824, 9390
|
913, 937
|
6414, 7840
|
4302, 4345
|
7955, 8052
|
6329, 6391
|
8106, 8801
|
952, 1399
|
243, 269
|
4374, 4925
|
495, 725
|
747, 782
|
798, 897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,021
| 178,275
|
43187+43188+58595+58596
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2167-7-27**] Discharge Date: [**2167-8-17**]
Date of Birth: [**2112-4-9**] Sex: M
Service:
DISPOSITION: The patient is transferred to the general
medical floor at this time.
HISTORY OF PRESENT ILLNESS: This is a 55 year-old male with
a history of atrial fibrillation, depression, alcohol abuse,
hypertension and hyperlipidemia who was transferred from an
outside hospital with increasing hepatic failure, renal
failure, tremors, change in mental status and possible sepsis
in the setting of an elevated white count with bandemia and
mild respiratory distress. The patient had presented to
[**Hospital 1558**] Medical Center on [**2167-6-17**] after
injuring his knee from a fall at work. He was found to have
a right patellar fracture and was transferred to [**Hospital6 **], closer to his home, where his hospital course there
was significant for atrial flutter that developed on the day
of his admission. The patient was then monitored on
telemetry. During his hospital stay he had increasing
respiratory distress and was eventually intubated on [**2167-6-20**].
The patient was suspected to be in delirium tremens and was
also diagnosis with a Staphylococcus aureus pneumonia. On
[**2167-6-27**] he was diagnosed with an Alpha Strep bacteremia by
positive blood culture. A lumbar puncture done on [**2167-6-28**]
ruled out meningitis. Bronchial washings done on [**2167-7-5**]
were significant for growth of [**Female First Name (un) 564**] Albicans and also the
catheter tip culture grew coagulation negative Staph, two
bottles, from a blood culture also on [**2167-7-5**].
During his hospital course his hematocrit dropped from 38 to
25. His liver function also worsened, AST changing from 105
to 133, ALT from 77 to 113 and total bilirubin from 1.9 to
17.5. Renal failure also worsened throughout his hospital
stay. BUN changed from 17 to 57 and creatinine from 0.8 to
2.9. In addition, a stage two decubitus ulcer developed in
his perianal area.
PAST MEDICAL HISTORY: Atrial fibrillation treated with
Propanthenone for approximately five years. History of
hyperlipidemia, depression, hypertension, history of alcohol
abuse, gout.
MEDICATIONS: Medication on transfer from outside hospital
were Propanthenone 150 mg p.o. t.i.d., Thiamine 100 mg p.o. q
day, Folate one tablet p.o. q day, Multivitamin p.o. q day,
Flovan 110 mcg inhaled two puffs b.i.d., Protonix 40 mg p.o.
q day and Flagyl 500 mg p.o. b.i.d., Morphine 2 mg
intravenously p.r.n., lactulose 15 ml p.o. b.i.d., Actigall
300 mg p.o. b.i.d., Prednisone 60 mg p.o. q times five days,
antifungal cream.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married but separated from his wife. Denies
recent smoking. The patient has a long history of alcohol
abuse. The patient works as a construction supervisor.
FAMILY HISTORY: Family history is significant for both
parents with a history of cirrhosis without A-B hepatitis
diagnosis.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs temperature 97.4, heart rate 130, blood
pressure 112/82, respiratory rate 24, pulse oximetry 95
percent on two liters. General jaundiced tremulous
diaphoretic, moderately obese male. Head, eyes, ears, nose
and throat examination revealed positive marked icterus,
extraocular movements intact, pupils equally reactive to
light and accommodation. Next, no jugulovenous distension,
no bruits, no lymphadenopathy. Lungs, diffuse crackles,
increased bibasilar. Heart, normal S1, S2, no rubs, murmurs
or gallops, irregularly irregular. Abdomen, positive bowel
sounds, distended, no masses, positive fluid wave with
shifting dullness. Extremities, marked peripheral and
truncal edema. Neurological examination notable for tremors
in all extremities, most marked in the arms. The patient was
alert and oriented to name only. Moving all extremities.
LABORATORY DATA: White count of 22, 81 percent neutrophils,
8 percent bands, 8 percent lymphocytes, 2 percent monocytes.
Hematocrit 31.1. Platelet count 295. MCV 95. Electrolytes,
sodium 142, potassium 4.2, chloride 113, bicarbonate 50, BUN
76, creatinine 3.3, calcium 9.1, magnesium 2.0, phosphate
5.3, glucose 127, ionized calcium 1.27, lactate 3.5. Arterial
blood gases 7.27, PCO2 37, PO2 77, INR 1.5, PT 15, PTT 34.
AST 133, ALT 113, alkaline phosphatase 357, total bilirubin
16.7, LDH 303, CK 26, albumin 2.5, uric acid 13.8.
Abdominal ultrasound on admission negative for significant
ascites. Hepatobiliary ducts are patent. Positive
gallbladder edema. No evidence of stones of sludge. At the
outside hospital Hepatitis B and C antibodies are negative.
Cerebrospinal fluid studies were negative on [**2167-6-28**]. Urine
eosinophil is positive on [**2167-7-22**]. Bronchial washings
[**2167-7-6**] negative for malignant cells. CT of the head on
[**2167-7-1**] was negative.
ASSESSMENT AND PLAN: A 55 year-old male with history of
alcohol abuse, hypertension, atrial fibrillation who presents
with multi-organ failure, namely hepatic failure, renal
failure and respiratory distress following a prolonged course
at an outside hospital.
HOSPITAL COURSE: Problem #1: Renal. The patient has renal
failure of an etiology that is multifactorial by history.
The patient had likely acute tubular necrosis from a
hypotensive episode at the outside hospital. Also, the
patient had positive eosinophils at the outside hospital and
was diagnosed with acute interstitial nephritis and was
finishing a course of prednisone for this diagnosis during
the time of transfer to this hospital. Here he was found to
have a positive antistreptolysin O antibody and therefore was
diagnosed with a post Streptococcal glomerular nephritis,
treatment for which was conservative. Intravenous fluids
were continued for prerenal azotemia and ongoing
intravascular depletion. The patient's creatinine improved
throughout his hospital stay, decreasing from 3.3 to 0.9 on
the time of transfer. The patient had marked anasarca and
was continually diuresed throughout his hospital stay,
however, the patient also had ongoing hypernatremia which was
addressed with intravenous fluids D5W and free water boluses
four times each day while also receiving free water with his
tube feeds. His sodium level did return to within normal
limits on this regimen and much of his edema had resolved by
the time of transfer.
Problem #2: Cardiovascular. The patient presented with
atrial fibrillation, a chronic issue. His Propanthenone was
discontinued as it had not been effective for several years.
The patient was continued on Metoprolol t.i.d. for control of
his heart rate. His anticoagulation was continued for the
majority of his stay, initial Coumadin and then later changed
to heparin which was held on occasions for concerns about
decreasing hematocrit on several occasions. When the patient
was extubated, he developed marked elevation of his blood
pressure and his heart rate and did require a Diltiazem drip
which was changed to a Labetalol drip for better control of
these abnormalities. He was quickly weaned back to a regimen
of Metoprolol and Diltiazem. An echocardiogram done during
his hospital stay showed ejection fraction of 50 to 55
percent, marked left atrial and right atrial dilation
secondary to an atrial septal defect, 4+ tricuspid
regurgitation and 2+ mitral regurgitation.
Problem #3: Respiratory. The patient was initially treated
for respiratory acidosis with intermittent BIPAP to bring his
pH from below 7.2 to above 7.3, however, due to ongoing
issues with poor control of his respiratory acidosis he was
intubated on [**2167-8-4**] after a prolonged weaning on pressor
support and back to assist control. The patient was
eventually extubated on [**2167-8-14**] and his respiratory status
improved to a point where he was adequate saturations on two
liters of nasal cannula. The etiology of his respiratory
failure included pneumonia and pulmonary edema with marked
effusion.
Problem #4: Gastrointestinal. The patient presented in
marked liver failure with hepatic encephalopathy. His
transaminases and total bilirubin were markedly elevated on
admission. The etiology of his liver failure was suspected
to be alcoholic hepatitis. Viral and autoimmune causes were
ruled out and drug reaction was also considered a
contributing factor. Serial ultrasounds ruled out
significant ascites that would necessitate paracentesis. The
patient was continued on a course of Versadile and Lactulose
in addition to tube feeds for nutrition to address his
ongoing liver failure and resulting encephalopathy. His AST
improved from 113 to 46, ALT from 133 to 50, alkaline
phosphatase from 357 to 229 and his total bilirubin from 16.7
to 5.3 during his Medical Intensive Care Unit stay. His
hepatic encephalopathy largely resolved during this time.
Problem #5: Neurology/mental status. The patient's mental
status was altered secondary to hepatic encephalopathy and
uremic encephalopathy, however, even with resolution of both
of these abnormalities his mental status was persistently
altered and other factors such as hypernatremia, hypoxia and
acidosis were suspected to be contributing to his altered
state. An electroencephalogram done was consistent with a
metabolic encephalopathy. A CT of the head was negative for
hemorrhage or mass. An Magnetic resonance scan showed a
right frontal lobe lesion that did not account for mental
status change. A lumbar puncture was also done to rule out
infectious causes of mental status change. On the day of
transfer, the patient had marked improvement of his
alertness, awareness and orientation.
Problem #6. Infectious disease. The patient was diagnosed
with a pneumonia shortly after admission. He was initially
treated with Zosyn and Vancomycin for a suspected nosocomial
pneumonia. The patient developed a rash with this antibiotic
course and this treatment was discontinued. The patient
later developed urinary tract infection with pseudomonas and
E coli growth and also spiked fevers from the suspected line
sepsis in which blood cultures had grown coagulation negative
Staphylococcus. The patient was started on a course of
ciprofloxacin and vancomycin. He again developed a rash that
was attributed to vancomycin and a course of Linasoid was
started. A lumbar puncture during the hospital course ruled
out meningitis.
Problem #7: Hematology. During the hospital course the
patient received five units of packed red blood cells for
ongoing issues of decreased hematocrit. No evidence of
bleeding or hemolysis was discovered during the [**Hospital 228**]
hospital stay. A retroperitoneal bleed was ruled out by a
CAT scan as well. The etiology of his anemia is likely
multifactorial.
Problem #8: Orthopedics. The patient presented with a
fractured right patella. Per orthopedic's recommendations,
the right leg was kept immobilization and surgical
intervention was deferred until his medical issues had
resolved.
Problem #9: Fluid electrolytes and nutrition. The patient
was markedly acidotic on admission and throughout much of the
early part of his hospital stay. The acidosis was
multifactorial including an andiron gap acidosis initially
from a lactic and uremic source. These abnormalities
resolved with improved liver and renal function. Non-andiron
gap acidosis was more persistent due to ongoing diarrhea
induced by lactulose treatment.
For nutrition, tube feeds were continued throughout the
[**Hospital 228**] hospital stay. Folic acid and thiamin
supplementation was also continued.
Problem #10. Endocrinology. The patient was continued on a
regular insulin sliding scale for intermittently high blood
sugars.
Problem #11. Dermatology. The patient had cutaneous
candidiasis most marked on his left axilla which was treated
with Miconazole powder.
Problem #12: Prophylaxis. The patient was continued on
anticoagulation, Coumadin and later heparin and also
Metoprolol.
Problem #13: Access. The right internal jugular vein
central line and a left arterial line were discontinued
during the final week of the [**Hospital 228**] Medical Intensive Care
Unit stay. The right arm PICC line was placed on [**2167-8-11**].
Please see subsequent discharge summary addendums for the
remaining hospital course and discharge plans.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2167-8-18**] 23:08
T: [**2167-8-19**] 05:00
JOB#: [**Job Number **]
Admission Date: [**2167-7-27**] Discharge Date: [**2167-9-8**]
Date of Birth: [**2112-4-9**] Sex: M
Service:
REASON FOR ADMISSION: The patient was initially admitted
with renal failure, hepatic failure, and streptococcal
sepsis. Please see the Discharge Summary from Intensive Care
Unit. This Discharge Summary will entail the patient's
course on the floor.
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
gentleman with a history of alcohol abuse and atrial
fibrillation who was originally admitted to an outside
hospital for a open reduction/internal fixation of his right
patella which he had fractured back in [**2167-5-24**] but was
never repaired since the patient went into a delirium tremens
secondary to alcohol withdrawal requiring intubation and
subsequently developing aspiration pneumonia, a stage II
decubital ulcerations, a gout flare, acute renal failure
(thought to be possibly secondary to post streptococcal
glomerulonephritis secondary to streptococcal sepsis), and
hepatic failure with encephalopathy.
The patient was initially admitted to the Intensive Care Unit
here on [**7-27**]. During his Intensive Care Unit course, he
recovered his renal and liver function. He had a waxing and
[**Doctor Last Name 688**] mental status which was subsequently attributed to
first to hepatic encephalopathy; as lumbar punctures were
done which were negative, and an electroencephalogram was
consistent with a metabolic encephalopathy. Also during this
hospital Medical Intensive Care Unit course, the patient was
briefly intubated secondary to a hypoventilatory pattern
which eventually self corrected; the etiology of which was
uncertain. The patient also had hyponatremia which improved
with free water boluses, a left lower lobe pneumonia with
gram-positive cocci in the sputum (which was treated with
vancomycin initially which was discontinued secondary to a
rash that was thought to be secondary to linezolid), and
continued difficulty with atrial fibrillation while holding
anticoagulation because of a possible decreased hematocrit
although no obvious bleed was ever located, and also
transient hypertension requiring labetalol.
The [**Hospital 228**] Medical Intensive Care Unit course was also
complicated by hypothyroidism and coagulase-negative
staphylococcal bacteremia (which was treated with a 14-day
course of linezolid).
The patient was initially transferred from the Intensive Care
Unit to the floor on [**8-17**]. The patient had been stable
in terms of his hemodynamics and his respiratory status with
minimal oxygen support, and his waxing and [**Doctor Last Name 688**] mental
status which was initially attributed to toxic/infectious
etiology had been improving. However, the patient was still
noted to have fevers and also found to be tremulous. On the
floor, his peripherally inserted central catheter line was
discontinued, and the tip was sent for cultures as well as
blood cultures being sent on [**8-18**]. It was felt that
possibly his peripherally inserted central catheter line was
the source of his fevers. Both cultures ended up being
negative to date. His fever curb had been improving, and his
Synthroid was discontinued initially for his hypothyroidism.
However, the patient had a magnetic resonance imaging showing
increased diffuse white matter hyperintensity suggesting
ischemia versus ongoing inflammation process versus a
leukoencephalopathy.
Meanwhile, the patient had received several units of packed
red blood cells for an anemia and had been consulted by
Infectious Disease for these persistent fevers which were
initially thought to be possibly secondary to his known
coagulase-negative staphylococcal bacteremia. The patient
was continued on linezolid while fungal cultures were sent.
This was going on while on the floor, and the patient
actually began to eat on [**8-20**].
However, on the evening of [**8-20**] and [**8-21**], the
patient became increasingly hypoxemic with a low oxygen
saturations on room air; down to 85% which improved to 90s on
2 liters with an arterial blood gas showing a pH of 7.42, a
carbonate dioxide of 51, and an oxygen of 48, on 96% on 4
liters. The patient had also spiked at this point to 101.5
and had increased tremulousness. He also had a decreased
mental status.
Repeat blood gases on 4 liters nonrebreather showed an
arterial blood gas of 7.43/49/68, but the patient had a
lactate of 3.8. The patient was then transferred to the
Intensive Care Unit for a subsequent evaluation of his
decreased mental status and his persistent hypoxia.
At this point, a Discharge Summary will be added by the
Intensive Care Unit team who cared for him from the period of
[**2167-8-21**] until [**2167-8-29**]. The dictation will
resume at this point on [**2167-8-29**].
From a respiratory standpoint in the Intensive Care Unit, the
patient had come in with increased hypoxemia. He had
experienced chronic hypoxia which had actually been managed
on a face mask since last nasal cannula in the Intensive Care
Unit. It was presumed during the Intensive Care Unit stay
that the patient had an aspiration event. The patient was
initially treated empirically with clindamycin and linezolid.
The clindamycin was discontinued after a 5-day course, and
the patient was nearing the completion of his 14-day course
of linezolid by the time of being discharged from the Unit.
Also from a respiratory standpoint, the patient had pleural
effusions that were identified as transudative in nature by a
thoracentesis under radiographic assistance with both
negative cultures and Gram stains. The patient had been
briefly intubated on [**8-26**] during his Intensive Care
Unit stay for an elective transesophageal echocardiogram and
magnetic resonance imaging and was extubated on [**8-27**]
without any complications. The patient was able to maintain
his oxygen saturations on nasal cannula; although, arterial
blood gases during the Intensive Care Unit stay showed
persistent hypercarbia of unclear etiology. It was possibly
thought that he had an obstructive sleep apnea which could
possibly be worked up at a later time.
From a neurologic standpoint, the patient had experienced
encephalopathy and waxing and [**Doctor Last Name 688**] mental status; for which
Neurology had been consulted (as previously mentioned
earlier).
The patient had a repeat magnetic resonance imaging which
showed metabolic/toxic encephalopathy that improved over the
last several days. The magnetic resonance imaging on
[**8-27**] showed improved diffuse white matter changes when
compared with the previous examination earlier at the end of
[**Month (only) 216**]; which was consistent with resolving encephalopathy.
As mentioned above, the patient's mental status had improved
clinically; although, mental status was still waxing and
[**Doctor Last Name 688**] at times.
From an Infectious Disease standpoint, the patient had last
spiked fevers on [**8-28**] to 102 degrees Fahrenheit. At
the time of transfer to the floor, the patient had been
completing a 14-day course of linezolid for
coagulase-negative staphylococcal bacteremia.
Upon admission to the Intensive Care Unit, his second time
around, the patient had been started on clindamycin and
linezolid for a presumed aspiration pneumonia. The
clindamycin was discontinued after five days. Meanwhile, the
patient had urine cultures from [**8-20**] and [**8-26**].
They were positive for Pseudomonas. He was initially started
on ciprofloxacin and gentamicin with the Pseudomonas
resistant to both these, so it was changed to ceftazidime for
several days; which was discontinued on [**8-25**], per
Infectious Disease recommendations.
Meanwhile, the patient had been maintained on linezolid for a
14-day course. He had a urine cultures on [**8-26**] which
was positive for Pseudomonas; however, a repeat urine culture
from [**8-28**] was negative.
Meanwhile, the patient had a transesophageal echocardiogram
on [**8-26**] which was negative for any endocarditis. He
underwent a thoracentesis from the pleural space and a
paracentesis under ultrasound-guidance assistance. All of
these cultures were negative for growth to date.
The patient did spike to 102 degrees Fahrenheit; most
recently on [**8-27**] and [**8-28**]. The patient was
afebrile since the period leading to his time on the floor
with a stable white blood cell count.
From a cardiovascular standpoint, the patient had an
echocardiogram (as mentioned above) and had atrial
fibrillation which had been reasonably well rate controlled
with diltiazem and metoprolol without anticoagulation
secondary to concerns about possible bleeding.
Initially, it was felt that possibly the patient had a
component of heart failure that was causing his hypoxia. The
patient had been given some Lasix.
From a gastrointestinal standpoint, the patient had been on
tube feeds but had now been changed to soft solids which he
had been tolerating very well. He had passed a swallowing
study earlier during his hospital course. His liver function
tests remained stable. As mentioned above, his abdominal
ultrasound and paracentesis showed a fatty liver and sludging
of the gallbladder. The peritoneal fluid was no growth to
date.
Meanwhile, from a hematologic standpoint, the patient had
received transfusions. His hematocrit remained stable as did
his renal function. The patient was still with a metabolic
alkalosis of unclear etiology.
PAST MEDICAL HISTORY: His past medical history (as
summarized in the previous dictation summaries) was:
1. Alcohol abuse.
2. Atrial fibrillation.
3. Decubitus ulcerations.
4. Acute renal failure; resolved.
5. Hypertension.
6. Depression.
7. Lipids.
8. Status post right patellar fracture.
ALLERGIES: His allergies included VANCOMYCIN (which was
presumed to be causing a rash).
MEDICATIONS ON TRANSFER: (His medications on transfer
included)
1. Metoprolol 75 mg by mouth three times per day.
2. Linezolid 600 mg by mouth q.12h.
3. Diltiazem 60 mg by mouth three times per day.
4. Captopril 6.25 mg by mouth three times per day.
5. Subcutaneous heparin twice per day.
6. Albuterol and ipratropium inhalers.
7. Ursodiol 300 mg by mouth twice per day.
8. Folate 1 mg by mouth once per day.
9. Thiamine 100 mg by mouth once per day.
10. Lansoprazole 30 mg by mouth once per day.
PHYSICAL EXAMINATION ON TRANSFER: On transfer, his vital
signs revealed his temperature was 99.4 degrees Fahrenheit,
his blood pressure was 120/70, his heart rate was in the 60s,
his respiratory rate was 18, and his oxygen saturation was
96% on 2 liters. In general, he was awake and alert. He was
following commands. He was oriented to year and hospital.
His head, eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Extraocular movements were
intact. Pupils were equal, round, and reactive to light and
accommodation. Mildly scleral icterus. His mucous membranes
were moist. The oropharynx was clear. Carotids were 2+. No
bruits. No lymphadenopathy. Cardiovascular examination
revealed a irregularly irregular with a 2/6 systolic ejection
murmur at the left sternal border. Pulmonary examination
revealed diffuse bilateral crackles about a quarter of the
way up the bases. Abdominal examination revealed multiple
ecchymoses. Rectal examination with brown stool and mildly
protuberant. Positive bowel sounds. Soft, nontender, and
nondistended. His extremity examination revealed multiple
circular nodules soft in consistency, nonerythematous and
nontender, which were seen below his left patellar on his
left radial styloid process and the digits of his upper
extremities and lower extremities. His cranial nerve
examination revealed cranial nerves II through XII were
grossly intact. He followed commands. He did not have any
asterixis.
PERTINENT LABORATORY VALUES ON TRANSFER: His complete blood
count on transfer revealed his white blood cell count was
9.6, his hematocrit was 32.7, and his platelet count was 180.
His coagulations revealed a prothrombin time of 14.1, his
partial thromboplastin time was 29.1, and his INR was 1.3.
His chemistries revealed sodium was 138, potassium was 3.6,
chloride was 92, bicarbonate was 37, blood urea nitrogen was
9, creatinine was 0.5, and his blood glucose was 82. His
calcium was 8.1, his magnesium was 1.4, and his phosphorous
was 2.3. His liver function tests revealed AST was 46, ALT
was 22, lactate dehydrogenase was 238, alkaline phosphatase
was 205, and total bilirubin was 4. His urinalysis showed
specific gravity of 1018, small amounts of blood, bilirubin,
3 to 5 red blood cells, and several white blood cells. His
urine cultures from [**8-28**] were negative. Urine
cultures from [**8-26**] and [**8-23**] revealed Pseudomonas.
His blood cultures from [**8-28**], [**8-23**], and [**8-22**]
were negative. His stool cultures revealed he was
Clostridium difficile negative times three. His peritoneal
cultures from [**8-28**] were negative. His pleural
cultures from [**8-25**] were negative.
PERTINENT RADIOLOGY/IMAGING: He had a transesophageal
echocardiogram on [**8-26**] which showed patent foramen
ovale, dilated right atrium, left ventricular ejection
fraction of 55% or greater, with moderate mitral
regurgitation. No evidence of an vegetations.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: (On
arrival to the floor)
1. NEUROLOGIC ISSUES: From a neurologic standpoint, the
patient had a waxing and [**Doctor Last Name 688**] mental status that had been
worked up previously by Neurology (as mentioned in previous
dictation summaries).
It was thought most likely that the patient's mental status
changes were secondary to a metabolic-type picture. During
his stay on the wards, and the remainder of his hospital
course, his mental status did continue to wax and wane;
tending to wane during periods of fevers but then improving
when treated supportively. Currently, he has been oriented
to hospital and time. No other treatment has been necessary
from this standpoint.
2. CARDIOVASCULAR ISSUES: From a cardiovascular standpoint,
the patient came in with a diagnosis of atrial fibrillation
during his Intensive Care Unit course. There had been
reports of the patient having difficulty with rate control
and hypertension. However, while the patient was on the
floor, following his second Medical Intensive Care Unit stay,
the patient had achieved excellent rate control on his
diltiazem and metoprolol with heart rates in the 80s and 90s.
He was hemodynamically stable as well.
Anticoagulation has been an issue for the patient. As of
now, he has not been anticoagulated; but rather on aspirin.
Initially, there was question of whether or not the patient
would possibly be going to the operating room for repair of
his right patellar fracture and there was concern about
anticoagulating the patient prior to surgery. However, now
that the patient will not be going to the operating room
until a later date, it was likely that the patient will begin
to be anticoagulated; to begin with Coumadin. An Addendum
will be added to this Discharge Summary as to whether or not
the patient will be anticoagulated; just making sure that the
patient is not a fall risk; given that at times his waxing
and [**Doctor Last Name 688**] mental status.
Otherwise, in preparation for possible surgery, the patient
underwent a Persantine MIBI on [**9-4**] which essentially
was negative for any possible ischemic changes. There was
concern about the previous echocardiograms. The patient had
experienced mildly depressed right ventricular function with
a dilated right ventricle and occasional reports of some mild
systolic function from the left ventricle. The last report
showed an ejection fraction of about 55%.
There was concern that this right ventricular
dilation/dysfunction might be secondary to a pulmonary
embolism. As such, a computed tomography angiogram was done
on [**9-4**] which essentially was negative for a
pulmonary embolism.
The patient was to be maintained on his ACE inhibitor which
will be transferred over from captopril to a once per day
dosing of lisinopril. Otherwise, there were no other
cardiovascular issues.
3. PULMONARY ISSUES: From a pulmonary standpoint, the
patient had come from the Intensive Care Unit with this
persistent hypoxia and increased hypercarbia. The etiology
was unclear of his hypercarbia. It was postulated during the
Intensive Care Unit course that the patient may have had some
type of obstructive sleep apnea. Also, a possibility that
the patient had some type of metabolic alkalosis that was
contributing to his hypercarbia/hypoxia.
On the floor, after his second discharge from the Intensive
Care Unit, the patient maintained his oxygen saturations
reasonably well on 1 liters to 2 liters of nasal cannula. At
the time of discharge, the patient was saturating well on
room air. It was felt that the patient may have had a mild
component of heart failure. As such, the patient was mildly
diuresed. In addition, it was thought possibly that the
patient may have had some underlying atelectasis from his
prolonged immobility and would probably would benefit from
incentive spirometry.
Meanwhile, as mentioned above, the patient did have an
additional computed tomography angiogram performed on
[**9-5**] which essentially was negative for a pulmonary
embolism and did show some bilateral pleural effusions and
atelectasis. In addition, it showed some mediastinal
lymphadenopathy 11 mm in its largest dimension. These nodes
were also located in the paratracheal region and the
subcarinal region. This was not worked up at this point.
Otherwise, as mentioned above, despite his past episodes of
hypoxia and intubations, the patient has been stable from
this standpoint.
4. GASTROINTESTINAL ISSUES: From a gastrointestinal
standpoint, the patient had initially been admitted with a
component of hepatic failure of unclear etiology; whether it
was alcoholic or drug induced.
After his second Intensive Care Unit stay, the patient's
liver function tests remained fairly stable with the
exception of a mildly elevated bilirubin which has not shown
significant changes or fluctuations. The patient has been
alert in terms of mental status. He has taken by mouth. He
was to be maintained on a Protonix for gastrointestinal
prophylaxis.
5. HEMATOLOGIC ISSUES: From a hematologic standpoint, the
patient's hematocrit remained stable during the remainder of
his hospital course on the general medicine [**Hospital1 **]. He was not
anticoagulated initially secondary to a question about
whether the patient would be going to the operating room for
repair of his patellar fracture. The patient was maintained
on aspirin and deep venous thrombosis prophylaxis. Pending
discussions with Physical Therapy and after judging the
patient's risk for fall, the patient may be restarted on
anticoagulation with Coumadin.
6. INFECTIOUS DISEASE ISSUES: The patient had a very
complicated Infectious Disease course with a history of
recurrent fevers during his hospital course even after his
second Medical Intensive Care Unit course.
Initially when the patient came back to the floor, the
patient had a history of a recent urinary tract infection
with Pseudomonas with cultures from [**8-26**], but negative
on [**8-28**]. At the time of arrival to the floor, the
patient was completing his 14-day course of linezolid which
subsequently was discontinued.
However, on the morning of [**8-31**], the patient had
spiked a fever to 101.5 degrees Fahrenheit with decreased
mental status. Blood cultures and urine cultures were sent
which ended up growing out Pseudomonas, and the patient was
restarted on a 7-day course of ceftazidime, of which he ended
up completing. Repeat urine cultures from [**9-5**]
showed essentially less than 10,000 organisms. It was felt
reasonably that the patient could be discontinued from any
further antibiotics. Blood cultures from these areas were
also negative to date. Infectious Disease Service was
consulted for this, and they recommended continuing on the
ceftazidime (as mentioned above) and culturing for
temperatures of greater than 100.4.
Meanwhile, at the time of the development of these fevers,
the patient also had new extremity nodules; most prominent on
his left knee and left wrist and fingers which were new from
during his earlier hospital course. There was concern about
whether or not these nodules could be in fact related to his
possible fevers. As such, two of these nodules (one from the
left knee and one from the left wrist) were drained.
Cultures and Gram stains from this fluid were negative for
any organisms; although, they did show significant amounts of
white blood cells. Ultimately, they were just
believed/presumed to be secondary to gout, as they were
confirmed to have sodium urate crystals on the microscopy.
Rheumatology was consulted for this, and this will be
addressed later on during this Discharge Summary. The
patient also had Clostridium difficile toxin which was
negative.
7. RENAL ISSUES: From a renal standpoint, the patient had
come in initially with renal failure during his first stay in
the Intensive Care Unit.
During the remainder of his hospital course, after his second
transfer from the Intensive Care Unit, his electrolytes
remained stable. He had previously had a metabolic alkalosis
of unclear etiology which was concerning given the fact that
he had a very tenuous respiratory status; as evidenced by two
prior intubations for hypercarbic arrest. His electrolytes
were just followed during the remainder of his hospital
course, and they gradually improved on their own. His renal
function was stable as well.
Meanwhile, the patient had his Foley catheter discontinued
and was urinating on his own. There was a persistent
hypomagnesemia of undetermined etiology. The patient will
have to be discharged with standing doses of magnesium oxide
to replete this constant electrolyte disorder.
8. ENDOCRINE ISSUES: As mentioned above, the patient had
the onset of development of these new multiple soft nodules
throughout his extremities; most prominent on his left and
left wrist, but also on the fingers of his left and right
upper extremities.
Given his history of gout, there was concern about whether
this could be a new gout flare which could possibly be
causing fevers. As mentioned above, these nodules were
nontender, and for the most part nonerythematous or warm with
the exception of one nodule on his knee. These nodules were
drained on [**8-31**] and showed over 20,000 to 30,000 white
blood cells. As mentioned above, the Gram stain was negative
and the cultures were all negative. However, they did show
sodium urate crystals consistent with gout.
Rheumatology was consulted for further assistance in this
matter, and they seemed to think that this was tophaceous
acute-on-chronic gout. They recommended starting colchicine
which the patient is now on and later possibly switching to a
anti-hyperuricemic [**Doctor Last Name 360**] such as allopurinol at a later date.
The patient was scheduled for a follow-up appointment with
Rheumatology on [**10-2**] at 9 o'clock in the morning.
9. MUSCULOSKELETAL ISSUES: Finally, but most importantly,
from a musculoskeletal standpoint, the patient was initially
admitted back in [**Month (only) **] at an outside hospital and later in
[**Month (only) 216**] at [**Hospital1 69**] for possible
repair of a right patellar fracture. However, this was not
able to be repaired secondary to his very complicated medical
course. It was initially hoped that the patient would
undergo surgical intervention when medically stable; which he
was felt to be by his primary team. The patient had
follow-up x-rays on [**9-3**] which showed a widely
separated patellar fracture and a possible medial fracture on
the right side.
Orthopaedics has evaluated the patient, and thought at this
point that the patient could be discharged with physical
therapy with a knee immobilizer and full weightbearing with
possibly followup with Dr. [**First Name (STitle) **] at the patient's own
discretion for ultimate repair of this right patellar
fracture. The patient will need physical therapy, and at
this point is believed to weightbearing as tolerated.
DISCHARGE DIAGNOSES:
1. Right patellar fracture.
2. Hepatic/renal failure; resolving.
3. Metabolic/toxic encephalopathy; resolved.
4. Hypercarbic respiratory arrest; now stable.
5. Acute-on-chronic tophaceous gout; improving.
6. Coagulase-negative staphylococcal bacteremia; resolved.
7. Urinary tract infections with Pseudomonas; now resolved.
CONDITION AT DISCHARGE: His condition on discharge right now
is improving.
MEDICATIONS ON DISCHARGE: (The patient's medications on
discharge were to include the following)
1. Lisinopril 10 mg by mouth once per day.
2. Diltiazem-XR 240 mg by mouth once per day.
3. Heparin 5000 units subcutaneously q.12h.
4. Colchicine 0.6 mg by mouth once per day.
5. Ursodiol 300 mg by mouth twice per day.
6. Folate 1 mg by mouth once per day.
7. Thiamine 100 mg by mouth once per day
8. Protonix 40 mg by mouth once per day.
9. Albuterol nebulizer solution one q.2h. as needed.
10. Atrovent nebulizer q.4-6h. as needed.
11. Metoprolol 75 mg by mouth three times per day.
12. Magnesium oxide 800 mg by mouth twice per day.
NOTE: The remainder of his Discharge Summary will be added
in an Addendum in terms of his ultimate destination for acute
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4122**], M.D. [**MD Number(1) 33539**]
Dictated By:[**Last Name (NamePattern1) 5539**]
MEDQUIST36
D: [**2167-9-8**] 15:42
T: [**2167-9-8**] 17:32
JOB#: [**Job Number 93072**]
Name: [**Known lastname 14665**], [**Known firstname 14666**] Unit No: [**Numeric Identifier 14667**]
Admission Date: [**2167-7-27**] Discharge Date: [**2167-9-9**]
Date of Birth: [**2112-4-9**] Sex: M
Service:
ADDENDUM:
The discharge summary has been outline as in previous
discharge summary.
His medicines now will be dictated.
DISCHARGE MEDICATIONS:
1. Thiamine 100 mg q. day.
2. Folate 1 mg q. day.
3. Diltiazem 240 mg q. day.
4. Magnesium oxide 1200 mg twice a day.
5. Tylenol one to two tablets p.r.n.
6. Atenolol 75 mg q. day.
7. Colchicine 0.6 mg p.o. q. day.
8. Protonix 40 mg q. day.
9. Aspirin 325 mg p.o. q. day.
10. Lisinopril 10 mg p.o. q. day.
11. Heparin 5000 subcutaneously q. 12.
12. Calcium 500 mg twice a day.
13. Ursodiol 3 mg twice a day.
14. Albuterol nebulizer q. two hours p.r.n.
15. Miconazole powder twice a day.
DISCHARGE DIAGNOSES:
1. As above with hepatic renal failure resolved.
2. Metabolic hepatic encephalopathy, improved.
3. Hypercarbic respiratory failure status post intubation
times two, now stable.
4. Coagulase negative Staphylococcus bacteremia, resolved on
Lanezalid.
5. Pseudomonas urinary tract infection resolved with
ceftazidime.
6. Right patellar fracture.
7. Acute on chronic tophaceous gout.
DISCHARGE INSTRUCTIONS:
1. Follow-up with Orthopedics, Dr. [**First Name (STitle) **], told to call up
for an appointment for evaluation of his right knee fracture.
2. Also follow-up with Rheumatology, Dr. [**Last Name (STitle) 14668**], on [**10-2**], at 09:00 in the morning.
3. He will be going to Physical Therapy.
DISPOSITION: Discharged to the [**Hospital6 8525**]
rehabilitation in her hospital in [**Location (un) **].
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Last Name (NamePattern1) 9409**]
MEDQUIST36
D: [**2167-9-13**] 15:58
T: [**2167-9-13**] 18:57
JOB#: [**Job Number 14669**]
Name: [**Known lastname 14665**], [**Known firstname 14666**] Unit No: [**Numeric Identifier 14667**]
Admission Date: [**2167-7-27**] Discharge Date: [**2167-9-9**]
Date of Birth: [**2112-4-9**] Sex: M
Service: [**Hospital1 248**]
MEDICATIONS ON DISCHARGE:
1. Thiamine 100 mg q.d.
2. Folate 1 mg q.d.
3. Diltiazem 240 mg SA q.d.
4. Magnesium oxide 1200 mg b.i.d.
5. Tylenol prn.
6. Atenolol 75 mg q.d.
7. Colchicine 0.6 mg q.d.
8. Protonix 40 mg q.d.
9. Aspirin 325 mg q.d.
10. Lisinopril 10 mg q.d.
11. Heparin 5,000 mg subcutaneous q.12.
12. Calcium 500 mg b.i.d.
13. Ursodiol 300 mg b.i.d.
14. Albuterol nebulizers q prn.
15. Miconazole powder prn.
DISCHARGE DIAGNOSES:
1. Hepatic/renal failure resolved.
2. Metabolic toxic encephalopathy improved.
3. Hypercarbic respiratory failure status post intubation x2
stable.
4. Coagulase negative Staph bacteremia resolved with
linezolid.
5. Pseudomonas urinary tract infection resolved with
ceftazidime.
6. Status post right patella fracture awaiting surgical
intervention.
7. Acute on chronic tophaceous gout.
DISCHARGE CONDITION: Stable.
DISPOSITION: He was to be discharged to the [**Hospital3 14670**] Rehab Hospital. He has follow-up appointments with
Dr. [**First Name (STitle) **] from Orthopedics, and told to call for an
appointment and Rheumatology, Dr. [**Last Name (STitle) 14668**] on [**10-2**] at 9
o'clock in the morning.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 77**] 12-986
Dictated By:[**Last Name (NamePattern1) 9409**]
MEDQUIST36
D: [**2167-9-13**] 16:01
T: [**2167-9-14**] 04:54
JOB#: [**Job Number 14671**]
|
[
"599.0",
"038.19",
"507.0",
"427.31",
"572.8",
"041.7",
"584.9",
"291.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.04",
"54.91",
"96.72",
"38.93",
"81.91",
"96.71",
"34.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
41649, 42186
|
2860, 2969
|
41241, 41627
|
38909, 39406
|
40824, 41220
|
5171, 12996
|
39839, 40798
|
26022, 37006
|
2992, 5153
|
37384, 37436
|
13026, 22088
|
22503, 25988
|
22111, 22477
|
2682, 2843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,327
| 108,154
|
29058
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 70000**]
Admission Date: [**2164-1-26**]
Discharge Date: [**2164-1-28**]
Date of Birth: [**2083-8-23**]
Sex: M
Service: VSU
PRINCIPAL DIAGNOSIS: Abdominal aortic aneurysm, 6.2 x 6.3 x
9.6 cm from the infrarenal to the aortic bifurcation seen on
CTA on [**2164-1-5**].
PROCEDURES:
1. Abdominal aortic aneurysm repair with tube graft via
retroperitoneal approach on [**2164-1-26**].
2. Emergency laparotomy on [**2164-1-27**], with resection
of necrotic large bowel.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of atrial fibrillation and flutter.
3. History of right inguinal hernia.
4. History of right radical neck resection for squamous cell
carcinoma.
5. Right thoracotomy.
6. Right knee surgery.
MEDICATIONS:
1. Coumadin.
2. Lovastatin.
BRIEF HOSPITAL COURSE: Mr. [**Known lastname 47777**] is an 80-year-old
gentleman who was admitted on [**2164-1-26**] to [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for elective repair of
retroperitoneal abdominal aortic aneurysm for a 6.2 x 6.3 x
9.6 cm aneurysm. He was taken to the operating room on
[**2164-1-26**], and had a retroperitoneal approach for his
abdominal aortic aneurysm repair with tube graft from the
infrarenal side to his aortic bifurcation. Postoperatively he
was noted to be hypotensive and was started on Neo-
Synephrine. Over the course of the evening he had a rising
lactate and increasing pressor requirement. There was concern
of some ischemic episode and he was taken emergently to the
operating room on [**2164-1-27**], for exploratory
laparotomy. At this point his large bowel and his colon was
noted to be green and necrotic. He had a total abdominal
colectomy with ileostomy done emergently. His abdomen was
left open with I-band and Broca to the bag. He was taken back
now to the surgical intensive care unit where he stabilized,
still requiring pressors and IV fluids throughout the
evening.
On [**2164-1-28**], his pressor requirement continued to go
up and he had a Swan in place which showed elevation of PA
numbers. He was maxed out on Levophed and Neo-Synephrine at
this point as well as vasopressor 1.2 per hour. At this point
because of his increasing PA pressures, there was a concern
that he may be having a cardiac dysfunction. His lactate
remained elevated at 4, however it did not rise. A second
look was done at the bedside serially of his abdominal
contents to see if there are any signs of small bowel
ischemia, however upon inspection there were no clear signs
of small bowel ischemia. He also had a stat echo done to
evaluate for cardiac function because of his increasing
pressor requirement and hypotension.
Upon evaluation of his cardiac echo he was noted to have
significant left ventricular dysfunction with very poor
ejection fraction indicating that he had a myocardial event.
At this point we discussed with the family that there is
significant change in his overall status in that in addition
to having some septic physiology he likely was in a
cardiogenic shock as well. He went into rapid atrial
fibrillation requiring synchronized cardioversion because of
hypotension. He was cardioverted twice and went into
asystole. Chest compressions were immediately started. He
received boluses of epinephrine. He was noted then to be in
ventricular tachycardia and again hypotensive. He was
cardioverted. He was coded for approximately 30 minutes.
A lengthy discussion was carried out with the family as to
how they would like to proceed. During this time he had
somewhat stabilized, however was still hypotensive requiring
maximal pressors and was on epinephrine drip. The family,
after a lengthy discussion, felt that he would not want to
proceed with any further care and he was made CMO.
The patient expired shortly thereafter at 6:20 p.m. Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] was informed of the patient's status this
entire time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Name8 (MD) 57264**]
MEDQUIST36
D: [**2164-1-29**] 06:00:46
T: [**2164-1-29**] 14:13:35
Job#: [**Job Number 70001**]
|
[
"995.92",
"550.90",
"V58.61",
"286.9",
"441.4",
"551.29",
"998.2",
"440.0",
"V10.83",
"557.0",
"410.91",
"721.8",
"276.2",
"575.8",
"401.9",
"998.11",
"038.9",
"785.51",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"99.04",
"51.22",
"99.07",
"99.05",
"39.32",
"38.44",
"53.59",
"45.8",
"99.60",
"99.15",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
834, 4329
|
537, 810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,289
| 116,246
|
23585
|
Discharge summary
|
report
|
Admission Date: [**2145-8-25**] Discharge Date: [**2145-8-30**]
Date of Birth: [**2087-4-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
CHIEF COMPLAINT: shortness of breath
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: 58 year old male with
metastatic renal ca to lung and bone (last chemo [**2145-8-10**]), who
presented to [**Hospital **] clinic on day of admission with 2 days of
shortness of breath with occasional mild confusion, found to be
hypoxic to high 80's on room air. Wife states that for the past
few weeks, he has had dyspnea on exertion, it had been
attributed to anemia and he received pRBC trasnfusions, however,
shortness of breath became more pronounced over the past 2 days.
In clinic, he was placed on 4L nasal canula and O2 sat
increased to 93% with resp rate of 40. He denied any chest pain
or abdominal pain. He complained of slight cough. Per wife, he
had fever to 101F at home the night prior to admission but
afebrile in clinic.
.
ED: He was intubated and sedated with fentanyl/versed. Given
sodium bicarb, calcium chloride, insulin with D50 for K 6.8.
EKG showed low voltage and bedside Echo with pericardial
effusion and tamponade physiology. CXR with pulm edema,
bilateral pleural effusions. He was given levofloxacin 750mg
iv x 1 for possible pneumonia. Cardiology was consulted and he
was taken urgently to cath lab where 1260cc straw colored fluid
drained from pericardium.
.
Review of systems limited by patient intubation/sedation. Per
records and discussion with family, there is no prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
hemoptysis, black stools or red stools. 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,
palpitations, syncope or presyncope. (+) shortness of
breath/DOE
.
Past Medical History:
PAST MEDICAL HISTORY:
CAD s/p MI [**2136**], s/p stent
atrial fibrillation
HTN
hypercholesterolemia
gout
anxiety
right wrist fusion [**2133**]
GERD
bilateral hearing loss
.
Onc Hx: Metastatic Renal Cell
1. Nephrectomy for clear cell carcinoma in 09/[**2140**].
2. Resection of a right seventh rib metastasis, which revealed
metastatic high-grade renal cell carcinoma.
3. High-dose IL-2 therapy, which was complicated by the
development of accelerated angina. He is now status post cardiac
catheterization with coronary artery stent placement.
4. CyberKnife therapy to a medial paramediastinal lung lesion.
5. Sutent as a single [**Doctor Last Name 360**] begun in 09/[**2144**]. This was
complicated by severe GI side effects and dehydration. The dose
was reduced and despite this reduction, he was admitted in
[**Month (only) 956**] to a local hospital with rapid atrial fibrillation and
associated syncope which resulted in an accident while driving.
He sustained several rib fractures as a result.
6. Currently, cycle 8 of Sutent 2 weeks on/ 1 week off, plus
Gemzar begun because of disease progression.
.
Social History:
Social History: Married, grown children, lives with wife, 2
dogs, 1 cat, on disability from running shelter for homeless
veterans in [**Hospital1 392**].
Family History:
.
Family History: Mother, 89 h/o ovarian ca, Aunt w/ ovarian CA,
father deceased 83 w/ CAD
.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 96.9F HR 83 BP 122/79 RR 16 100% on AC
600x14/100%/5PEEP
ABG on AC settings: 7.31/44/130
Gen: intubated, lightly sedated
HEENT: intubated, NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Neck: difficult to assess JVP
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: crackles at left base anteriorly, no wheeze. Pericardial
drain with small amount of straw colored fluid
Abd: soft, ND/NT, No abdominal bruits.
Ext: warm, trace ankle edema bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: 2+ DP
Left: 2+ DP
Pertinent Results:
Admission Labs: ([**8-25**])
LABORATORY DATA:
130.|.100.|.18 121
---------------
6.5.|.22.|.1.7
Ca: 8.7 Mg: 2.2 P: 4.6 D
.
[**8-25**] 3:05 p.m. CK: 119 MB: 4 Trop-T: 0.02
.
WBC 9.4 Hct 29.4 Plt 250 MCV 103
N:86.1 L:6.7 M:6.9 E:0.2 Bas:0.2
.
PT: 16.5 PTT: 27.2 INR: 1.5
.
Studies:
EKG: NSR HR 79, Nl axis and slight pr prolongation 208msec.
low voltage (although unchanged from [**8-13**] is lower voltage than
[**2143**])
.
CXR: Limited study with marked cardiomegaly, pulmonary edema,
and
bilateral pleural effusions, new since the [**8-13**] examination. A
focal
consolidation, particularly on the left, cannot be excluded.
.
ECHO ([**8-25**]):
Large pericardial effusion. RV diastolic collapse, c/w impaired
fillling/tamponade physiology. Significant, accentuated
respiratory variation in mitral/tricuspid valve inflows, c/w
impaired ventricular filling. Overall left ventricular systolic
function is low normal (LVEF 50-55%). RV systolic function
appears depressed.
.
Cardiac Cath/ Pericardiocentesis ([**8-25**]):
1. Pericardiocentesis revealed initial elevated pericardial
pressure of 35mmHg subsequently decreasing to 13mmHg after
drainage of 1.4 liters of serosanguinous pericardial fluid.
.
ECHO ([**8-26**] - s/p pericardiocentesis)
LV wall thicknesses and cavity size are normal. Mild regional
left ventricular systolic dysfunction with
inferior/inferolateral
thinning and hypokinesis. Overall left ventricular systolic
function is mildly depressed (LVEF= 40-45%). There is no
pericardial effusion.
.
ECHO ([**8-28**]):
Mild regional LV systolic dysfunction with inferolateral
akinesis and inferior hypokinesis. Overall LV systolic function
is mildly depressed (LVEF= 40-45 %). RV size normal. Small to
moderate sized pericardial effusion. There is significant,
accentuated respiratory variation
in mitral valve inflows, consistent with impaired ventricular
filling. Not right ventricular/right atrial collapse identified.
Compared with the prior study (images reviewed) of [**2145-8-27**],
left ventricular wall motion abnormlaity appears similar.
Respiratory variation in mitral inflow is unchanged. The
pericaridal effusion is now slightly larger.
.
ECHO ([**8-30**]):
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. RA pressure is 5-10 mmHg. LV wall thicknesses
and cavity size are normal. Mild regional LV systolic
dysfunction with focal akinesis of the basal half of the
inferolateral wall and hypokinesis of the inferior wall. RV
size and free wall motion are nl. No valvular disease. Mild
pulmonary artery systolic hypertension. There is a small to
moderate sized circumferential pericardial effusion most
prominent around the right atrium. Brief right atrial diastolic
collapse but normal transmitral Doppler spectra.
Compared with the prior study (images reviewed) of [**2142-8-29**],
the size of the effusion is slightly greater around the right
atrium, but transmitral Doppler no longer suggests impaired
filling. Left ventricular systolic function is similar.
Brief Hospital Course:
In summary, Mr. [**Known lastname 37025**] is a 58 year old male with renal cell
ca with metastases to the lung, bone, liver and right adrenal
who presented with 2 days of increasing shortness of breath. In
the ER, he was hypoxic and found to have pericardial tamponade.
He got a pericardiocentesis on [**8-25**] with drainage of 1.2 L.
.
Tamponade. Patient was known to have a pericardial effusion by
CT on [**2145-8-9**] (2 weeks prior to admission. Echo showed
intermittent RV collapse suggestive of tamponade and a
significant pericardial effusion. On [**8-25**], Cardiology drained
1300cc of straw colored fluid, which was sent for cytology. A
repeat echo the morning after pericentesis showed resolution of
the effusion. Drain output decreased and so the pericardial
drain was removed on [**2145-8-26**]. Serial echocardiograms showed a
gradual reaccumulation of pericardial fluid, but no acute signs
of cardiac tamponade. Consequently, a pericardial window
procedure was not pursued at this time. On the day of
discharge, he was asymptomatic, denied chest pain, shortness of
breath, or lightheadedness and was displaying normal vital
signs. He will go home with repeat echo on Thursday ([**9-2**]) with
close follow-up with his outpatient cardiologist.
.
Mechanical ventilation. Patient was found to be tachypneic and
hypoxic in the ED. He was intubated in the ED. His repiratory
failure was thought to be due to pulmonary edema from tamponade
in addition to a questionable pnuemonia. Patient had
improvement of respiratory status after pericardiocentesis.
Patient quickly weaned from vent and extubated within 18 hours.
He was requiring oxygen by nasal canula during stay which was
titrated down with diuresis.
.
Pulmonary edema. Patient has CXR consistent with pulmonary
edema, likely secondary to decreased cardiac output from
pericardial tamponade. Patient was given lasix with good
response.
.
Questionable pneumonia. Patient had a fever to 101 on evening
prior to admission and has possible infiltrate on CXR. He was
started on levofloxacin on [**2145-8-25**]. On [**8-28**], he was febrile
to 101, so antibiotics were broadened to aztreonam and flagyl,
which was converted to levofloxacin and flagyl as an outpatient.
.
Atrial fibrillation. Patient went into Atrial fibrillation with
RVR on [**2145-8-26**] with a stable blood pressure. This was intially
treated with IV lopressor. He was subsequently started on
aspirin and standing metoprolol. He was loaded with IV
amiodarone for 24 hours and then started on PO amiodarone. He
was started on a heparin drip on [**8-29**] because he reamined in
atrial fibrillation for 48 hours. He converted to normal sinus
rhythm on the morning of [**8-29**] and remained in such until
discharge.
.
Hyperkalemia. Patient was initially hyperkalemic secondary to
ARF. This was treated with calcium gluconate, glucose and
insulin, and kayexalate with resolution of hyperkalemia.
.
Acute Renal Failure. ARF is likely due to decreased cardiac
output as a result of tamponade. Baseline creatinine is 1-1.2.
Creatinine improved with drainage of pericardial fluid and
gentle diuresis.
.
Metastatic Renal Cell CA. Patient has RCC with metastases to
the lung, bone, right adrenal, and liver. Lung metastases were
treated with cyberknife. He is currently on Gemzar and Sutent
with reportedly good response according to his oncologist.
.
Anemia. Patient was anemic on admission, likely due to
myelosuppressive therapy with gemzar.
.
Hypercholesterolemia. On Zetia for hypercholesterolemia.
Medications on Admission:
CURRENT MEDICATIONS:
Loperamide 2 mg po qid prn diarrhea
Pantoprazole 40 mg PO Q24H
Lorazepam 1 mg PO Q8H prn anxiety
Clonazepam 2mg PO QHS
Quetiapine 400 mg po qhs
Zolpidem 5 mg PO HS prn
Ezetimibe 10 mg PO daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablets Sustained Release 24 hrs PO once a day.
Disp:*45 tablets* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
pericardial tamponade
atrial fibrillation
renal cell cancer
pneumonia
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with a build up of fluid
around your heart which was treated with pericardial drainage.
You also had a heart arrhythmia called atrial fibrillation which
we are treating with aspirin and a new medication called
Amiodarone.
.
Please continue to take all medicines as prescribed. Your Imdur
was held while you were in the hospital due to low blood
pressure. Please speak to your cardiologist before restarting
this medication.
.
We are also treating you for pneumonia. You were prescribed two
antibiotics - levofloxacin and flagyl, and you will have 5 more
days of each to complete the course.
.
If you have any chest pain, shortness of breath, heart
palpitations or lightheadedness please seek immediate medical
attention because this could be a sign of arrhythmia or of
reaccumulation of fluid around your heart.
.
Please go to the echocariogram lab on [**Hospital Ward Name **] 3 to obtain copies
of your echocardiograms before you leave and bring them with you
to your cardiology appointment.
.
You have an echocardiogram scheduled for Thursday ([**9-2**]) to look
at the amount of fluid around your heart, your cardiologist will
Dr. [**Last Name (STitle) 45513**] will follow-up the results with you.
Please make sure to follow up with your oncologist and with your
cardiologist; we have made appointments for you.
Followup Instructions:
Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within
one week of discharge from the hospital - please speak with your
PCP about restarting Synthroid and following up thyroid function
tests.
[**2145-9-13**] 1:00pm with your Cardiologist Dr. [**Last Name (STitle) 45513**]
[**Hospital3 3383**] Hospital
[**Location (un) **].
[**Location (un) 686**], [**Numeric Identifier 60377**]
Phone: [**Telephone/Fax (1) 60378**]
[**2146-9-3**] 9:00am Echocardiagram at [**Hospital3 3383**] Hospital.
Dr. [**Last Name (STitle) 45513**]
[**Location (un) **].
[**Location (un) 686**], [**Numeric Identifier 60377**]
Phone: [**Telephone/Fax (1) 60378**]
Other appointments:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2145-9-8**]
1:00
Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2145-9-8**]
1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-9-8**] 1:00
|
[
"197.0",
"198.5",
"285.9",
"428.0",
"486",
"423.9",
"518.81",
"787.91",
"427.31",
"413.9",
"V42.0",
"584.9",
"420.91",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.0",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12280, 12286
|
7251, 10815
|
310, 330
|
12400, 12407
|
4210, 4210
|
13807, 14965
|
3412, 3488
|
11081, 12257
|
12307, 12379
|
10841, 10841
|
12431, 13784
|
3503, 3503
|
3525, 4191
|
251, 272
|
10862, 11058
|
358, 2070
|
4226, 7228
|
2114, 3206
|
3239, 3378
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,370
| 127,673
|
14543+14544
|
Discharge summary
|
report+report
|
Admission Date: [**2171-8-8**] Discharge Date: [**2171-8-28**]
Date of Birth: [**2100-12-24**] Sex: F
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: This is a 70 year old woman who
was the passenger in a car traveling approximately 40 miles
per hour that was T-boned by a truck on [**2171-8-8**]. She
initially presented to an outside hospital complaining of
right clavicular pain. When evaluated there, she was noted
to have EKG changes and developed supraventricular
tachycardia. She was transferred to [**Hospital1 190**] for an evaluation of an myocardial infarction.
In the Emergency Department here, she was re-evaluated as a
trauma patient and found to be tachycardic and hypotensive.
A DPO was performed and was grossly positive; she was
therefore taken to the Operating Room for an exploratory
laparotomy.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Vitreus bleeds.
4. Hypercholesterolemia.
MEDICATIONS AT HOME:
1. Insulin.
2. Lipitor.
3. Zestril.
ALLERGIES: She is allergic to Vioxx and aspirin.
PHYSICAL EXAMINATION: On admission, heart rate 80 to 100,
normal sinus rhythm; blood pressure 90/50; saturations of
100%. Head within normal limits. Pupils equal, round and
reactive to light. Chest clear to auscultation. Heart
regular rate and rhythm. Abdomen obese, nontender,
distended. Pelvis was stable. Rectal examination showed
poor tone with no blood. Extremities palpable femoral
pulses.
LABORATORY: On admission, white blood cell count 13.5,
hematocrit 26.1, platelets 175, fibrinogen 208.
Urinalysis was nitrite positive with 6 to 10 white blood
cells. Chem-7 was sodium 141, potassium 4.3, chloride 104,
bicarbonate 17, BUN 20, creatinine 1.3, glucose 445, amylase
99.
HOSPITAL COURSE: Resuscitation in the Trauma Room included
six liters of Crystalloid and four units of packed red blood
cells. In addition, the patient was intubated and then
emergently taken to the Operating Room. She underwent an
exploratory laparotomy and was found to have a ruptured
spleen and a contused jejunum. She underwent a splenectomy
and jejunal resection with a side-to-side anastomosis. She
tolerated the procedure well and was then transferred to the
Trauma Surgical Intensive Care Unit.
Her postoperative course is summarizes as follows:
1. Neurologic: Initially, the patient was kept sedated with
high doses of morphine. Those were gradually weaned and
prior to discharge the patient is alert, oriented,
communicating with her surroundings, following commands, with
pain well controlled with p.r.n. Dilaudid as needed only.
2. Cardiovascular: Immediately postoperatively, troponin
levels were elevated to 29. EKG showed no changes from an
old study and no signs of an acute myocardial infarction.
She was followed for a period of time by Cardiology after her
admission. It is recommended that once she recovers from her
current injury that she should undergo a further cardiac
work-up including a stress test and other imaging studies.
She was not started on aspirin because of her allergy.
Cardiac postoperative complications: The patient was started
on beta blockers. On postoperative day 17, she went into
atrial fibrillation but remained hemodynamically stable. Her
beta blocker dose was increased, after which she went into
sinus bradycardia of 30. After converting to sinus and due
to her bradycardia, the beta blocker treatment was stopped.
Prior to discharge, the patient has been stable in sinus
rhythm of 60 to 80.
3. Respiratory: She was gradually weaned on the ventilator
but failed extubation twice. She therefore underwent a
tracheostomy on [**8-20**], with no complications. It was
thought that the difficulty in weaning her off the ventilator
was mainly due to her morbid obesity and was position
related. Once the patient was able to be seated up in a
special bed, we were able to go down on her ventilatory
support to a minimum. Prior to discharge, she has been
tolerating pressure-support ventilation over a whole day with
pressure supports of 5 and a PEEP of 5.
During her prolonged period of ventilation and intubation,
the patient developed hospital acquired pneumonia. She grew
Enterobacter from her sputum on [**8-16**], for which she was
treated with Ampicillin, Gentamicin and Levofloxacin for a
full course. After improvement and a short period with no
antibiotic treatment, she redeveloped fevers and her white
count went up. New cultures from [**8-27**] are growing
Gram positive cocci and she was started on a course of Zosyn
on that same day. She currently is stable, afebrile; white
count is down to 15.
4. Gastrointestinal: The patient was started on tube feeds
which she tolerated well and was advanced to goal. No PEG
was placed secondary to her morbid obesity and the high risk
in such a procedure.
5. Genitourinary: She maintained good urine output
throughout her hospitalization with normal renal function.
She was diuresed for a period of time after her surgery in
order to eliminate some of the volume overload. She is
currently off Lasix and her urine output is good.
6. Hematologic: She is on Lovenox for prophylaxis. She is
a very high risk patient and she should continue on that.
She had a negative Duplex of her lower extremities on [**8-27**]. Her hematocrit has been stable over days.
7. Endocrine: She was on an insulin drip for many days
after surgery, and this was slowly changed over to insulin
treatment with NPH and Regular insulin by sliding scale.
DISPOSITION: The patient is transferred to a [**Hospital 42933**]
Rehabilitation Facility to continue weaning off the
ventilator.
DISCHARGE INSTRUCTIONS:
1. It is noted that it is important for the patient to
remain sitting upright in order to allow for ventilatory
weaning.
2. She should follow-up with Dr. [**Last Name (STitle) **] in Clinic two
weeks after discharge.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg per NG tube q. day.
2. Ativan 1 mg q. six hours p.r.n.
3. Zosyn 4.5 grams intravenously q. eight hours for a total
of ten days (last treatment with Zosyn should be on [**9-6**]).
4. Carafate one gram p.o. twice a day.
5. Sertraline 50 mg p.o. q. day.
6. Percocet Elixir 5 to 10 ml p.o. q. four to six hours
p.r.n.
7. Albuterol nebs one to two puffs q. four to six hours
p.r.n.
8. Lovenox 30 mg subcutaneously twice a day.
9. Colace 100 mg per NG tube twice a day.
10. NPH insulin, 70 units twice a day.
11. Tube feeds are Impact with fiber at 75 cc an hour.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2171-8-28**] 16:02
T: [**2171-8-28**] 16:37
JOB#: [**Job Number 42934**]
Admission Date: [**2171-8-8**] Discharge Date: [**2171-9-11**]
Date of Birth: [**2100-12-24**] Sex: F
Service:
The patient is being discharged from the Trauma Surgery
Service at [**Hospital1 69**].
ADDENDUM: [**First Name8 (NamePattern2) **] [**Known lastname 28660**] remained in the hospital further since
his discharge dictation awaiting rehabilitation bed. During
that time her progress has been satisfactory and is described
briefly as below.
Neurologically [**First Name8 (NamePattern2) **] [**Known lastname 28660**] continues to be alert and oriented
and although she was trached is able to communicate well.
She is requiring minimal pain medication and should be able
to move to Tylenol from Roxicet fairly soon. She continues
to be on Zoloft which currently is at 100 mg per nasogastric
tube q day.
Cardiovascular. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] has remained stable from a
cardiovascular perspective and has been put on Lopressor for
rate control and cardiac protection. Her current Lopressor
dose is 25 mg per nasogastric b.i.d.
Respiratory. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] continues to make progress on her
vent as she is diuresed. Her current settings are minimal at
CPAP and pressure support of five. She should tolerate vent
wean at rehabilitation. She has finished her course of Zosyn
for pneumonia and has been afebrile off antibiotics.
Gastrointestinal. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] has been on tube feeds at goal
for several days. Her tube feeds have been changed to Nepro
at 45 per hour goal to minimize volume intake. She is also
on Prevacid prophylaxis. She is to remain on aspiration
precautions.
Infectious Disease. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] has been afebrile off
antibiotics for several days.
Renal. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] had a brief episode of ATN which is now
resolving and she has improving creatinine which is currently
at 1.4. She is being diuresed with Lasix to help her
ventilatory wean. She will also get one day of Diamox to
help her diuresis and help her high bicarbonate level.
Prophylaxis. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] gets Prevacid for prophylaxis and
also gets Lovenox for deep vein thrombosis prophylaxis given
her obesity and post trauma status.
Wound care. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] has well healing granulating two
small open wounds in her midline abdominal incision. These
are to be changed with wet-to-dry dressings three times a
day.
Endocrine. [**First Name8 (NamePattern2) **] [**Known lastname 28660**] has history of diabetes for which she
has been controlled with insulin standing dose and sliding
scale at the hospital. Please adjust the sliding scale as
needed to control sugars and check fingersticks four times a
day.
FOLLOW-UP: [**First Name8 (NamePattern2) **] [**Known lastname 28660**] should follow-up with the Trauma
Clinic at [**Hospital1 69**] within two
weeks of discharge.
MEDICATIONS ON DISCHARGE: Note, some of these medications
are changed from her prior dictation.
1. Tube feeds, Nepro at 45 per hour which is goal.
2. Lovenox 30 mg subcutaneously twice a day.
3. Zoloft 100 mg per nasogastric once a day.
4. Prevacid 30 mg per nasogastric once a day.
5. Colace 100 mg per nasogastric twice a day.
6. Lopressor 25 mg per nasogastric twice a day.
7. Lasix 60 mg intravenous once a day until weight returns
to baseline. [**Month (only) 116**] switch to p.o. Lasix if the patient
is diuresing well.
8. Diamox 250 mg intravenous q 8 hours times two doses.
10. Tylenol p.r.n.
11. Roxicet elixir p.r.n. for pain, please wean as tolerated.
12. Picc line flushes for routine Picc line care. Please
remove Picc line once intravenous access is not needed
or peripheral IV's obtained.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2171-9-11**] 11:43
T: [**2171-9-11**] 12:21
JOB#: [**Job Number **]
|
[
"865.04",
"250.00",
"427.31",
"997.3",
"863.30",
"486",
"863.50",
"458.9",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"54.11",
"31.42",
"31.1",
"45.93",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
5934, 9905
|
9932, 10997
|
1781, 5667
|
5691, 5911
|
977, 1069
|
1092, 1763
|
168, 839
|
861, 956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,523
| 106,421
|
50493
|
Discharge summary
|
report
|
Admission Date: [**2158-7-2**] Discharge Date: [**2158-8-2**]
Date of Birth: [**2074-6-4**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ceftazidime
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Ileus and altered mental status
Major Surgical or Invasive Procedure:
PICC line insertion
History of Present Illness:
Mr. [**Known lastname 656**] is an 84 year old gentleman recently readmitted after
a prolonged hospital course for ileus. He initally presented to
an outside Emergency Room on [**6-5**] after a fall, found to have
hemothorax with an INR of 11. His hospital course was
complicated by continued intractable pain, nerve blocks and
transfers to and from the surgical floor. He developed atrial
fib with RVR and increased work of breathing and was found to
have a loculated R pleural effusion. He underwent VATS converted
to thoracotomy for decortication. He grew out MRSA and MSSA with
ID recommending Vancomycin until [**7-31**]. He had difficulty weaning
form the vent and was put in for a trach/PEG. He was discharged
to rehab with a PICC in place to treat the infection above,
still with what may have been hypoactive delirium.
.
The patient was readmitted on [**7-2**] with AMS, ileus and concern
for a bowel obstruction. He was found to have + blood cultures
from his PICC (with associated clot, PICC changed), and found to
have Klebsiella & Pseudomonas VAP for which he is on a 21 day
course of Ceftaz/Cipro to end [**7-24**]; TEE negative. He has also
developed Afib with RVR for which he has been started on
Amiodarone; hypertension intermittently controlled with Nitro
gtt; worsening renal function and agitated delirium for which
geriatics is following.
.
At the time of transfer, the patient is not easily arousable and
cannot answer questions. A discussion with his primary TSICU
team and Geriatrics consultant yields the concerns above.
.
Review of systems: Unable to obtain, patient not easily
arousable/oriented
Past Medical History:
Past Medical History:
1. s/p fall with hemothorax ([**2158-6-8**])
2. DVT, right leg in 11/[**2156**].
3. Hypertension
4. COPD
5. elevated cholesterol
6. Osteoarthritis of the hip
7. BPH
Past Surgical History:
[**2158-6-18**] Right video-assisted thoracoscopy converted to right
thoracotomy, decortication of lung and evacuation of retained
hemothorax/empyema.
[**2158-6-22**] Percutaneous tracheostomy placement and
gastroesophagoscopy with percutaneous gastrostomy tube
placement.
Social History:
No drug abuse
Married, former smoker
Family History:
Positive for cancer in brother, heart disease,
mother, father, kidney disease, aunt.
Physical Exam:
On Admission:
101.6 F 71 133/61 25 100% CMV 1 350x23 +5
GEN: sedated, NAD
HEENT: trach in place, No scleral icterus, mucus membranes moist
Skin: no rash, wounds. PICC in LUE- no edema, erythema,
drainage
CV: irreg, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: obese, firm, distended, appears tender-max RUQ, no rebound
or guarding, no palpable masses
Ext: No LE edema, LE warm and well perfused
On discharge:
Afebrile, VSS
GEN: awake, alert, appropriate, NAD
HEENT: trach in place, moist mucous membranes
Pulm: Clear to auscultation bilaterally anteriorly
CV: irregular, no m/r/g noted
Abd: soft, NT, ND, +BS
Ext: 1+ pitting edema in the LE bilaterally to the knees
Rash: Diffuse erythematous morbilliform eruption worse from the
waist down
Pertinent Results:
Imaging:
[**7-2**] pCXR - Moderate right pleural effusion with bibasilar
opacity. Overall, this may represent cardiac congestion with
associated volume loss. Other less likely considerations include
aspiration or bilateral infectious consolidation.
[**7-2**] CT torso - new dilated loops of small bowel concerning for
early SBO, possible closed loop obstruction. transition point
somewhere in LLQ with distortion of mesentery ?rotation of
bowel. new free fluid within abdomen. scattered areas of bowel
wall thickening. +gallstones, unchanged. b/l basilar
consolidations. (preliminary)
[**7-3**]- UE US- Grayscale and Doppler son[**Name (NI) 1417**] of the left
internal jugular, subclavian, axillary, brachial, and basilic
veins demonstrate normal flow,
compressibility, augmentation, and waveforms. At the site of the
bandage and prior PICC at the left cephalic vein there is
intraluminal distention and thrombus with no flow present.
[**7-4**]- ECHO No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There are
simple atheroma and focal nonmobile (>4mm) plaque in the
descending thoracic aorta and aortic arch. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
[**7-13**]- ct HEAD: No acute intracranial hemorrhage, large mass or
mass effect is identified.
There is no large hypodense area to suggest an acute infarct.
There is a
small hypodense focus in the right posteroinferior frontal lobe
which is more
conspicuous than a recent head CT performed [**2158-6-17**]. This
may represent
volume averaging or a small area of intraparenchymal change
(2:15).
Note is made of bilateral tortuous ophthalmic veins, which are
unchanged from
prior study. There is no increased density in the cavernous
sinuses to
suggest thrombus. There is diffuse opacification at the
bilateral mastoid air
cells, which is new since prior study. There are air-fluid
levels in the left
sphenoid sinus. There is diffuse osteopenia. No other bony
abnormalities are
identified.
[**7-17**]- MRI:
IMPRESSION:
1. No evidence of acute cerebral infarction.
2. Minimal if any small vessel ischemic disease.
3. Symmetric prominent bilateral superior ophthalmic veins raise
question of
carotid-cavenous fistla. This is similar as compared to [**2158-6-17**].
Clinical correlation to symptoms is recommended.
4. Paranasal sinus disease.
[**7-19**] - RUQ US: Sludge-filled gallbladder, as seen previously,
not suggestive of cholecystitis
[**7-28**] - Upper extremity dopplers: No new DVT (old dvt in left
cephalic vein remains)
ADMISSION LABS:
[**2158-7-2**] 12:45AM BLOOD WBC-14.8* RBC-3.00* Hgb-8.9* Hct-27.2*
MCV-91 MCH-29.8 MCHC-32.9 RDW-16.3* Plt Ct-557*
[**2158-7-2**] 12:45AM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.2
Eos-0.2 Baso-0.3
[**2158-7-19**] 02:59AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2158-7-2**] 12:45AM BLOOD Plt Ct-557*
[**2158-7-2**] 12:45AM BLOOD PT-14.4* PTT-24.2 INR(PT)-1.2*
[**2158-7-2**] 12:45AM BLOOD Glucose-150* UreaN-45* Creat-2.0* Na-146*
K-3.9 Cl-103 HCO3-30 AnGap-17
[**2158-7-2**] 12:45AM BLOOD ALT-28 AST-33 LD(LDH)-301* AlkPhos-322*
Amylase-38 TotBili-1.9* DirBili-1.1* IndBili-0.8
[**2158-7-2**] 12:45AM BLOOD Albumin-2.9* Iron-80
[**2158-7-3**] 12:21AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.9*
[**2158-7-2**] 12:45AM BLOOD calTIBC-203* Ferritn-1196* TRF-156*
[**2158-7-2**] 02:35AM BLOOD Type-ART Rates-14/15 Tidal V-450 FiO2-40
pO2-318* pCO2-43 pH-7.47* calTCO2-32* Base XS-7
Intubat-INTUBATED
DISCHARGE LABS:
[**2158-8-2**] 03:25AM BLOOD WBC-10.6 RBC-3.16* Hgb-9.6* Hct-28.3*
MCV-90 MCH-30.4 MCHC-33.9 RDW-17.7* Plt Ct-292
[**2158-8-2**] 03:25AM BLOOD Neuts-82.5* Lymphs-10.9* Monos-4.1
Eos-2.3 Baso-0.1
[**2158-8-2**] 03:25AM BLOOD Glucose-112* UreaN-58* Creat-1.3* Na-140
K-3.8 Cl-97 HCO3-36* AnGap-11
[**2158-8-2**] 03:25AM BLOOD ALT-33 AST-34 LD(LDH)-265* AlkPhos-239*
TotBili-0.6
[**2158-8-2**] 03:25AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.0 Mg-2.1
Brief Hospital Course:
#) Agitated Delirium: While the patient was originally admitted
to [**Hospital1 18**] to the surgical service for management of his SBO vs.
ileus, the reason for his extended stay was his agitated
delirium. While in the surgical ICU, he was started on
precedex, and as per geriatrics consult, he was started on
standing seroquel and his sleep wake cycle was re-established.
However, his precedex was stopped as this isn't a long term
solution, and his delirium worsened. Organic causes of the
agitated delirium were ruled out. He was transferred to the
medical ICU for continued care of his agitated delirium. While
in the medical ICU, we tried a multitude of medications,
including a change in his antipsychotics, as well as a variety
of benzodiazepines. Geriatrics and psychiatry continued to
consult, however all prn and standing medications tried were
unsuccessful. Ultimately, we restarted precedex drip in an
effort to wash out all other psychoactive medications. Over the
course of 5 days, we were able to wean off the precedex while
starting clonidine. While the clonidine is for his blood
pressure, it was thought that since it works on the same
receptor as the precedex, it would also assist in the control of
his agitated delirium. After weaning off the precedex, he
remains on 0.1 mg of clonidine POBID and has been clear in terms
of his sensorium for over 3 days now. He has also been started
on depakote as per our geriatrics team.
.
#) DRESS (drug rash with eosinophilia and systemic symptoms):
The patient developed a morbilliform rash that was through
secondary to the ceftazidime that was started for his
pseudomonas and klebsiella from the sputum. His eosinophils
increased to a peak of 15%, and associated with this was an
increase in his LFTs as well as progression of his renal
failure. A derm consult agreed and they suggested three days of
IV solumedrol. Afterward, he was started on a prednisone taper
(120 mg x 3 days, 80 mg x 3 days, and 40 mg x 3 days). For
symptomatic control, we used barrier creams. On the day of
discharge, his rash seems to be a little worse, so rather than
continuing with the taper, we have decided to continue him on 40
mg of prednisone and to slow the taper. Now, he should receive
three more days of the 40 mg dose (until the [**7-5**]),
and then transitioned to 20 mg daily. He should also NOT
receive ceftazidime, nor should he receive any lasix (the sulfa
groups thought to be contributing to the DRESS).
.
#) Renal failure: The patient's creatinine continued to rise
throughout his hospitalizations. Urine electrolytes and
eosinophils were sent which were consistent with ATN rather than
AIN. Given the DRESS (see above), we felt that this was the
likely reason for the renal failure. His Cr has returned to
baseline prior to transfer to rehabilitation. While he had ATN,
we kept him even in terms of ins and outs. He was refractory to
lasix when he was acutely in renal failure. Also, given the
thought that the sulfa group in lasix may worsen DRESS, he
instead was placed on 100 mg of ethacrynic acid POBID which has
worked well for him.
.
#) Respiratory distress: The patient required being placed on
the ventilator via his trach in what was thought to be volume
overload and ventilator associated pneumonia. His sputum grew
pseudomonas, and as above, ceftazidime was not helpful as it
caused the DRESS syndrome. He was ultimately treated for his
VAP with 8 days of cipro and meropenem, as well as an earlier
course of cefepime. For gram positive coverage, the patient was
continued on his vancomycin (see below). Also, during his
hospitalization, his trach was changed x 1 as he had a cuff leak
upon arriving to the MICU. In terms of the volume overload, he
was started on 100 mg of ethacrynic acid POBID to help him
slowly diurese some of the fluid off. His volume status is much
improved from when his Cr peaked at 3.0. He was ultimately
weaned from the ventilator approximately 1.5 weeks prior to
discharge.
.
#) Staph bacteremia: The patient had GPCs in the blood early in
his hospitalization. The patient's vancomycin (originally
started for MRSA in the pleural cavity) was continued and an ID
consult was done. They felt the course should continue until
[**7-31**], and vancomycin was stopped on that date. Future blood
cultures have been negative. A TEE was done and was negative
for endocarditis.
#) Ileus vs SBO: Pt was initially admitted to the surgical team
for management of this issue. After multiple scans, it was
thought that this was an ileus secondary to narcotic usage.
Also, with the renal failure, the level of bowel edema likely
contributed to the inability to take tube feeds. After his
creatinine normalized, he was able to take tube feeds more
consistently and has been at goal. This has largely resolved,
and we are continuing to diurese him for his bowel edema.
.
#) Atrial fibrillation: Anticoagulation was not initiated for
him as his risk of stroke while in house was considered to be
low, and given the recent surgical procedure, we held off in the
setting of his other medical issues. He is maintained on
metoprolol tartrate 25 mg POTID for his rate control and this
has not been an issue in the few days leading up to discharge.
.
#) Hypertension: The patient's blood pressure would acutely
increase with his agitated delirium, however he was also found
to be hypertensive at baseline. His blood pressure medications
were titrated, and a nitro gtt was used intermittently while
titration was attempted. Ultimately, his pressures and regimen
stabilized and clonidine was started in an effort to also help
with his mental status. Please see his medication list for his
current regimen.
.
#) Anemia: The patient has worsening anemia with no new
suggested bleeding sites, could represent underproduction, bone
marrow suppression from infection, abx, renal disease or
nutritional deficiency. His Hct stabilized and was checked
daily.
.
#) Elevated blood glucose: No history of diabetes. SSI for
glucose control, goal <200
We continued him on 12 units of lantus QHS. He has been doing
well on this regimen, however, it will likely need to be
titrated in the future once his prednisone taper continues.
#) h/o DVT: not currently candidate for anticoag. LENIs
negative, UENI?????? no new DVT
Will consider anticoagulation at a later date
#) Code Status: The patient was originally full code, however
during his hospitalization, his family decided to change him to
DNR. This will have to be an ongoing discussion with the
patient and his family.
Medications on Admission:
Vancomycin 1 gram q24 (last trough [**7-1**]- 32)
Finasteride 5 mg Tab Oral 1 Tablet(s) Once Daily
Combivent 1 Aerosol(s) Four times daily nebulizer
Docusate Sodium 50 mg/5 mL Oral 2 Liquid(s) Twice Daily
Esomeprazole Magnesium 40 mg Once Daily
Heparin (Porcine) 5,000 unit/mL TID
Losartan 100 mg Tab Oral 1 Tablet(s) Once Daily
Methadone 10 mg/5 mL Oral Soln Oral 1 Solution(s) every 8 hours
Metoprolol Tartrate 25 mg Tab Oral 1 Tablet Twice Daily 8AM &
2PM
Quetiapine 50 mg Tab Oral [**12-12**] Tablet(s) Twice Daily 8AM & 2PM
Senna 187 mg Tab Oral 2 Tablet(s) Once Daily, at bedtime
Simvastatin 10 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
Tamsulosin SR 0.4 mg 24 hr Cap Oral 1 Capsule, Sust. Release 24
hr(s) Once Daily
Tramadol 50 mg Tab Oral [**12-10**] Tablet(s) every 6 hours
Insulin Regular Human 100 unit/mL Cartridge Injection
sliding scale Cartridge(s) Four times daily
Erythromycin Ethylsuccinate 250mg/6.25ml Suspension(s) every 6
hours
Miconazole Powder Misc.(Non-Drug; Combo Route) to sacral wound
Powder(s) every 8 hours
Metoclopramide 10 mg Tab Oral 1 Tablet(s) every 6 hours
Bumetanide 0.25 mg/mL Injection Injection 0.5mg Solution(s) Once
Daily at 8PM
Acetaminophen 650 mg/20.3 mL Oral Soln Oral
1 Solution(s) every 4 hours, as needed
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Tablet,Rapid
Dissolve, DR(s)
2. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
3. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: One (1) Capsule,
Sprinkle PO QID (4 times a day).
4. Ammonium Lactate 12 % Lotion [**Last Name (STitle) **]: One (1) application Topical
twice a day as needed for rash.
5. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily):
Continue with 2 tabs daily for 3 days, then taper to 1 tab daily
for 3 days.
7. Ethacrynic Acid 25 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO BID (2
times a day).
8. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6
hours).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for scrotum erythema.
11. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO BID
(2 times a day).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Delirium, ventilator associated pneumonia, bacteremia and renal
failure, ileus now resolved
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:
Please follow your rash closely. You are currently on prednisone
which will be decreased over the next few days. Currently you
are on 40 mg of prednisone daily for 3 more days followed by 20
mg for 3 more days.
Please contact your PCP for any concerning changes in mental
status or if your urine output drops off.
Followup Instructions:
You will be following up with the physician at the rehab center.
Completed by:[**2158-8-2**]
|
[
"E930.5",
"V12.51",
"V44.1",
"510.9",
"041.7",
"V15.88",
"518.83",
"041.11",
"041.12",
"790.7",
"451.82",
"293.0",
"999.31",
"427.31",
"V55.0",
"693.0",
"997.31",
"403.90",
"585.9",
"560.1",
"288.3",
"E935.2",
"041.3",
"349.82",
"276.0",
"V58.65",
"584.5",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.72",
"96.6",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
17464, 17536
|
7800, 14381
|
311, 332
|
17671, 17671
|
3448, 5049
|
18186, 18282
|
2564, 2651
|
15691, 17441
|
17557, 17650
|
14407, 15668
|
17847, 18163
|
7329, 7777
|
2219, 2494
|
2666, 2666
|
3096, 3429
|
1928, 1986
|
240, 273
|
360, 1909
|
5058, 6367
|
6383, 7313
|
2680, 3082
|
17686, 17823
|
2030, 2196
|
2510, 2548
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,496
| 165,002
|
20150
|
Discharge summary
|
report
|
Admission Date: [**2194-6-18**] Discharge Date: [**2194-6-23**]
Date of Birth: [**2154-6-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
dyspnea and tachycardia x 48h
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
39 y.o. F w/h/o etoh and crack cocaine abuse as well as h/o
psychosis w/h/o of multiple hospitalizations for her psychiatric
issues who p/w SOB which began during her most recent inpatient
stay for detoxification at [**Hospital **] Hospital([**Date range (1) 54167**]). She had
been transferred there from [**Hospital 1474**] Hospital where she spent 24
h, [**Date range (1) 54168**]. Per her brother, she has been in and out of
hospitals for the past 4-5 years for psychiatric and substance
abuse issues. He notes that she "smokes more than anyone he
knows" and notes that he thinks that her friend has been
bringing her crack cocaine with greater frequency lately. Per
brother, she had been admitted to [**Name (NI) 1474**] Hospital because her
[**Name (NI) 269**] was concerned about her because her heart rate was high, her
temp at home was "99". She was at [**Hospital1 1474**] for 24 h but was
transferred to [**Hospital **] Hospital for her substance abuse issues.
There, she was noted to have SOB and wheezing and began to be
treated for COPD/asthma flare. CXR there was unremarkable. She
was transferred to [**Hospital1 18**] for further management of her medical
problems.
.
In the ED, she was hypertensive to 160s tachycardic to the 120s
afebrile and sating 100%RA; she had diffuse wheezes on exam. Her
CXR was unrevealing and CT chest was negative for PE. She
received 1.5 LNS and 20mg valium as well as combivent nebs,
Azithromycin, and steroids for COPD flare.
.
Currently, unable to relate hx, denies current SOB, denies pain;
would like to go home. Does endorse having had cough, SOB
before. Denies recent drug use but notes that she did have a
drink prior to admission to the hospital- likely [**Hospital1 1474**].
Unable to relay how much.
Past Medical History:
1. Basal ganglia/frontal cortical axis dysfunction
complicated by Parkinson-like symptoms with baseline tremor
and slurred speech as well as acute psychosis
2. History of sexual abuse by her brother.
3. History of alcohol abuse.
4. History of crack cocaine abuse.
5. h/o anticholinergic tox syndrome
Social History:
Smokes 2ppd, unable to relay how much she drinks, denies other
drug use. Lives at home w/[**Last Name (LF) 269**], [**First Name3 (LF) **] brother has a friend who
brings her crack cocaine.
Family History:
mother w/emphysema, father w/cerebral aneurysm, both parents
w/h/o HTN
Physical Exam:
MICU ADMISSION PHYSICAL EXAM:
==============================
VS: T 100.4 HR 124 BP 111/49 RR 36 sat 99 on 6LNC
GEN: weepy, difficult to understand, but speaking in full
sentences
HEENT: AT, NC, Pupils small but reactive BL, EOMI, no
conjuctival injection, anicteric, OP clear, MMM
Neck: flat JVP, supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, +systolic murmur, no rubs, gallops
PULM: diffuse wheezes BL, no rhonchi, rales
ABD: soft, NT, ND, + BS, no HSM noted
EXT: warm, dry, +2 distal pulses BL
NEURO: "[**Month (only) **]" for date, unable to describe reason for being
here, unable to understand her statment for place, CN II-XII
grossly intact, 5/5 strength throughout. No sensory deficits to
light touch appreciated. No asterixis.
PSYCH: weepy, responds but unintelligibly, often inappropriately
Skin: no rashes
PHYSICAL EXAM ON TRANSFER TO MEDICINE FLOOR:
============================================
Vitals - T: 96.3 BP: 99/64 (from 130/70) HR: 86 RR: 28 02 sat:
94% RA
GENERAL: NAD, speaking in full sentences, rocking back and forth
HEENT: EOMI, PERRL, anicteric, OP - no exudate, no erythema, no
LAD
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: prolonged expiratory phase with expiratory wheezes
throughout, no rales/rhonchi
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: cooperative, denies AH and VH, although states that "God
is talking to her."
Pertinent Results:
ADMISSION LABS:
===============
13.3
8.8 >-------< 296
40.4
MCV 92 Neuts 80.1 Bands 0 Lymphs 16.9 Monos 2.2 Eos 0.5
Basos 0.3
140 103 12
-----|-----|-----< 152
3.0 24 0.8
ALT 18 AST 21 LDH 216 Alk Phos 33 Bili 0.2 Alb 4.5
Ca 8.6 Phos 2.9 Mg 1.8
CK 137 MB 5 Trop <0.01
TSH 3.5
Serum Tox Screen: negative
Urine Tox Screen: negative
Lactate 2.8
UA negative
PERTINENT LABS DURING HOSPITALIZATION:
=======================================
WBC trend: 8.8 - 6.2 - 11.1
BNP 191
Labs at discharge:
creatinine 0.6
bicarbonate 20
WBC 10.9, Hct 38.7, Plt 386
MICROBIOLOGY:
=============
[**6-18**] BCx x 2: NGTD
[**6-18**] UCx: negative
STUDIES:
========
[**6-18**] EKG:
Sinus tachycardia. Left atrial enlargement. Compared to the
previous tracing of [**2189-11-10**] there are non-specific
inferolateral ST segment changes and an increase in rate.
Otherwise, no diagnostic interim change.
[**6-18**] PCXR:
IMPRESSION: No cardiopulmonary process.
[**6-18**] CTA CHEST W&W/O C&RECONS, NON-CORONARY
IMPRESSION:
1. No evidence of pulmonary embolus or acute thoracic aortic
dissection.
2. Findings suggestive of esophageal diverticulum without any
the secondary signs to suggest a fistula. Consider further
evaluation with esophagram if warranted clinically.
[**6-19**] CHEST (PORTABLE AP)
IMPRESSION: No acute intrathoracic pathology including no
pneumonia or heart failure.
6/19 ESOPHAGUS
IMPRESSION: Unremarkable barium esophagram, without evidence of
a
tracheoesophageal fistula.
TTE (Complete) Done [**2194-6-20**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size 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 appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. IMPRESSION:
Normal study. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified.
[**6-20**] CXR (PA & LATERAL)
FINDINGS: In comparison with the study of [**6-19**], there is no
interval change. The cardiac silhouette remains within normal
limits with no evidence of vascular congestion, pleural
effusion, or acute pneumonia. Of incidental note is contrast
material, possibly from a recent CT, in the
left upper quadrant of the abdomen.
Brief Hospital Course:
MICU COURSE SUMMARY:
=====================
Ms. [**Known lastname 5108**] is a 39 y.o. with alcohol and crack cocaine abuse
history, h/o psychosis and multiple hospitalizations for psych
issues, and no known pulmonary disorder, transferred from OSH
for dyspnea and tachycardia during her most recent inpatient
stay for detox at [**Hospital **] Hospital ([**Date range (1) 54167**]). She then was
transferred to [**Hospital 1474**] Hospital because her [**Hospital 269**] noticed that
she was tachycardic, her temperature was "99". She was there for
24 hours, then transferred to [**Hospital **] Hospital for substance abuse
issues. She was noted to have increased SOB and wheezing and
treated for COPD/asthma flare. Prior to this, she reports having
a cough for about 2 weeks. She was transferred to [**Hospital1 18**] for
further management of her medical problems.
In the ED, she was hypertensive to 160s tachycardic to the 120s
afebrile and sating 100%RA. She had diffuse wheezes on exam. Her
CXR was unrevealing and CT chest was negative for PE. She
received 1.5 L NS and 20mg Valium as well as Combivent nebs,
Azithromycin, and steroids for COPD flare.
In the MICU, pt had insp/exp stridor. CTA initially showed ?
esoph diverticulum vs tracheoesophageal fistula (final read did
not show TEF). She underwent bronch and barium study, which were
both neg for fistula. ENT was consulted, and it was thought she
had paradoxical vocal cord motion causing insp stridor. Exp
wheezing was thought from a possible COPD flare (but no prior hx
of COPD). She was treated with levofloxacin and IV steroids, and
her stridor improved. She was persistently tachy up to 120's,
with some improvement to 110's after IVF. Tachycardia was
thought to be sinus tach [**2-1**] COPD flare and EtOH/cocaine
withdrawal. She was also agitated on admission to the MICU and
was hearing voices, got haldol, and was seen by psych who rec'd
continuing outpt regimen plus haldol prn.
MEDICINE FLOOR SUMMARY:
=======================
# Wheeze: Unclear etiology, but now improved. Patient without
known asthma or COPD, but has a significant smoking history. No
PE on CTA. She was continued on po steroids that will be
tapered over 3 weeks. She was also treated with levofloxacin to
complete a 7 day course. She was placed on standing and prn
albuterol and atrovent. CXR did not show any cardiopulmonary
process. Pulmonary consult saw the patient and recommended long
3 week steroid taper as well as outpatient follow up in
[**Hospital1 1474**]. She should have PFTs in the future.
# Stridor: Patient initially had stridor heard bilaterally on
exam, but now only expiratory wheezing heard. No signs of
tracheoesophageal fistula by bronch or barium study. Stridor
likely due to paradoxical vocal cord motion per ENT. If pt
continues to have episodes of stridor, she may follow up with
[**Hospital **] Clinic as outpatient.
# Tachycardia: On admission, the patient was tachycardic. Her
sinus tachycardia somewhat improved with IVF and valium. Likely
multifactorial in setting of ? COPD exacerbation, EtOH/cocaine
withdrawal. Tachycardia began to resolve. She was monitored on
telemetry.
# Etoh abuse: Multiple hospitalizations for detoxification;
unclear when her last drink was, or how much she drinks at
baseline. CIWA scale initiated with po Diazepam but
discontinued on her 2nd day on the medical floor. Aspiration
precautions maintained. Social work/addiction consulted.
# Psych: Psychiatry followed patient while in the
hospitalization. Risperdal and trileptal continued. 1:1 sitter
maintained. She is being discharged to [**Hospital 1680**] Hospital for
further inpatient psychiatric treatment.
# ? Sz d/o: Was on trileptal at [**Hospital **] Hospital and continued in
[**Hospital1 18**].
# CODE: FULL
# CONTACT: [**Name (NI) 892**] ([**Telephone/Fax (1) 54169**]
Medications on Admission:
Home Medications: Risperdal, o/w unknown (per brother)
Transfer Medications from OSH: colace, risperdal, trileptal,
flovent, albuterol, MOM, [**Name (NI) 54170**], MOM, Mylanta, [**Name (NI) 54171**]
gum
Transfer Medications from MICU to Medcine Floor:
Transfer meds:
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
MethylPREDNISolone Sodium Succ 50 mg IV Q8H
Diazepam 5 mg PO Q4H PRN CIWA > 10
Nicotine Patch 14 mg TD DAILY
Oxcarbazepine 300 mg PO BID
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Heparin 5000 UNIT SC TID
Ipratropium Bromide Neb 1 NEB IH Q4H
Levofloxacin 500 mg PO Q24H
Risperidone 3 mg PO HS
Senna 1 TAB PO BID:PRN
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizers Inhalation Q4H (every 4
hours).
Disp:*qs nebulizers* Refills:*2*
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs units* Refills:*2*
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Disp:*120 nebulizer* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 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*
9. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: please take 6 tablets x 6 days ([**6-24**] - [**6-26**]), then take 4
tablets x 5 days ([**6-27**] - [**7-1**]), then 2 tablets x 4 days ([**7-2**] -
[**7-5**]), then 1 tablet x 3 days ([**7-6**] - [**7-8**]), and then [**1-1**] tablet x
3 days ([**7-9**] - [**7-11**]).
Disp:*51 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis:
1. Paradoxical Vocal Cord Motion
2. Presumed COPD Exacerbation/Asthma
Secondary Diagnosis:
1. Alcohol abuse
2. Psychiatric disorder
Discharge Condition:
Stable. Ambulating. Oxygenating well.
Discharge Instructions:
You were admitted with shortness of breath, wheezing, and
stridor. You were admitted to the ICU for respiratory distress.
ENT evaluted you and believe that you have paradoxical vocal
cord motion. You also were treated for a COPD flare and treated
with inhalers, steroids, and antibiotics. Once you were
stabilized, you were transferred from the MICU to the medicine
floor. You got better with medical management.
You should continue to take all your medications as prescribed.
You will go home on a 3 week steroid (prednisone) taper.
Please make all your medical appointments.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, abdominal pain, or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35266**], your primary care physician, [**Name10 (NameIs) **]
schedule an appointment in [**1-1**] weeks. Phone: [**Telephone/Fax (1) 35269**].
Please follow up with [**Hospital **] Clinic if you continue to have
stridor. Call ([**Telephone/Fax (1) 6213**].
Please ask your doctor to give you a referral to a pulmonologist
in [**Hospital1 1474**]. You will need follow up for possible COPD/asthma.
Completed by:[**2194-6-23**]
|
[
"374.43",
"V11.3",
"530.6",
"786.1",
"493.22",
"427.89",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
12931, 13012
|
6943, 10798
|
345, 360
|
13208, 13248
|
4166, 4166
|
14067, 14579
|
2695, 2767
|
11489, 12908
|
13033, 13033
|
10824, 10824
|
13272, 14044
|
2812, 4147
|
10842, 11466
|
276, 307
|
4705, 6920
|
388, 2148
|
13144, 13187
|
4182, 4686
|
13052, 13123
|
2170, 2472
|
2488, 2679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,440
| 113,236
|
16065
|
Discharge summary
|
report
|
Admission Date: [**2164-3-27**] Discharge Date: [**2164-4-5**]
Date of Birth: [**2094-7-25**] Sex: M
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old man
with a history of coronary artery disease status post
coronary artery bypass graft times four, who presented to
[**Hospital1 69**] for an esophagectomy on
[**2164-3-27**].
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2158**].
2. Transient ischemic attack.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Hypertension.
6. Esophageal cancer.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times four in [**2158**].
2. Back surgery.
3. Shoulder surgery.
4. Cholecystectomy.
5. Hernia repair.
ALLERGIES:
1. Tetracycline.
2. Zestril.
3. Ibuprofen.
4. Demerol.
5. Motrin.
6. Advil.
MEDICATIONS AT HOME:
1. Synthroid.
2. Lipitor.
3. Avalide.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a former smoker and denies
any history of alcohol use.
HOSPITAL COURSE: The patient underwent an Ivor-[**Doctor Last Name **]
esophagectomy and feeding jejunostomy on [**2164-3-27**].
The patient tolerated the procedure well, received 8 liters
of intravenous fluids intraoperatively and estimated blood
loss was 700 cc. The patient was admitted to the surgical
Intensive Care Unit for management immediately
postoperatively. The patient had two chest tubes placed
intraoperatively, and the Foley catheter was placed as well
as an nasogastric tube. The patient was kept NPO with
intravenous fluids. The patient was placed on Kefzol and
Flagyl for infection prophylaxis. On postoperative day
number one the patient was hemodynamically stable. The
patient was started on tube feeds at 10 cc an hour. On
postoperative day number two the patient was determined to be
stable enough for transfer to the floor for care. The
patient was transferred to the floor on telemetry. The
patient's tube feeds were gradually increased to a goal of 70
cc an hour. On postoperative day number six the patient
underwent a barium swallow study. The barium swallow study
showed no leakage at the anastomosis site. The patient's
nasogastric tube was taken out. The patient was started on a
clear liquid diet. The patient tolerated the diet well and
was advanced gradually to a full diet. The patient's tube
feeds were cycled for nutritional support. The patient was
able to ambulate on his own. Chest tubes were discontinued
on postoperative day number eight with a follow up chest
x-ray showing no pneumothorax. The patient is stable for
discharge on [**2164-4-5**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg q day.
2. Synthroid .137 mg q.d.
3. Avalide 300/12.5 mg q.d.
4. Zantac 150 mg b.i.d.
5. Percocet one to two tablets po q 4 to 6 hours as needed
for pain.
6. Colace 100 mg b.i.d. when taking Percocet.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Transient ischemic attack.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Hypertension.
6. Carcinoma of the esophagus.
FOLLOW UP PLANS: The patient was instructed to follow up
with Dr. [**Last Name (STitle) 957**]. The patient was instructed to call Dr.[**Name (NI) 7012**] office for an appointment. The patient was
instructed not to lift heavy objects. The patient should
also follow up with the oncology service with Dr. [**First Name (STitle) **] as
well as Dr. [**Last Name (STitle) 776**] from radiation/oncology for
postoperative cancer management.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2164-4-5**] 10:38
T: [**2164-4-5**] 10:59
JOB#: [**Job Number **]
|
[
"272.0",
"150.5",
"250.00",
"278.01",
"424.0",
"244.9",
"553.20",
"412",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.29",
"42.51",
"42.42",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
2672, 2710
|
935, 953
|
2978, 3815
|
2733, 2957
|
1059, 2650
|
876, 918
|
621, 855
|
173, 379
|
401, 598
|
970, 1041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,061
| 110,994
|
36210
|
Discharge summary
|
report
|
Admission Date: [**2155-12-3**] Discharge Date: [**2155-12-4**]
Date of Birth: [**2080-12-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
left carotid artery stenosis
Major Surgical or Invasive Procedure:
Carotid artery angioplasty and stenting
History of Present Illness:
The pt is a 74-yo man with hyperlipidemia, possible
hypertension, ischemic cardiomyopathy with EF 25-45%, CAD s/p MI
and emergent 4vCABG + LV Aneurysmectomy [**2151**], and left carotid
artery stenosis, who presents for angiography and
revascularization of carotid artery stenosis. Recent
surveillance testing has shown the left carotid artery to have
80-99% stenosis with a peak systolic velocity of 514 cm/sec and
diastolic velocities of 151 cm/sec. There was retrograde flow
involving the left vertebral artery consistent with a probable
subclavian artery stenosis. The patient has no history of prior
stroke or TIA, and has not had any neurological symptoms
including difficulty with speech, headaches, changes in vision,
weakness, numbness or tingling. He also denies any cardiac
symptoms including chest pain, SOB, DOE, orthopnea, PND, leg
swelling, palpitations, syncope or presyncope, or claudication.
.
The pt underwent carotid angiography and stent placement in the
cardiac cath lab, and is admitted to the CCU for further care
and monitoring.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (?)Hypertension
2. CARDIAC HISTORY:
- Ischemic cardiomyopathy with EF 25-45%
- CAD s/p MI and emergent 4vCABG + LV Aneurysmectomy [**2151**] at [**Hospital1 112**]
- Severe left carotid artery stenosis
3. OTHER PAST MEDICAL HISTORY:
- Rectal cancer diagnosed over 40 years ago, s/p colostomy
- Bladder cancer, diagnosed in [**2147**] and [**2152**], s/p BCG treatment
x 2
- Prior remote knee surgery
Social History:
Married w/ 4 children, lives with wife. Semi-retired dentist.
Remote tobacco history, no EtOH.
Family History:
Brother w/ CHF in 60s, otherwise non-contributory.
Physical Exam:
VS: T=98.2F, BP=119/48, HR=62, RR=17, O2 sat=97% 2L NC
GENERAL: WDWN elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD. +Left carotid bruit -? radiation of RUSB
murmur.
CARDIAC: RRR, normal S1-S2, +II/VI SM @ RUSB. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft/NT/ND. +Colostomy on left abdomen. No
palpable masses or HSM.
EXTREMITIES: WWP, no c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+ Radial 2+
Left: DP 2+ PT 2+ Radial 2+
Pertinent Results:
[**2155-12-3**] 07:50AM BLOOD WBC-7.6 RBC-3.80* Hgb-12.0* Hct-34.5*
MCV-91 MCH-31.7 MCHC-34.9 RDW-13.7 Plt Ct-246
[**2155-12-3**] 07:50AM BLOOD Neuts-87.5* Lymphs-7.4* Monos-4.2 Eos-0.7
Baso-0.3
[**2155-12-3**] 04:27PM BLOOD CK(CPK)-147
[**2155-12-3**] 04:27PM BLOOD CK-MB-3
[**2155-12-4**] 06:31AM BLOOD WBC-8.6 RBC-3.39* Hgb-10.8* Hct-30.9*
MCV-91 MCH-31.9 MCHC-35.0 RDW-13.7 Plt Ct-207
[**2155-12-4**] 06:31AM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1
[**2155-12-4**] 06:31AM BLOOD Glucose-105 UreaN-15 Creat-1.0 Na-142
K-4.1 Cl-108 HCO3-27 AnGap-11
[**2155-12-4**] 06:31AM BLOOD CK(CPK)-233*
[**2155-12-4**] 06:31AM BLOOD CK-MB-4
[**2155-12-4**] 06:31AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
.
[**2155-12-3**] Cardiac Catheterization (Preliminary Report):
1. Severe left internal carotid artery stenosis
2. Successful PTCA and stenting of the left ICA with a bare
metal stent.
3. Left subclavian artery stenosis (50 mm Hg gradient between
non-invasive blood pressure monitoring)
4. Abdominal aneurysm
5. Successful closure of the right femoral arteriotomy site
with a 6F
closure device.
.
[**2155-12-3**] ECG: NSR @ 80, RAD/RBBB, non-specific ST-Twave changes
.
Results Pending at the Time of Discharge:
Final Cardiac Catheterization Report
Brief Hospital Course:
Mr. [**Known lastname **] presented with severe left carotid artery stenosis.
He underwent angiography and stent placement of the left carotid
artery. He was then admitted to the CCU for intense blood
pressure monitoring and frequent neuro checks. He was given
neosynephrine to maintain blood pressures over 100 systolic. He
did not require nitroglycerin for hypertension. He was
monitored with serial neuro exams and did not experience any
neurologic symptoms. He was continued on his aspirin and
plavix. No changes were made to his medications. He was weaned
off the neosynephine on the morning of discharge and remained
symptomatically well. He was ambulating without difficulty. He
was put on pneumoboots for DVT prophylaxis. He was discharged
with follow-up appointments for a repeat carotid ultrasound and
appointment with Dr. [**First Name (STitle) **] on [**2155-1-15**].
Medications on Admission:
- Zocor 20mg every evening
- Plavix 75mg daily every evening
- Toprol XL 150mg every morning
- ASA 81mg every morning (took 324mg today)
- Doxazosin 4mg every evening at bedtime
- MVI
Discharge Medications:
1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary -
Carotid artery stenosis s/p stent placement
Secdonary -
Conronary artery disease
Ischemic cardiomyopathy
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital to have a stent placed in your
carotid artery to open a blockage which was found by your
cardiolgoist. The stent was placed during your hospitalization.
You will need to take plavix 75 mg daily and ASA 325 mg daily.
You had been started on the plavix and ASA prior to your
admission. No changes were made to your medications.
Go to the emergency room or call your primary docotor if you
experience fevers, chills, chest pain, shortness of breath,
vision change, weakness in your extremities, numbness or
tingling, dizziness, blood in your stool, or black stool.
Followup Instructions:
You will need to follow up with with Dr. [**First Name (STitle) **] on [**1-15**] at
11:40am. The office is located on [**Hospital Ward Name 23**] 7 ([**Hospital1 18**] [**Hospital Ward Name 516**])
in the Cardiology Suite.
A carotid ultrasound has been scheduled for [**1-5**] at 1:30pm. The
radiology suite is ocated on [**Hospital1 18**] [**Hospital Ward Name 517**], Clinical Center
[**Location (un) 470**].
Please call Dr.[**Name (NI) 66745**] office to schedule a follow-up
appointment. The number is [**Telephone/Fax (1) 1690**].
|
[
"433.10",
"272.4",
"V45.81",
"414.8",
"V44.3",
"412",
"V10.06",
"V10.51",
"428.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.40",
"00.63",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
5772, 5778
|
4134, 5025
|
344, 386
|
5953, 5962
|
2874, 4111
|
6611, 7156
|
2062, 2114
|
5259, 5749
|
5799, 5932
|
5051, 5236
|
5986, 6588
|
2129, 2855
|
1569, 1735
|
276, 306
|
414, 1469
|
1766, 1934
|
1491, 1549
|
1950, 2046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,280
| 145,373
|
22105
|
Discharge summary
|
report
|
Admission Date: [**2105-8-19**] Discharge Date: [**2105-9-3**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Tunnelled line placement for hemo dialysis on [**2105-8-24**]
History of Present Illness:
85 yo man with several recent hospitalizations for gallstone
pancreatitis who was admitted to an OSH [**8-14**] with blood-loss
anemia and renal failure. Recent PMHx begins in late [**6-24**] when
he was admitted here with gallstone pancreatitis. ERCP was
attempted but they could not cannulate the CBD; symptoms
improved with supportive care and the pt was d/c home after one
week. Sx recurred in mid-[**7-25**] when he was admitted to an OSH.
There he was felt to need a ccy and so was sent here, where an
ERCP was repeated and the CBD cannulated with sphincterotomy and
stone extraction; duodenal ulcers were also incidentally noted
during this study. A CT scan showed ? non-enhancing lesion at
the head of the pancreas (necrotizing pancreatitis vs.
pseudocyst). His hospital course was c/b MRSA bacteremia found
on routine blood cxs [**7-28**]. A subsequent TEE was equivocal (debris
with calcifications vs. vegetations), so the plan was made for
empiric treatment of endocarditis with vanco x6 weeks through a
LUE PICC. The pt was ultimately discharged from the [**Hospital1 18**] on
[**8-5**] to a NH. There he was getting vanco [**Hospital1 **] for 7-8 days, also
prn Lasix for LE edema. He was sent in to an OSH [**8-13**] with a Cr
of 4.4 (baseline 1.4), Hct 25 (baseline 30). His anemia was
thought to likely be multifactorial (PUD vs. LGIB vs. renal
failure). He was initially given two unit pRBCs with an
appropriate response. His FeNa there was c/w pre-renal azotemia
in the setting of total body volume overload. His meds renally
dosed and his diuretics were held due to presumed intravascular
volume depletion. Despite low-salt albumin and the pRBC
transfusions noted above, his creatinine had increased to 6.0 on
the day prior to transfer here. He has also been oliguric
(200-400 cc/day for 5-6 days prior to transfer), and he has
developed hyperkalemia and pulmonary edema. Discussions were
held with the patient and his family regarding the initiation of
hemodialysis, and ultimately the decision was made to pursue a
trial of hemodialysis. He is therefore transferred here for
initiation of hemodialysis.
Of note, the patient has reportedly also had progressive
abdominal distension over the [**Last Name (un) 18712**] 1-2 weeks. A KUB done at the
OSH on the day prior to transfer was suggestive of a partial
SBO. At no point, however, has he had n/v or abd pain. He is
having bowel movement and passing flatus, and he is tolerating a
po diet. His lipase and amylase were also increasing, thus
raising the question of recurrent pancreatitis. For these
reasons, he was made NPO on the night prior to transfer.
Past Medical History:
1. recurrent gallstone pancreatitis s/p cannulation of the CBD
and sphincterotomy [**7-25**]
2. cholelithiasis
3. presumptive diagnosis of endocarditis and MRSA bacteremia
[**7-25**]
4. UTI
5. gout
6. HTN
7. PUD
8. COPD
9. dyslipidemia
10. DM-II
11. chronic renal failure
12. achalasia/GERD
13. hiatal hernia
14. brachial nerve injury c/b RUE weakness
15. bipedal neuropathy [**12-22**] remote injury
16. prostate cancer (untreated)
17. colonic polyps
18. carpal tunnel syndrome
19. glaucoma
20. OA
21. MRSA (blood and sputum)
22. VRE (urine)
23. chronic L pleural effusion
Social History:
World War II veteran. Lives in [**Location 620**] with his wife. [**Name (NI) **] has a
remote history of heavy alcohol use and now has 1-2 drinks
during the weekend. He no longer smokes but also has a remote
history of tobacco use. He is a retired salesman. His daughter
is [**Name (NI) 553**] [**Last Name (NamePattern1) 57771**], [**First Name3 (LF) **] [**Company 191**] Clinical triage nurse.
Family History:
Noncontributory.
Physical Exam:
Temp 97.2, BP 133/64, HR 75, RR 22, SpO2 97% 2L nasal
cannula
Gen: Pleasant, obese man appearing his stated age and in mild
respiratory distress but able to speak in full sentences.
HEENT: NCAT, no sinus tenderness, PERRL, dry oral mucosa, OP
clear.
Neck: Soft and supple.
CV: Irregular rate, normal S1 and S2, no m/r/g, no carotid
bruits.
Pulm: Diffuse rhonchi with decreased breath sounds, crackles,
and dullness to percussion over the lower third of the lung
fields bilaterally.
Abd: Soft, non-tender, distended, active bowel sounds, mild
diffuse guarding but no rebound.
Back: No CVA or paraspinal tenderness.
Ext: 4+ bilateral lower extremity pitting edema, 2+ DP pulses.
Nodes: No cervical or inguinal adenopathy.
Skin: Telangiectasias over the superior-anterior chest wall,
mild diffuse erythema, no other focal lesions.
Neuro: Waxing and [**Doctor Last Name 688**] mental status with intermittently
appropriate responses to questions, very hard of hearing.
Pertinent Results:
WBC-12.0 HCT-33.5 MCV-94 PLT COUNT-323
PT-13.9 PTT-26.8 INR(PT)-1.2
SODIUM-137 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-18 UREA N-107
CREAT-6.0 GLUCOSE-191
CALCIUM-7.0 MAGNESIUM-2.2 PHOSPHATE-8.9 ALBUMIN-2.5
ALT-12 AST-8 ALK PHOS-64 TOT BILI-0.4 AMYLASE-197 LIPASE-116
CXR: Enlarged cardiac silhouette, prominent vasculature
consistent with pulmonary edema, bilateral pleural effusions (L
> R), no free air under the diaphragm
KUB: Non-specific bowel gas pattern, no evidence of obstruction
Brief Hospital Course:
85 yo man with several recent hospitalizations for gallstone
pancreatitis now transferred from OSH with acute renal failure.
1. Acute Renal Failure: Cr of 6.0 on admission markedly elevated
from prior baseline of 1.2. Differential initially included
intravascular volume depletion vs. ATN (contrast nephropathy?)
vs. medication toxicity. OSH FeNa of 0.8% was c/w pre-renal
etiology. Pt was total-body volume overload. This gradually
improved with hemo dilysis. As the admission progressed, renal
felt etiology more likely to be cholesterol emboli. Renal US was
done which ruled out obstructive etiology. Renal consult was
obtained on admission and hemo dialysis was initiated. Pt was
stabalized on a Mon-Wed-Fri regimen. Decision was made not to
persue a renal biopsy as pt and family did not want any invasive
procedures. Hemodialysis became increasingly challenging
secondary to hypotension. On [**2103-9-1**], family decided not to
continue with dialysis.
2. Pancreatitis/Pseudocyst: Enzymes mildly elevated on admission
([**Doctor First Name **] 197, lipase 116). Noncontrast CT of abdomen was obtained
which was concerning for a pancreatic pseudocyst. Surgery was
initially consulted but did not feel surgical intervention was
warrented. Pt was initially kept NPO with a NG tube and TPN for
nutrition. However, he self discontined the NG tube on
[**2105-7-23**]. On [**2105-7-26**], the pt developed increased abdominal
pain on exam. Abdominal film was unremarkable. After extensive
discussion with the pt and family, they decided not to persue
further imaging including CT scan or MRCP. They declined any
invasive intervention no matter the cause of abdominal pain. At
that time, the TPN was discontinued. Pt was allowed to eat as
desired with a pureed diet. However, he took little by mouth. Pt
was covered throughout the admission with meropenem and was
discontinued on the day of discharge.
5. Pneumonia: Unclear diagnosis at OSH, although there was a
question of bibasilar infiltrates on admission CXR. He was
treated with ceftriaxone and flagyl. He is currently
comfortable on room air with prn nebulizer treatments for
audible wheezing.
5. Anemia: Lab panel at OSH c/w anemia of chronic disease. Hct
stable here.
7. MRSA Bacteremia: Patient was treated with vancomycin dosed by
level and was maintained on contact precautions. Vancomycin was
discontinued when pt was made CMO as levels were no longer
obtained.
8. VRE: Likely simply colonization of urinary tract.
9. Access: LUE PICC, dialysis catheter
10. F/E/N: POs as tolerated.
11. Communication: With wife and daughter.
12. Code: DNR/DNI. CMO status established on [**2105-9-1**] after
extensive discussions with wife and daughter.
13. Disposition: Hospice
Medications on Admission:
1. imipenem 250 mg iv every twelve hours
2. metronidazole 500 orally twice daily
3. vancomycin dosed at hemodialysis
4. ferrous sulfate 325 mg daily
5. Advair 50/500 one puff twice daily
6. ASA 81 mg daily
7. pilocarpine ophthalmic drops 0.5% one both eyes four times
daily
8. zinc sulfate 220 mg daily
9. pantoprazole 40 mg daily
10. metoprolol 25 mg twice daily
11. amlexanox 5% 1/4 inch to mouth ulcers three times daily
12. docusate 100 mg twice daily
13. heparin 5000 units twice daily
14. timoptic ophthalmic drops 0.25% one drop left eye twice
daily
15. ursodiol 300 mg orally twice daily
16. regular insulin sliding scale
17. sevelamer 2400 mg three times daily
18. morphine sulfate as needed
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*10 nebs* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*100 cc* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q 72 HOURS ().
Disp:*10 Patch 72HR(s)* Refills:*0*
4. Morphine Sulfate 10 mg/5 mL Solution Sig: 5-10 cc PO Q2H
(every 2 hours) as needed.
Disp:*50 cc* Refills:*0*
5. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.2-0.4 cc PO q2
as needed for agitation, anxiety, tremor.
Disp:*20 cc* Refills:*0*
6. hycosamine Sig: 0.2 ml every six (6) hours as needed for
end stage congestion: Please dispense 1.25mg/ml suspension.
Disp:*2 cc* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 13054**] Hospice/[**Last Name (un) 2646**] Health Services
Discharge Diagnosis:
Primary diagnosis:
Renal failure on hemo dialysis
Secondary diagnosis:
Pancreatitis
Pseudocyst
MRSA bacteremia
Possible MRSA endocarditis
HTN
COPD
Pneumonia
GERD
Type 2 diabetes mellitus
Glaucoma
Discharge Condition:
Prognosis poor
Discharge Instructions:
None
Followup Instructions:
No follow up needed
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**0-0-0**]
|
[
"790.7",
"577.2",
"112.0",
"486",
"584.9",
"440.24",
"285.29",
"428.0",
"560.1",
"250.00",
"458.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"38.95",
"96.08"
] |
icd9pcs
|
[
[
[]
]
] |
9855, 9956
|
5566, 8303
|
275, 339
|
10197, 10213
|
5051, 5543
|
10266, 10407
|
4029, 4047
|
9054, 9832
|
9977, 9977
|
8329, 9031
|
10237, 10243
|
4062, 5032
|
216, 237
|
367, 3000
|
10049, 10176
|
9996, 10028
|
3022, 3597
|
3613, 4013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,325
| 130,040
|
49597
|
Discharge summary
|
report
|
Admission Date: [**2133-1-14**] Discharge Date: [**2133-1-18**]
Date of Birth: [**2070-7-22**] Sex: M
Service: MEDICINE
Allergies:
Insulins
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
need for insulin desensitization
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63yoWM DM, CRI with cr ~ 2.0), insulin-dependant since [**2131**] with
urticaria to insulin over past 6 weeks, transferred from [**Hospital1 3325**] for need for insulin desensitization.
Pt has had chief complaint of generalized urticaria for past 1.5
months. Pt has been on insulin for past year, ~10 months prior
to start of symptoms. His urticaria originated on his buttocks,
was treated initially with prednisone, then two days ago has had
worsening, generalized urticaria on his torso and buttocks, with
1 day of urticaria and rash on his bil upper arms. Patient's
insulin regimen has been lantus 39u [**Hospital1 **] and humalog sliding
scale. It was noted at OSH that 30 mins after administration pt
developed urticaria, noticed by staff. He was treated with
prednisone, benadryl, and iv zantac with moderate response.
There was no airway compromise noted. Endocrinology was
consulted, recommended levemir substitution for lantus with same
reaction noted, no airway compromise. Patient transferred to
[**Hospital1 18**] for insulin desentiziation.
Of note, hospitalist at [**Hospital1 46**] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1528**] [**0-0-**]
page [**Pager number **]) reports no new other new drugs as inciting factor.
Transfer arranged for Dr [**Last Name (STitle) 2603**] and Allergy/ Immunology and
endocrinology to review case tomorrow before desensitization.
There was query as to whether insulin pump covered by insurance
per Dr[**Name (NI) 103739**] request.
Initial endocrine/[**Last Name (un) **] recs from fellow [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **]:
[**Telephone/Fax (1) 103740**] for insulin specific IgE and IgG and protamine
antibodies (would ask pharmacy what all insulin formulations are
available at [**Hospital1 18**]).
Of note, pt recently hospitalized on Cape ~1month ago for
"burning on his spine," got LP, work-up for Lyme's DZ,
reportedly (-).
Upon transfer to floor, vss. ROS notable for decreased UOP over
the past two to three days, in addition to new upper extremity
rash and pruritus. No acute vision changes, headaches, chest
pain, shortness of breath, diarrhea, fevers, systemic illness,
or joint pain.
Past Medical History:
1. TII diabetes mellitus
2. coronary artery disease
3. myocardial infarction, [**2128**] - DESx1?
4. hyperlipidemia
5. hypertension
6. chronic renal insufficiency
7. diverticulitis/diverticulosis - reported bowel perforation in
90s
8. proctitis
9. anemia - unknown cause
10. diastolic dysfunction
11. ulcerative colitis
Social History:
no tobacco use, retired ten years ago, past construction worker,
currently retired. Lives alone. Has had two sexual partners over
past 2 years, female and male, reportedly no receptive
intercourse, all oral sex. Last HIV test 4 years ago, was (-).
STD hx as teenager.
Family History:
notable for heart disease, dm, UC.
Physical Exam:
Vitals: T: 98 BP: 117/73 P: 84 R: 16 99%ra
General: Alert, oriented, no acute distress, walking around room
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: macular rash noted on inferior abd, back (morbiliform
appearing with sandpaper feel upon palpation), multiple on
anterior thighs. No penile lesions noted. No LAD noted.
Pertinent Results:
CXR [**1-15**]: FINDINGS: No previous images. Relatively low lung
volumes most likely account for the prominence of the transverse
diameter of the heart. No vascular congestion or pleural
effusion. No evidence of acute focal
pneumonia.
.
[**2133-1-14**] 10:27PM URINE HOURS-RANDOM UREA N-496 CREAT-37
SODIUM-57
[**2133-1-14**] 10:27PM URINE HOURS-RANDOM
[**2133-1-14**] 10:27PM URINE OSMOLAL-430
[**2133-1-14**] 10:27PM URINE GR HOLD-HOLD
[**2133-1-14**] 10:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2133-1-14**] 10:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2133-1-14**] 10:27PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2133-1-14**] 07:17PM GLUCOSE-365* UREA N-39* CREAT-1.6* SODIUM-133
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-18* ANION GAP-21*
[**2133-1-14**] 07:17PM estGFR-Using this
[**2133-1-14**] 07:17PM ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-204
CK(CPK)-83 ALK PHOS-78 TOT BILI-0.3
[**2133-1-14**] 07:17PM TOT PROT-7.0 ALBUMIN-4.5 GLOBULIN-2.5
CALCIUM-9.7 PHOSPHATE-3.5 MAGNESIUM-2.4
[**2133-1-14**] 07:17PM FREE T4-1.2
[**2133-1-14**] 07:17PM tTG-IgA-3
[**2133-1-14**] 07:17PM WBC-11.3* RBC-4.50* HGB-12.3* HCT-37.9*
MCV-84 MCH-27.4 MCHC-32.5 RDW-15.1
[**2133-1-14**] 07:17PM NEUTS-80.1* LYMPHS-15.1* MONOS-4.5 EOS-0.2
BASOS-0.1
[**2133-1-14**] 07:17PM PLT COUNT-357
<br>
[**2133-1-14**] 7:17 pm SEROLOGY/BLOOD
CHM S# [**Serial Number 103741**]N RPR ADDED 2114 [**2133-1-14**].
**FINAL REPORT [**2133-1-15**]**
RAPID PLASMA REAGIN TEST (Final [**2133-1-15**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Brief Hospital Course:
63 yo M IDDM, cad, cri transferred from OSH with 1.5 months of
urticaria, likely from insulin preparations, admitted to [**Hospital Unit Name 153**]
for allergy and endocrine consultation for insulin
desensitization. Currently having recurrent uticaria on floor,
mild, treated with prn benadryl, on scheduled H2 blockers. No
sx of uticaria for 24h at time of d/c - doing well with novolog
SSI - seen by [**Last Name (un) 387**] again at time of d/c with recs to cont SSI
with novolog and start qhs lantus 12u and d/c glyburide. This
plan was d/w with Dr. [**Last Name (STitle) **] - was ok with plan will pt will have
close f/u with AI (Dr. [**Last Name (STitle) **] this next week and [**Hospital **] clinic,
pt given instructions to make appointments as such.
<br>
#) HIVES/UTICARIA
Although transfer for desensitization, given pt had been on
insulin for >10 months prior to symptoms (even though reports
suggest clinical signs worsen after administration of insulin),
differential should be expanded to include medication effects,
infectious cause, or vasculitiditis.
His lisinopril was started >1yr prior and now discontinued
initially [**12-29**] to concern as cause, kept off with SBPs in 90-100s
(though ASx). He has been on metoprolol for years, as well as
asacol for his UC. He completed a 21d course of doxycycline in
[**Month (only) 1096**] for a tick-borne illness, even though serologies were
negative as per patient.
-*****Insulin Ab pending, C1 esterase pending at time of d/c -
PCP/Dr. [**Last Name (STitle) **]/[**Last Name (un) **] provider all to please follow-up on results
-D/W Dr. [**Last Name (STitle) **] from AI - plan to d/c H2 blockers, only to use
prn benedryl if hives re-start - no monoleukast, no steroids,
and now d/c H2 blockers
-plan as d/w Dr. [**Last Name (STitle) **] to hold of further skin testing for now
as tolerating novolog and as present will not requiring
desensitization
<br>
# hyperglycemia/insulin desensitization: BS better controlled
now, intially with +ketones in serum at OSH. Will need to
control glucoses, despite risk for further allergic reactions,
at least with modest glucose parameter goals of <250.
- novolin ss post iv benadryl to maintain glucoses <250 o/n
along with glyburide 10 mg [**Hospital1 **]
- he has doses of novolin off benadryl with good effect
- diabetic diet
- patient strongly educated about the need for exercise
- greatly appreciate Dr.[**Last Name (STitle) 20017**] recommendations:
- d/c po hypoglycemics (glyburide) at this time AND start Lantus
12u qhs with cont NOVOLOG SSI (not humolog)
<br>
# cad/htn: had been on lisinopril as outpt- held [**12-29**] to renal
failure per patient.
- continue plavix
- discontinued lisinopril, though pt stating baseline Cr around
1.5/1.6 - no records available to confirm, however main point is
pts SBPs in 90-100s at time of d/c and would not re-start
lisinopril based on this point **** will need PCP to [**Name Initial (PRE) **]/u on
this.
- for same reason, holding beta blockade for now
<br>
# CKD, stage III: appears around baseline - no prior to compare,
at current level wouldn't recommend metformin. Per pt, followed
by outside nephrologist.
- renally dose medications
- avoid nephrotoxins
- calcitriol 0.5 mcg qd
- holding ace-i for reasons above for now - plan to restart once
more room available per blood pressures
<br>
# hyperlipidemia: cont crestor
<br>
# diverticulitis/UC: continue asacol 3000mg tid/folic acid 1 mg
qd
- hydrocort enemas prn
- continue vitamin B12 supplementation.
- pt requesting 1 tab percocet as uses prn for pain - having
mild pain at time of d/c - gave 10 tabs
<br>
# FEN: diabetic diet
# ppx: sq heparin here, ppi as o/p
# access: peripherals
# code: full
#dispo: d/c to home today as not having further uticaria - d/w
Dr. [**Last Name (STitle) **] and [**Last Name (un) **] Attending - plan as detailed above - both
to f/u with pt within 1 week
<br>
# communication: Patient
Medications on Admission:
1. fluticasone spray qam
2. crestor 40mg qd
3. ascorbic acid 500mg qd
4. calcitriol 0.25mcg [**Hospital1 **]
5. plavix 75mg qd
6. cyanocobalamin 1000mcg qam
7. fexofenadine 60mg qd
8. folic acid 1mg qd
9. metoprolol xl 50mg qd
10. pantoprazole 40mg qd
11. prednisone (has taken 20mg to 40mg for small "flares" over
past month, total of about 10 days). He has taken prednisone in
past for UC, last flare 8 months ago.
13. enoxaparin 40mg qd (on typed med list)
14. levemir 39u [**Hospital1 **]
15. diphenhydramine prn
16. doxepin 25-50mg qhs prn
17. percocet prn
(at home meds also included lisinopril 5mg qd, hydrocort enemas
prn, humalog, asacol 3000 tid)
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
[**Hospital1 **] (2 times a day) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 12 units
Subcutaneous at bedtime.
Disp:*qs 12 units* Refills:*2*
11. Novolog 100 unit/mL Cartridge Sig: One (1) sliding scale
Subcutaneous qac and qhs: ****PLEASE USE PER SLIDING SCALE
PRINTED OUT FOR YOU AT THE TIME OF YOUR DISCHARGE - (ATTACHED TO
YOUR INSTRUCTIONS).
Disp:*QS QS* Refills:*2*
12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO Q4H PRN as
needed for allergy symptoms: only take as needed for hives - you
should call your provider if this situation is required.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
# Uticaria - presumed most likely due to humolog insulin taken
prior
# Diabetes
# CAD
# HTN
# Chronic Kidney Disease
# Hyperlipidemia
# Ulcerative Colitis
Discharge Condition:
good
Discharge Instructions:
Your diagnoses as below - main reason for admission was for your
hives (uticaria) with reason most likely due to your humolog
(not confirmed). Since you were tolerating the novolog at time
of d/c - plan will be to continue taking as needed per your
sliding scale prescribed - AND starting lantus 12units every
night.
<br>
If you start re-developing any hives, new sob - please call your
provider (if new and worsening shortness of breath - best to go
straight to an emergency facility). If you get new hives, you
will be prescribed today benadryl 25mg to be taken ONLY AS
NEEDED for this - no further medications required at this point
- further per instructions of your provider.
<br>
Note your lisinopril will be held till re-evaluated by your
provider as your blood pressure was in lower range at time of
discharge. Also by adding lantus the diabetic doctors
recommended [**Name5 (PTitle) **] STOPPING your glyburide.
Followup Instructions:
1. Please call and make an appointment with your PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 70948**] to be seen in the next 1-2 weeks.
<br>
****2. Call tomorrow to make an appointment with the [**Hospital **]
clinic to be seen within 1 week (bring your blood sugar log)
(provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4379**] or Dr. [**First Name (STitle) **] - [**Telephone/Fax (1) 2384**] or
[**Telephone/Fax (1) 103742**].
<br>
****3. Call tomorrow to make an appointment with your
allergist, Dr. [**Last Name (STitle) **], to be seen within 1 week. [**Telephone/Fax (1) 9316**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2133-1-18**]
|
[
"429.9",
"250.00",
"708.0",
"585.3",
"562.10",
"V58.67",
"556.9",
"285.9",
"E932.3",
"412",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11788, 11794
|
5674, 9625
|
302, 308
|
11993, 12000
|
3950, 5651
|
12974, 13779
|
3186, 3222
|
10333, 11765
|
11815, 11972
|
9651, 10310
|
12024, 12951
|
3237, 3931
|
230, 264
|
336, 2541
|
2563, 2885
|
2901, 3170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 135,926
|
2544
|
Discharge summary
|
report
|
Admission Date: [**2126-1-21**] Discharge Date: [**2126-1-26**]
Date of Birth: [**2044-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 82 yom with hx of ESRD on HD, Atrial
Fibrillation/Flutter, C.diff, CVA x 2, CAD s/p MI, diastolic
CHF, hx of Klebsiella urosepsis, MDR E.Coli Sepsis, MRSA Sepsis
who presents with one day of nausea, vomiting and weakness.
Patient went to lunch today with his wife and began to feel
weak, +lightheadedness. He then had nausea with one episode of
non-bloody emesis, no coffee ground. He reports 3 episodes of
diarrhea since that time, non-bloody, no melena. He denies any
recent fevers, chills, chest pain, SOB, abdmominal pain,
dysuria, hematuria, urinary frequency or back pain. he does
report abdominal cramping with his diarrhea today. Wife became
worried at the restaurant and called EMS. He was taken to [**Hospital 12914**] hospital and BPs noted to be in 70s and 80s. He was given
1.5L of IVF, CTX 1gm IV x 1, Vanco 1gm IV x 1 and transferred
here.
In the ED: Temp 98.6, BP 117/68, HR 90, RR 16, 98% RA. Labs
sent and lactate noted to be elevated at 4.1. He was given 3.5
L of NS IVF in the ED, along with Zosyn 4.5mg IV x 1, Zofran 4mg
IV x 1 and transferred to the ICU for further care.
Past Medical History:
-Stage V CKD on HD with h/o nephrolithiasis w/ stent and
nephrostomy tube (AV fistula [**7-27**])
-Atrial fibrillation/flutter not on coumadin
-h/o GI bleed, diverticulitis
-C. Diff colitis
-CVA [**28**] years ago w/ right-sided weakness; second CVA 5 years
ago
-CAD s/p MI, diastolic HF EF 60%
-sleep apnea not on cpap
-klebsiella(ESBL) urosepsis
-depression
-PFTs [**2117**] with mild restrictive ventilatory defect
-Anemia with h/o iron deficiency
Social History:
Lives with wife [**Name (NI) **], h/o smoking [**12-21**] PPD for 50 years, quit
20 years ago, does not drink alcohol, no drugs.
Family History:
non-contributory
Physical Exam:
Vitals: T: 95.7 BP: 98/57 P: 102 R: 18 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx dry
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes, Left IJ HD catheter with no erythema/exudate at
insertion site, no TTP of inserstion site
Pertinent Results:
[**2126-1-21**] 09:54PM BLOOD WBC-22.2*# RBC-5.91# Hgb-16.9# Hct-53.9*#
MCV-91 MCH-28.6 MCHC-31.4 RDW-19.5* Plt Ct-208
[**2126-1-22**] 03:25AM BLOOD WBC-18.6* RBC-4.64 Hgb-13.8*# Hct-41.9#
MCV-90 MCH-29.7 MCHC-32.9 RDW-19.6* Plt Ct-162
[**2126-1-23**] 04:26AM BLOOD WBC-7.6# RBC-3.96* Hgb-11.2* Hct-35.6*
MCV-90 MCH-28.3 MCHC-31.5 RDW-18.7* Plt Ct-133*
[**2126-1-24**] 08:01AM BLOOD WBC-6.3 RBC-4.10* Hgb-11.8* Hct-37.2*
MCV-91 MCH-28.8 MCHC-31.8 RDW-19.2* Plt Ct-139*
[**2126-1-21**] 09:54PM BLOOD PT-16.0* PTT-26.1 INR(PT)-1.4*
[**2126-1-24**] 08:01AM BLOOD PT-14.4* PTT-30.2 INR(PT)-1.3*
[**2126-1-21**] 09:54PM BLOOD Glucose-149* UreaN-33* Creat-4.7*# Na-144
K-4.6 Cl-101 HCO3-23 AnGap-25*
[**2126-1-24**] 08:01AM BLOOD Glucose-84 UreaN-24* Creat-3.8* Na-141
K-4.2 Cl-106 HCO3-28 AnGap-11
[**2126-1-22**] 03:25AM BLOOD ALT-13 AST-23 CK(CPK)-25* AlkPhos-89
Amylase-136* TotBili-0.5
[**2126-1-22**] 03:25AM BLOOD CK-MB-6 cTropnT-0.05*
[**2126-1-23**] 04:26AM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-1-22**] 03:25AM BLOOD Calcium-7.9* Phos-5.7*# Mg-1.6
[**2126-1-24**] 08:01AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.5*
CXR [**2126-1-21**]:
FINDINGS: As compared to the previous radiograph, the old
central venous
access line has been removed, there is a new double-lumen
catheter inserted via the left internal jugular vein and
projecting with its tip against the lateral wall of the superior
vena cava. The lung volumes are low, there is a small
retrocardiac atelectasis, but no evidence of focal parenchymal
opacity suggestive of pneumonia. No evidence of overhydration.
Mild aortic tortuosity.
EKG: irregular rate and rhythm, no acute ST or T wave changes
.
[**2126-1-24**] 5:18 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2126-1-24**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-1-24**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative
.
[**2126-1-23**] 3:46 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
.
[**2126-1-22**] 2:04 am URINE Source: Catheter.
**FINAL REPORT [**2126-1-23**]**
URINE CULTURE (Final [**2126-1-23**]):
YEAST. >100,000 ORGANISMS/ML.
.
[**2126-1-21**] 10:44 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2126-1-25**]**
FECAL CULTURE (Final [**2126-1-25**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2126-1-24**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-1-22**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Brief Hospital Course:
82 yom with history of ESRD on HD, Atrial Fibrillation/Flutter,
C.diff, CVA x 2, CAD s/p MI, diastolic CHF, hx of Klebsiella
urosepsis, MDR E.Coli Sepsis, MRSA Sepsis who presented to the
hospital with one day of nausea, vomiting and weakness.
.
# Viral Gastroenteritis: Mr. [**Known lastname 12731**] presented with symptoms of
nausea, vomiting, weakness and diarrhea which are all consistent
with a viral gastroenteritis. Symptoms resolved within 1 day.
Concern initially was for sepsis as he presented with SBP in the
80s and leukocytosis to 22. He was initially treated with
Vanco/Zosyn which was then changed to Linezolid/Meropenem based
on previous culture data. The patient remained afebrile and
blood pressures remained stable. Blood cultures show no growth
to date. Stool cultures sent and also show no growth to date.
C.diff was negative. Urine culture showed yeast and foley was
[**Known lastname 8910**]. ID was consulted given significant history of
bactermias and resistant organisms. Linezolid and Meropenem
were continued for two days and then [**Known lastname 8910**] as no source
of bacterial infection was found. Patient has now remained
afebrile off of antibiotics and is ready to be discharged home.
Of note, patient had Guaiac positive stools while in the
hospital and HCT remained stable. Patient will need to follow
up with Gastroenterology as an outpatient for further workup.
.
# ESRD on HD: Patient was continued on his T/Th/Sat dialysis.
.
# COPD: cont home spiriva, atrovent.
.
# Atrial Fibrillation: Patient with history of atrial
fibrillation on on anticoagulation. He was admitted with atrial
fibrillation which was thought secondary to infection. Cardiac
enzymes were done and were negative.
.
# Depression: patient was continued on her home Fluoxetine
.
Medications on Admission:
Home Medications:
Tiotropium Bromide 18 mcg Capsule daily
Pantoprazole 40mg daily
Aspirin 325mg daily
Fluoxetine 10 mg daily
Multivitamin
B Complex-Vitamin C-Folic Acid 1 mg Capsule
Atrovent MDI 1 puff q4h PRN
Bisacodyl 5mg PRN
Docusate 100mg [**Hospital1 **]
Fish Oil
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
Viral Gastroenteritis
Hypotension
Discharge Condition:
Afebrile, BP stable
Discharge Instructions:
You were admitted with nausea, vomiting and weakness and were
found to have a low blood pressure. You were treated with fluids
with improvement. You had blood, urine and stool cultures sent
which showed no evidence of infection. You were treated with
antibiotics which have no been stopped as all of your cultures
have been negative. Your blood pressure has remained stable and
you have been without fever.
.
While you were here you were found to have blood in your stools.
Your blood counts have remained stable. It is important that you
follow up with Gastroenterology for further workup of this
bleeding.
.
It is very important that you return to the ER if you develop
fever, nausea, vomiting or weakness. Please also return if you
notice blood in your stools. You should return for any symptoms
that concern you.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week.
Please call [**Telephone/Fax (1) 1579**] to schedule an appointment.
.
Please follow up with Gastroenterology for evaluation of your
guaiac positive stools. Please call ([**Telephone/Fax (1) 451**] to schedule an
appointment.
.
Please continue your hemodialysis as scheduled.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"438.89",
"427.32",
"458.9",
"008.8",
"585.6",
"428.23",
"780.57",
"496",
"311",
"427.31",
"280.9",
"412",
"428.0",
"403.91",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8560, 8579
|
5490, 7296
|
328, 334
|
8666, 8688
|
2780, 4798
|
9553, 10031
|
2118, 2137
|
7615, 8537
|
8600, 8645
|
7322, 7322
|
8712, 9530
|
2152, 2761
|
7340, 7592
|
4832, 5467
|
280, 290
|
362, 1479
|
1501, 1954
|
1970, 2102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,244
| 183,783
|
4247
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 18458**]
Admission Date: [**2133-9-8**]
Discharge Date: [**2133-9-10**]
Date of Birth: [**2064-8-27**]
Sex: F
Service: VSU
CHIEF COMPLAINT: Thoracoabdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old female who
was transferred from [**Hospital 8**] Hospital with a known TAA who
presented with a heart rate in the 40s, blood pressures in
the 70s. A CT was done which showed fusiform TAA with
contained rupture at the SMA. Creatinine was elevated at
1.9, baseline 0.9. The patient denied any symptoms. The
patient was transferred here for further treatment and
evaluation.
PAST MEDICAL HISTORY: COPD O2 dependent, pulmonary
hypertension with a pulmonary artery pressure of 77, steroid
dependent COPD, current tobacco user, history of coronary
artery disease status post myocardial infarction, history of
transitional cell renal cell carcinoma status post left
nephrectomy, history of spinal canal surgery status post
lumbar surgery, history of GERD, history of depression,
history of steroid myopathy, history of anal squamous cell
carcinoma status post chemotherapy and radiation, history of
type 2 diabetes controlled, history of carotid disease status
post left CEA, status post total abdominal hysterectomy.
Aortic aneurysm, carotid stenosis status post left carotid
endarterectomy, osteoarthritis status post right hip
replacement, squamous cell carcinoma anal status post
radiation and chemotherapy, status post transitional cell
carcinoma status post left nephrectomy radical. History of
COPD with pulmonary hypertension, O2 dependent, steroid
dependent. Right middle lobe pulmonary nodule. Current
smoker. Type 2 diabetes noninsulin-dependent controlled.
History of spinal canal stenosis status post lumbar surgery.
History of GERD. History of coronary artery disease status
post myocardial infarction. History of steroid myopathy.
History of pulmonary hypertension. Status post total
abdominal hysterectomy, status post appendectomy.
MEDICATIONS: On admission Lipitor 10 mg daily, sertraline
100 mg daily, tizanidine 4 mg q.i.d., Spirolactone 25 mg
daily, Toprol XL 50 mg daily, lisinopril 10 mg daily,
magnesium oxide 400 mg daily, Protonix 40 mg daily, Plavix 75
mg daily, Mirapex 0.125 mg t.i.d., gabapentin 300 mg in the
a.m. and afternoon and 600 mg at bedtime, trazodone 300 mg at
h.s., calcium 600 mg t.i.d., aspirin 325 mg daily, Advair
[**5-/2076**] 1 puff b.i.d., DuoNeb treatments 4 times a day.
SOCIAL HISTORY: Current smoker of a pack per day. The
patient lives alone.
PHYSICAL EXAMINATION: Vital signs: Pulse 59, respirations
17, O2 sat 91% on 6 liters nasal cannula, blood pressure
154/76. General appearance: In no acute distress; oriented
x3. Heart is regular rate and rhythm without murmur, gallop
or rub. Breath sounds are diminished at the bases
bilaterally. Abdomen is soft, nontender and nondistended. A
well-healed left flank incision. Abdominal aorta not
prominent. Pulse exam shows palpable femoral and pedal
pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit. CT surgery was requested to see the patient. The
patient underwent CT chest, abdomen and pelvis with
reconstruction and 3-D imaging. The chest portion showed
extensive emphysema changes throughout both lungs. There was
an 8.2 x 6.7 mm nodular density in the right upper lobe.
There is atelectasis present in the base. There were several
large intrathoracic mediastinal nodes. There were several
scattered sub centimeter mediastinal lymph nodes. CT of the
abdomen with and without contrast revealed the left kidney
was absent. There is free fluid in the upper abdomen
surrounding liver and spleen. The pancreas is atrophic. The
right renal gland and right renal kidney appear unremarkable.
The pelvis CT with and without contrast revealed streaked
artifacts and bilateral hip replacements. Diverticular
disease in the sigmoid colon without evidence of
diverticulitis. There is no significant pelvic
lymphadenopathy. Musculoskeletal shows degenerative changes
present in the lumbar spine as well as a well defined
sclerotic focus in the left iliac bone most likely a bone
island. CT of the abdomen with extensive atherosclerotic
disease of the aorta and its branches. The right and left
coronary arteries arise from a normal expected anatomical
location. The descending aorta at the level of the right
main pulmonary artery is 38 x 38 mm. There is extensive
concentric noncalcification plaque present in the descending
thoracic and abdominal aortas. There are multiple ulcerative
plaques throughout the entire course of the descending aorta.
The descending aorta at the level of the left inferior
pulmonary vein measures 42.2 x 37.4 mm. The abdominal aorta
in the upper abdomen above the celiac access measures 37.3 x
49.3 mm. The celiac access, superior mesenteric artery are
widely patent. Inferior mesenteric artery was not clear to
visualize. There is an abdominal aortic aneurysm that
measures 63.5 x 65.1 mm in maximum transverse diameter.
There is a 24 x 24.6 mm right common iliac aneurysm which
contains concentric mural thrombus. CT surgery was consulted
after review of the CT scan. In discussion with Dr. [**Last Name (STitle) 1391**]
and CT surgery Dr. __________ it was determined the patient
was not a surgical candidate because of extensive medical
problems, respiratory problems. The patient was made DNR,
DNI. Blood pressure medications were adjusted to stabilize
blood pressure. The patient was transferred out of the ICU
to the regular nursing floor on [**2133-9-9**]. The patient was
discharged to home with well controlled blood pressure
without any symptoms. The patient's creatinine at discharge
was 1.1. The patient should follow up with the primary care
physician for continued blood pressure monitoring and blood
pressure medication adjustment. She should call primary care
if she develops any chest, back, abdominal pain or near
syncopal episodes.
DISCHARGE DIAGNOSES:
1. Thoracoabdominal aneurysm.
2. History of chronic obstructive pulmonary disease, O2
dependent, steroid dependent.
3. History of coronary artery disease status post
myocardial infarction.
4. History of pulmonary hypertension secondary to chronic
obstructive pulmonary disease.
5. History of transitional cell renal cell carcinoma status
post radical nephrectomy.
6. History of spinal canal stenosis status post lumbar
surgery.
7. History of gastroesophageal reflux disease.
8. History of depression.
9. History of steroid myopathy.
10.History of carotid stenosis status post left carotid
endarterectomy.
11.History of squamous cell anal cancer status post
chemotherapy and radiation therapy.
12.Status post total abdominal hysterectomy.
13.Status post appendectomy.
14.History of hypertension.
15.History of type 2 diabetes noninsulin-dependent,
controlled.
16.History of osteoarthritis status post bilateral total
hip replacements.
DISCHARGE MEDICATIONS: Fluticasone Solu-Medrol 250/50 mcg
disk b.i.d., tiotropium bromide 18 mcg capsule with
inhalation device daily, __________ 10 mg daily, sertraline
100 mg daily, trazodone 300 mg at bedtime, propofol sustained
release 50 mg daily, prednisone 10 mg daily, gabapentin 300
mg b.i.d., gabapentin 600 mg at bedtime, lisinopril 20 mg
daily, spirolactone 25 mg daily, hydralazine 20 mg q.6 h,
Ativan 0.5 mg tablets q.8 h p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2133-9-10**] 08:56:47
T: [**2133-9-10**] 10:05:24
Job#: [**Job Number 18459**]
|
[
"V58.65",
"305.1",
"412",
"V43.64",
"359.4",
"250.00",
"V10.06",
"V10.52",
"E932.0",
"530.81",
"441.7",
"492.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6054, 7025
|
7049, 7741
|
3074, 6033
|
2596, 3056
|
178, 213
|
242, 641
|
664, 2495
|
2512, 2573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,072
| 160,953
|
11794
|
Discharge summary
|
report
|
Admission Date: [**2200-5-27**] Discharge Date: [**2200-6-2**]
Date of Birth: [**2172-9-19**] Sex: M
Service:
PRINCIPAL DIAGNOSIS: Major depressive disorder with
psychotic features.
DISCHARGE CONDITION: Stable.
HISTORY OF PRESENT ILLNESS: [**Known firstname 11805**] [**Known lastname 3234**] is a 27 year old
right hand male transferred from the Medicine Department to
the Epilepsy Service for evaluation of paroxysmal events and
unresponsiveness. He presented on [**5-27**], after becoming
unresponsive at work. He was in his usual good health until
then and told co-workers that he was going to "go down" and
then appeared to pass out. He collapsed to the ground, and
did not suffer any trauma as he was aided immediately by his
friends. Emergency medical services was called and found him
unresponsive at the scene. Finger stick was 87. He was
given Naloxone without improvement. Electrocardiogram showed
a normal sinus rhythm. His vital signs were otherwise
unrevealing. There was no incontinence, tongue-biting or
shaking associated with the event. He was transferred to the
Medical Intensive Care Unit at [**Hospital6 2018**] where head computerized tomography scan, toxicology
screen, electrocardiogram, transthoracic echocardiogram,
chest x-ray, magnetic resonance imaging scan of the brain and
electroencephalogram had been normal. He awoke briefly and
told the residents in the Medicine Intensive Care Unit that
he recalls feeling lightheaded and that "something was not
right." He then became unresponsive again.
On [**5-30**], he was transferred to the [**Hospital1 **] Epilepsy Service.
Longterm electroencephalogram monitoring while the patient
was unresponsive was entirely normal. A review of his past
medical history revealed a similar episode approximately two
months prior to admission precipitated by financial
difficulty. He was placed briefly on Dilantin while on LTM
monitoring. However, Dilantin was discontinued after LTM
revealed normal activity. Psychiatry consult was called and
Mr. [**Known lastname 3234**] was started on Zoloft and Risperdal.
He was discharged on [**6-27**] and was to follow up with
Psychiatry as an outpatient. Discharge condition was
responsive, improved relative to admission.
DISCHARGE MEDICATIONS:
1. Zoloft
2. Risperdal
DISCHARGE FOLLOW UP: Psychiatry as scheduled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37274**], M.D. [**MD Number(1) 37275**]
Dictated By:[**Name8 (MD) 22618**]
MEDQUIST36
D: [**2200-9-24**] 17:41
T: [**2200-9-24**] 20:07
JOB#: [**Job Number 37276**]
|
[
"780.09",
"592.0",
"427.31",
"311",
"349.0",
"780.2",
"275.3",
"E879.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"88.41",
"03.31",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
226, 235
|
2298, 2334
|
2346, 2640
|
264, 2275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,158
| 131,180
|
6521
|
Discharge summary
|
report
|
Admission Date: [**2153-1-15**] Discharge Date: [**2153-1-20**]
Date of Birth: [**2076-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2153-1-15**]
1. Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna Ease
aortic valve bioprosthesis, model number 3300TFX, serial number
[**Serial Number 25009**].
2. Coronary artery bypass grafting x2 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the aorta to the first diagonal
coronary artery.
History of Present Illness:
76 year old male with severe aortic stenosis who has been
followed by Dr. [**Last Name (STitle) **]. An echo over the summer demonstrated
severe aortic stenosis. Since the summer he has noted almost
nightly PND and chest pressure. He goes to sleep without a
problem, usually with only one pillow, and then wakes up with
chest pressure. He then sleeps the rest of the night in a chair.
He also notes occasional lightheadedness when he stands up to
quickly or with bending over. He occasionally feels "fluttering"
in his chest which last a moment. [**Name2 (NI) **] was referred for a cardiac
catheterization to further evaluate. He is now being referred to
cardiac surgery for an aortic valve replacement and
revascularization.
Past Medical History:
Severe Aortic Stenosis
Hypertension
GERD
Dyslipidemia
Type 2 Diabetes Mellitus
Precancerous lesion on scalp
Kidney Stones s/p Lithotripsy
Peptic Ulcer Disease 40 years ago
Social History:
Last Dental Exam:6 months ago, patient was given fax number and
will have dentist fax clearance
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone# [**Telephone/Fax (1) 25010**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx:smoked a few years in his
20's
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-9**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Father with "heart disease"
but unclear to what extent. Father was living in [**Country 5881**] at the
time and the patient does not know any details.
Physical Exam:
Pulse:63 Resp:14 O2 sat:100/RA
B/P Right:158/75 Left:160/78
Height:5'6" Weight:178 lbs
General: awake, alert, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _III_
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Discharge Exam:
VS: T: 98.5 HR: 60-70 SR BP: 116-131/70 Sats: 94% RA
General: 76 year-old male in no apparent distress
Card: RRR normal S1,S2
Resp: diminished breath sounds throughout otherwise clear
GI: benign
Extr: warm RLE trace edema, left none
Incision: sternal no erythema, discharge or sternal click, RLE
VV site clean dry intact
Neuro: awake, alert oriented, ambulates with rolling walker
Pertinent Results:
[**2153-1-15**] Echo: Prebypass: No spontaneous echo contrast is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. 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.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate
([**12-4**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**12-4**]+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results on [**2153-1-15**] at
900 am.
Postbypass: The patient is in sinus rhythm on low dose
phenylephrine infusion. There is a well seated bioprosthetic
valve in the aortic position. There is no AI. The peak and mean
gradients across the valve are 18mmHg & 7mmHg, respectively. The
biventricular function is maintained. The remaining valves are
unchanged. The aorta remains intact.
.
[**2153-1-18**] Chest X-ray: The patient is status post median
sternotomy, coronary bypass surgery and aortic valve replacement
procedure. Cardiomediastinal contours are within normal limits.
Improving atelectasis and effusion at left lung base. Right lung
and pleural surfaces are clear except for minimal linear
atelectasis at the right base. Small air-fluid level is present
in the retrosternal region. It may reflect a small anterior
loculated hydropneumothorax or postoperative changes in the
retrosternal region related to recent sternotomy.
.
[**2153-1-20**] WBC-8.3 RBC-3.19* Hgb-10.0* Hct-29.3 Plt Ct-225#
[**2153-1-15**] WBC-7.1# RBC-3.70*# Hgb-11.7*# Hct-33.1 Plt Ct-226
[**2153-1-20**] UreaN-34* Creat-1.1 Na-142 K-4.3 Cl-101
[**2153-1-15**] UreaN-20 Creat-0.8 Na-142 K-4.4 Cl-111* HCO3-24
AnGap-11
[**2153-1-20**] Mg-2.5
Micro: [**2153-1-15**] MRSA SCREEN (Final [**2153-1-17**]): No MRSA
isolated.
Brief Hospital Course:
Mr. [**Known lastname 25011**] was a same day admit and on [**1-15**] was brought to the
operating room where he underwent an aortic valve replacement
and coronary artery bypass graft x 2. Please see operative note
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on
beta-blockers and diuretics and diuresed towards his pre-op
weight. Chest tubes and epicardial pacing wires were removed per
protocol. On post-op day two he was transferred to the step-down
floor for further care. He worked with physical therapy for
assistance with strength and mobility. He continued to make good
progress and on post-op day 5 he was discharged home with
[**Hospital 119**] Homecare services [**Telephone/Fax (1) 13046**] and the appropriate
medications and follow-up appointments.
Medications on Admission:
CAPTOPRIL 50 mg [**Hospital1 **]
GLIPIZIDE 10 mg [**Hospital1 **]
METFORMIN 500 mg Tablet - 2 Tablets by mouth in AM and 1 in PM
SIMVASTATIN 40 mg daily
ASPIRIN 81 mg daily
DOCUSATE SODIUM 100mg daily
PRILOSEC 20 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain/fever.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. metformin 500 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
13. captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Stenosis and Coronary artery disease s/p Aortic valve
replacement and coronary artery bypass graft
Past medical history:
Hypertension
GERD
Dyslipidemia
Type 2 Diabetes Mellitus
Precancerous lesion on scalp
Kidney Stones s/p Lithotripsy
Peptic Ulcer Disease 40 years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check: [**Hospital Unit Name **] [**Last Name (NamePattern1) **], [**Hospital Unit Name **] on [**2153-1-30**]
at 10AM
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2153-2-5**] at 1PM [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2153-2-19**] at 3:20PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**] in [**3-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2153-1-20**]
|
[
"396.2",
"285.9",
"V15.82",
"414.01",
"564.00",
"401.9",
"530.81",
"458.29",
"518.51",
"272.4",
"250.00",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"96.71",
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8186, 8244
|
5615, 6573
|
323, 714
|
8564, 8803
|
3400, 5592
|
9572, 10362
|
2084, 2271
|
6846, 8163
|
8265, 8371
|
6599, 6823
|
8827, 9549
|
2286, 2981
|
2997, 3381
|
269, 285
|
742, 1470
|
8393, 8543
|
1681, 2068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,709
| 193,063
|
26682+57510
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-4-30**] Discharge Date: [**2194-5-3**]
Date of Birth: [**2154-1-4**] Sex: M
Service: MEDICINE
Allergies:
Glucophage / vancomycin
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Diabetic ketoacidosis, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 32713**] is a 40M with a history of HIV (CD4 870, on HAART),
HCV (untreated), type I diabetes who presents with nausea and
vomiting, found to be in DKA. He states that about 3pm on the
day of presentation he started to feel dehydrated and nauseous.
He vomited non-bilious non-bloody material. He walked to CVS to
buy something to drink, about 3 blocks away, and had to stop
several times due to fatigue and lightheadedness. He felt
unsteady on his feet and had a pre-syncopal episode with chills,
lightheadedness, and shortness of breath. On returning home he
again felt nauseous and vomited again. He then called EMS for
hospital transfer. During the day he ate 2 glucernas and [**First Name8 (NamePattern2) **]
[**Location (un) 2452**] and drank copious amounts of water.
He notes that he has not checked a fingerstick blood sugar in a
couple of days. He gave himself 2 insulin injections with
Humalog yesterday, although he does not recall how many units.
He states that he uses his sliding scale, but he does not check
his fingersticks so it is not clear how he determines how much
insulin to use. He states simply that he "knew it would be
high". He did not use Lantus the night prior to presentation,
but thinks he may have the night before that. He does not use
Lantus every night, and uses Humalog 1-2 times daily. His last
insulin injection was just over 24 hours prior to presentation.
Prior to presentation the patient does not recall any other
change in his health. He denies fever, cough, wheezing,
nausea/vomiting, (prior to day of presentation), diarrhea, skin
changes, or any other problems. [**Name (NI) **] does note that a week prior
to presentation he sprained his ankle while moving and had some
muscle cramps.
Of note, the patient had a recent admission in early [**Month (only) 547**] for
DKA and on previous occasions at clinic visits was noted to have
hyperglycemia > 500. These episodes appear to be secondary to
insulin non-compliance.
In the ED, initial vitals were 121, 102/60, 21, 100% RA with
FSBS critically high. He received 2L NS, the 2nd liter with 40
mEq of KCl. He was bolused 7 units insulin (0.1 unit/kg) and
started on insulin gtt at 7 units/hr. Per report at 2300 his
FSBS was 249, however this is not documented and chemistry at
2340 showed glucose of 655. He also received Zofran 4mg for
nausea.
On arrival to CCU, the patient complains of gastric discomfort
("hunger pains") and thirst, no other complaints. He is
breathing comfortably on room air.
Past Medical History:
- HIV: Diagnosed in [**2183**]. Started treatment [**2189**], now on Truvada
and Sustiva. No history of OIs. CD4 870 1/[**2193**].
- HCV. Diagnosed in [**9-8**]. Not being treated. Baseline LFTs 100s
- Diabetes Mellitus Type 1. Diagnosed in [**2179**]. Poorly controlled
with most recent A1C of 13.0% on [**2194-4-5**]. Followed by Dr.
[**Last Name (STitle) **] at [**Last Name (un) **]. Multiple prior hospitalization for DKA.
- CKD. Baseline creatinine of 1.6-1.9. Assumed to be diabetic
nephropathy.
- h/o MRSA cellulitis. Multiple prior infections, hospitalized
previously at [**Hospital3 **].
- Left posterior cervical lymph node biopsy in [**2185**]. Negative
work-up.
- Intramuscular lipoma on back. Resected in [**2187**].
Social History:
Lives alone in an apartment in [**Location (un) 686**].
- Tobacco: None
- Alcohol: Rare
- Illicits: None current (former drug user)
Family History:
Both parents still living and in fairly good health. Grandfather
had a stroke.
Physical Exam:
Physical Exam on Admission:
Vitals: afebrile 115/74 122 15 99% RA weight 68 FSBS
critical high
General: Alert, oriented, no acute distress. Odd affect but
cooperative with exam.
HEENT: Sclera anicteric, slightly dry MM, oropharynx clear,
EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, mildly tender to palpation, non-distended, bowel
sounds hypoactive but present, no organomegaly
Ext: warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII tested and intact. Strength exam deferred.
Gait not tested. No gross deficits.
.
Discharge physical exam:
Vitals: Tmax 99.0 Tc 97.9 BP 124/84 (115-130/72-88) HR 88 RR 18
O2 Sat 100% on RA
FSBG 233, 222, 401 (this AM)
General: Well-appearing patient, engaged in coversation, in NAD
HEENT: Left pupil dilated when compared with the right pupil.
Both pupils round. Tonuge midline. MMM. OP without erythema,
exudate, or ulcerations.
CV: RRR. No M/R/G.
Lungs: Clear to auscultation bilaterally. No crackles of
wheezes. Nml work of breathing, no accessory muscle use.
Abdomen: NABS+. Soft. NT/ND.
Ext: WWP. 2+ DPs bilaterally. No clubbing, cyanosis, or pitting
edema
Pertinent Results:
Admission labs:
[**2194-4-30**] 08:37PM BLOOD WBC-10.6 RBC-5.07 Hgb-15.7 Hct-49.1
MCV-97 MCH-31.0 MCHC-32.0 RDW-12.5 Plt Ct-231
[**2194-4-30**] 08:37PM BLOOD Neuts-79.6* Lymphs-16.7* Monos-3.0 Eos-0
Baso-0.7
[**2194-4-30**] 08:37PM BLOOD Glucose-709* UreaN-43* Creat-2.4* Na-129*
K-4.4 Cl-79* HCO3-20* AnGap-34*
[**2194-5-1**] 05:25AM BLOOD ALT-42* AST-39 AlkPhos-75 TotBili-0.6
[**2194-5-1**] 02:04AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.6
[**2194-4-30**] 11:40PM BLOOD Osmolal-317*
[**2194-5-1**] 05:25AM BLOOD TSH-PND
[**2194-5-1**] 12:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2194-5-1**] 12:40AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2194-5-1**] 12:40AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2194-5-1**] 12:40AM URINE Mucous-RARE
[**2194-5-1**] 02:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
Microbiology:
[**2194-5-1**] 12:40 am URINE Source: CVS.
**FINAL REPORT [**2194-5-2**]**
URINE CULTURE (Final [**2194-5-2**]): <10,000 organisms/ml.
HIV Viral load: PENDING
Imaging:
[**2194-4-30**] PA and lateral views of the chest: Lungs are clear.
Cardiomediastinal Preliminary Reportsilhouette and hilar
contours are unremarkable. There is no pneumothorax or pleural
effusion. IMPRESSION: No acute cardiopulmonary process
.
Discharge labs:
[**2194-5-3**] 08:15AM BLOOD WBC-9.6 RBC-5.04 Hgb-15.5 Hct-47.0 MCV-93
MCH-30.7 MCHC-32.9 RDW-12.2 Plt Ct-184
[**2194-5-3**] 08:15AM BLOOD Glucose-203* UreaN-23* Creat-1.3* Na-142
K-3.3 Cl-100 HCO3-33* AnGap-12
[**2194-5-3**] 08:15AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.5*
Brief Hospital Course:
Patient is a 40yo M with PMHx of HIV (most recent CD4 870), HCV
(not treated), poorly controlled type I DM (HbA1c 13.0%) who
presented with nausea/vomiting found to have DKA.
.
# DKA: The patient presented in DKA with an anion gap of 30. The
precipitant of his DKA on this occasion is once again poor
compliance with his insulin regimen. Infectious etiology was
unlikely given negative work-up (chest x-ray and urine culture)
and lack of infectious symptoms. He has had multiple admissions
for DKA for this reason and his A1c was 13.0% earlier this
month. The patient was initially on an insulin gtt, which was
discontinued on the morning of transfer to the general medicine
floors. He was started on his home dose of insulin glargine and
his humalog insulin sliding scale according to his last
discharge summary. The patient was followed by [**Last Name (un) **]; he was
noted to have hypeglycemia in the morning. 10 units of Lantus at
bedtime was added to the patient's insulin regimen and the
patient's sliding scale was increased as follows:
(Insulin Type: Humalog)
FSBG Breakfast Lunch Dinner
Bedtime
0-70 mg/dL
71-110 mg/dL 8 Units 8 Units 8 Units 0 Units
111-150 mg/dL 9 Units 9 Units 9 Units 0 Units
151-190 mg/dL 10 Units 10 Units 10 Units 6 Units
191-230 mg/dL 15 Units 15 Units 15 Units 7 Units
231-270 mg/dL 16 Units 16 Units 16 Units 8 Units
271-310 mg/dL 17 Units 17 Units 17 Units 9 Units
311-350 mg/dL 18 Units 18 Units 18 Units 10 Units
351-400 mg/dL 19 Units 19 Units 19 Units 10 Units .
Electrolytes were monitored and repleted as necessary.
Outpatient follow-up was scheduled with the patient's primary
care physician as well as with [**Last Name (un) **] and a diabetes educator.
.
# HIV: Diagnosed in [**2183**]. Started treatment [**2189**], now on Truvada
and Sustiva. No history of OIs. CD4 870 1/[**2193**]. CD4 count and
HIV viral load were drawn during this admission. HIV viral load
and CD4 count was pending on day of discharge.
OUTPATIENT ISSUES: Follow-up of pending HIV viral load and CD4
count.
.
# HCV: Diagnosed in [**9-8**]. Not being treated. Baseline LFTs
100s.
.
# CKD: Thought to be secondary to DM, baseline Cr 1.6-1.9.
Elevated to 2.4 on presentation, possibly due to pre-renal state
from DKA. Patient's serum creatinine within baseline upon
transfer from ICU and upon discharge.
.
# Insomnia: Patient has disturbed sleep-wake cycle that may
contribute to poor medication compliance and dietary choices.
Seen previously by Social Work, hoped that this would improve
with changes in his living situation. Medication reconciliation
showed that the patient was prescribed trazodone 50-100mg qHS
PRN insomnia by his outpatient provider.
# DKA/T1DM, [**1-30**] non-compliance with insulin use. The patient
presented in DKA with an anion gap of 30. HgbA1C was 13 earlier
this month. He missed [**Last Name (un) **] follow-up. Nausea/vomiting could
be precipitant but more likely the result of the DKA. He was
transitioned to po by the morning. [**Last Name (un) **] was consulted. SW
was also consulted for further exploration of barrier to
compliance
# Contact: Sister [**Name (NI) **] is emergency contact; however, FAMILY
DOES NOT KNOW HE IS HIV+
# Code: Full (confirmed with patient)
Medications on Admission:
(per Discharge Summary [**2194-4-7**]):
- melatonin 1 mg QHS
- Sustiva 600 mg QPM.
- emtricitabine-tenofovir 200-300 mg Tablet QODHS (every other
day at bedtime)
- pravastatin 20 mg HS
- aspirin 81 mg daily
- multivitamin daily
- Lantus Solostar 40 Units SC QHS
- Humalog SS (for breakfast, lunch, and dinner)
Blood sugar Humalog
71-110 8 units
111-150 9 units
151-190 10 units
191-230 14 units
231-270 15 units
271-310 16 units
311-350 17 units
- Humalog SS (QHS)
Blood sugar Humalog
71-110 0 units
111-150 0 units
151-190 2 units
191-230 3 units
231-270 4 units
271-310 5 units
311-350 6 units
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
6. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qAM.
7. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
8. Humalog 100 unit/mL Solution Sig: According to sliding scale
Units Subcutaneous qACHS: Please see the attached sheet. .
9. trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Diabetic Ketoacidosis
Type 1 Diabetes Mellitus
Secondary diagnosis:
HIV
Hepatitis C
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 32713**],
You were hospitalized for Diabetic Ketoacidosis as a result of
not taking your insulin. Initially, you were in the Medical
Intensive Care Unit on an insulin drip. With stabilization of
your labs, you were transferred to the medicine floor for
further stabilization of your blood sugars.
While on the medicine floor, your blood sugars were very
elevated. However, they improved with long-acting insulin.
The [**Last Name (un) **] Diabetes Center followed you during the
hospitalization and made modifications to your insulin regimen:
1. **ADDED** 10 units of insulin glargine at bedtime
2. **INCREASED** your Humalog insulin sliding scale- see the
attached sheet.
3. Magnesium supplement every day
If you only can remember to take one type of insulin, take the
insulin glargline (also known as Lantus) regularly.
Keep all hospital follow-up appointments. Your up-coming
appointments are listed below.
Followup Instructions:
Department: [**Last Name (un) **] Diabetes Center
Name: Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 7852**] for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: [**Last Name (NamePattern1) 766**] [**2194-5-5**] at 1:30 PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Notes: You will see the Nurse Educator at 2:30 PM.
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **] for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Wednesday [**2194-5-7**] at 3:40 PM
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 798**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Name: [**Known lastname 11072**],[**Known firstname 4253**] Unit No: [**Numeric Identifier 11537**]
Admission Date: [**2194-4-30**] Discharge Date: [**2194-5-3**]
Date of Birth: [**2154-1-4**] Sex: M
Service: MEDICINE
Allergies:
Glucophage / vancomycin
Attending:[**First Name3 (LF) 11538**]
Addendum:
HIV: Please note that on discharge, the patient's Truvada
frequency was increased to every 24 hours from every 48 hours
given the patient's creatinine clearance during this admission.
Defer further management of patient's HIV medication to
outpatient provider in light of HIV viral load results and CD4
count.
Discharge Disposition:
Home
[**Name6 (MD) 634**] [**Name8 (MD) 635**] MD [**MD Number(1) 636**]
Completed by:[**2194-5-7**]
|
[
"V58.67",
"585.9",
"070.54",
"780.52",
"V08",
"250.13",
"250.43",
"V15.81",
"584.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14869, 15000
|
6946, 10300
|
322, 329
|
12103, 12103
|
5221, 5221
|
13221, 14846
|
3820, 3901
|
11064, 11903
|
11953, 11953
|
10326, 11041
|
12254, 13198
|
6652, 6923
|
3916, 3930
|
243, 284
|
357, 2898
|
12041, 12082
|
5237, 6636
|
11972, 12020
|
3944, 4621
|
12118, 12230
|
2920, 3654
|
3670, 3804
|
4646, 5202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,846
| 193,486
|
6077
|
Discharge summary
|
report
|
Admission Date: [**2136-10-4**] Discharge Date: [**2136-10-23**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation and bronchoscopy
History of Present Illness:
Patient is a 62 year old female with recent admission and
drainage of hemorrhagic pericardial effusion with
supratherapeutic INR, end-stage renal disease on dialysis,
diabetes, and diastolic heart failure who presents from dialysis
after developing acute onset of palpitations. She was in her
usual state of health and went to HD today. After ~2 hours into
the session and ~2.5kg removed, she noted the sudden onset of
palpitations in her chest. These were not associated with
shortness of breath or chest pain. She stated that she has felt
something stuck in her throat since yesterday when she ate
grapes. She denies abdominal pain, rash, fevers/chills/sweats
or dysuria.
.
In the ED, her initial vital signs were 98.4 150 139/55 18
98%2L. She received 1 L of NS and 3 doses of 5 mg IV metoprolol
with her blood pressure dropped to 100s systolic. She had a
bedside TTE that showed no significant pericardial effusion, and
preserved biventricular function. A CTA chest was done that was
negative for pneumonia or PE but showed only small to moderate
left-sided pleural effusions.
Past Medical History:
PAST MEDICAL HISTORY:
- hemorrhagic pericardial effusion
- Bilateral internal jugular thromboses, restarted on coumadin
[**8-24**]
- h/o bilateral lower extremity DVT's
- ESRD on HD T, Th, Sat
- IDDM
- Diastolic heart failure
- Pulmonary hypertension
- Hypercholesterolemia
- OSA, noncompliant with CPAP as outpatient
- OA
- h/o C. Diff
- GERD
- Depression
- Morbid obesity
- Fibroid uterus; vaginal bleeding
- h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc
- h/o Multiple line infections
**[**2135-12-17**]: Providencia, treated with 4 wk course of
aztreonam
**[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin
and gentamicin
**[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks
**[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz
and vanc
.
PAST SURGICAL HISTORY:
- L forearm radial-basilic AV graft, s/p infection, thrombosis
and abandonment ([**12-21**])
- Multiple lines in L upper arm with AV graft
- 1/07 L femoral PermaCath placed
- L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**])
- [**4-23**] Excision of left upper arm infected AV graft; associated
MRSA bacteremia treated with 6 weeks vancomycin.
- Right upper extremity AV fistula creation [**10-23**] s/p revision
- [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring
and IVC filter removed
Social History:
Patient denies a tobacco, alcohol or illicit drug use. She lives
in a nursing home (?[**Hospital3 2558**]). She is separated from her
husband. She has 5 children in [**Location (un) 86**] [**Doctor Last Name **] area.
Family History:
Not obtained.
Physical Exam:
Gen: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Unable to assess venous distension due to body habitus.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Distant heart sounds due to body habitus.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles bilateral
bases. No wheezes or rhonchi.
Abd: Round, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars.
Pertinent Results:
Admission Labs:
Trop-T: 0.05
.
Na 142 Cl 102 BUN 30 Gluc 150 AGap=13
K 4.3 CO2 27 Cr 4.2
.
CK: 12 MB: Notdone
Ca: 9.5 P: 4.9
.
WBC 5.8 Hb 11.7 Hct 39.2 Plt 468 MCV 103
N:76.3 L:16.2 M:3.8 E:3.1 Bas:0.5
.
PT: 21.3 PTT: 30.3 INR: 2.0
.
Microbiology:
[**2136-10-12**] Abscess swab: MRSA
.
[**2136-10-4**] EKG: narrow complex tachycardia @ 150. appears sinus
mechanism. shortened PR interval compared to priors. no Q waves.
old diffuse TW flattening.
Imaging:
[**2136-10-4**] CXR - Left retrocardiac patchy opacity, which could
represent
atelectasis but superimposed infection cannot be excluded.
[**2136-10-4**] CTA chest:
1. No large, central pulmonary embolus seen.
2. Small-to-moderate left pleural effusion, with related
compressive
atelectasis.
3. Mediastinal lymph nodes, measuring up to 13 mm in short axis.
4. Endplate changes at T9-10 suggestive of prior infection,
corresponding to findings on prior MR [**Name13 (STitle) 23840**] of [**2136-6-12**].
.
[**2136-10-7**] Bilateral Femoral Vein US: Bilateral lower extremity
DVTs (left greater than right), likely chronic given some
re-canalization. Common femoral veins are patent bilaterally.
.
[**2136-10-7**] Femoral Vascular US: 1. Very small, 10 x 6 mm probable
pseudoaneurysm in the right common femoral artery, but with no
clear connection to the venous system. 2. High velocities within
the right common femoral vein suggesting abnormal communication
from the arterial system either via fistula not seen, or small
malformation (also not definitively seen).
.
[**2136-10-9**] CTA Femoral vasculature: 1. Imaging findings are more
compatible with diagnosis of arteriovenous malformation rather
than arteriovenous fistula. But if patient has had prior
procedure in the area, both diagnosis should be considered. 2.
Uterine fibroids.
Brief Hospital Course:
# Superventricular Tachycardia: This was thought to be from
ectopic atrial focus, although other causes of SVT remain on the
differential. Initially attempted to control tachycardia with
esmolol drip without effect. Tachycardia rapidly resolved
following a dose of Adenosine 6mg. EP consult was obtained to
consider ablation of ectopic atrial focus. Pt agreed to
ablation. Coumadin was held in preparation for the procedure.
Once INR fell below 2.0 pt was started on heparin gtt. Because
of history of manipulation and HD cath placement, the evaluation
for her procedure included a femoral vascular ultrasound. The
decision was made at this time not to proceed with the procedure
and to medically manage her tachycardia. She was started on
metoprolol 12.5 [**Hospital1 **]. Pt did not experience any additional
episodes of tachycardia after the initial episode in the ICU
that was responsive to adenosine. She will follow up with [**Hospital **]
clinic.
#. R femoral AV malformation/fistula: Ultrasound showed
possibility of right femoral artery pseudoaneurysm and distal
bilateral femoral vein DVTs which appeared to be chronic.
Vascular Surgery was consulted to determine safety of using R
femoral vein for the procedure. They recommended CTA of femoral
vaculature. This did not show a pseudoaneurysm rather a
possible AV fistula or AVM. Pt will follow up with vascular
clinic.
# Coagulopathy: Unlikely to be a true coagulation disorder.
History of bilateral DVTs (also seen on current US) and
bilateral IJ clots are more likely attributed to multiple
manipulations and foreign bodies related to her dialysis. Upon
reviewing old records she was not on Coumadin from [**2136-5-17**]
until discovery of IJ occlusion in [**2136-8-17**]. Pt's home
coumadin regimen was held for the potential of having the
ablation performed. She was started on a heparin drip that was
continued until coumadin was restarted and INR returned to
therapeutic levels. Pt was not increasing to therapeutic level
on 2mg (home regimen), increased dose after 5days to 5mg, and
also because pt was started on Rifampin. Pt was therapeutic on
discharge, and was d/c on 9mg of coumadin QD. Pt needs close
follow up on INR, especially with recent change in bactrim dose.
# MRSA Abscesses: On presentation pt had a single self draining
abscess on her back. Throughout her hospitalization she
developed several other large abscesses on her back. General
surgery was consulted and a single large abscess in the central
thoracic region was I&D'd. Culture of abscess revealed MRSA.
Pt was started on Vancomycin per HD protocol. Levels were
monitored daily and adjusted accordingly. Sensitivites came
back and pt was switched to Bactrim DS 2 tabs QD and Rifampin
300mg. However the abscesses did not resolve, and it was thought
that the pt may have been underdosed. During this time pt
developed another smaller abscess at the L upper back. On day of
discharge spoke to pharmacy about this issue who agreed and said
her correct dose is 6mg/kg (based on trimethoprim) which would
put her at Bactrim DS 4 tabs QHD - to take 2 tabs immediatly
afterward and the remaining 2 tabs 6hrs later for less gastric
irritation. Pt should be kept on this indefinately, since being
Diabetic she is at risk for recurrent abscesses. This can be
reevaluated in the future.
#. Gyn: Pt noticed a small nodule in her vagina - not causing
itching or pain. Gyn was consulted and it was determined to be a
sebacous cyst. Pt also had a vaginal discharge which was due to
Bacterial Vaginosis. They did not recommend treating this since
she was asymptomatic. Pt also was found to on [**1-24**] to have 10mm
thickening of the endometrium. Pt denied current bleeding, and
denied bleeding for 5 years. Pt is scheduled for a pelvic US on
[**11-21**] as outpt, and will have follow up with this on [**11-22**] with
Gyn.
#. Asymtomatic pyuria- Pt has been anuric, but had a sample of
urine sent for culture on [**10-21**] by cath and was found to have
100,000 of G(-)rods. Pt was symptomatic at the time, but
currently denied any symptoms ([**10-23**]) and denied any suprapubic
tenderness. The bacteria is likely due to colonization, and
decided not treat.
# Hx of hemorrhagic pericarditis: TTE was performed last on
[**10-4**], which showed trivial pericardial effusion. No futher
evaluation was pursued during this admission. The cultures of
periciardial fluid returned negative.
# ESRD on HD: While inpatient she was continued on her
outpatient HD regimen (T, Th, Sat) and renal diet.
#. Diabetes type 2: Glucose was well controlled while
inpatient. Pt was continued on home regimen of Glargine 10
Units Subcutaneous at bedtime and Humalog sliding scale.
Continue ASA daily and Reglan prn.
.
# History of orthostatic hypotension: Continued Midodrine 10 mg
TID. No episodes of orthostatis during this current admission.
Medications on Admission:
Warfarin 2 mg daily
Paroxetine HCl 20 mg daily
Ascorbic Acid 500 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) q6hrs:
Midodrine 10 mg TID
Folic Acid 1 mg DAILY
Aspirin 81 mg daily
Senna 8.6 mg [**Hospital1 **]:prn
Bisacodyl 5 mg DAILY
Pantoprazole 40 mg PO Q24H
Metoclopramide 5 mg q6hours:prn
Lantus
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q12H (every
12 hours) as needed.
15. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Insulin
Please continue your home glucose monitoring and insulin
regimen.
17. Bactrim DS 160-800 mg Tablet Sig: Four (4) Tablet PO QHD:
Dose after HD on dialysis days; take 2 tabs immediately after
HD, and take the other 2 tabs 6 hours later that day.
Disp:*48 Tablet(s)* Refills:*3*
18. Mupirocin Calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **]
(2 times a day) for 3 days.
Disp:*qs 6* Refills:*0*
19. Chlorhexidine Gluconate 2 % Liquid Sig: One (1) to infected
areas Topical daily () as needed for MRSA abscesses: apply to
skin daily.
Disp:*qs for 1 month supply* Refills:*3*
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
21. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
(take total of 9mg QD and titrate to INR [**2-19**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Atrial tachycardia
Diabetes Mellitus
End Stage Renal Disease
Deep Venous Thrombuses
Right Femoral artery AVM vs AVF
Discharge Condition:
Good; vital signs are stable; pt is tolerating po diet and
medication, she does not require supplemental oxygen
Discharge Instructions:
You were admitted to the hospital for fast heart rate and
palpitations. You were evaluated by the cardiology team.
Because of your poor venous access the decision was made not to
treat your heart rate with a procedure, and to conservatively
treat your heart rate with medications. You tolerated the
medication well and your increased heart rate did not return
during your hospitalization.
.
During your hospitalization you developed several abscesses on
your back. The surgical team was consulted and a single abscess
was surgically drained. You were started on antibiotics. You
should follow up with your primary care physician to monitor the
resolution of the abscesses and the healing of the incision.
.
The following changes were made to your medications:
1) Added metoprolol 12.5 mg by mouth twice a day.
2) Added Bactrim DS 2 tabs immediately after HD, and then 2 more
tablets 6 hours later, indefinitely
3) Mupirocin Calcium 2 % Ointment, apply to nose twice a day
for 3 more days
4) Chlorhexidine Gluconate 2 % liquid cream, apply topically to
skin daily
.
Please continue taking all other medications as previously
directed.
.
Please notify your physician or return to the hospital if you
experience chest pain, palpitations, shortness or breath, fever,
chills or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Ob/Gyn, Dr. [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) **] on [**2136-11-22**] at 9am
[**Location (un) **] Clinical building [**Hospital Ward Name **] center
[**Telephone/Fax (1) 2664**]
Please follow up with vascular surgery in clinic on:
Wednesday [**10-24**] at 12:15pm, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
[**Last Name (un) 2577**] Building [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Please follow up with [**Hospital **] clinic for your Atrial Tachycardia
Friday 0ct 24th 1:40pm with Dr. [**Last Name (STitle) 23841**] ([**Telephone/Fax (1) 62**])
Please follow up with your primary care provider within the next
two weeks.
Completed by:[**2136-10-23**]
|
[
"428.0",
"276.1",
"682.2",
"447.8",
"416.0",
"286.9",
"616.4",
"V12.51",
"041.12",
"285.9",
"427.89",
"272.0",
"428.30",
"250.43",
"585.6",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12981, 13051
|
5602, 10481
|
306, 335
|
13211, 13325
|
3771, 3771
|
14701, 15475
|
3078, 3093
|
10887, 12958
|
13072, 13190
|
10507, 10864
|
13349, 14678
|
2300, 2825
|
3108, 3752
|
247, 268
|
363, 1457
|
3787, 5579
|
1501, 2277
|
2841, 3062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,248
| 131,999
|
5933+5934
|
Discharge summary
|
report+report
|
....................
Name: [**Known lastname 23406**],[**Known firstname **] Unit No: [**Numeric Identifier 23407**]
Admission Date: [**2107-7-26**] Discharge Date: [**2107-8-1**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 50 -year-old male with
a history of coronary artery disease, status post right
coronary artery stent on [**2107-7-20**], being transferred from the
Medical Intensive Care Unit with persistent fevers of unknown
etiology and acute pulmonary changes. The patient presented
to the Emergency Room on [**2107-7-24**] with a history of two days
of fever, chest pain, and fatigue. Prior to the procedure,
the patient reports low grade fevers with cough, upper
respiratory infection symptoms, dysuria, frequency, and
approximately one month prior to the procedure the patient
had experienced increased fatigue. The patient underwent
right coronary artery stent placement on [**2107-7-20**] and went
home on [**2107-7-21**] after the procedure.
Two days after the procedure, the patient began to have
fevers up to 101 F with chest pain at rest, shortness of
breath, nausea, diaphoresis, and only minimal relief with
nitroglycerin paste. The patient came to the Emergency Room
on [**2107-7-24**] with a 102.7 F temperature in the Emergency Room
with chest pain, shortness of breath. She was admitted to
the floor. Over the course of the night the patient became
hypoxic, hypotensive, with a systolic blood pressure down to
70 and a pulse equal to 60. Her O2 requirement increased
from 0 liters to 5 liters to keep oxygenation saturation up
to 93%. The patient was started on vancomycin, gentamicin,
and Ceptaz, and was given 2.5 liters of normal saline with
blood pressure stabilized. The patient underwent
bronchoscopy while on the unit and also was ruled out for an
acute myocardial infarction while on the unit. The patient
was transferred to the Medical Service on [**2107-7-26**].
PAST MEDICAL HISTORY:
1. Depression.
2. History of alcohol and drug abuse. The patient stayed
sober for twelve years.
3. History of bronchitis times two years.
4. Increased cholesterol.
5. Coronary artery disease, status post myocardial
infarction in 12/00. In 11/00, the patient had an ejection
fraction of 40-45%. The patient underwent stress test on
[**2107-6-20**], with a positive exercise tolerance test with
electrocardiogram changes.
6. The patient is HIV negative one month ago.
7. On [**2107-7-20**], underwent right coronary artery stent
placement.
MEDICATIONS ON ADMISSION FROM MICU: Aspirin 325 mg q day,
Lipitor 10 mg po q day, Plavix 75 mg po q day, vancomycin 1.0
gm IV q twelve hours, fluoxetine 20 mg po q day, Zantac 150
mg po bid, heparin subcutaneous 5,000 units [**Hospital1 **], Levaquin 500
mg po q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a homosexual, denies any
recent travel history.
FAMILY HISTORY: Significant for coronary artery disease,
hypertension, and cerebrovascular accidents.
PHYSICAL EXAMINATION: On admission vital signs: temperature
97.6 F, pulse 68, blood pressure 101/46, respirations of 20,
and oxygen saturation of 97% on four liters nasal cannula.
Cardiovascular examination: regular rate and rhythm, normal
S1, S2. Pulmonary examination: positive breath sounds
bilaterally, no wheezing, no crackles. Abdomen: positive
breath sounds, soft, nontender, nondistended. Extremities:
no clubbing, cyanosis, or edema.
ADMISSION LABORATORY DATA: White count of 8.2, hemoglobin of
10.1, hematocrit of 30.8, platelets of 346,000. INR 1.1,
sodium of 138, potassium of 4.3, chloride of 101, bicarbonate
of 27, BUN of 9.0, creatinine of 0.8, glucose of 109.
Neutrophils of 68, bands 0, lymphs 21.7. Calcium of 8.5,
magnesium of 2.0, phosphorus of 4.1.
The patient underwent a CT scan angiogram on [**2107-7-25**] with no
evidence of pulmonary embolism. Significant mediastinal
lymphadenopathy, extensive intra-alveolar thickening
(especially at apices), with intra-alveolar opacities.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 420**] 11-628
Dictated By:[**Last Name (STitle) 23408**]
MEDQUIST36
D: [**2107-12-5**] 11:06
T: [**2107-12-5**] 11:24
JOB#: [**Job Number 21151**]
1
1
1
R
Admission Date: [**2107-7-26**] Discharge Date:
Date of Birth: Sex: M
Service: #58
HOSPITAL COURSE: This is a 50 year-old male with a history
of coronary artery disease status post right coronary artery
stent placed on [**2107-7-20**] now with fevers of unknown etiology.
Admission to the medical Intensive Care Unit and transferred
to the Medicine Floor with resolved hypotension and acute
pulmonary changes transferred to the Medical Intensive Care
Unit on [**2107-7-26**].
1. Cardiovascular: The patient is status post right coronary
artery stent [**7-20**]. The patient was ruled out for myocardial
infarction on this admission with no electrocardiogram
changes. No evidence of congestive heart failure. The
patient was continued on aspirin, Plavix and his usual beta
blocker was held. There was no indication for repeat
catheterization at this time per cardiology. Blood pressures
were stable and no further hypertension persisted while on
the Medicine Service. The patient's cardiovascular issues
remained stable throughout hospital course.
2. Pulmonary: The patient was found to have pulmonary
changes on CT angio. There was no evidence of pulmonary
embolism, however, there was significant mediastinal
lymphadenopathy and significant extensive intra-alveolar
thickening especially at the apicis and intra-alveolar
opacities. Differential diagnosis on initial presentation
was congestive heart failure with emphysema versus
infectious cause. The patient underwent bronchoscopy and
cultures were sent. The patient was continued on Levaquin
and Vancomycin as the cause was thought to be infectious in
etiology. Infectious disease was consulted. Cultures were
negative and etiology of fever and symptoms were unclear.
The patient was continued on Levaquin po antibiotics only per
infectious disease recommendations. Over the course of
hospitalization the patient's O2 requirements improved and
the patient was back to normal saturation levels on room air.
The patient also transiently had an increased eosinophilia on
8/40 and the eosinophilia was 10.4. On discharge the patient
had declined to 6.1. The patient also had an elevated
erythrocyte sedimentation rate of 120 on [**2107-7-30**], which had
also declined. The patient underwent repeat chest CT on
[**2107-8-1**] with marked interval improvement and diffuse lung
abnormalities as compared with [**2107-7-25**] chest CT with only
minimal residual patchy ground glass opacities, apparent
marked reduction of mediastinal, however, lymphadenopathy was
seen. The patient's fever, shortness of breath,
eosinophilia had resolved with decrease in erythrocyte
sedimentation rate and negative PPD and all cultures viral,
fungal and bacteria were negative. The patient's symptoms
and fever were thought to be secondary to an atypical
pneumonia. The patient was stable and was discharged to home
with follow up with primary care physician [**Last Name (NamePattern4) **] [**2107-8-2**].
3. Hematology: The patient was found to have a hematocrit
of 30.7 on admission with a baseline running in the low 30.
The patient's hematocrit was stable. On discharge the
patient's hematocrit was at 34.6. The patient was to follow
up as an outpatient for baseline anemia.
4. The patient has a history of depression. The patient was
on __________, Amitriptyline and Neurontin. The patient
continued his medications and the symptoms were stable during
hospital course. The patient was discharged to home on
[**2107-8-2**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
Atypical pneumonia.
FOLLOW UP: The patient is to follow up with primary care
physician following week after discharge for rechecking of
laboratories and follow up on pathology results.
Dictated By:[**Last Name (NamePattern4) 23409**]
MEDQUIST36
D: [**2107-12-5**] 11:38
T: [**2107-12-5**] 11:48
JOB#: [**Job Number **]
|
[
"424.0",
"780.6",
"300.4",
"V45.82",
"413.9",
"414.01",
"782.2",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.3"
] |
icd9pcs
|
[
[
[]
]
] |
2957, 3044
|
7882, 7903
|
4431, 7827
|
7915, 8217
|
3067, 4413
|
283, 1980
|
2002, 2859
|
2876, 2940
|
7852, 7861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,758
| 145,903
|
14494
|
Discharge summary
|
report
|
Admission Date: [**2156-8-5**] Discharge Date: [**2156-8-8**]
Date of Birth: [**2097-1-3**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a
fifty-nine-year-old man with hypertension on no medications
who presented to [**Hospital3 417**] Hospital in [**Hospital1 1474**] on [**2156-8-4**]. Six hours prior to his presentation to the Emergency
Department, the patient had developed chest pain, severe
indigestion, shortness of breath, diaphoresis and tingling
down both arms. An electrocardiogram done in the Emergency
Department showed 5 mm to [**Street Address(2) 7565**] elevations in the
anterolateral leads. The patient was thrombolysed with 8 mL
TNK and treated with 81 mg aspirin, Lopressor 15 mg
intravenous, Heparin GTT. The patient's indigestion continued
throughout the night but it had resolved upon transfer to
[**Hospital1 69**] in the morning on [**2156-8-5**]. At the outside hospital, cardiac enzymes were
initially normal but peaked with a creatine phosphokinase of
30/64, creatine kinase myocardial bound 438 and Troponin 219.
Upon arrival to [**Hospital1 69**], the
patient's electrocardiogram showed continue ST elevations in
the anterolateral lead and the patient was taken directly to
the catheterization laboratory. The patient's catheterization
showed normal left ventricular main coronary artery, 50%
proximal left anterior descending artery, 90% focal mid with
20% diffuse OM lesion, focal 50% mid right coronary artery
and an left ventricular function of 30% with a cardiac index
of 2.2. Ventriculogram showed moderate systolic ventricular
dysfunction with mild systolic biventricular dysfunction. The
left anterior descending artery was stented with 0% residual
on TIMI three flow. Due to the large area of infarct, as well
as persistent ST elevations in the anterolateral leads, the
patient was transferred to the CCU for monitoring.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia.
PAST SURGICAL HISTORY: Past surgical history is unknown.
SOCIAL HISTORY: Four to five alcoholic drinks per night.
Tobacco, two packs per day. The patient is married, lives
with his family out in [**Hospital1 1474**] and works as a bus mechanic.
FAMILY MEDICAL HISTORY: Negative for heart disease.
OUTPATIENT MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Physical examination on admission to
the CCU, temperature 101.2 F, blood pressure 130/68, heart
rate 84, respiratory rate 20, 97% on two liters nasal
cannula. In general, the patient is in no acute distress. The
patient is somnolent but answers questions appropriately.
Head, eyes, ears, nose and throat examination, oropharynx
clear. Mucous membranes moist. Poor dentition. JVP not well
seen due to the necessity of the patient lying flat,
secondary to femoral sheath. Chest, clear to auscultation
anteriorly. Cardiovascular, regular rate, normal S1, S2,
positive S3, no murmurs or rubs. Abdomen was soft, nontender,
nondistended, normal active bowel sounds. Extremities, right
groin site with femoral sheath and Swan-Ganz catheter without
oozing or hematoma, 1 to 2+ posterior tibialis and dorsalis
pedis pulses bilaterally. The skin was warm and dry.
LABORATORY DATA: Laboratory studies sent from outside
hospital, white blood cell count 16.1, hemoglobin 16,
hematocrit 47.8, platelet count 229,000.
Chemistry panel, sodium 137, potassium 4.4, chloride 100,
bicarbonate 28, blood, urea and nitrogen 10, creatinine 0.9,
glucose 136.
Partial prothrombin time 26.
Total cholesterol 182, high-density lipoprotein 51,
low-density lipoprotein 112, triglycerides 97.
AST 507, ALT 105, alkaline phosphatase 98, total bilirubin
0.2, albumin 3.2, LDH 262.
IMPRESSION: Fifty-eight-year-old male with no known coronary
disease, history of hypertension, hyperlipidemia presenting
with a large anterolateral ST elevation. Myocardial
infarction which was lysed at outside and an left anterior
descending artery stented with 0% residual, now with
anterolateral apical dyskinesis, akinesis and ejection
fraction of 35%.
HOSPITAL COURSE: Cardiovascular, A) coronary artery disease,
please see above History of Present Illness for cardiac
catheterization results. Following catheterization, the
patient was started on aspirin, Plavix and Integrilin which
was continued for eighteen hours. The patient was started on
Heparin following Integrilin being discontinued and femoral
sheath being pulled. As transaminitis resolved on repeat
laboratory studies at [**Hospital1 69**]
with an AST of 113, ALT of 66, the patient was started on
Lipitor 10 mg every day. Cardiac enzymes peaked at outside
hospital with a creatine kinase of 3564, creatine kinase
myocardial bound 438.6 and an index of 6.8 with a Troponin of
219. Cardiac enzymes during hospital course at [**Hospital1 346**] showed creatine kinase peak at 1431,
creatine kinase myocardial bound 94 and index of 6.6 on [**2156-8-5**], at 6 p.m. Cardiac enzymes trended down throughout
the remainder of the hospital course. B) Systolic
dysfunction. The patient with an ejection fraction of 35% by
ventriculogram in the catheterization laboratory. Follow-up
GTE, the following day showed ejection fraction of 40%,
anterior distal septal and apical akinesis. Due to risk of
left ventricular thrombus formation due to akinesis, the
patient was loaded with Heparin and started on Coumadin prior
to discharge. C) Hypertension. The patient was on no
medications on admission and was started on Metoprolol 25
twice a day which was increased to 50 twice a day and
switched to Toprol XL 100 every day on discharge. An ACE
inhibitor was also started and the patient was discharged on
Enalapril 2.5 mg every day. Throughout the hospital course,
the patient's systolic blood pressure ranged from high 80's
to approximately 110 and therefore, the patient was not
titrated up any further on antihypertensives. D) Rhythm and
rate. The patient had a six beat run of nonsustained
ventricular tachycardia approximately twenty-four hours after
onset of symptoms. Electrophysiology was consulted and will
be following up with the patient with further studies as an
outpatient. The patient was on telemetry for his entire
hospital course and no other arrhythmias were noted.
2) Gastrointestinal. The patient had transient transaminitis
present in outside hospital which trended down throughout
hospital course here. Transaminitis was considered secondary
to myocardial ischemia and it was felt safe to start Lipitor.
3) Hematology. On admission, the patient with hematocrit of
40 which showed a drop to 34 on hospital day number two,
(which was later noted to be a laboratory error). However,
stools were guaiac and the patient was found to be guaiac
positive times one. The patient's hematocrit with the
exception of the laboratory error was constant at 40
throughout the hospital course and it was deemed appropriate
to follow-up with an outpatient colonoscopy. The patient
reported no bright red blood per rectum or melena throughout
the hospital course.
4) Infectious Disease. On admission to outside hospital, the
patient was febrile with increased white blood cell count.
Both trended down throughout the hospital course and were
felt to be attributed to myocardial infarct.
5) DISPOSITION: Physical Therapy saw and evaluated the
patient and it was felt safe for the patient to be discharged
to home. The patient to follow-up as an outpatient with
Cardiology, cardiac rehabilitation.
CONDITION AT DISCHARGE: Improved and stable.
DISCHARGE DIAGNOSES: 1) Status post anterolateral myocardial
infarct with stent placement. 2) Hypertension. 3)
Hyperlipidemia.
DISCHARGE MEDICATIONS: Aspirin 325 mg every day, Plavix 75 mg
every day times thirty days, Toprol XL 100 every day, Lipitor
10 every day, Enalapril 2.5 mg every day, Warfarin 5 mg every
day.
FOLLOW-UP: Follow-up appointments, 1) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Location (un) **], primary care physician. [**Name10 (NameIs) **] patient to
schedule appointment for the week of [**2156-8-9**]. 2) Prior
to follow-up appointment, the patient to receive Coumadin
check, including international normalized ratio and complete
blood count, secondary to guaiac positive stools. 3)
Electrophysiology, the patient to follow-up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Telephone/Fax (1) 5518**] for planned
electrophysiologic study in one month including TWA, EPS and
single average electrocardiogram. 4) The patient is to
follow-up with outpatient Cardiology in [**Hospital1 1474**]. The patient
was given names of cardiologists in the area.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2156-8-8**] 13:50
T: [**2156-8-8**] 14:37
JOB#: [**Job Number 42828**]
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
|
[
"410.11",
"401.9",
"305.1",
"427.1",
"272.0",
"414.01",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.56",
"36.06",
"37.23",
"36.01",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
7526, 7633
|
7656, 9018
|
4074, 7469
|
1977, 2012
|
2278, 2322
|
2344, 4057
|
7483, 7505
|
161, 1901
|
1923, 1954
|
2028, 2254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,143
| 125,842
|
41492
|
Discharge summary
|
report
|
Admission Date: [**2162-11-15**] Discharge Date: [**2162-11-16**]
Date of Birth: [**2078-12-15**] Sex: F
Service: MEDICINE
Allergies:
Omega-3 Fish Oil
Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
altered mental status, swelling and shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 90256**] is an 83 year old lady with a past medical history
of systolic/diastolic heart failure (EF 25%), hypertension,
hyperlipidemia, squamous cell lung cancer (Stage T3a-IV), COPD
on 3L home oxygen, anemia (baseline 26) and CKD (baseline 1.63),
who presented to [**Hospital1 18**] with altered mental status, peripheral
swelling and shortness of [**Hospital1 1440**]. The patient's daughter has
noticed that she has been going downhill for the past 6 months,
and had been planning to arrange for hospice since [**Month (only) 205**]. She
was started on home oxygen in [**Month (only) 956**] at 2L, which was
increased to 3L in the past month. Her blood pressure has been
lower since [**Month (only) 958**] in the 100s-110s systolic at her PCP's office
since then (may be lower at home). Over the past two weeks, the
patient has had increasing edema, for which her furosemide has
been augmented by metolazone twice, the first time on [**10-15**] and
the second time on [**11-9**]. It was reported that the patient had
increasing dyspnea and peripheral edema for the 24-48 hours
prior to this admission. Additionally, the patient had been
screaming, agitated and uncomfortable. At 3 pm on the day of
admission, the patient's daughter found her unresponsive with a
"swollen tongue." The patient's daughter's worry escalated as
she could not ascertain what was bothering her mother. EMS, who
were called 7pm, were initially concerned for an allergic
reaction.
.
On arrival to the [**Hospital1 18**] ED, initial vital signs were 97.2 95
77/45 31 100% 12L on a non-rebreather. Her tongue was noted to
be normal in appearance, but the patient was having problems
[**Name (NI) 19788**] and her legs were noted to be swollen and tight. For
systolic blood pressures in the 70s, she was 250 cc NS bolus,
with response to 93/46. She was then started on dobutamine
drip, with improvement of blood pressure to 132/86. After
improvement of her blood pressure, she was noted to be [**Name (NI) 19788**]
better. A right IJ central venous line was placement and x-ray
confirmed placement. Also received empiric levaquin 750 mg IV
x1 and Percocet x1 for pain. Labs were notable for proBNP [**Numeric Identifier 90258**]
pg/mL, troponin 0.15, Hct 24.3 (from baseline 26), Cr 2.5 (from
baseline 1.63), albumin 2.9, and UA with moderate leukocytes and
few bacteria. She was Guaiac negative. Initial EKG was a poor
study with tachycardia, and subsequent EKG showed NSR @ [**Street Address(2) 90259**] elevations or depressions. Chest x-ray showed mild
interstitial edema and a right-sided pleural effusion. She had
minimal UOP, and a Foley was placed. VS on transfer were: 98.4
95 24 108/56 (on dobutamine 6mcg/kg/min) 95% 3L.
.
On arrival to the CCU, the patient was agitated and screaming.
She only said a few words and was intermittently able to
localize pain to her legs. Her initial vital signs were 96.8
113/59 131 27 91% 4L. Details of the HPI were corroborated with
her daughter.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- systolic/diastolic CHF, EF 25%: started metolazone (Zaroxlyn)
with administrations on [**2162-10-15**] and [**2162-11-9**]. Of note, patient
had been admitted in [**2162-7-30**] for dyspnea, thought to be
secondary to acute on chronic heart failure, with bilateral
pleural effusions. The left was drained with a pigtail catheter
for 1L of transudative fluid. ProBNP at that time was [**Numeric Identifier 90255**].
3. OTHER PAST MEDICAL HISTORY:
- squamous cell lung cancer: Diagnosed by biopsy of subcarinal
lymph node in [**2162-3-30**]. PET scan [**4-22**] showed diffuse central
lobular emphysema, an 11 x 6 mm spiculated right upper lobe
opacity which was FDG-avid, an SUV max of 2.2, a 7 mm nodule in
the left upper lobe,
more inferiorly in the left upper lobe, 6 mm nodule also
demonstrating FDG avidity, a spiculated opacity in the left
upper lobe, also another nodule in the right middle lobe and in
the
posterior segment of the right upper lobe. There were also in
the superior segment of the right lower lobe perivascular
nodules. Left perihilar soft tissue opacity demonstrating FDG
avidity of 2.25. There was no evidence of any FDG-avid disease
below the diaphragm in the liver or the adrenal gland. Stage
T3a-IV. Dr. [**Last Name (STitle) **], who has been following, offered localized
radiation treatment for any specific symptoms (i.e. bony
metastasis) as palliation but no IV chemotherapy. Patient has
not pursued palliative treatment.
- COPD/emphysema: severe, with PFTs in [**3-/2162**] FVC 61% predicted,
FEV1 47% predicted, FEV1/FVC 69% predicted. On 3L home oxygen.
Baseline SaO2 in office 88%.
- current tobacco use
- anemia: secondary to B12 deficiency, baseline Hct 26
- chronic kidney disease: baseline Cr 1.63
- peripheral vascular disease
- MGUS
- proteinuria
- osteoporosis
- glaucoma
- recently complete 10-day course of metronidazole for diarrhea
Social History:
She has 3 children, 2 sons and 1 daughter. She lives with one of
her grandsons and her daughter is involved in her care.
# Tobacco: Smokes [**1-31**] PPD for many years, has smoked more in
past
# Alcohol: Occasional social drinking
# Drugs: None
Family History:
Glaucoma on mother's side of family.
Physical Exam:
Admission
VS: 96.8 113/59 131 27 91% 4L
GENERAL: NAD. Oriented to person and hospital. Agitated and
screaming.
HEENT: NCAT. Sclera anicteric. +Cataracts bilaterally. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma. No tongue swelling noted.
NECK: Supple with distended neck veins to the angle of the jaw.
Right IJ in place without hematoma or oozing.
CARDIAC: PMI displaced. Tachycardic, regular rhythm. Normal S1,
S2. No M/R/G.
LUNGS: Breathing was unlabored. End-inspiratory rales at the
leftlung base. Otherwise clear without wheezes or rales.
ABDOMEN: Slightly distended with involuntary guarding and TTP.
Normooactive bowel sounds.
EXTREMITIES: Chronic venous stasis changes in lower extremities,
with tight lower extremity edema.
SKIN: No ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP dopp PT dopp
Left: Carotid 2+ DP dopp PT dopp
Discharge: deceased
Pertinent Results:
pt deceased
Brief Hospital Course:
Ms. [**Known lastname 90256**] is an 83 year old lady with a past medical history
of systolic/diastolic heart failure (EF 25%), hypertension,
hyperlipidemia, squamous cell lung cancer (Stage T3a-IV), COPD
on 3L home oxygen, anemia (baseline 26) and CKD (baseline 1.63),
who presented to [**Hospital1 18**] with altered mental status, peripheral
swelling and shortness of [**Hospital1 1440**], all likely connected to acute
exacerbation of systolic and diastolic CHF. She was initially
very agitated and disoriented, consistent with acute delerium.
She became anuric, and pressors were started to maintain blood
pressures and to attempt to held urine output.On the morning of
HD 2, she was unresponsive to voice, touch, or pain, and
appeared to have agonal breathing. Her family was called, and it
was decided that the patient be made comfort measures only. She
expired from respiratory failure at 7:40pm on [**2162-11-16**].
Medications on Admission:
x- furosemide 80 mg PO qAm and 40 mg qPM since at least 1 month
x- irbesartan 75 mg PO daily
x- metolazone 2.5 mg PO thirty minutes before furosemide ([**10-15**]
and [**11-9**])
x- metoprolol succinate 100 mg PO daily
x- KCl extended release 10 mEq PO daily
x- rosuvastatin 10 mg PO daily
x- aspirin 81 mg PO daily
X- ipratropium-albuterol 0.5 mg -3 mg (2.5 mg base)/3 mL
nebulizer, use TID and PRN (forces her to use it TID)
X- fluticasone-salmeterol (Advair Diskus) 100-50 mcg/dose 1
inhalation [**Hospital1 **]
- timolol maleate 0.5% ophthalmic gel forming solution 1 drop in
each eye [**Hospital1 **]
- brimonidine 0.2% ophthalmic drops 1 drop in each eye [**Hospital1 **]
- pilocarpine HCl 4% ophthalmic gel apply in left eye at bedtime
- latanoprost 0.005% ophthalmic drops 1 drop to both eyes at
bedtime
x- lorazepam 0.25 mg PO BID PRN anxiety (taking once a day)
x- trazodone 50 mg PO qHS PRN insomnia
x- folic acid 1 mg PO daily
x- omeprazole 20 mg PO PRN GERD
x- docusate sodium 100-200 mg PO daily PRN constipation
x- caltrate 600 tablet 600-200-25 PO (Ca carbonate/vitamin
D2/soyb) [**Hospital1 **]
x- ferrous gluconate 325 mg PO daily
x- MVI daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
expired secondary to congestive heart failure, lugn cancer,
acute kidney injury
Discharge Condition:
deceased
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
|
[
"293.0",
"492.8",
"285.21",
"428.0",
"585.9",
"443.9",
"196.1",
"733.00",
"V66.7",
"V49.86",
"162.3",
"428.43",
"785.51",
"305.1",
"403.90",
"584.9",
"365.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8890, 8899
|
6712, 7638
|
359, 365
|
9022, 9032
|
6676, 6689
|
9095, 9112
|
5687, 5726
|
8851, 8867
|
8920, 9001
|
7664, 8828
|
9056, 9072
|
5741, 6657
|
3515, 3935
|
242, 321
|
393, 3407
|
3966, 5407
|
3429, 3495
|
5423, 5671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,759
| 177,867
|
35991
|
Discharge summary
|
report
|
Admission Date: [**2121-3-18**] Discharge Date: [**2121-3-24**]
Date of Birth: [**2057-2-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Pollen Extracts
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left lung cancer, status post chemotherapy and radiation
therapy.
Major Surgical or Invasive Procedure:
[**2121-3-18**]: Flexible bronchoscopy with therapeutic aspiration,
left intrapericardial pneumonectomy and a mediastinal
lymphadenectomy.
History of Present Illness:
Ms. [**Known lastname 81697**] is a 64-year-old woman with over an 80-pack year
history of smoking who was found to have a lung mass on chest
x-ray during workup for shoulder pain. Subsequent workup found
her to have a large left-sided hilar
adenocarcinoma. She underwent chemotherapy and XRT and presented
for subsequent pneumonectomy.
Past Medical History:
Removal of vocal cord polyp
Hypercholesterolemia
Peripheral Vascular Disease
Goiter
Face lift
Tonsillectomy
Social History:
Married lives in [**State 108**]. Tobacco:80 pack year. Quit 12 months
ago
ETOH: [**6-30**] oz day
Family History:
Mother: colon cancer
Physical Exam:
VS: T: 98.1 HR: 75 SR BP: 146/80 Sats: 97% RA
General: 64 year-old female no apparent distress
HEENT: mucus membranes
Neck: supple, no lymphadenpathy
Card: RRR. normal S1,S2 no murmur/gallop/rub
Resp: right breath sounds clear, left absent breath sounds
GI: benign
Extr: warm no edema
Incision: Left thoracotomy site clean, dry, intact
Neuro: non-focal
Pertinent Results:
[**2121-3-20**] WBC-7.6 RBC-2.94* Hgb-9.7* Hct-28.8* Plt Ct-232
[**2121-3-19**] WBC-9.6# RBC-2.84* Hgb-9.4* Hct-27.5* Plt Ct-245
[**2121-3-17**] WBC-4.8 RBC-2.98* Hgb-9.9* Hct-29.7* Plt Ct-301
[**2121-3-23**] Glucose-78 UreaN-16 Creat-0.9 Na-139 K-4.0 Cl-102
HCO3-27
[**2121-3-22**] Glucose-90 UreaN-21* Creat-1.0 Na-137 K-4.1 Cl-101
HCO3-25
[**2121-3-20**] Glucose-74 UreaN-29* Creat-1.4* Na-139 K-4.9 Cl-106
HCO3-25
[**2121-3-18**] Glucose-167* UreaN-19 Creat-1.2* Na-140 K-4.2 Cl-108
HCO3-22
[**2121-3-17**] UreaN-20 Creat-1.4* Na-140 K-4.2 Cl-102 HCO3-28
AnGap-14
[**2121-3-17**] ALT-10 AST-15 LD(LDH)-180 AlkPhos-71 Amylase-41
TotBili-0.4
CXR:
[**2113-3-24**] FINDINGS: In comparison with the study of [**3-22**], there
is little change. Again there is a long air-fluid level in the
left hemithorax at the level of the hilum. The right pleural
effusion has decreased.
[**2121-3-22**] The fluid level in the left hemithorax has again
slightly
increased. No other changes in the left hemithorax. The right
hemithorax has also unchanged appearance, including a minimal
right basal pleural effusion.
[**2121-3-19**]: Interval increase in amount fluid in the
left pleural cavity. Expected elevated left hemidiaphragm. There
is interval decrease of amount of subcutaneous gas in left chest
wall. Unchanged appearance of right small pleural effusion.
Right lung is clear.
[**2121-3-18**]: Status post left-sided pneumonectomy. Only minimal
left-sided
mediastinal shift.
Brief Hospital Course:
Mrs. [**Known lastname 81697**] was admitted on [**2121-3-18**] for Flexible
bronchoscopy with therapeutic
aspiration, left intrapericardial pneumonectomy and a
mediastinal lymphadenectomy. She was extubated in the operating
and transferred to the SICU for further management. The NGT was
to low-wall suction, left Penrose drain in place. Her pain was
managed by the acute pain service with via Bupivacaine &
Dilaudid epidural with good control. On POD1 she transferred to
the floor, the penrose drain and NGT tube were removed. She was
scoped by ENT for hoarness which showed a paretic left vocal
cord with minimal glottic gap. On POD2 she had a video swallow
which showed no aspiration. She was started on a regular diet
which she tolerated and her home medications. On POD3 the
epidural was removed and her pain was well controlled with PO
pain meds. The foley was removed and she voided. She was
maintained on a 1.0-1.5L
liter restriction. Her electrolytes were monitored and repleted
as needed. She was followed by serial chest films. She was
re-scoped by ENT on POD5 which showed no change. They
recommended no treatment at this time. She was seen by physical
therapy. On POD6 she continued to do well and was discharged to
the Holiday Inn with her husband and son. She will follow-up
with Dr. [**Last Name (STitle) **] in 1 week.
Medications on Admission:
fluticasone 110mc 2 puffs [**Hospital1 **], docusate 100 mg [**Hospital1 **], omeprazole
40 mg qam, pentoxyfylline 400mg tid, senna [**Hospital1 **], lorazepam 0.5
qhs/prn
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
4. Fentanyl 25 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. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO at
bedtime.
Disp:*30 * Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
10. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day.
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lung cancer, status post chemotherapy and radiation
therapy.
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage. Steri-strips remove in 10 days or
sooner if start to come off.
-You may shower. No tub bathing or swimming for 6 weeks
-Take stool softners with narcotics.
-No driving while taking narcotics
-Walk for 10 mins intervals with goal of 30 mins a day
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] [**4-1**] at 2:00pm 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.
Completed by:[**2121-3-24**]
|
[
"196.1",
"272.0",
"478.31",
"162.2",
"443.9",
"240.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.59",
"33.22",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
5823, 5829
|
3036, 4385
|
349, 491
|
5939, 5948
|
1538, 3013
|
6453, 6820
|
1124, 1146
|
4607, 5800
|
5850, 5918
|
4411, 4584
|
5972, 6430
|
1161, 1519
|
243, 311
|
519, 858
|
880, 990
|
1006, 1108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,449
| 165,407
|
19287
|
Discharge summary
|
report
|
Admission Date: [**2198-5-3**] Discharge Date: [**2198-6-5**]
Date of Birth: [**2143-10-24**] Sex: M
Service: #58
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man
who has a history of atrial fibrillation diagnosed in
[**2197-12-9**]. He was asymptomatic at the time, and it is
unclear exactly when his atrial fibrillation began. The
patient was started on Coumadin and has been on metoprolol
for rate control.
Approximately a year ago, the patient had a failed
cardioversion at an outside facility. The patient had an
exercise stress test which was negative. An echocardiogram
showed a mildly dilated left atrium with mild left
ventricular hypertrophy. The patient was referred to [**Hospital1 1444**] and Dr. [**Last Name (STitle) **] for a
pulmonary vein ablation. The patient was admitted currently
for this procedure. He had a transesophageal echocardiogram
prior to the procedure, and it disclosed a dilated left
atrium with no evidence of thrombus. During the procedure,
the patient was noted to have a systolic blood pressure down
to the seventies, and a pericardial effusion was noted. An
emergent pericardiocentesis was performed, with removal of
480 cc of sanguinous fluid. It was thought that the patient
had a perforation during the procedure, leading to
pericardial effusion and tamponade. While in the
electrophysiology laboratory, the patient received
intravenous fluids and one unit of packed red blood cells
with improvement in his blood pressure and normalization of
the pulsus paradoxus. A pericardial drain was also placed
for drainage of any further accumulation of fluid. The
patient was transferred to the CCU for further monitoring and
management.
PAST MEDICAL HISTORY:
1. Migraines.
2. Umbilical hernia.
3. Atrial fibrillation.
MEDICATIONS:
1. Metoprolol 25 mg b.i.d.
2. Coumadin 10-15 mg q day.
3. Imitrex p.r.n.
4. Cafergot p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and works as a
consultant. Occasional alcohol. No tobacco or other drug
use.
FAMILY HISTORY: The patient has several uncles with atrial
fibrillation. However, there is no history of sudden cardiac
death in the family.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96.2, blood pressure 114/67, heart
rate 74, respiratory rate 16, oxygen saturation 100% on
assist control 800 by 12 on 100% O2.
GENERAL: The patient is intubated and sedated.
HEENT: Normocephalic, atraumatic. Pupils are equal, round,
and reactive to light. Endotracheal tube was in place.
NECK: No jugular venous distention.
CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2
and no murmur, rub or gallops. There is a pericardial drain
in place.
LUNGS: Clear to auscultation anteriorly.
ABDOMEN: Benign.
EXTREMITIES: No edema. Good distal pulses. The patient has
a right arterial femoral artery sheath.
LABS ON ADMISSION: CBC shows a white count of 9.6,
hematocrit 38.6, platelet count 166. Chem-7 is within normal
limits except for a bicarbonate of 22. INR is 1.3. The last
arterial blood gases showed pH 7.29, pCO2 41 and pO2 of 304
on the ventilator settings of assist control 800 cc x 14
breaths per minute at 100% FIO2 and 5 of PEEP.
ELECTROCARDIOGRAM: Post-procedure electrocardiogram showed
normal sinus rhythm with sinus arrhythmia with normal
interval and normal axis. There was a left atrial
enlargement.
SUMMARY OF HOSPITAL COURSE BY ISSUE:
1. Cardiac tamponade. The patient had a pericardial drain
placed in the E.P. laboratory for continual drainage of the
pericardial fluid to prevent tamponade. Initially the
pericardial drain put out approximately 400 cc over the first
12 - 24 hours. However, this output slowly tapered off. A
repeat echocardiogram was done, which did not show any
significant new fluid accumulation. The drain was removed at
that time. During the hospital course, the patient's
hematocrit remained stable.
Initially, the patient's anticoagulation was held for several
days after the removal of the pericardial drain. It was then
restarted. There were no further signs of pericardial
tamponade.
2. Atrial fibrillation. The patient was in normal sinus
rhythm briefly after the pulmonary vein ablation procedure.
However, the morning after being admitted to the CCU, the
patient reverted back into atrial fibrillation with a rapid
rate. He received several doses of intravenous Lopressor for
rate control. He was then restarted on Lopressor p.o. As he
could not be anticoagulation with Coumadin initially, he was
only placed on aspirin. Since the patient had reverted back
to atrial fibrillation, he was taken for another attempt at
D.C. cardioversion. This was performed the day prior to
discharge, and was only successful temporarily. After a
brief period in normal sinus rhythm, the patient reverted
back to atrial fibrillation.
The patient was continued on Toprol XL for rate control at
that point, after the failed cardioversion. He was restarted
on anticoagulation with Coumadin. The patient was also
started on p.o. amiodarone. He was to take 400 mg b.i.d. x
two weeks, then 400 mg once a day for one week, at which
point he would be re-evaluated by the electrophysiology
service for a possible repeat D. C. cardioversion.
3. Respiratory status. The patient arrived to the CCU
intubated due to the procedure. His sedation with propofol
was quickly weaned off, and he was changed over to pressor
support and then extubated without any complications. He did
have some hypoxia after being extubated. It was thought that
this was secondary to splinting from the pain that he was
having due to the pericardial drain that was in place. Once
his pain improved and the patient was able to take deep
inspirations, his oxygenation improved.
4. Pain control. The patient was in a significant amount of
pain while his pericardial drain was in place, due to the
irritation. He was maintained on high doses of narcotics for
pain relief, though he never achieved complete relief until
the pericardial drain was removed.
5. Cardiomyopathy. The echocardiogram done showed that the
patient had an ejection fraction of 20-25%. This was thought
possibly secondary to chronic atrial fibrillation. The
patient was started on an ACE inhibitor for afterload
reduction and treatment of heart failure. He was discharged
on Zestril 5 mg q day. He had no signs or symptoms of acute
heart failure or decompensation.
6. Code status. The patient was full code on admission and
at discharge.
DISCHARGE STATUS: The patient was discharged home.
DISCHARGE CONDITION: The patient was in good condition. He
was hemodynamically stable.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation.
2. Pericardial effusion.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg q day.
2. Lopressor 75 mg q day.
3. Zestril 5 mg q day.
4. Coumadin 7.5 mg q h.s.
5. Amiodarone 400 mg b.i.d. for one week, then 400 mg once a
day for the following three weeks.
DISCHARGE INSTRUCTIONS AND FOLLOWUP PLANS: The patient was
to have his INR checked in two to three days after discharge
for adjustment of his Coumadin to a goal INR of [**3-13**]. The
patient was to call Dr.[**Name (NI) 7914**] office to follow up in
appointment in about one month for possible repeat
cardioversion. He is also to see his primary care physician
in two to four weeks.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2198-6-5**] 16:51
T: [**2198-6-5**] 22:23
JOB#: [**Job Number 52541**]
|
[
"427.31",
"428.0",
"423.9",
"425.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.0",
"37.26",
"88.72",
"37.34",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
6598, 6666
|
2080, 2206
|
6687, 6737
|
6760, 7591
|
2228, 2884
|
160, 1717
|
2899, 6576
|
1739, 1943
|
1960, 2063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,365
| 173,270
|
26194
|
Discharge summary
|
report
|
Admission Date: [**2198-3-22**] Discharge Date: [**2198-3-30**]
Date of Birth: [**2147-12-5**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: End stage liver disease admitted for
potential liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old
male with alcoholic cirrhosis, ascites refractory to therapy
status post multiple failed (TIPS) requiring paracentesis.
Score of 20. Last [**Hospital1 69**]
admission was [**2198-1-25**] to [**2198-2-14**] with
shortness of breath, fatigue, status post tap at an outside
hospital during admission was found to be clotted. Chest tube
was revised x2 during that hospital course. Hypocoagulable
work up performed which was unremarkable. He was treated for
encephalopathy and hepatorenal syndrome. Renal function
improved. Rectal bleeding occurred. A colonoscopy
demonstrated polyp 1 cm and a polypectomy was done. Internal
hemorrhoid was treated with Amatol.
Since admission he has done well. Patient stable.
Paracentesis was last done on [**2198-3-20**] without
complication. Patient was without dyspnea on exertion. Denies
fevers, chills, rash, headache, dizziness, nausea, vomiting,
abdominal pain or constipation.
PAST MEDICAL HISTORY: Alcoholic cirrhosis, refractory
ascites, history of multiple paracentesis, umbilical hernia
[**2197-2-12**]. Rectal bleeding: Colon polypectomy.
Transesophageal echocardiography was done [**2198-1-7**] with
ejection fraction of 75%, hyperdynamic bubbles that likely
represents arteriovenous malformation. TMIBI [**2197-2-14**]
which is normal.
PAST SURGICAL HISTORY: TIPS and TIPS revision [**2198-1-30**] and [**2198-2-8**].
ALLERGIES: Percocet causes pruritus.
MEDICATIONS ON ADMISSION: Aldactone 50 mg q day, Lasix 20 mg
q day, __________ 200 mg b.i.d., lactulose 15 cc p.o. p.r.n.
for bowel movements, clotrimazole troches 5x a day, Levaquin
500 mg q day, __________ 75 mg q day.
PHYSICAL EXAMINATION: Patient is afebrile, vital signs
stable. Weight 78.4. Awake, alert, mild anxiety. Wife is
present. Patient is in no acute distress. Pupils equal,
round, reactive to light. Extraocular movements are full.
Scleral icterus. Mouth: No thrush. Teeth: Upper and lower
teeth poor dentition. Neck: No jugular venous distension, no
bruits. Carotids 1+ bilaterally. Lungs are clear.
Cardiovascular: Regular rate and rhythm. Normal S1, S2.
Abdomen: Positive bowel sounds, nontender, severe ascites.
Reducible umbilical hernia. Extremities: No clubbing,
cyanosis, edema. Neurologic: Awake and alert, cranial nerves
2 through 12 intact. No asterixis. Strength upper and lower
extremities [**5-11**] bilaterally. Vascular: 1+ bilaterally, 2+
dorsalis pedis. Reflexes are symmetric. Rectal examination:
Hemorrhoid present, guaiac positive.
HOSPITAL COURSE: So patient was preopped for liver
transplant. Chest x-ray is clear. No infiltrates.
Electrocardiogram: Sinus rhythm, no acute changes, poor R
wave progression. Patient was placed on antibiotics and seen
for the operating room. Solu-Medrol and MMF were ordered.
Laboratories were obtained. WBC 9.4, hematocrit 38.2, INR
1.4. AST 60, ALT 28, alkaline phosphatase 305, total
bilirubin 0.2, sodium 123, 4.8, 101, 14, BUN/creatinine
56/1.2. The patient went to the operating room on [**2198-3-22**] in which an orthotopic liver transplant, piggyback
technique, common duct to common duct. No T tube portal vein
to portal anastomosis and aortic conduit for arterial inflow
performed by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see
detailed informed regarding operative note. Postoperatively
he went to the Intensive Care Unit. Patient received 2 units
of packed blood red blood cells, 2 units of fresh frozen
plasma. Patient was placed on Unasyn, incentive air, heparin,
insulin, Solu-Medrol, MMF was given. Postoperatively patient
was in Intensive Care Unit for 4 days. On [**2198-3-24**]
laboratories were as follows: WBC of 13, hematocrit of 29.4,
platelets 87, sodium 136, 4.1, 106, 24, 34, creatinine 0.8,
glucose 117. AST is 468, ALT 353, alkaline phosphatase 73,
total bilirubin 1.1. Ultrasound was done [**2198-3-23**] which
demonstrated an unremarkable appearance of the transplanted
liver with patency of the major hepatic portal veins and
hepatic arteries. Last day in Intensive Care Unit was on
[**2198-3-25**]. On [**2198-3-26**] patient had a CT of the
chest because patient required increased oxygen demonstrating
a widespread ground glass opacities with intralobular
thickening "crazy-paving" pattern. Considering its acute
onset the major differential considerations are pulmonary
edema, hemorrhage, atypical infection. Radiologist: Bilateral
small to moderate amount of pleural effusions. Post surgical
changes in the upper abdomen, distended stomach with no
nasogastric tube insertion. Patient was placed on Zosyn and
Vancomycin. Patient received Unasyn for 4 days, Zosyn for 2
days and Vancomycin for 2 days. Patient was on ganciclovir
for a total of 9 days, continued on fluconazole, heparin
subcutaneously, morphine, Protonix, Bactrim, Dilaudid and
patient was on Levaquin for 3 days. Pulmonary medicine was
consulted because of the finding on the CT of the chest. It
was thought that patient was volume overloaded and
recommended keeping the patient when .5 to 1.0 liters
negative. Infectious disease was also consulted for pulmonary
infiltrate. After diuresing chest x-ray was obtained on [**2198-3-27**] demonstrating that this previous pulmonary edema has
been markedly improved. There is probably a small right
pleural effusion. Pulmonary had felt that the findings on the
chest x-ray was most likely related to congestive heart
failure rather than atypical infection and that at that point
they would not recommend a bronchoscopy. On [**2198-3-28**]
another chest x-ray was obtained demonstrating resolving
pulmonary edema, small bilateral effusions. Patient was
saturating well making good ins and outs. On [**2198-3-28**],
postoperative day 6, hospital day 7 prescription was written
for prednisone 20, MMF 1 gram b.i.d. Afebrile, vital signs
stable. Making good ins and outs. Urine output was 1425.
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] with recent lateral drained [**2177**]. Levaquin was
stopped per infectious disease. Patient was out of bed,
ambulating well, eating well. On [**2198-3-29**] laboratories
were the following: WBC 9.7, hematocrit 27.9, 61, 137, 4.6,
106, 25. BUN/creatinine 41/1.2, glucose 94, AST 31, ALT 77,
alkaline phosphatase 100, total bilirubin 0.4, INR is 0.9.
Patient's level on [**3-29**] was 12.2. patient was receiving 4
and 4. On [**2198-3-30**] patient continued to do well, was
saturating well, afebrile, vital signs stable. So on [**2198-3-30**] patient was discharged home on the following
medications: Fluconazole 400 mg q day, prednisone 20 mg q
day, Bactrim SS 1 tablet q day, Protonix 40 mg q day, MMF
1,000 mg b.i.d., tacrolimus 400 mg b.i.d., Dilaudid 1 to 2
tablets q 3 to 4 hours p.r.n., potassium 900 mg q day.
Patient did not need any services. Patient has appointments
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the following dates: [**2198-4-2**] at 10:40 A.M., [**2198-4-9**] at 11:40 A.M., [**2198-4-16**] at 11:20 A.M. The patient was instructed to call
transplant surgery immediately at [**Telephone/Fax (1) 673**] for any
fevers, chills, nausea, vomiting, abdominal pain and to call
immediately if he is unable to drink or having difficulty
with urination or if there is any increased redness of the
incision or any discharge or edema. Patient was to have
laboratories every Monday and Thursday in which a CBC, chem-
10, AST, ALT, alkaline phosphatase, albumin, total bilirubin
and Prograf level are to be drain. Results should be faxed
immediately to the transplant service.
FINAL DIAGNOSIS: Alcoholic cirrhosis, status post liver
transplant [**2198-3-22**].
SECONDARY DIAGNOSIS: Congestive heart failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2198-4-2**] 11:54:22
T: [**2198-4-2**] 13:48:04
Job#: [**Job Number 64921**]
|
[
"789.5",
"571.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
1735, 1933
|
2800, 7938
|
7956, 8024
|
1609, 1708
|
1956, 2782
|
271, 1217
|
8046, 8338
|
176, 242
|
1240, 1585
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,963
| 123,445
|
13958
|
Discharge summary
|
report
|
Admission Date: [**2156-2-26**] Discharge Date: [**2156-2-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
S/p mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 84 male with a PMH of afib on coumadin who fell
down and hit his head after tripping on a curbside. He denies
LOC, headache, dizziness, paresthesias, or motor weakness. His
wife, however, reports that he has had double vision over the
past few days, nausea for the past 2 weeks, and lately has been
more unsteady on his feet.
The patient intially presented to [**Hospital1 **] which showed SAH,
left orbital fx, left zygomatic fx, left maxillary sinus fx. CT
c-spine was negative for fractures or dislocations. He was
given 1 gram of dilantin, 1u FFP, 5mg vit K, and was then sent
to [**Hospital1 18**] for further evaluation.
Past Medical History:
HTN, left tonsillar CA, A-fib on coumadin, tongue implant,
requires frequent suctioning, prone to aspiration PNA, PEG
Social History:
Lives in [**Location 47**] with his wife. [**Name (NI) **] tobacco, etoh.
Family History:
NC
Physical Exam:
Vitals: 98.2 78 148/82 18 98% RA
Gen: Significant oral secretions
HEENT: Lacerations over the left zygoma, left forehead; left eye
with significant periorbital swelling/ecchymosis without
proptosis/enopthalmos; PERRL, EOMs-intact; poor dentition
Neck: Supple. No point tendnerness
Lungs: Oral secretions, upper airway sounds
Cardiac: RRR. S1/S2
Abd: +BS, soft, NT/ND; PEG in place
Rectal: sphincter intact, no frank blood
Spine: No point tenderness
Extrem: warm with BCRs digits, no c/c/e
MSK: TTP left shoulder, otherwise unremarkable.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Communciationg but phonation difficult due [**2-23**] to
tonsillar CA and tongue implant as well as large amount of
secretions
CNII-XII intact to direct testing
Motor: [**4-25**] left deltoid (unbale to test pronator drift),
otherwise [**5-25**] throughout
Sensory: SILT throughout
Pertinent Results:
Imaging:
[**2-26**] CT head/sinus/mandible/maxillofacial:
1. Small foci of acute intracranial hemorrhage both
intraparenchymal (left temporoparietal region and right parietal
lobe) and subarachnoid (left parietal lobe sulcus, right
temporal lobe sulcus). No major mass effect or herniation.
2. Acute facial fractures including left zygomatic arch, left
inferior and
possibly lateral orbital walls and lateral wall of the left
maxillary sinus.
3. Left periorbital hematoma. The globes remain intact.
Left shoulder films:
Severe degenerative change of acromioclavicular joint and
glenohumeral joint. No fractures/dislocations.
[**2-27**] Head CT:
1. Continued evolution of multiple foci of intracranial
hemorrhage both
intraparenchymal and subarachnoid. No new hemorrhage.
2. Left periorbital hematoma, unchanged.
3. Multiple facial bone fractures, better delineated on
dedicated CT.
CXR [**2-28**]:
Bilateral lower lung zone interstitial linear opacities
radiating from hila. This may represent chronic radiation
changes with possible superimposed aspiration. More nodular
opacites in both lungs are noted, measuring up to 10mm. No
evidence of ptx.
Labs on admission:
[**2156-2-26**] 04:30PM BLOOD WBC-15.5* RBC-4.29* Hgb-15.6 Hct-43.8
MCV-102* MCH-36.4* MCHC-35.6* RDW-12.9 Plt Ct-162
[**2156-2-26**] 04:30PM BLOOD Neuts-93.2* Lymphs-3.7* Monos-2.6 Eos-0.2
Baso-0.3
[**2156-2-26**] 04:30PM BLOOD PT-26.0* PTT-30.6 INR(PT)-2.6*
[**2156-2-26**] 04:30PM BLOOD Glucose-125* UreaN-23* Creat-0.7 Na-140
K-4.6 Cl-100 HCO3-27 AnGap-18
[**2156-2-26**] 04:30PM BLOOD CK(CPK)-120
[**2156-2-26**] 04:30PM BLOOD cTropnT-<0.01
[**2156-2-26**] 04:30PM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0
[**2156-2-27**] 04:01AM BLOOD Phenyto-11.2
Latest Labs:
[**2156-2-28**] 05:55AM BLOOD WBC-11.1* RBC-3.49* Hgb-12.7* Hct-35.9*
MCV-103* MCH-36.4* MCHC-35.5* RDW-13.0 Plt Ct-164
[**2156-2-28**] 07:20PM BLOOD PT-14.5* PTT-21.0* INR(PT)-1.3*
[**2156-2-28**] 07:20PM BLOOD Glucose-134* UreaN-23* Creat-1.0 Na-141
K-3.9 Cl-100 HCO3-28 AnGap-17
[**2156-2-28**] 07:20PM BLOOD Calcium-8.9 Phos-4.1# Mg-2.0
[**2156-2-28**] 05:10PM BLOOD Type-ART pO2-84* pCO2-74* pH-7.23*
calTCO2-33* Base XS-0 Comment-O2 DELIVER
[**2156-2-28**] 05:10PM BLOOD Lactate-1.9
Brief Hospital Course:
Head CT showed both a right parietal and left temporoparietal
intraparenchymal hemorrhage and small SAH in the left parietal
lobe sulcus, right temporal lobe sulcus without mass effects.
CT sinus/mandible/maxillofacial showed acute facial fractures of
the left zygomatic arch, left inferior and possibly lateral
orbital walls, and lateral wall of the left maxillary sinus.
His left shoulder films were negative for fractures or
dislocations. Laboratory findings on admission were significant
for an INR of 2.6. In the ED he was given vit K 10mg IV and 2u
FFP. Patient was admitted to the TSICU for q 1hour neurochecks
and made NPO. His coumadin was held. Neurosurgery, plastics,
and opthomalogogy consults were immediately obtained.
Neureosurgery recommended repeat head CT in am, holding coumadin
with INR goal of <1.4, dilantin, q1 hour neurochecks, and
SBP<140. Plastics recommended sinus precautions (including
augmentin PO), closed treatment of facial fractures given that
he did not chew food and was Gtube dependent. Opthomalogy
agreed that orbital fxs were nonoperative as well. Repeat INR
was 1.7, and an additional unit of FFP was given. On HD2 a
repeat head CT was stable, again without any mass effects. His
neuro exam was stable and he did not show signs/sypmtoms of left
eye compartment syndrome or entrapment. He was transferred to
the floor in stable condition. On the floor the patient had
stable vital signs and was restarted on his home regimen of tube
feeds. Physical therapy was consulted. The patient continued to
require frequent oral suctioning of secretions as he does at
baseline at home, but maintained good O2 sats on room air. In
the evening of [**2156-2-28**], the patient developed increasing dyspnea
and tachypnea and decrease in mental status. His O2 sats were in
the 80s on 4L NC. The patient was placed on a non-rebreather,
with O2 sats improving to the 90s. Blood pressure and heart rate
remained stable. An EKG was performed that showed strain, but no
acute STEMI. A chest xray was performed showing bibasilar
infilatrates, the wet read by radiology suggested aspiration. An
ABG was performed revealing acidemia and hypercarbia. The
patient was then transferred to the TSICU and his family was
notified. The patient was DNR/DNI. In the TSICU the patient had
stable vital signs on non-rebreather and continued to be
suctioned. His wife and secondary health proxy were both
present. The options for aggressive management of his
respiratory distress were discussed and the family decided to
follow the patients wishes for comfort measures only. With the
family present, the patient expired and was pronounced at 01:08
on [**2156-2-29**].
Medications on Admission:
Coumadin 5, Jevity 1.0, Lasix 40, Verapimil 80, Lansoprazole 30,
Valsartan 80, doxycycline 100mg Fri,Sat,Sun.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"427.31",
"873.42",
"E880.1",
"V44.1",
"518.5",
"873.44",
"787.29",
"801.21",
"V58.61",
"802.4",
"V10.02",
"802.8",
"401.9",
"V66.7",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7320, 7329
|
4448, 7132
|
281, 287
|
7380, 7389
|
2206, 2842
|
7440, 7445
|
1210, 1214
|
7293, 7297
|
7350, 7359
|
7158, 7270
|
7413, 7417
|
1229, 1773
|
222, 243
|
315, 961
|
2851, 3360
|
3374, 4425
|
1788, 2187
|
983, 1103
|
1119, 1194
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,146
| 159,378
|
40464
|
Discharge summary
|
report
|
Admission Date: [**2101-6-24**] Discharge Date: [**2101-7-4**]
Date of Birth: [**2046-9-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
asymptomatic left chest mass
Major Surgical or Invasive Procedure:
[**2101-6-24**]
1. Left radical chest wall resection and reconstruction
with [**Doctor Last Name 4726**]-Tex mesh.
2. Removal of breast implant.
3. Left exploratory thoracoscopy.
[**2101-6-27**]
Bronchoscopy
[**2101-6-27**]
Right PICC line
History of Present Illness:
Ms [**Known lastname 6993**] is a 54 yo woman with a history of Breast cancer.
She has a new erosive mass L chest wall
underneath breast implant, worrisome for recurrence of breast
cancer or a new malignancy. Pt had a CT guided chest wall bx
[**5-5**] with path returned as spindle cell lesion. She denies any
pain, SOB, fever, or other sx at this time. She presents now for
resection.
Past Medical History:
PMH: bilat invasive DCIS [**2097**], neoadjuvant chemo then bilat
mastectomy w/ reconstruction then chemo and xrt to bilat chest
walls, Right breast T4N3M0 stage IIIC, left breast T1N1M0 stage
IIa, Anemia, Vitamin D deficiency, Seasonal allergies, Mild left
upper extremity lymphedema
PSH: Port placement and removal, Appendectomy, Cesarean section,
Bilat mastectomy w/ reconstruction/implants [**2097**], R breast
implant removal due to erosion
Social History:
Cigarettes: [x ] never [ ] ex-smoker [ ] current
Pack-yrs:____
quit: ______
ETOH: [x ] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x ] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:accountant
Marital Status: [ ] Married [x ] Single
Lives: [ ] Alone [ x] w/ family [ ] Other:
Other pertinent social history:
Travel history:
Family History:
Aunt with breast cancer
Physical Exam:
Temp 97.9 HR 57 BP121/64 RR18 100% RA
Gen: NAD, AOX3
CV: RRR
Resp: CTAB
Chest: s/p radical resection of left chest wall tumor and
reconstruction. Sutures without erythema. 2 JP drains in place
w/ serosangunious output
Abd: soft, NTND
Ext: No LE edema
Pertinent Results:
[**2101-6-24**] 12:12PM GLUCOSE-108* LACTATE-0.7 NA+-140 K+-2.8*
CL--113*
[**2101-6-24**] 12:12PM HGB-8.4* calcHCT-25
[**2101-6-24**] 08:00PM GLUCOSE-160* UREA N-9 CREAT-0.6 SODIUM-138
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-19* ANION GAP-13
[**2101-6-24**] 08:00PM CALCIUM-7.2* PHOSPHATE-3.7 MAGNESIUM-1.7
[**2101-6-24**] 08:00PM WBC-9.4# RBC-3.82* HGB-11.0* HCT-33.5* MCV-88
MCH-28.8 MCHC-32.8 RDW-14.4
[**2101-6-25**] Cardiac echo :
The left ventricle is not well seen, but seems to have normal
function. The right ventricular cavity may be mildly dilated.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
[**2101-6-27**] CXR :
Since [**2101-6-25**], left lower and mid lung consolidation has
worsened and associated with mild-to-moderate left pleural
effusion, while mild-to-moderate right pleural effusion is new.
[**2101-6-30**] CXR:
Surgical changes in left chest wall, with minimal residual air
[**2101-7-1**] Chest CT :
Left c/w resection with large L and small R pleural effusions.
Large simple multiloculated L pleural collections w/o hematoma
or active extrav. No drainable collections at JP drain site.
[**2101-7-4**] LUE US:
No left upper extremity deep venous thrombosis.
Brief Hospital Course:
Ms. [**Known lastname 6993**] was admitted to the hospital and taken to the
Operating Room where she underwent a Left radical chest wall
resection and reconstruction with [**Doctor Last Name 4726**]-Tex mesh,
Removal of breast implant, and Left exploratory thoracoscopy.
She tolerated the procedure well and returned to the SICU in
stable condition. She remained intubated upon transfer out of
the OR and over the next 2 days she was gradually weaned and
extubated. She received one unit of blood post op for a
hematocrit of 23 and she subsequently remained stable in the 30
range. Her pain was controlled with a Dilaudid PCA and she
maintained stable hemodynamics and was transferred to the
Surgical floor on post op day #3.
She continued to progress well with ambulation, maintaining
sternal precautions and weaning from oxygen. Her Surgical JP
drains remained in place and were draining bloody fluid post op.
Her chest tube was removed on [**2101-6-29**] and a subsequent chest
xray showed minimal para mediastinal air. Her oxygen
saturations were 96% on room air.
Ms. [**Known lastname 6993**] was evaluated by the nutrition team as her oral
intake was minimal and her transferrin and albumin were low
along with an elevated INR. They felt that she chronically had
a poor oral intake, spent time with her reviewing high protein
foods and recommended protein supplements. She realizes that
she has multiple wounds to heal and will try her best to improve
her caloric intake.
On [**2101-7-1**] in the early morning hours, Ms. [**Known lastname 6993**] started
having increasing sainguinous output from her anterior JP drain.
It was notably different in appearance than prior thin
serosainguinous fluid and put out about 500 cc in 8 hours which
is significantly higher than prior. She was made NPO, IVF were
started, and a foley was placed. Her type and screen was updated
and she was cross matched for 4 units. Her INR had been elevated
1.8-2 likely secondary to poor nutritional status. Her
hematocrit was stable 31.2->29.6->29.9. Her PICC was changed out
for a power PICC to facilitate injection of IV contrast. A CT
scan was obtained, significant for multiloculated simple pleural
fluid and axillary superficial simple fluid collection. IP was
consulted to drain the pleural fluid from a left lateral
approach.
Ms.[**Known lastname 6993**] has prior LUE edema from mastectomy. An ultrasound
was performed on [**2101-7-4**] to confirm she had no DVT. This
ultrasound was normal.
Her pain was controlled with Ultram and Tylenol and her
incisions were healing well. Her JP drains will remain in place
along with oral antibiotics and she will be seen by Dr. [**First Name (STitle) 1022**] next
week. She will have VNA services for help with drain management
and recording outputs. She will also follow up with Dr.
[**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
arimidex 1mg daily, vit D 5000 u/wk, claritin D prn
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*30 Capsule(s)* Refills:*2*
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
8. Vitamin D3 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left chest wall tumor.
Acute blood loss anemia
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 for surgery to remove a mass
on your chest wall. Dr. [**Last Name (STitle) **] was assisted by Dr. [**First Name (STitle) 1022**]
from the Plastic Surgery service. You've recovered well. You are
now ready for discharge but will still need close follow up by
Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 1022**].
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* The 2 JP drains will remain in place and will need to be
emptied daily. The VNA will help you with this.
* Write down the amount of drainage from each tube daily so that
Dr. [**First Name (STitle) 1022**] can see the drainage decrease and decide when to remove
them.
* Your antibiotics will continue until the drains are out.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving over the next 4 weeks.
* Take Tylenol 650 mg every 6 hours in between your Ultram.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
* You will need to maintain sternal precautions over the next
4-6 weeks while going through the healing process.
1. Do NOT lift more than 10 lbs for the next 6 weeks.
2. Do NOT let people pull you by your arms when they are
trying to help you move.
3. Do NOT reach backwards with your arms.
4. You may use your arms within a pain free range but avoid
reaching backwards.
5. You may use your arms when getting out of a bed or chair
but try to keep them close to your sides.
6. You can bend forward to do things like tie your shoes.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: PLASTIC SURGERY
When: WEDNESDAY [**2101-7-6**] at 4:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2101-7-19**] at 9:30 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: WEST Best Parking: [**Street Address(1) 592**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) 470**] of the [**Hospital Ward Name 517**]
Clinical Center for a chest xray.
Department: [**Hospital 2039**] CARE CENTER
When: FRIDAY [**2101-7-29**] at 8:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 88653**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2101-7-4**]
|
[
"285.1",
"511.89",
"268.9",
"V45.71",
"E878.8",
"518.0",
"195.1",
"457.0",
"V10.3",
"780.62",
"998.11",
"286.7",
"458.29",
"738.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.94",
"96.71",
"34.91",
"34.4",
"34.06",
"34.79",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7200, 7258
|
3547, 6416
|
307, 555
|
7349, 7349
|
2209, 3524
|
10065, 11321
|
1895, 1921
|
6519, 7177
|
7279, 7328
|
6442, 6496
|
7500, 10042
|
1936, 2190
|
239, 269
|
583, 971
|
7364, 7476
|
993, 1443
|
1861, 1879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,176
| 118,765
|
9213
|
Discharge summary
|
report
|
Admission Date: [**2118-11-23**] Discharge Date: [**2118-11-26**]
Date of Birth: [**2055-5-23**] Sex: M
Service: MEDICINE
Allergies:
Egg
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
-[**2118-11-24**]: esophagogastroduodenoscopy
-[**2118-11-24**]: colonoscopy
-[**2118-11-25**]: capsule endoscopy
History of Present Illness:
63 yo M with h/o colonic avm, NASH cirrhosis, esophageal varices
s/p banding; who p/w dark stools and dizziness.
.
Yesterday patient had 5-6 episodes of dark brown loose stools.
Also felt dizzy when standing. Denies any associated abdom pain,
BRBPR, also denies coughing or vomiting up blood. This morning
he had [**1-28**] more dark loose stools and made appt to see pcp. [**Name10 (NameIs) **]
PCP office he was orthostatic. Denied CP, palpitations,
diaphoresis, SOB, exertional dyspnea, orthopnea, PND, and
syncope. Has not taken ASA yet today but is on plavix for
CABG/stent. Last EGD/[**Last Name (un) **] was in [**5-/2118**] and showed both Grade I
varices and GAVE on EGD and colonic AVMs on [**Last Name (un) **]. Seen at [**Hospital1 34**] ED
3 weeks ago for 'observation' admission for similar symptoms.
At that time he had a self-limited GIB requiring blood
transfusion of 2 units. Once again only noted dark brown stools
denies melena or BRBPR. No scope was done at that time. Pt
sent to ED by PCP.
.
In the ED, VS 132/54, 100 sitting; 122/50 standing with symptoms
of dizziness. NG lavage was performed and was negative. He had
maroon stool in ED that was grossly guaiac positive. Hct was 25
(last check in [**Hospital1 18**] system was 33). Two 18G PIVs were placed
and he received 2L NS, 2 units PRBC, and 1 unit platelets. Also
given 1g ceftriaxone. VS at the time of transfer were 98 132/53
100/RA. Hepatology was consulted. He was started on PPI and
octreotide drip.
.
On arrival to the MICU, the pt was hemodynamically stable, alert
and oriented in no acute distress.
Past Medical History:
CAD: CABG [**2103**], stenting in [**2106**], [**2109**]? Cards Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7389**]
NEBH. Per him needs plavix for life
NASH cirrhosis: followed by Dr [**Last Name (STitle) **], c/w Distant h/o ascites.,
encephalopathy, esophogeal varices (no prior bleeding), s/p
banding
DM II on insulin with frequent episodes of hypoglycemia in the
past.
TIA [**1-6**] followed by Dr [**Last Name (STitle) **]
Squamous cell carcinoma
HTN
HL
Social History:
He works as a plumber for [**Company 31653**]. He was a
heavy smoker, but quit many years ago. He has not drunk in many
years. He says he was a heavy drinker as a teenager, but not
since that time. No illicit drug use. He is married and his
wife is present with him today.
Family History:
He has got a brother with asthma. Mom with diabetes and breast
cancer, sister who had a heart attack in stroke in her 50s and
father who died of stomach cancer at age 63.
Physical Exam:
Vitals: T:98.8 BP:147/61 P: 94 R:16 O2:100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops,old sterotomy scar from prior CABG
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no masses palpated
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no ulcers or sores on feet b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
.
DISCHARGE Physical Exam:
Vitals: 98.1, 66, 135/52, 18, 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated (8cm at 30deg), no LAD
CV: Regular rate and rhythm, normal S1 + S2, faint 2/6 systolic
murmur at RUS border, no rubs or gallops, sternotomy scar from
prior CABG
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no masses palpated
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no ulcers or sores on feet b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
Pertinent Results:
ADMISSION LABS:
[**2118-11-23**] 03:50PM BLOOD WBC-5.7 RBC-2.60* Hgb-7.9* Hct-24.5*#
MCV-94 MCH-30.3 MCHC-32.2 RDW-14.7 Plt Ct-156
[**2118-11-23**] 03:50PM BLOOD Neuts-76.7* Lymphs-10.8* Monos-7.3
Eos-4.5* Baso-0.6
[**2118-11-23**] 03:50PM BLOOD PT-12.6* PTT-26.9 INR(PT)-1.2*
[**2118-11-23**] 03:50PM BLOOD Glucose-143* UreaN-25* Creat-1.1 Na-131*
K-4.4 Cl-105 HCO3-19* AnGap-11
[**2118-11-23**] 03:50PM BLOOD ALT-46* AST-46* AlkPhos-81 TotBili-0.4
[**2118-11-23**] 03:50PM BLOOD Albumin-3.4*
[**2118-11-24**] 01:05AM BLOOD Calcium-7.3* Phos-4.1 Mg-1.8
[**2118-11-25**] 05:55AM BLOOD calTIBC-238* VitB12-562 Ferritn-55
TRF-183*
.
DISCHARGE LABS:
[**2118-11-26**] 06:30AM BLOOD WBC-3.9* RBC-3.17* Hgb-9.8* Hct-29.8*
MCV-94 MCH-30.9 MCHC-32.9 RDW-15.5 Plt Ct-148*
[**2118-11-26**] 06:30AM BLOOD Glucose-95 UreaN-16 Creat-1.1 Na-135
K-4.5 Cl-107 HCO3-20* AnGap-13
[**2118-11-26**] 06:30AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8
.
MICROBIOLOGY:
[**2118-11-24**] 1:05 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2118-11-26**]**
MRSA SCREEN (Final [**2118-11-26**]): No MRSA isolated
.
IMAGING:
.
-[**2118-11-24**] EGD:
Impression: Tortuous esophagus.
Varices at the middle third of the esophagus and lower third of
the esophagus
GAVE of moderate severity was noted in gastric antrum. No fresh
blood was present.
Otherwise normal EGD to third part of the duodenum
.
-[**2118-11-24**] Colonoscopy:
Impression: Diverticulosis of the sigmoid colon
One (1) of small non bleeding rectal varices was identified
Grade 1 internal hemorrhoids
Normal terminal ileum
No evidence of polyps, masses or active bleeding
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: 1. Resume diet as tolerated
2. High fiber diet
3. Follow up hepatology recs
4. Repeat colonoscopy in 10 years
5. Check HCT q12 hrs
.
-[**2118-11-25**] Capsule endoscopy: results PENDING
Brief Hospital Course:
63 yo M CAD s/p CABG and stent x 2 ('[**06**] and '[**09**]), NASH cirrhosis
c/b esophageal varices s/p banding, HTN, HLD, TIA [**2116**]
presenting to ED with GI bleeding; he was in the MICU where he
received cscopy and EGD, and then was called out to the floor.
At time of d/c, there is no particular identified bleeding
source.
.
ACTIVE ISSUES:
.
# GI Bleeding: pt remained hemodynamically stable, but as yet
uncertain source of bleeding - pt has h/o of esophageal varices,
GAVE, and colonic AVMs. Hepatology completed an EGD that showed
varices but no active bleeding sources and a colonoscopy that
did not reveal any obvious bleeding sources. Given these results
a capsule endoscopy study was completed, whose results are
pending at time of discharge. Given his GI bleeding we held his
aspirin and plavix on initial presentation to the MICU. These
were resumed prior to discharge. He was on a PPI gtt and
octreotide gtt which were d/c'd upon transfer to the medical
floor. The pt remained HD stable and had stable Hct's in the
high 20's upon discharge; diet was well-tolerated after
advancement to regular foods and BM's did not have gross blood.
.
# NASH cirrhosis: We held lasix and spironolactone in setting of
volume depletion on initial admission the MICU, but cont
Rifaximin 550mg [**Hospital1 **]
.
CHRONIC ISSUES:
.
# CAD: held ASA and plavix in setting of GI bleeding but
restarted upon d/c home.
.
# HTN: restarted lasix, lisinopril upon d/c home.
.
# HLD: continued lipitor
.
# DM2: maintained on ISS while in house.
.
TRANSITIONAL ISSUES:
.
The following changes were made to his medications:
NEW:
-Nadolol 10mg PO daily (for varices in esophagus)
-Benzonatate, 1 week's worth (for cough)
.
-[**2118-11-25**]: capsule endoscopy results are PENDING as of time of
discharge; pt has f/u with Dr. [**Last Name (STitle) **] on [**2118-12-1**].
.
Recs upon d/c home: The anemia should be further worked up
depending on the results of the capsule endoscopy. If the study
demonstrates AVM's in the small bowel, then the patient should
have an entersocopy. If the study is normal, then I would
recommend a repeat EGD with APC ablation of mild GAVE found in
the stomach.
Medications on Admission:
Medications CONFIRMED:
RIFAXIMIN 550MG [**Hospital1 **]
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth po
daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth daily
EZETIMIBE [ZETIA] - (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
10 mg Tablet - 1 Tablet(s) by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30 FLEXPEN] - 100
unit/mL (70-30) Insulin Pen - inject 24-30 units sq twice a day
26 units qam, 24 units with dinner
LACTULOSE - (On Hold from [**2118-6-27**] to unknown for diarrhea) -
10 gram/15 mL Solution - 15 ml by mouth three times a day as
needed titrate to [**1-28**] bowel movements daily
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth dailiy
LOPERAMIDE - 2 mg Capsule - 1 Capsule(s) by mouth every four (4)
hours as needed for diarrhea
NITROGLYCERIN - (Prescribed by Other Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7389**] MD) - 0.1
mg/hour Patch 24 hr - Daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - one
Tablet(s) by mouth twice a day
SPIRONOLACTONE - 50 mg Tablet - One Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use to
test blood glucose up to five times daily as directed
COENZYME Q10 - (Prescribed by Other Provider) - 50 mg Capsule -
1 Capsule(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (OTC) - 500 mcg
Tablet - 1 Tablet(s) by mouth daily
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65
mg
iron) Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. insulin aspart 100 unit/mL Insulin Pen Sig: One (1)
Subcutaneous twice a day: inject 24-30 units twice a day:
26 units every morning, 24 units with dinner .
8. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day: titrate to [**1-28**] bowel movements daily.
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed for diarrhea.
11. nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1)
Transdermal once a day.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a
day.
16. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO once a day.
17. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
18. benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
19. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gastrointestinal bleeding
Secondary diagnosis:
cirrhosis secondary to non-alcoholic steatohepatitis
coronary artery disease
diabetes
hypertension
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 privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you had
dizziness and gastrointestinal bleeding. You were initially in
the intensive care unit, where you were given blood transfusions
and received camera studies of your esophagus, stomach, and
colon which did not find a clear source of bleeding. You were
transferred to the regular medical floor, where you received the
capsule endoscopy study. The results of this study will be
followed up at your upcoming appointment with Dr. [**Last Name (STitle) **]. Your
condition has improved and you can be discharged to home.
The following changes were made to your medications:
NEW:
-Nadolol (for varices in esophagus)
-Benzonatate (for cough)
CHANGED: None
STOPPED: None
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2118-12-1**] at 11:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2118-12-20**] at 2:15 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: TUESDAY [**2119-1-10**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
Completed by:[**2118-11-26**]
|
[
"401.9",
"571.8",
"250.00",
"V45.81",
"272.4",
"572.3",
"578.9",
"V45.82",
"571.5",
"V58.67",
"537.82",
"414.00",
"276.50",
"562.10",
"455.0",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.19",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
12081, 12087
|
6407, 6740
|
280, 396
|
12297, 12297
|
4476, 4476
|
13346, 14356
|
2838, 3010
|
10400, 12058
|
12108, 12108
|
8615, 10377
|
12448, 13323
|
5123, 6384
|
3025, 3717
|
7965, 8589
|
228, 242
|
6755, 7719
|
424, 2027
|
12175, 12276
|
4492, 5107
|
12127, 12154
|
12312, 12424
|
7735, 7944
|
2049, 2530
|
2546, 2822
|
3742, 4457
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,155
| 112,474
|
48871
|
Discharge summary
|
report
|
Admission Date: [**2150-6-22**] Discharge Date: [**2150-7-2**]
Date of Birth: [**2080-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic ascending Aneurysm
Major Surgical or Invasive Procedure:
[**2150-6-25**]
Redo sternotomy, replacement of ascending aorta
and hemiarch using deep hypothermic circulatory arrest with a
30-mm Vascutek Dacron tube graft.
History of Present Illness:
This is a 69-year-old gentleman with history of rheumatic heart
disease status post mechanical AVR and MVR in [**2137**], who
currently
presents for evaluation of stable ascending thoracic aortic
aneurysm, estimated on recent MRA as measuring 6.2 cm in its
maximal dimension. This has been stable on serial
echocardiograms measurements as well as compared to prior MRA
obtained in [**2149-9-7**]. He remains asymptomatic.
Past Medical History:
Ascending Aortic Aneurysm
PMH:
- Chronic Systolic Congestive Heart Failure
- History of Rheumatic heart disease
- Hypertension
- Atrial fibrillation
- Colonic adenomas
- ?Osteoporosis
- BPH
- Remote CVA was noted on brain CT and MRI [**2132**] (R thalamic)
Past Surgical History
- s/p mechanical AVR (#29 Carbomedics) and MVR (#31 carbomedics)
in [**2137**]
- Laparoscopic right colectomy complicated by anastomotic bleed
requiring exploratory laparoscopy [**2149-9-7**]
- Appendectomy
- Bilateral Shoulder
- Left Foot Bunion
Social History:
Lives with: Wife
Occupation: Retired construction worker
Tobacco: 5 cigars per month
ETOH: nightly Glass of wine with dinner
Family History:
Father had valvular heart disease. Mother had
[**Name2 (NI) 499**] CA
Physical Exam:
Pulse: 87 Resp: 16 O2 sat: 99%
B/P Right: 105/73 Left: 117/73
Height: 69 inches Weight: 200 lbs
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur - crisp mechanical clicks
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact
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: none Left: none
Pertinent Results:
[**2150-6-25**] Intra-op TEE
Conclusions
PRE-CPB:
The left atrium is moderately dilated. The pt is in atrial
fibrillation. No thrombus is seen in the left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The LV
chamber is severely dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 25-30%) with the inferior
wall appearing more hypokinetic than other wall segments. Right
ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is severely dilated. While the entire visualized
ascending aorta appears dilated, there appears to be a focal
outpouching at the level just below the RPA. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen.
A bileaflet mechanical aortic valve prosthesis is present. There
appear to be three small paravalvular leaks, two in the area
near the interatrial septum, and one next to the area by the
pulmonary valve. The prosthetic valve appears to be well-seated
with normal leaflet motion.
A bileaflet mitral valve prosthesis is present. The normal
washing jets of this mechanical prosthesis is seen. The valve
appears to be well-seated. Occasionally, one leaflet is slower
than the other to close, possibly due to poor LV contractility.
POST-CPB:
The patient is now on Epi, Phenylephrine, and Milrinone
infusions. The LV EF appears improved on inotropic support,
estimated EF is 40-50%. The inferior wall still appears to be
more hypokinetic than other wall segments.
The bioprothetic valves continue to show appropriate function.
The aortic valve paravalvular leaks remain unchanged from
pre-op. The peak gradient across the aortic valve is 20mmHg, and
the mean gradient is 9mmHg with a CO of 7.
There is no evidence of aortic dissection.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2150-6-25**] 18:44
Radiology Report CHEST (PA & LAT) Study Date of [**2150-6-30**] 7:24 PM
Final Report: PA and lateral upright chest radiographs were
reviewed in comparison to [**2150-6-28**] and several prior studies
dating back to [**2148**].
The cardiomegaly is unchanged, including both left and right
ventricle. Two replaced valves are noted, unchanged since the
prior examination. The small amount of right pleural effusion is
unchanged. Anterior mediastinal air with small air-fluid level
noted on the lateral view are redemonstrated with the air-fluid
level potentially representing small loculated anterior
pneumothorax in combination with post-surgery air in the
mediastinum. Small amount of pneumopericardium cannot be
excluded laterally, although it might represent summation of
shadows. Continued followup is recommended.
Post-sternotomy wires appear intact.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Discharge Labs:
[**2150-7-1**] 04:10AM BLOOD WBC-5.1 RBC-2.91* Hgb-9.7* Hct-27.7*
MCV-95 MCH-33.4* MCHC-35.1* RDW-14.2 Plt Ct-201
[**2150-7-1**] 04:10AM BLOOD Plt Ct-201
[**2150-7-1**] 04:10AM BLOOD UreaN-16 Creat-0.8 Na-133 K-4.1 Cl-98
Admission labs:
[**2150-6-22**] 04:47PM PT-15.6* PTT-27.7 INR(PT)-1.4*
[**2150-6-22**] 04:47PM PLT COUNT-139*
[**2150-6-22**] 04:47PM WBC-4.1 RBC-3.78* HGB-13.0* HCT-36.5* MCV-97
MCH-34.4* MCHC-35.6* RDW-13.3
[**2150-6-22**] 04:47PM %HbA1c-5.7 eAG-117
[**2150-6-22**] 04:47PM ALBUMIN-4.3 MAGNESIUM-2.0
[**2150-6-22**] 04:47PM ALT(SGPT)-16 AST(SGOT)-23 LD(LDH)-322* ALK
PHOS-47 TOT BILI-0.5
[**2150-6-22**] 04:47PM GLUCOSE-95 UREA N-24* CREAT-0.8 SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-29 ANION GAP-10
Brief Hospital Course:
The patient was a direct admission to the operating room on
[**2150-6-25**] where the patient underwent replacement of ascending
aorta and aortic hemiarch. Please see the operative report for
details. In summary he had:
Redo sternotomy, replacement of ascending aorta and hemiarch
using deep hypothermic circulatory arrest with a 30-mm Vascutek
Dacron tube graft, catalog number [**Serial Number 102644**], lot number [**Serial Number 102645**],
serial number [**Serial Number 102646**]. His CARDIOPULMONARY BYPASS TIME was 119
minutes, with a CROSSCLAMP TIME of 75 minutes, and CIRCULATORY
ARREST TIME of 18 minutes.
He tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. Heparin was initiated as a bridge to coumadin for
his mechanical valves. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #7 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged on to home
with VNA services, in good condition with appropriate follow up
instructions advised.
Medications on Admission:
Warfarin 6 mg Daily (last dose [**2150-6-19**])
Alendronate 70 mg Daily; Carvedilol 6.25 mg [**Hospital1 **]; Eplerenone 50
mg
Daily; Flomax 0.4 mg Daily; Benicar daily; Calcium + Vit D
Daily;
Magnesium
Discharge Medications:
1. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 5 days.
Disp:*5 Packet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. carvedilol 12.5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
6. alendronate 70 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO 1X/WEEK (ONCE
PER WEEK).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
7. oxycodone 5 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 [**Hospital1 8426**](s)* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. warfarin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO ONCE (Once) for
1 doses.
Disp:*1 [**Hospital1 8426**](s)* Refills:*0*
10. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*5 [**Hospital1 8426**](s)* Refills:*0*
11. warfarin 2.5 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR
goal= 3-3.5 for double mechanical valves.
Disp:*180 [**Last Name (Titles) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Ascending Aortic Aneurysm
PMH:
- Chronic Systolic Congestive Heart Failure
- History of Rheumatic heart disease
- Hypertension
- Atrial fibrillation
- Colonic adenomas
- ?Osteoporosis
- BPH
- Remote CVA was noted on brain CT and MRI [**2132**] (R thalamic)
Past Surgical History
- s/p mechanical AVR (#29 Carbomedics) and MVR (#31 carbomedics)
in [**2137**]
- Laparoscopic right colectomy complicated by anastomotic bleed
requiring exploratory laparoscopy [**2149-9-7**]
- Appendectomy
- Bilateral Shoulder
- Left Foot Bunion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2150-7-8**]
10:15
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**], [**2150-7-21**] 1:30
Cardiologist Dr. [**Name (NI) **], [**Telephone/Fax (1) 62**], [**2150-7-30**] 11:00
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 7726**],[**First Name3 (LF) 177**] A. [**Telephone/Fax (1) 7728**] in [**5-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for mechanical AVR and MVR
Goal INR 3-3.5
First draw day after discharge:[**2150-7-3**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name (STitle) **]
Results to fax- [**Telephone/Fax (1) 3341**]
Completed by:[**2150-7-2**]
|
[
"441.2",
"416.8",
"600.00",
"V58.83",
"V45.3",
"V58.61",
"428.22",
"285.9",
"V43.3",
"401.9",
"780.62",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"38.45",
"88.42",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10179, 10238
|
6538, 8173
|
321, 483
|
10808, 10964
|
2444, 5752
|
11752, 12709
|
1646, 1718
|
8427, 10156
|
10259, 10787
|
8199, 8404
|
10988, 11729
|
5768, 5990
|
1733, 2425
|
249, 283
|
511, 937
|
6006, 6515
|
959, 1487
|
1503, 1630
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,867
| 140,636
|
44809
|
Discharge summary
|
report
|
Admission Date: [**2125-10-8**] Discharge Date: [**2125-10-19**]
Date of Birth: [**2055-7-28**] Sex: F
Service: OMED
Allergies:
Codeine / Carboplatin / Cisplatin
Attending:[**Last Name (NamePattern1) 5062**]
Chief Complaint:
Fatigue, acute hematocrit drop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
INITIAL HX PRIOR TO ICU ADMISSION:
This is a 70 yo F w/ h/o relapsing papillary serous ovarian
cancer last first diagnosed in [**2117**]. She was last admitted to
this hospital for her 7th cycle of cisplatin. She was given
[**Doctor Last Name **]/taxol once in [**2117**], and was changed to [**Doctor Last Name **]-cytoxan for
low counts in 01/[**2118**]. She tne received six cycles of cisplatin
started in [**1-/2125**] and administered in the hospital because of
the questionable history of allergic reaction to carboplatin.
-
Since that admission, she showed signs of fluid retention, both
in her legs and in her ascites but she did not have any evidence
of congestive heart failure based on exam with normal lungs and
flat JVD. There was concern that perhaps her cancer was
progressing and that is the reason for her tense ascites, but
consideration was also given to worsening renal failure as
explanation for increased ascites. CT scan taken [**2125-9-21**] showed increased ascites, but otherwise stable exam with
mesenteric masses and evidence of peritoneal carcinomatosis that
appear unchanged when compared to [**2125-7-25**].
-
Her husband reported some recent confusion during their clinic
visit on [**9-26**]. Due to her creatinine clearance of about
20mL/min, the decision was made during this visit to switch the
patient to weekly gemzar despite the stability of dz achieved
w/cisplatin. Due to her decreased creatinine clearance, a
reduced dose of 500 mg per meters squared was chosen. She was
started on this dose on [**10-3**] and acutely tolerated it well. The
plan was for weekly gemzar, three weeks on and one week off.
-
The patient first felt different from her normal self on
Saturday, when she "started to feel lousy." She saw an
accupuncturist on Sat. for posterior neck pain; needles were
inserted into her head, back and ankles. On Sunday, her
weakness progressed to the point that she could no longer stand.
Her husband noted a bloodshot left eye ealier today, now
resolved. She recently fell on her left buttock.
-
On ROS, the patient notes moderate to severe abdominal pain for
the past several days, especially before meals and sometimes
resolved with food. She sleeps with three pillows.
-
Today, the patient's fellow contact[**Name (NI) **] her. She reported the
above symptoms and was told to come to clinic. Her hematocrit
has decreased from 33 to 17 and so she was admitted to omed and
immediately transferred to ICU as INR>60.
ON TRANSFER BACK TO OMED FROM ICU:
Mrs. [**Known lastname 1661**] is a 70 y/o F with recurrent ovarian CA, s/p CABG,
s/p MV repair, and hypothyroid, presented from onc clinic on
[**2125-10-8**] with weakness, nausea, and decreased PO intake since
gemcitabine tx on [**2125-10-3**] and on clinic visit [**10-8**] was found to
be hyptotensive, decrease hct (from 33.0 to 17.1), and INR>60.
Patient was initially admitted to OMED service, but transferred
to MICU for further evaluation. Please see MICU Admit note for
more information on past medical hx and course during stay. In
brief, patient was admitted for hemodynamic stability and work
up of coagulopathic state. Mrs. [**Known lastname 1661**] denied diarrhea,
hematuria but did report very slight BRBPR on toilet paper. She
was trace guiac positive on admission. She had diffuse
ecchymosis over lower extremities, back, and buttocks. She
received 6 units of PRBC's with appropriate bump in hct to 34.1
on [**10-16**]. In terms of her coagulopathy, it is thought that a
combination of coumadin (for h/o DVT), decrease PO intake, and
recent administration of gemcitabine were instigating factors.
Coumadin held on admission. She received 1 unit FFP and was
initially treated with PO vitamin K while in MICU, with decrease
in INR to 3.0 on morning of [**10-17**]. On [**10-17**] she received 1 mg IV
vitamin K. Her initial mixing studies were negative for
inhibitors. Shortly after receiving the 6 units of blood,
patient became SOB secondary to fluid overloaded state. She was
diuresed and responded well to lasix; however, creatinine began
rising (above baseline of ~2.6) likely because of hypovolumia
and decrease blood flow to kidneys. Patient was subsequently
gently hydrated, with impoved renal status. Creatinine 2.8 on
[**10-16**]. During fluid overloaded state, Mrs. [**Known lastname 1661**] also developed
AFib, which per family was new onset. After cardiology consult
and discussion with primary oncology team, it was decided to
cardiovert patient. She tolerated well and is now in NSR.
Nutrition is still an issue for patient, as she has decrease
appetite. Also, she was seen by PT for gait instability/[**Month (only) **]
balance. Mrs [**Known lastname 1661**] appears well and states that she is feeling
good. She is anxious to get up and walk around the floor.
Patient currently denies and n/v/dizziness. No f/c/ns/sob/cp.
She has not urinated since foley d/c'ed this morning but feels
that she might be able to go soon. Urinary retention was not a
problem for her prior to admission.
Past Medical History:
1.Relapsing papillary serous ovarian CA as above--hx onc
therapy:
She was diagnosed in [**2117**].
She is status post carboplatin and Taxol times one in [**2117**],
changed to [**Doctor Last Name **]- Cytoxan because of low counts in 01/[**2118**].
Status post Cytoxan and cisplatin times two and then Cytoxan and
carboplatin times four from [**6-/2119**] to 09/[**2119**].
Status post [**Doctor Last Name **] times six until 05/[**2121**].
Status post Taxol times eight from [**3-/2123**] to 10/[**2123**].
Status post oral etoposide times one, discontinued because of
mouth sores in 11/[**2123**].
Status post carboplatin times two, discontinued because of an
allergic reaction that occurred in 12/[**2123**].
Status post cisplatin times three from [**1-/2124**] to [**4-/2124**],
discontinued because of rising creatinine.
Status post weekly Taxol but discontinued because of disease
progression.
Started on cisplatin 50 mg/m2 in [**9-/2124**] status post two cycles
at that time, discontinued because of rising creatinine.
Status post two cycles with Navelbine, discontinued because of
disease progression.
Status post seven cycles of cisplatin started in [**1-/2125**] and
administered in the hospital because of the questionable history
of allergic reaction to this medication given the fact that she
had an allergic reaction to carboplatin in the past. Cisplatin
was discontinued due to rising Cr.
Status post Gemzar treatment last wednesday, [**2125-10-3**]
-
2. Yeast infection [**2125-8-29**]
-
3.CAD s/p CABG and MVR
-
4. h/o LE DVT
-
5.CRI
-
6. hyperchol.
-
7. gout
-
8. hypothyroidism
Social History:
Married, 30 pack yr tob, quitx20 years, no EtOH, no IVDA.
Family History:
Mother=[**Name (NI) **]
father:prostate CA
brother:PD
M aunt=ovarian CA
cousin=ovarian CA
Physical Exam:
[**10-8**]:
Vitals: 99.4 76-80 (76) 94/42
Gen: Pale woman relaxing in bed in NAD, brighter appearing than
yesterday evening or this morning
NECK: supple, PERRL, EOMI, conjunctivae remain pale, mouth and
oropharynx clear
LUNGS: CTAB
Heart: RRR
ABD: soft, distended, NT
EXT: Warm X 4 with pulses X 4
Skin: Left large ecchymosis on buttocks slighly increased in
size and color since yesterday, bil hands, abdomen
[**10-16**]:
PE:T:98.0 P: 68-75 BP: 86-128/44-99 RR:24 O2:93-98%
Gen: Patient is pleasant, pale appearing elderly female, NAD
HEENT: PERRL - consenusally, EOMI, sclerae anicteric; supericial
ulcer on R side of tongue, blood blister on back L tongue; neck:
supple, FROM, no LAD
LUNGS: CTA with bibasilar crackles
CARDIAC: rrr, no m/g/r
ABD: moderate distention-but not firm, no peritoneal signs,
nontender, no masses appreaciated, +BS, resolving ecchymosis on
LUQ of abd.
EXT: 2+ pitting edema of LE bilat. diffuse ecchymosis of b/l
buttocks R>L, and upper thighs, mostly resolved on L left
extremity; few small ecchymosis on L wrist. Resolving per MICU
notes.
NEURO: A&OX3; responding appropriately, very talkative, CN2-12
intact with no focal deficit. Strength 5/5 throughout.
Pertinent Results:
Crit: Baseline mid 20s; [**10-3**] 33 [**10-5**] 17.1 9/21@1430 following
3u 28.6
PT: [**9-5**] 13.7 [**10-8**] >100 [**10-9**] following 1U FFP 24.8, 32.6
PTT: [**9-5**] 23.6 [**10-8**] 150, 143 [**10-9**] following 1U FFP 61.7, 48.8
Platelets: [**10-8**] 263 [**10-9**] 162
CT OF THE CHEST WITHOUT IV CONTRAST: There are minor dependent
atelectatic
changes. Extensive atherosclerotic changes of the aorta and
coronary arteries
are evident. Multiple prominent but nonpathologically enlarged
mediastinal
lymph nodes are identified. There is a large hiatal hernia. No
pleural or
pericardial effusions are present.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a
moderate-to-large amount of
ascites within the abdomen, but no evidence of an intra- or
retroperitoneal
hematoma. Allowing for the limitations of a noncontrast exam,
the liver,
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
within normal
limits. Extensive aortic calcifications are again noted. No
pathologically
enlarged retroperitoneal or mesenteric lymph nodes are
identified in this
limited study. There is no free air.
CT OF THE PELVIS WITHOUT IV CONTRAST: A large volume of ascites
is present
within the pelvis. The urinary bladder is unremarkable. There is
sigmoid
diverticulosis without diverticulitis.
BONE WINDOWS: No suspicious lytic or blastic leions are
identified.
IMPRESSION: Moderate-to-large volume of ascites, but no evidence
of intra- or
retroperitoneal hemorrhage.
[**10-9**] Chest AP:
PORTABLE AP CHEST: Comparison is made with a chest CT scan from
[**2125-10-8**]. Again seen is a left subclavian port with the tip in the
SVC, in
satisfactory position. There is no pneumothorax. There are
multiple
mediastinal clips and a prosthetic mitral valve. There is stable
cardiomegaly
with mild upper lung zone redistribution. There is a large
hiatal hernia with
associated atelectasis in the left lower lobe. There is
worsening right lower
lobe atelectasis.
Brief Hospital Course:
A/P: Mrs. [**Known lastname 1661**] is a 70 yo female with h/o recurrent ovarian
cancer who recieved first dose of gemcitabine on [**2125-10-3**] and
presented to clinic on [**10-8**] with hypotension, drop in hct
(33-->17), and INR>30, admitted to ICU. ICU course c/b fluid
overload, acute on chronic renal fl., and AFib. Transferred to
OMED on [**10-16**] hemodynamically stable, INR 3.0 and 34.1.
1. Coagulopathy - Patient admitted with an INR >60, 3.0 on [**10-16**].
Thought to be [**2-19**] combination of decrease PO intake, coumadin,
and gemcatabine. Continue to hold coumadin. As per HPI, treated
with FFP and vitamin K in ICU with INR decrease to 3.0. Given
1gm vitamin K IV [**10-16**] prior to transfer to floor. INR 2.1 day
prior to discharge and 2.9 on day of discharge. Per primary
oncology team, she was given 10mg PO vitamin K prior to
discharge and will f/u in clinic in 3 days to have INR
rechecked. Coumadin was held on discharge.
2. Anemia - Patient with chronic anemia, but acute blood loss
internally to buttocks thighs in setting of coagulopathic state.
Responded appropriately to 6 units PRBC's in ICU with hct
remained stabe once transferred to oncology service. She was
receiving procrit about once a week prior to admission to
hospital and received injection 3X/week during admisison. She is
to f/u with primary team on monday to discuss continuation of
procrit.
3. HTN: Blood pressures had been fluctuating while in ICU and
initially holding of metoprolol. Outpatient dose of metoprolol
25mg [**Hospital1 **] and was restarted and switched to 12.5mg TID for while
in the ICU. Her blood pressures were well controlled on this
dose and she was discharged on 12.5 mg TID.
4. Acute on chronic renal insufficiency - Patient with baseline
creatinine of 2.4-2.7. Creatinine had increased [**2-19**] to prerenal
azotemia while being diuresed in ICU. Trending to baseline on
transfer to floor. Creatinine was 2.7 on day of discharge.
Nephrotoxic medications were avoided during admission.
5. Ovarian Cancer - S/p gemcitabine treatment [**10-3**], preceeding
admission and onset of previoulsy discussed adverse events. Will
discuss with primary oncologist future treatment plans.
6. Nutrition - Mrs [**Known lastname 1661**] has had poor appetite for some time,
which may have attributed to coagulopathic state. Seen and
evaluated by nutrition service. Patient notes that her appetite
is slowly increasing and appeared to be eating about [**Date range (1) 5082**] of
food on tray. Discussed importance of eating green vegetables -
ie broccoli- but encouraged any PO intake for now.
7. Constipation - Mrs. [**Known lastname 1661**] has had difficulty moving bowels
X 1 week despite aggressive treatment. She was managed on senna
and colace and responded well to .5L of golytely to get bowels
started and then occassional miralax.
8. PT: Physical therapy evaluated patient today and suggested
3-5 visits/wk to help with balance, gait, and transfers.
Suggested possible rehab on discharge, but patient refused and
stated that she preferred home PT. Also with OT evaluation with
suggestion of home aide to supervise shower transfers and home
safety evaluations.
9. CAD/Hyperlipidemia - continue atorvastatin during admission
and on dsicharge.
10. Hypothyroid - Continued outpatient dose of levothyroxil
during admission and on discharge.
11. Episode of AFib - Patient was noted to be in AFib during ICU
stay (as per HPI). Because of the desire to avoid need for
anticoagulation (if need for cardioversion if in AFIB >48 hours)
she was successfully cardioverted on [**10-12**]. NSR throughout rest
of hospitalization.
12. FEN: Continue protonix, phosphagel, tums, and pneumoboots.
13. CODE: DNR/DNI
Medications on Admission:
Levoxyl 75 mcg p.o. daily, Prilosec, Coumadin 1mg QD,
Lipitor, atenolol, Anzemet, Celexa, OxyContin b.i.d., iron,
Procrit, Renagel 40mg QD and Ativan daily.
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Coagulopathy
Secondary Diagnosis
1. Ovarian cancer
2. Malignant ascities
3. Chronic Renal Insufficiency
4. Congestive heart failure
5. h/o DVT
6. s/p MVR
Discharge Condition:
Stable.
Discharge Instructions:
Please call your PCP or come to the ED if you have notice
worsening bruising, bloody stools, shortness of breath, chest
pain, feves/chills, or other worrisome symptoms.
Please follow up on Monday in the [**Hospital **] clinic to have your
labs drawn.
Do not restart coumadin on discharge. Please discuss restarting
this medication with your doctor when you return to the [**Hospital **]
Clinic on [**10-22**].
Followup Instructions:
1. Please return to the oncology clinic on Monday, [**2125-10-22**] to have your labs drawn.
2. Please call your oncologist for an appointment in [**1-19**] weeks.
3. Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at ([**Telephone/Fax (1) 95873**] for an
appointment in [**1-19**] weeks.
|
[
"781.2",
"V58.61",
"285.1",
"V43.3",
"286.9",
"V10.43",
"V45.81",
"780.94",
"584.9",
"593.9",
"427.31",
"197.6",
"428.0",
"564.00",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
15541, 15599
|
10435, 14155
|
330, 336
|
15819, 15828
|
8447, 10412
|
16287, 16613
|
7123, 7215
|
14362, 15518
|
15620, 15620
|
14181, 14339
|
15852, 16264
|
7230, 8428
|
260, 292
|
364, 5406
|
15639, 15798
|
5428, 7032
|
7048, 7107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,675
| 185,843
|
9345
|
Discharge summary
|
report
|
Admission Date: [**2131-12-5**] Discharge Date: [**2131-12-12**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
gentleman transferred from [**Hospital 26200**] Hospital. The
patient admitted there with generalized weakness, and
malaise, and inability to walk with progressive weakness over
the last week.
On [**11-30**], his right leg gave out and he fell on the
carpet. The patient was taken to the [**Hospital 26200**]
Hospital Emergency Department where his right leg was unable
to move almost immediately. The left leg had decreased
ability to move as well but not as bad as the right. He had
pain in his right upper quadrant of the chest wall which was
worse with movement. There was no back pain. No
paresthesias in the leg; although occasionally felt
intermittent sensation on the soles of his feet. The patient
denied any bowel or bladder dysfunction but was diapered and
constipated. The patient's fever was 99 and shortness of
breath. The patient was on oxygen for the last month at
home. No chest pain. The patient complains of osteoporosis
pain in the chest. While at [**Hospital 26200**] Hospital, he
was treated for a chronic obstructive pulmonary disease
exacerbation and was started on Levaquin. He had a Pulmonary
consultation.
Also while at [**Hospital 26200**] Hospital, he had a Neurology
consultation for paraplegia. He had a magnetic resonance
imaging scan on [**12-4**] showing moderate thoracic/moderate
cord impingement by compression deformity displaced by the T4
interspinal canal, some cervical spondylosis, and a L1-L4 old
compression deformity.Also T11 old compression fracture.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's vital signs were stable. Head,
eyes, ears, nose, and throat examination was unremarkable.
Pulmonary examination revealed the lungs with scattered
wheezes and decreased aeration in the lower lobes.
Cardiovascular examination revealed irregular. The abdomen
was soft and nontender. There were positive bowel sounds.
Extremity examination revealed 2+ pitting edema. Neurologic
examination revealed the patient was alert, awake, and
oriented times three. The patient was cooperative and was
following commands. Sensation was intact to light touch and
pinprick in both upper and lower extremities. Strength
testing revealed the patient was 4+ in the biceps and
triceps, 1 in the iliopsoas, zero in the anterior tibial, and
0 in the extensor hallucis longus on the right. On the left
strength testing revealed 4+ in the biceps and triceps, 1 in
the iliopsoas, 3 in the anterior tibial, and 4 in the
extensor hallucis longus. Proprioception was not intact
bilaterally. The patient could wiggle his left toes. His
tone was flaccid. The toes were upgoing. There was
decreased rectal tone. Reflexes were 2+ in the upper
extremities on the left, 3+ on the right, 0 reflexes in the
lower extremities.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to [**Hospital1 69**]. The patient was
seen by Dr. [**Last Name (STitle) 739**]. A Medicine Service consultation
was obtained to maximize chronic obstructive pulmonary
disease prior to surgery.
The patient was taken to the operating room on [**2131-12-6**] and underwent T3 to T7 laminectomy and T4 epidural
hematoma evacuation without intraoperative complications.
Postoperatively, the patient had no movement in the lower
extremities; as per preoperative status. His vital signs
were stable. The patient was afebrile. He had a Swan-Ganz
catheter in place and remained in the Recovery Room for close
monitoring for his chronic obstructive pulmonary disease and
volume status.
On [**12-7**], the patient's neurologic examination revealed
he had [**2-28**] iliopsoas on stimulation in the bilateral lower
extremity, [**12-31**] voluntary plantar flexion on the left, [**1-31**]
voluntary dorsiflexion on the left, and nothing on the right
to dorsiflexion stimulation. Reflexes were absent. He toes
continued to upgoing. His dressing was clean, dry, and
intact.
The patient continued to be followed by the Medicine Service
to maximize his pulmonary status. The patient was fitted for
a TLSO brace. The patient was out of bed in his brace with
the Physical Therapy Service. They recommended acute
rehabilitation.
DISCHARGE DISPOSITION: The patient was transferred to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Percocet one to two tablets by mouth q.4h. as needed
(for pain).
2. Lasix 20 mg by mouth once per day.
3. Pantoprazole 40 mg by mouth once per day.
4. Miconazole powder topically as needed.
5. Albuterol nebulizers 1 to 2 puffs inhaled q.6h. as
needed.
6. Insulin sliding-scale.
7. Heparin 5000 units subcutaneously q.12h.
8. Ipratropium bromide nebulizer q.6h. as needed.
9. Digoxin 0.25 by mouth every day.
10. Prednisone 40 mg by mouth once per day.
11. Senna one tablet by mouth twice per day.
12. Colace 100 mg by mouth twice per day.
13. Milk of Magnesia 30 cc by mouth q.6h. as needed.
14. Tylenol 650 mg by mouth as needed.
The patient continued to be followed by the Medicine Service
who recommended tapering steroids when the patient's
pulmonary status improved. Also, a transthoracic
echocardiogram which was to be done on [**12-10**].
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: The patient was to be discharged to
rehabilitation in stable condition.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to have staples to be removed
on postoperative day 10.
2. The patient was instructed to follow up Dr. [**Last Name (STitle) 739**]
in two to three weeks' time.
Patient may have HOB<30-40 degrees when not wearing the brace.
He should ambulate with brace.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2131-12-10**] 09:57
T: [**2131-12-10**] 10:25
JOB#: [**Job Number 31941**]
|
[
"733.00",
"E888.9",
"507.0",
"491.21",
"427.31",
"515",
"806.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
4350, 4418
|
4445, 5378
|
5568, 6101
|
2975, 4326
|
5393, 5535
|
114, 2946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,413
| 177,715
|
39420
|
Discharge summary
|
report
|
Admission Date: [**2196-10-26**] Discharge Date: [**2196-11-4**]
Date of Birth: [**2122-3-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
BenGay
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
Ascending aorta and hemiarch replacement [**2196-10-28**]
History of Present Illness:
Mr. [**Known lastname 32296**] is a 74 year old male who was seen by Dr. [**Last Name (STitle) **] for
an aortic aneurysm that was incidently found 1 year ago. A
recent CT scan of his aorta showed his aneurysm to measure 5cm
where it was 4.8cm in [**2195-8-6**]. Given the progression of his
disease, he was referred to Dr. [**Last Name (STitle) 914**] for consultation. His
review determined aorta to be 5.2 cm. he will need will need his
aneurysm repair prior to hip surgery.
Past Medical History:
Aortic aneurysm
AV block Mobitz 1
Remote pericarditis
Jaundice as a teenager
Osteoarthritis
BLE varicosities
Dyslipidemia
Hypertension
Migraines
Chronic back pain
Depression
Sleep apnea ( has not been able to use CPAP in past)
Atrial fibrillation
Vitamin D Defficiency
One kidney from a remote injury playing football
Occasional testicular pain ( Rx neurontin)
Ventral hernia
Left Nephrectomy at age 15
Appendectomy
Back surgery for ruptured disc
Hand surgeries
Partial Left knee replacement [**6-14**]
Social History:
Mr. [**Known lastname 32296**] lives with his wife and is a retired banker. He
smoked his last cigarette 40 yrs ago and has a 40-45 pack-year
history. He drinks 2-7 alcoholic beverages per week.
Family History:
non-contributory
Physical Exam:
Pulse: 54 Resp: 18 O2 sat: 98%
B/P Right:121/80 Left: 124/79
Height: 5'[**96**]" Weight: 215 lbs
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade _-none_____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]; no HSM
Extremities: Warm [x], well-perfused [x] Edema [] _none____
Varicosities: severe BLE
Neuro: Grossly intact [x]; MAE 5./5 strengths; nonfocal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: Left:
Carotid Bruit Right: none Left:none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87122**] (Complete)
Done [**2196-10-28**] at 9:24:12 AM FINAL
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: [**2122-3-30**]
Age (years): 74 M Hgt (in): 61
BP (mm Hg): 124/79 Wgt (lb): 215
HR (bpm): 63 BSA (m2): 1.95 m2
Indication: Aortic valve disease. Atrial fibrillation. Left
ventricular function.
ICD-9 Codes: 427.31, 424.1, 441.2
Test Information
Date/Time: [**2196-10-28**] at 09:24 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW3-: Machine: us3
Echocardiographic Measurements
Results Measurements Normal Range
Right Atrium - Four Chamber Length: *6.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Lateral Peak E': 0.80 m/s > 0.08 m/s
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.8 cm <= 3.0 cm
Aorta - Ascending: *4.8 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Pressure Half Time: 887 ms
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No
spontaneous echo contrast in the body of the RA. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Simple atheroma in aortic
arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild to
moderate ([**2-7**]+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**2-7**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Pericardial calcifications.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. See Conclusions for post-bypass
data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The right atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the mid inferior septal wall. The remaining
segments contract normally (LVEF =55X %). Overall left
ventricular systolic function is low normal (LVEF 50-55%). with
normal free wall contractility.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild to moderate ([**2-7**]+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior mitral leaflet.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There are pericardial calcifications.
Dr. [**Last Name (STitle) 914**] was notified in person of the results before
surgical incision
POST-BYPASS:
Preserved biventricular sytolic function.
Intact thoracic aortic graft.
No new valvular findings.
Mild AI.
LVEF 55%
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2196-10-28**] 19:16
[**2196-11-2**] 06:23AM BLOOD WBC-8.2 RBC-3.41* Hgb-10.2* Hct-30.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.0 Plt Ct-191
[**2196-11-2**] 06:23AM BLOOD PT-14.0* INR(PT)-1.2*
[**2196-11-2**] 06:23AM BLOOD UreaN-34* Creat-1.1 Na-138 K-3.8 Cl-97
[**2196-11-3**] 04:58AM BLOOD WBC-8.1 RBC-3.60* Hgb-11.1* Hct-31.9*
MCV-89 MCH-30.9 MCHC-34.9 RDW-15.2 Plt Ct-218
[**2196-11-3**] 04:58AM BLOOD PT-14.6* INR(PT)-1.3*
[**2196-11-3**] 04:58AM BLOOD UreaN-30* Creat-1.2 Na-141 K-4.3 Cl-100
Brief Hospital Course:
On [**10-26**] Mr. [**Known lastname 32296**] was admitted for cardiac catheterization in
preparation for an ascending aneurysm repair scheduled for the
following day. This study revealed no significant coronary
artery disease. On [**10-28**] he underwent an ascending aorta and
hemiarch replacement, performed by Dr. [**Last Name (STitle) 914**]. Please see the
operative note for details. He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He extubated on the following day
but woke agitated and therefore received haldol. Over the next
couple of days his mental status started to clear and hid QTc
prolonged, so haldol was discontinued. Coumadin was restarted
for atrial fibrillation. His epicardial wires and chest tubes
were removed. He was transferred to the step down floor and
seen in consultation by the physical therapy service. By
post-operative day six he was ready for discharge to [**Location (un) 582**] at
[**Hospital 7658**] Rehab. The patient's expected length of stay is less
than 30 days. All appropriate follow-up appointments were
advised.
Medications on Admission:
Fiorcet 50-325mg prn
Percocet 5/325mg Three times daily
Aspirin 81mg daily
Cyclobenzaprine10mg daily
Coumadin 5mg daily for afib
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. ezetimibe 10 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 40 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. gabapentin 300 mg Capsule [**Hospital **]: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
5. furosemide 20 mg Tablet [**Hospital **]: Two (2) Tablet PO once a day for
10 days.
Disp:*20 Tablet(s)* Refills:*2*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals [**Hospital **]:
Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*2*
7. Coumadin 2.5 mg Tablet [**Hospital **]: Two (2) Tablet PO once a day: or
as directed by the office of Dr. [**Last Name (STitle) 82226**] [**Name (STitle) **] [**Telephone/Fax (1) 87123**],
ask for [**Doctor First Name **] or [**Doctor First Name **].
Disp:*60 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
INR check on [**11-4**] with results to the office of Dr. [**Last Name (STitle) 82226**]
[**Name (STitle) **] [**Telephone/Fax (1) 87123**], ask for [**Doctor First Name **] or [**Doctor First Name **]. INR goal for
afib is 2-2.5
9. tramadol 50 mg Tablet [**Doctor First Name **]: One (1) Tablet PO every four (4)
hours as needed for pain.
10. docusate sodium 100 mg Capsule [**Doctor First Name **]: One (1) Capsule PO BID
(2 times a day).
11. magnesium hydroxide 400 mg/5 mL Suspension [**Doctor First Name **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. acetaminophen 325 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. bisacodyl 10 mg Suppository [**Doctor First Name **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Doctor First Name **]: One (1) Inhalation Q6H (every 6 hours).
15. ipratropium bromide 0.02 % Solution [**Doctor First Name **]: One (1) Inhalation
Q6H (every 6 hours).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
18. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
Aortic aneurysm, AV block Mobitz 1, remote pericarditis,
jaundice(teenager), osteoarthritis, BLE varicosities,
Dyslipidemia, Hypertension, Migraines, Chronic back pain,
Depression, Sleep apnea, Atrial fibrillation, Vitamin D
Deficiency, One kidney(remote injury playing football), occ.
testicular pain(Rx neurontin), ventral hernia
PSH: Left Nephrectomy(15yo), Appendectomy, Back surgery-ruptured
disc,
Hand surgeries, Partial Left knee replacement([**6-14**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] on [**12-13**] at 2:00pm
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] ([**Location (un) **])on [**11-25**] at 11:30am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**Last Name (STitle) **] [**Telephone/Fax (1) 82227**] in [**5-10**] 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 for afib
Goal INR 2-2.5
First draw [**11-4**]
Results to phone [**Telephone/Fax (1) 87123**], ask for [**Doctor First Name **] or [**Doctor First Name **] [**First Name8 (NamePattern2) **]
[**Doctor First Name **]
Completed by:[**2196-11-3**]
|
[
"V58.61",
"416.8",
"427.31",
"V45.73",
"V70.7",
"496",
"441.2",
"401.9",
"423.1",
"511.9",
"458.29",
"454.9",
"426.13",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"38.45",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12018, 12095
|
8122, 9268
|
287, 347
|
12599, 12812
|
2425, 5801
|
13736, 14622
|
1612, 1630
|
9447, 11995
|
12116, 12578
|
9294, 9424
|
12836, 13713
|
5850, 8099
|
1645, 2406
|
234, 249
|
375, 855
|
877, 1381
|
1397, 1596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,704
| 197,901
|
16789
|
Discharge summary
|
report
|
Admission Date: [**2188-2-6**] Discharge Date: [**2188-2-15**]
Date of Birth: [**2149-10-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old
gentleman with history of metastatic renal cell carcinoma
with metastases to the left hip, thoracic spine, lungs,
status post XRT to the left hip, thoracic spine and cervical
spine. The patient presents with five day history of lower
extremity weakness and inability to walk with sensory
deficits. The patient finished XRT to the cervical spine
five days prior to admission and noted left leg weakness at
that time. Three days ago, noted swelling and coldness and
numbness below the knee on the left leg. Last two days,
noted increased weakness of the right lower extremity. No
complaints of nausea, vomiting, diarrhea, positive
constipation, no bowel or bladder incontinence.
PHYSICAL EXAM:
VITAL SIGNS: Temperature is 98.2??????, blood pressure 138/70,
pulse 76, respiratory rate 24, saturations 97% on room air.
GENERAL: Patient is in no acute distress.
CHEST: Positive crackles at the left base, clear with cough.
CARDIAC STATUS: Regular rate and rhythm, no murmur, rub or
gallop.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds.
EXTREMITIES: Left lower extremity has some edema, but
positive pedal pulses and cool to the touch. Right lower
extremity no cyanosis, clubbing or edema and positive pedal
pulses.
NEUROLOGIC: Patient is awake, alert and oriented x3.
Cranial nerves II through XII are intact. His motor strength
in his upper extremities is [**4-28**]. He has no drift. Sensation
is intact to light touch in his upper extremities. In his
lower extremities, his motor strength, his right IP is at 2,
quad is 3, hamstring 3, AT 4, [**Last Name (un) 938**] 3, gastrocnemius 3. On the
left, he has 0 IP, 0 quad, 0 hamstrings, 0 AT, 1 [**Last Name (un) 938**] and 3
gastrocnemius. His reflexes are 2+ in the upper extremities,
3+ at the knees and 2+ at the ankles. He has sustained
clonus bilaterally. His joint position sense is intact.
RECTAL: His rectal tone is normal and his sensation is
intact to light touch throughout.
IMAGING: Patient had an MRI of the thoracic spine that
showed compression fracture at the renal cell metastatic
disease to the T4-T5 level. CT of the abdomen shows a left
kidney mass.
HOSPITAL COURSE: The patient was taken to the angio suite,
had a spinal embolization of the T4-T5 metastatic tumor and
then on [**2187-2-10**], patient underwent a T3-T4 transpedicular
decompression, T1 to T8 segmental fusion using rod, hook and
construct. The patient had no interoperative complications
postoperatively. The patient was awake, alert and oriented
x3, moving all extremities. His motor strength in his lower
extremities was 4+ IP on the right, 4 on the left. Quads
were 5, AT is 5- on the right, 4- on the left. [**Last Name (un) 938**] was 4 on
the right, 3 on the left. Gastrocnemius was 5 on the right,
4 on the left. His sensation was intact to light touch. His
dressing was clean, dry and intact. He had two JP drains in
place that were removed on postoperative day #3. He had
repeat thoracic spine films postoperative which showed good
positioning of the instrumentation. He was out of bed
ambulating with physical therapy, tolerating regular diet,
voiding spontaneously.
He will be discharged to acute rehabilitation with follow up
with Dr. [**Last Name (STitle) 1327**] in one week for staple removal and with
oncology for potential chemotherapy.
DISCHARGE CONDITION: Stable at the time of discharge.
DISCHARGE MEDICATIONS:
1. Morphine sulfate IR 20 to 40 mg po q3h prn
2. Protonix 40 mg po q day
3. Lorazepam 1 mg po q8h prn
4. Heparin 5000 units subcutaneous q 12 hours
5. Morphine sulfate sustained release 90 mg po q8h
6. Senna 1 tablet po q hs
7. Colace 100 mg po bid
8. Dulcolax 10 mg po q day prn
FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) 1327**] in one week for
staple removal. Follow up with the oncology service for
potential chemotherapy in two weeks.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2188-2-14**] 09:31
T: [**2188-2-14**] 09:35
JOB#: [**Job Number 16302**]
|
[
"729.81",
"197.0",
"336.3",
"530.81",
"V15.3",
"198.5",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.49",
"03.09",
"84.51",
"99.29",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
3557, 3591
|
3614, 3903
|
2368, 3535
|
887, 2350
|
3915, 4347
|
160, 872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,365
| 189,913
|
49259
|
Discharge summary
|
report
|
Admission Date: [**2181-12-22**] Discharge Date: [**2181-12-26**]
Date of Birth: [**2130-11-15**] Sex: F
Service: MEDICINE
Allergies:
Abacavir / Vancomycin / Haldol / Heparin Agents / Bactrim Ds /
Actonel
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD w/ banding to stomach + esophagus
History of Present Illness:
51 female with history of HIV infection, HCV cirrhosis s/p
orthotopic transplant in [**2179**] c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear and
varicies, pancytopenia, who presents after one episode of
hematemesis at approximately 2pm the day prior to admission. She
reports a large volume of blood, with clots, and pain in the
RLQ, along with nausea. She talked to her visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 103262**], who recommended that she come to the ED for
further evaluation.
.
In the ED, access was difficult to obtain, and a right femoral
TLC was eventually placed. No NG lavage was performed (as it
would not change management). Hepatology was consulted and plans
to perform urgent EGD in the ICU this morning. On arrival to the
ICU, an octreotide drip was started. GI was called and planned
urgent endoscopy. Two units of pRBC's were sent for crossmatch
(difficult crossmatch). Nicotine patch was started.
.
Of note, most recent EGD [**2181-11-21**] demonstrated Grade 1 varicies,
not actively bleeding. No blood in stomach or duodenum.
.
Review of Systems: Currently unable to obtain, as just received
sedation for EGD.
Past Medical History:
# HIV, last CD 4 count 80 and VL <50 in [**11-14**]
# HCV s/p liver transplant 2/[**2179**]. Transplant complicated by a
anhepatic period x 24 hours due to edematous primary transplant
necessitating second liver, Also complicated by PE with
placement of IVC filter. Recent liver biopsy [**11/2181**] showed
rurrent HCV (grade 2 inflammation and stage 3 fibrosis) -
currently being monitored.
Last VL [**2181-10-8**] 1,170,000 IU/mL -followed by Dr. [**Last Name (STitle) 497**] and Dr.
[**Doctor Last Name 724**]
# Pancytopenia: w/u Wih Dr. [**Last Name (STitle) 103261**] [**8-/2181**] (see note), BM biopsy
consistnet with HIV related anemia.
# Heparin-induced thrombocytopenia
# Chronic methadone use: recently stopped, now on oxycontin
# Depression - on celexa
# Fibromyalgia/Chronic Pain
# CRI (baseline creat 1.3-1.9)
# Anemia: baseline 28-30, BM bx thought c/w HIV related anemia
# H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear
# H/O Internal hemorrhoidal bleed
Social History:
Lives with boyfriend in [**Name (NI) 1411**]. Works in family restaurant.
Substance abuse counsellor. Divorced. Former IV heroine, cocaine
user. Tob: 1ppd, no EtOH.
Family History:
Mother with [**Name2 (NI) **], breast CA, AMI; Father with MI. Brother with
IVDU, sister with asthma. Uncle with [**Name2 (NI) 499**] CA.
Physical Exam:
VITALS: BP 108/67, HR 95, RR 23, Sat 95%RA
GENERAL: Somnolent, but appropriate, no acute distress
HEENT: Anicteric, PERRL
NECK: No JVD, no lymphadenopathy
CARD: RRR, normal S1/S2, [**3-13**] holosytolic murmur heard loudest at
LUSB
RESP: CTA bilaterally
ABD: Distended, tympanic. No rebound, voluntary guarding.
Decreased bowel sounds.
EXT: Trace edema bilaterally. 2+ DP pulses.
Pertinent Results:
Na 140 K 3.3 Cl 104 HCO3 28 BUN 20 Creat 1.6 Gluc
123
Ca: 8.3 Mg: 2.2 P: 3.4
.
ALT: 13 AST: 28 Tbili: 0.9 Alb: 3.3
[**Doctor First Name **]: 48 Lip: 51
.
WBC 2.2 Hgb 7.8 Hct 23.3 Plt 64 MCV 100
N:66.5 L:21.5 M:8.5 E:3.1 Bas:0.3
.
PT: 12.5 PTT: 28.9 INR: 1.1
.
<b>STUDIES:<b/>
EKG [**12-22**]: Sinus tachycardia at 93 bpm, no ischemic changes.
.
EGD [**2181-12-22**]:
Esophagus:
Protruding Lesions 1 cords of grade I varices were seen in the
lower third of the esophagus. The varices were not bleeding.
Stomach:
Mucosa: Granularity and mosaic appearance of the mucosa were
noted in the whole stomach. These findings are compatible with
portal hypertensive gastropathy.
Protruding Lesions A single varix with a cherry red spot was
seen in the cardia. It began spurting during the procedure. A
band was placed on the varix just below the spurting area and
hemostasis was achieved. A second band was placed on the varix
above the area which had been bleeding. 2 bands were
successfully placed.
Duodenum: Normal duodenum.
.
Abd U/S [**2181-12-22**]:
Son[**Name (NI) 493**] imaging in all four quadrants of the abdomen was
performed. A small amount of ascites is seen in the midline
sagittal above the bladder and left lower quadrant. There is no
right fluid pocket.
.
Abd XR [**2181-12-22**]:
Again seen is the IVC filter in similar location compared to the
prior study. There is a right femoral line. This is a single
supine film
only and there are few gas-filled loops of bowel, presumed
[**Month/Day/Year 499**], none of
which appear dilated. An upright or decubitus film would be
needed to
complete this abdominal series.
.
[**2181-12-25**] 04:40AM BLOOD B-GLUCAN-PND
[**2181-12-25**] 04:40AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2181-12-25**] 04:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
[**2181-12-24**] 06:00AM BLOOD FK506-6.3
[**2181-12-25**] 04:40AM BLOOD FK506-5.9
[**2181-12-26**] 05:10AM BLOOD FK506-4.7*
[**2181-12-26**] 05:10AM BLOOD VitB12-675 Folate-12.7
[**2181-12-22**] 04:11PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-POS amphetm-POS mthdone-POS
[**2181-12-25**] 01:57PM URINE bnzodzp-POS barbitr-NEG cocaine-POS
amphetm-NEG mthdone-POS
[**2181-12-25**] 01:57PM URINE HISTOPLASMA ANTIGEN-PND
Brief Hospital Course:
Patient is a 51 year old female with h/o HIV, HCV cirrhosis s/p
orthotopic transplant [**2179**], here with acute GI bleed most likely
variceal, without further bleeding and stable hematocrit.
Hospitalization was complicated by a fall with wrist fracture
and head trauma.
.
# Illicit Drug Use
Patient arrived w/ a positive toxicology screen for
amphetamines, opiates, methadone, and cocaine. She reported
taking cocaine intranasally and her boyfriend's methadone. prior
to admission. While in house there was concern that she was
continuing to use illicit substances; a repeat urine tox was
repeated w/ persistently positive cocaine. She frequently went
outside (off the floor) to "smoke a cigarette" against hospital
policies. She was directed many times to not leave the floor,
but did not adhere to these rules. She often was found to be
somnolent in her room, despite a lowered dose of oxycodone. She
denied using illicit drugs while inpatient; she was counseled on
drug use and offered support, which she declined.
.
# Fall / wrist fracture
The patient suffered a mechanical fall in her room toward the
end of the hospitalization. The details are unclear (all
history from the patient), however she fell while going to the
bathroom. Afterward she proceeded to go downstairs to smoke a
cigarette until she was found by a nurse to be bleeding from her
head. She was evaluated and not found to have had LOC. CT scan
was performed and found to be unremarkable; neurologic exam was
unchanged from baseline. X-rays of the right wrist were taken,
and showed distal ulnar, radial, and triqeutrum fractures.
Orthopedics reset the fractures and placed a soft brace. A 1:1
sitter was provided to reduce fall [**Last Name (un) **]. PT and OT were
consulted, and recommended home care w/ 24 hr support and
observation. Her boyfriend offered to do this, and she was
discharged home. She was scheduled to follow up in ~ 1 week for
a hard cast placement and possible surgery.
.
# Upper GI bleed
Patient presented w/ gross hematemesis. Recent EGD in [**11/2181**]
demonstrated grade 1 esophageal varices. Received one dose of
ceftriaxone in ED. Pt was maintained on IV PPI [**Hospital1 **]. EGD done
in ICU with transient intubation due to agitation despite
anaesthesia. Underwent variceal banding to stomach and
esophageal varicies. Pt was succefully extubated post-procedure
and transfused one unit of PRBC. Pt was transferred to medical
floor, where [**Hospital1 **] hcts were found to be stable. The femoral line
was removed (since the patient was ambulating against medical
advice w/ the line in place). An IJ line was placed for access
in case of emergent bleed. BP and other hemodynamics were also
stable after five days of observation. She was discharged to be
followed up w/ Dr [**Last Name (STitle) 497**] in 2 weeks for repeat EGD. She was
restarted on home nadolol for prophylaxis.
.
#) Acute renal failure on CKD.
Baseline 1.3-1.4. Peak 1.7. After IVFs trended down toward
baseline. For CKD, truvada dose was adjusted for low creat
clearance to q 48 hrs dosing.
.
#) HIV.
Chronically low CD4 counts (last CD4 80 on [**2181-11-8**]), viral load
undetectable, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. Truvada dose was
changed to q 48 hrs. Otherwise, she was continued on HAART, and
dapsone/azithromycin. She is scheduled to see Dr. [**Last Name (STitle) 724**] shortly.
.
# Lung nodules
Repeat CT scanning shows increasing size of small lung nodules.
Recently saw outpatient pulmonary who recommended follow up in 3
months w/ repeat CT. She was re-evaluated by ID and pulmonary,
and 3 month follow up was suggested instead of invasive
bronchoscopy, A) due to likely limited lifespan independent of
lung pathology and B) low liklihood that bronchoscopy would bear
positive results given low burden of current disease.
.
#) Cirrhosis / S/P Liver transplant
Patient has ESLD post transplant, from repeat HCV cirrhosis.
Lasix was initially held given her UGIB. Her tacrolimus levels
were followed throughout and dosed as needed. She was given an
extra dose on Monday before discharge ([**12-20**]) given a low AM
level (she had not taken her dose on the previous Friday). On
discharge her dose was adequate and she was restarted on her
usual dosing regimen of twice weekly, Mon / Friday. Lasix was
not restarted since she appeared euvolemic. This was deferred
until outpatient follow up..
.
#) Tobacco abuse.
Patient was counseled to stop smoking. She initially absconded
off the floor to smoke, but then was prevented from doing so. A
nicotine patch was provided when not able to smoke. Upon
discharge, and after discussion with pulmonary, the patient
agreed to attempt to quit smoking w/ treatment. A prescription
for varenecline was provided to start upon discharge.
.
#) Depression. Continued citalopram.
.
#) History of HIT. No heparin products were given.
Medications on Admission:
- Azithromycin 600 q Thursday
- Citalopram 60 qd
- Dapsone 100 qd
- Marinol 10 [**Hospital1 **]
- Truvada 200-300 qd
- Epo 40,000 units qweek
- Lasix 20 qd
- Ativan 1mg [**Hospital1 **] prn
- Nelfinavir 1250 [**Hospital1 **]
- Oxycontin 40 [**Hospital1 **]
- Oxycodone 5 prn
- Phenergan 25 prn
- Prograf 0.5 twice weekly (Monday/Friday)
- Nadolol 20mg daily
- Ibandronate 3 mg IV (q 3 months, last [**9-14**])
Discharge Medications:
1. Azithromycin 600 mg Tablet Sig: One (1) Tablet PO QTHUR
(every Thursday).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Dronabinol 2.5 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
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.
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO TWICE
WEEKLY ().
11. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO Q48H (every 48 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
15. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: One (1)
Tablets, Dose Pack PO once a day: Days [**1-10**]: 0.5 mg once daily;
Days [**4-14**]: 0.5 mg twice daily; after week 1 take 1 mg twice
daily.
Disp:*30 Tablets, Dose Pack(s)* Refills:*2*
18. Epogen 40,000 unit/mL Solution Sig: One (1) Injection once
a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-AIDS
-HCV
-Gastric + Esophageal varicies and bleeding
Secondary
- tobacco abuse
- lung nodule, NOS
Discharge Condition:
Hemodynamically stable.
With chronic abdominal pain.
With pain in right arm from fracture.
Discharge Instructions:
You were admitted to the hospital with upper GI bleeding
(vomiting up blood). You were found to have bleeding in your
esophagus and stomach; these arteries were banded and the
bleeding stopped. You were also seen by pulmonology in house
who recommended that you follow up in 6 months w/ repeat CT
scan.
.
You should stop smoking and using drugs. This will seriously
shortnen your life expectancy.
.
Med changes:
1. You should take truvada only 1 time every two days instead of
daily.
2. You should stop taking lasix. This will be re-addressed as
an outpatient.
3. Start taking calcium and vitamin D supplementation
4. Start taking chantix again.
.
You were also found to have a wrist fracture after falling in
the hospital. This was re-set while here. You need to follow
up with the orthopedic surgeon next week to determine if you
need surgery and for a cast to be placed. Keep your arm
elevated to reduce the swelling.
.
If you experience the following call your doctor or return to
the ED for evaluation: fevers, chills, vomiting, nausea,
lightheadedness, dark black stool, tarry stool, blood in the
stool, vomit with blood.
Followup Instructions:
Please keep the below appointments:
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2181-12-27**] 2:30
.
[**Month/Day/Year **]:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-1-3**] 7:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-1-3**] 8:00
.
[**2182-1-10**] 12:00p
[**Last Name (LF) **],[**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) 26**]
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
.
You will need repeat endoscopy in 2 weeks. Dr.[**Name (NI) 948**] office
will reschedule you for this appointment and contact you by
telephone.
.
You will need a CT scan in 3 months. You will then follow up
with Dr. [**Last Name (STitle) 4507**] in pulmonary. His office will contact you for
an appointment. Call ([**Telephone/Fax (1) 513**] with questions or if you do
not hear from then in 2 weeks to make this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"585.9",
"070.54",
"284.1",
"305.60",
"042",
"729.1",
"456.20",
"584.9",
"285.29",
"571.5",
"537.89",
"E888.9",
"996.82",
"456.8",
"813.44",
"578.0",
"305.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12771, 12777
|
5725, 10664
|
346, 386
|
12929, 13022
|
3430, 5702
|
14205, 15418
|
2876, 3015
|
11124, 12748
|
12798, 12908
|
10690, 11101
|
13046, 14182
|
3030, 3411
|
1562, 1627
|
295, 308
|
414, 1543
|
1649, 2678
|
2694, 2860
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,479
| 166,181
|
46091
|
Discharge summary
|
report
|
Admission Date: [**2146-12-8**] Discharge Date: [**2146-12-17**]
Date of Birth: [**2062-1-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Cellulitis/osteomyelitis/septic right knee joint and UTI
Major Surgical or Invasive Procedure:
[**2146-12-10**] I&D, washout, and liner exchange of the right knee
History of Present Illness:
Ms. [**Known lastname 98076**] is an 84 year-old woman with DM, HTN, HLD, CKD who
had a chair break from under her one week ago now presenting
with RLE swelling and erythmea. Patient reports that she landed
on her bottom and felt well initially however in the days that
followed she had stiffer back and neck and sore right leg,
athough she was able to walk. She then noticed RLE swelling two
day prior to presentation with redness of her RLE prompting
presentation to the ED.
Initial vitals in the ED were 98.7 106 148/74 18 97% RA. On
evaluation in the ED her BLE was noted to be swollen with
pronounced erythema consistent with cellulitis on the right leg
from ankle to thigh on the posterior side. Labs in the ED were
notable for lactate of 2.8, WBC 22.4 with 92.4% PMNs and UA c/w
UTI. She was given 1g vancomycin IV and 500mg levofloxacin IV
and was planned to be admitted to the medicine service.
Subsequently she was noted to have an episode of SVT with HR to
the 160s for which she received 20mg IV and 30mg of PO diltiazem
and the decision was made to admit her to the MICU for further
care. Vitals on transfer were 110 153/43 22 99% RA.
On the floor she appears comfortable and denies numbness,
tingling, weakness, or incontinence.
Past Medical History:
Type II diabetes,
hypertension, high cholesterol,
obesity,
mild renal insufficiency, and a
previous history of asthma.
problems with balance and has swelling of her foot.
right knee replacement surgery [**2137**] and left knee replacement in
[**2143**]. colonoscopy and had a small polyp removed in [**2136**] that
was
an adenoma no repeat given age and weight have offered repeat
colonoscopy.
Bone density study [**2141**] WNL.
Social History:
Normally walks with a cane, lives in senior apartment. Pt lives
alone and son "checks in on her" once daily but does not assist
with ADL's such as bathing.
Family History:
Her father had a ruptured gallbladder and cardiovascular
disease. Her mother died at the age [**Age over 90 **] ninety-five.
Physical Exam:
Admission exam (per ortho):
General: Morbidly obese, Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils 4mm-2mm
BL
Neck: plethoric neck, supple, no LAD
Lungs: Distant lung sounds BL, summetric breath shounds, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: Obese abodmen, soft, non-tender, nomal bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: BL LE Edema with lichenification and venous stasis changes.
Erythema of RLE from ankle to thigh. Skin breakdown on the back
of the right calf with minimal drainage noted.
On transfer to Medicine:
VS: T: 97.8; BP: 106/53 (83-120/38-65); HR: 83 (83-95) ; RR: 16
99% 2L
LOS: + 4256cc
GA: Obese women, lying flat, very pleasant, A&Ox3
HEENT: EOMI, MMM. no lymphadenopathy. neck supple. JVD difficult
to assess
Cards: RRR S1/S2 heard. no murmurs rubs or gallops
Pulm: Patient was unable to turn [**1-26**] pain of right knee so
difficult to assess, but lung sounds present with no audible
rales
Abd: soft, NT ND, +BS. Organomegaly difficult to assess
Extremities: RLE wrapped with JP drain in place. LLE with
chronic skin changes, minimal pitting edema
Skin: warm and moist
Neuro/Psych: CNs II-XII intact.
Discharge Exam:
VS: 98.2, 122/58, 84, 16, 94%RA FS 100s-200s
In: 360/8hr, Out 1000 (foley)
GA: Obese women, lying flat, sleeping, comfortable, pleasant,
A&Ox3
HEENT: MMM. no lymphadenopathy. JVD difficult to assess
Cards: distant, RRR S1/S2 heard. no murmurs rubs or gallops
Pulm: CTAB. no wheezes, rales or rhonchi, good inspiratory
effort.
Abd: obese, soft, NT ND, +BS. Organomegaly difficult to assess.
Extremities: RLE wrapped, knee with stapled incision looking
clean [**Last Name (un) **] intact and healing well. Right foot with 2+ edema. LLE
with chronic skin changes, minimal pitting edema, right hand
with mild erythema around the base of the thumb stable from
yesterday.
Skin: warm and moist
Neuro/Psych: less confused this morning, A&Ox3. CNs II-XII
intact. Moving all extremities.
Pertinent Results:
Admission Labs:
[**2146-12-8**] 11:30AM BLOOD WBC-22.4*# RBC-4.12* Hgb-13.3 Hct-41.5
MCV-101* MCH-32.2* MCHC-31.9 RDW-13.0 Plt Ct-291
[**2146-12-8**] 11:30AM BLOOD Neuts-92.6* Lymphs-4.4* Monos-2.3 Eos-0.4
Baso-0.2
[**2146-12-8**] 12:33PM BLOOD PT-13.7* PTT-29.7 INR(PT)-1.3*
[**2146-12-8**] 11:30AM BLOOD Glucose-274* UreaN-38* Creat-1.4* Na-133
K-4.6 Cl-97 HCO3-20* AnGap-21*
[**2146-12-8**] 11:37AM BLOOD Lactate-2.8*
.
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos
[**2146-12-9**] 10:50 [**Numeric Identifier 98077**]* [**Numeric Identifier **]* 100* 0 0
.
Inflammatory markers:
[**2146-12-12**] 07:00AM BLOOD ESR-127*
[**2146-12-12**] 07:00AM BLOOD CRP-142.8*
Discharge Labs:
[**2146-12-17**] 07:35AM BLOOD WBC-8.9 RBC-3.25* Hgb-10.3* Hct-31.7*
MCV-98 MCH-31.7 MCHC-32.5 RDW-13.1 Plt Ct-620*
[**2146-12-17**] 07:35AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
[**2146-12-17**] 07:35AM BLOOD Glucose-104* UreaN-24* Creat-1.1 Na-136
K-4.4 Cl-103 HCO3-26 AnGap-11
Urine Analysis:
[**2146-12-8**] 11:40AM URINE Color-AMBER Appear-CLOUDY Sp [**Last Name (un) **]-1.018
[**2146-12-8**] 11:40AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-2* pH-5.0 Leuks-LG
[**2146-12-8**] 11:40AM URINE RBC-44* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
Repeat after antibiotics:
[**2146-12-10**] 01:03PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2146-12-10**] 01:03PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-SM
[**2146-12-10**] 01:03PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
Microbiology:
[**12-8**] blood culture: BETA STREPTOCOCCUS GROUP G.
[**12-8**](second bottle), [**12-9**], [**12-11**], [**12-13**] blood culture NGTD
[**12-8**], [**12-10**] urine culture negative
[**12-8**] MRSA screen negative
[**12-9**] jount fluid:GRAM STAIN (Final [**2146-12-9**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Reported to and read back by TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @1345
[**2146-12-9**].
FLUID CULTURE (Final [**2146-12-12**]):
BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH.
SENSITIVITIES PER DR [**Last Name (NamePattern4) 98078**] #[**Numeric Identifier 98079**] [**2146-12-11**].
Sensitivity testing performed by Sensititre.
SENSITIVE TO CLINDAMYCIN MIC <=0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP G
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2146-12-10**] tissue: TISSUE BONE RIGHT KNEE.
GRAM STAIN (Final [**2146-12-10**]):
Reported to and read back by [**Doctor First Name 98080**] [**Doctor Last Name 39421**] @ 2211 ON [**12-10**]
- CC7D.
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
PAIRS AND SHORT CHAIN.
TISSUE (Final [**2146-12-13**]):
BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Imaging:
[**2146-12-8**] ECG: rate 100, Sinus tachycardia. Atrial ectopy. Left
bundle-branch block.
[**12-8**]//11 ECG: rate 169, Lead V1 is missing. Regular wide
complex tachycardia which is most likely a supraventericular
tachycardia with inverted P waves noted in the inferior leads.
Compared to the previous tracing of the same date
supraventricular tachycardia is new.
[**2146-12-8**] LENIs: No evidence of deep vein thrombosis in the right
lower extremity.
[**2146-12-8**] CT c-spine: 1. No acute fractures. Severe multilevel
degenerative changes. 2. Chronic bilateral maxillary sinus
disease.
[**2146-12-8**]: CXR: no pneumonia
[**2146-12-8**] Right wrist: No acute fracture or dislocation.
Moderate-to-severe
osteoarthritis of the first CMC and triscaphe joints.
[**2146-12-8**] right hip: No fracture or dislocation.
[**2146-12-8**] lumbosacral spine xray: No definite fracture or
subluxation.
[**2146-12-9**] ECG: rate 97, Artifact is present. Probable sinus
rhythmn with atrial eactopy. The P-R interval is 180
milliseconds. Left bundle-branch block. Compared to the previous
tracing of [**2146-12-8**] supraventricular tachycardia is no longer
present.
[**2146-12-9**] right knee xray: Limited examination due to body
habitus. Probable joint effusion. However this is difficult to
evaluate. Prior total knee arthroplasty. The hardware appears
intact. No definite peri-hardware lucency. No definite fracture
identified, however no true AP and lateral views were provided.
No definite dislocation.
IMPRESSION: Limited examination as above. No definite acute
abnormality.
[**2146-12-10**] right wrist xray: As compared to the prior study, there
is no substantial change with diffuse demineralization of the
osseous structures that were imaged. There is no evidence of
fracture or dislocation seen.
Severe degenerative changes of the first carpometacarpal joint
and triscaphe joint are noted with joint space narrowing,
subchondral sclerosis, and osteophyte formation, unchanged since
the prior study. No interval development of soft tissue
swelling, or subcutaneous or periarticular" gas is noted.
[**2146-12-12**] Echo: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. 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%). The aortic valve leaflets (?#) appear
grossly normal with good leaflet excursion. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears grossly structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. IMPRESSION:
Very suboptimal image quality. No definite vallvular pathology
or pathologic valvular flow identified. Normal left ventricular
cavity size with low normal global systolic function. Compared
with the report of the prior study (images unavailable for
review) of [**2136-7-3**], the severity of mtiral regurgitation is
now reduced.
[**2146-12-15**] TEE: Overall left ventricular systolic function is
normal (LVEF>55%). There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. No masses or vegetations
are seen on the aortic valve. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion. IMPRESSION: No evidence of
endocarditis.
Brief Hospital Course:
84 year-old woman with DMII, HTN, HLD, obesity and CKD presented
one week after a mechanical fall with right knee Group G strep
cellulitis, septic joint, and evidence of osteomyelitis of the
surrounding bones, as well as a UTI.
.
# Septic Joint/Osteomyelitis: Joint tap of the right knee showed
impressive septic joint, growing group G strep. Patient was
admitted to the unit after a run of SVT. Orthopedic surgery took
the patient to the OR and performed a right knee washout with
replacement of the plastic liner on [**2146-12-10**]. A JP drain was
placed for several day which drained serosanginous fluid. Tissue
and bone samples also growing Group G strep, pansensitive.
Patient was inititially started on vancomycin and levofloxacin
in the ED, but was broadened to Vanc/Zosyn in the unit, and then
switched to ceftriaxone once the cultures returned on [**12-11**]. ESR
(127), CRP (142.8), suggestive of osteomyelitis as well. Bone
sample also growing Group G strep. Midline catheter was placed
(there was difficulty advancing the PICC further). Infectious
disease was consulted and recommended at least 6 weeks of
ceftriaxone and weekly blood monitoring. Patient will have OPAT
monitoring in the outpatient setting ([**12-30**]). TTE study was
suboptimal but did not show vegetations on the valves. TEE did
not show any valvular vegetations. JP drain was removed 2 days
prior to discharge to rehab. Joint was bandaged with dry sterile
dressings during admission. Pain was managed initially with
dilaudid and transitioned to oxycodone.
.
#. Point tenderness and erythema over right wrist: Erythema and
tenderness is surrounding a previous IV site, which suggests
previous infilration by the IV. Xray more consistent with
osteoarthritis. Appearance is somewhat suggestive of a
cellulitis, however it has been improving since administration
of ceftriazone. It has also been treated with warm compresses.
.
#. UTI: Patient had a grossly positive UA with WBC greater than
assay and many bacteria. Initial urine culture was mixed flora
and second culture, after antibiotic administration, was
negative. Patient remained asymptomatic. Continued ceftriaxone
should adequately treat the infection.
.
#. Hypoxemia: Upon transfer from the MICU, patient was 5L above
her normal weight with an oxygen requirement. She was lying flat
and breathing comfortably on 2L nasal cannula. Patient was
given lasix 20mg IV and put out 4L of urine. Soon after, patient
was weaned off supplemental oxygen and breathing comfortably on
room air. Echo shows EF>55%.
.
#. SVT: Patient had a single observed run of SVT to 160s in the
ED likely secondary to infection. No repeat episode has been
observed. Patient was monitored in the MICU and transferred to
the floor, shortly after without any further events. During her
hospitalization, she remained on diltiazem. It was discontinued
several days prior to discharge without any further events.
.
#. DMII: Held oral diabetic medications while inpatient.
Continued home lantus therapy and covered with an ISS. Finger
sticks remained in the mid 100s - mid 200s.
.
#. HTN: Initially held lisinopril for concern of low blood
pressure and recurrence of SVT, but we were able to restart it
without any issues. Patient was also in diltiazem initially on
admission. Just prior to discharge, lisinopril with discontinued
for a rising creatinine (1.2) and K+ (5.2). Blood pressures were
monitored and systolics were below 140.
.
#. HLD: Continued statin therapy.
.
#. CKD: Initially held lisinopril for low blood pressure. It was
restarted prior to discharge, but again discontinued for rising
K+ and Creatinine. Urine Lytes were unrevealing and her
creatinine improved on [**2146-12-17**].
.
Transitional Issues:
- Foley Pulled [**2146-12-17**] at 7:30am, if does not urinate will need
Foley replacement and another trial of voiding in [**4-30**] days.
Patient will go to rehab to build up her strength.
Additionally, she will have follow up with Infectious Disease at
[**Hospital 4898**] clinic and weekly lab draws. She will also need to
schedule an appointment with her original orthopedic surgeon to
decide whether she will require further treatment of her knee or
replacement of the hardware present.
Medications on Admission:
Glimepiride 4mg [**Hospital1 **]
Metformin 250 mg [**Hospital1 **]
Lisiniprol 20 mg
Simvastatin 40
aspirin 81 mg
Januvia 100 mg
Levemir Insulin 55 units daily
Discharge Medications:
1. glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
2. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levemir 100 unit/mL Solution Sig: Fifty Five (55) units
Subcutaneous once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
Disp:*30 packet* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Do not exceed 4gm a day.
Disp:*100 Tablet(s)* Refills:*0*
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
12. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Continue until
the Infectious Disease specialists tell you to stop.
Disp:*84 grams* Refills:*0*
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*20 syringes* Refills:*1*
14. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 2 weeks.
Disp:*28 syringes* Refills:*0*
15. Outpatient Lab Work
Weekly labs while on Ceftriaxone: Please draw CBC with
differential, Basic Metabolic Panel, Liver Function Tests, ESR,
CRP and fax results to Infectious Disease at #[**Telephone/Fax (1) 1419**].
16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis: Septic knee
Secondary Diagnosis: Type II diabetes, hypertension, high
cholesterol, obesity, mild renal insufficiency, and a previous
history of asthma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 98076**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for an infection in your knee
which required a surgical procedure to remove the infected
material. The plastic liner in your knee was replaced during
the procedure. You were treated with antibiotics and are doing
better, although you will need to continue intravenous
antibiotics as an outpatient to fully treat the infection and
you will need to go to a rehabilitation facility to get your
mobility back. You should follow up with the infectious disease
specialists (see appointment below) and with your original
orthopedic surgeon at [**Hospital6 **].
The following medications were ADDED:
CONTINUE Ceftriaxone 2gm intravenously one time daily - course
will be decided by Infectious disease physicians.
TAKE tylenol 650mg every 4 hours as needed for pain. Do not
exceed 4gms per day.
TAKE oxycodone 5mg by mouth every 6hours as needed for pain.
CONTINUE lovenox 30mg 1 syringe twice daily, continue for 2
weeks
TAKE Lisinopril 10mg (you used to take 20mg) by mouth daily.
While on all these pain medications you are at risk risk for
constipation. Please take the following medications regularly
to keep your bowel movements soft.
TAKE senna 1 tablet by mouth twice daily.
TAKE docusate sodium 1 tablet twice a day by mouth.
TAKE Miralax 1 packet by mouth daily.
Please continue your other medications as prescribed. No other
changes have been made.
Followup Instructions:
Please schedule an appointment with your primary care doctor
after your leave rehab. Dr[**Doctor Last Name **] office number is:
#[**Telephone/Fax (1) 682**].
Please schedule a follow up appointment with the original
orthopedic surgeon that first operated on your knee. You should
schedule this appointment for as soon as possible.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2146-12-30**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2147-1-10**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will additionally need weekly blood draws for monitoring
while you are on the intravenous antibiotics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"V43.65",
"727.09",
"799.02",
"730.26",
"038.0",
"278.01",
"599.0",
"E878.1",
"585.9",
"427.89",
"995.91",
"682.4",
"403.90",
"996.66",
"250.00",
"711.06",
"715.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"84.56",
"80.76",
"88.72",
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17829, 17872
|
11581, 15293
|
362, 432
|
18087, 18087
|
4568, 4568
|
19761, 20977
|
2348, 2475
|
16019, 17806
|
17893, 17893
|
15836, 15996
|
18263, 19738
|
5269, 7924
|
2490, 3754
|
3770, 4549
|
15314, 15810
|
266, 324
|
460, 1706
|
17945, 18066
|
4584, 5253
|
17912, 17924
|
7960, 11558
|
18102, 18239
|
1728, 2159
|
2175, 2332
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,402
| 113,230
|
2637
|
Discharge summary
|
report
|
Admission Date: [**2156-5-5**] Discharge Date: [**2156-6-3**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve / Codeine / Depakote
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status after dialysis on [**2156-5-5**]
Major Surgical or Invasive Procedure:
Thoracentesis
Central Line Placement (left IJ)
Lumbar puncture
PICC line placement
Dialysis
History of Present Illness:
72F h/o T2DM, ESRD on HD, GAVE, HTN, MR, CAD, CHF w/ RV failure
and seizure disorder who presented to the ED on [**5-5**] after
experiencing somnolence at dialysis. It is not known how much
fluid was removed during HD. The pt has no recollection of being
at dialysis. In the ED, she stated that she felt fine, and
denied HA, vision changes, nausea, weakness, or sensory changes.
She also specifically denied any f/c/ns, abdominal pain, or CP.
She did report a non-productive cough for several days and
gradually worsening shortness of breath.
.
ED course: VS: 97.4, 121, 104/68, 14, 91RA
Ms. [**Known lastname **] mental status cleared throughout her course in the
ED.
She had no leukocytosis, and chem 7 was notable for K 2.7, Mg
1.5, Phos 0.5, with new mild elevations in her transaminases,
alk phos and Tbili. CT head was negative. CXR with improving
effusion but satting 91% RA. RUQ U/S was done given elevated
LFTs: there was a negative son[**Name (NI) 493**] [**Name2 (NI) **] sign, and
echogenic focus within GB wall c/w sludge, unchanged from [**Month (only) **]
[**2155**]. Levaquin was given for possible PNA. Pt also received
gentle IVF (1L NS), potassium and D50 as her BG was in the 60s
and her K was 2.7. HR improved slightly to the 100s at
admission.
Of note, shortly after being transfered to the floor, she
developed [**Year (4 digits) **]. She was triggered and transfered to the
MICU.
Past Medical History:
* Chronic Gastric Angiodysplasia (GAVE)and consequent chronic
low-grade UGIB, and has therefore been advised not to take
aspirin or other antiplatelet agents.
* DM type II: c/b nephropathy and neuropathy - currently not on
diabetic meds, has hypoglyemia [**12-27**] poor nutritional stores
* ESRD: HD MWF has fistula L arm
* CAD
* CHF, R-sided, [**Month/Day (2) 7216**] EF 50-55% with 4+ TR 2+ MR [**8-/2155**]
TTE, and in ICU with this admission
* Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
* colon polyps (hyperplastic) [**7-/2153**] colonoscopy
* gastritis and duodenitis [**7-/2153**] EGD
* gout
* pleural effusion s/p thoracentesis [**8-/2153**] negative cytology,
chemistry c/w exudate
* Seizure disorder -dose not know how seizures manifest
Social History:
Pt lives at [**Location **]. No ETOH, tobacco, or drugs.
Pt has four children, all involved in her care. There were
several family meetings during this admission with all her
children. They are very supportive and close family. No health
care proxy is assigned at this time ([**2156-5-31**]). She is aware that
she needs to choose one.
.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother
had an MI in her 80s.
Physical Exam:
At time of admission:
Physical exam:
VS: 97.3 102/palp 118 16 972L
Gen: elderly female in NAD.
HEENT: NCAT. Sclera icteric. PERRL, EOMI. No pallor or cyanosis
of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not elevated.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi. Decreased BS about [**11-27**] way up left
field w/ dullness to percussion.
Abd: Distended but soft. No HSM or tenderness. +BS, small
reducible umbilical hernia
Ext: No c/c/e. Good pulses, no asymmetry.
Skin: No rashes.
Neuro: non-focal, a&ox3, moving all ext's, 4-5/5 strength, 1+
reflex b/l, following commands
.
At time of transfer from ICU to Med floor:
VS: TM-97.2, TC-96.7 BP: 113/45 (85-132/31-50) HR: 81 (63-84)
RR: 20 SaO2: 100% 2L NC
Gen: elderly female, only resposive to some simple commands,
some moans
HEENT: NCAT. + Scleral ictertis, Mucous membranes slightly dry
Neck: Supple, no JVD, bandage from central line on the L neck
CV: irregular regular rhythm, normal rate, normal S1, S2. Unable
to ascultate a murmur (pt making noise)
Chest: Breathing comfortably, rhonchi bilaterally.
Abd: Soft, NT/ND. No HSM or tenderness. +BS, umbilical hernia
Ext: Pitting 1+ edema to the knees, peumatic compression devices
in place, 2+ DPs bilaterally
Skin: No rashes, or bed sores
Neuro: 1+ reflex b/l, will squeeze fingers bilaterally, PEERL,
unable to test other CN, pt does not move toes or open eyes to
command., pt moans occasionally, GCS of 9
Lines: PICC on rt arm, NGT, rectal tube (liquide dark green
stool)
Pertinent Results:
Admission labs:
[**2156-5-5**] 04:12PM GLUCOSE-66* LACTATE-1.7 K+-2.7*
[**2156-5-5**] 04:12PM HGB-12.5 calcHCT-38
[**2156-5-5**] 04:00PM GLUCOSE-66* UREA N-8 CREAT-1.8*# SODIUM-142
POTASSIUM-2.7* CHLORIDE-100 TOTAL CO2-35* ANION GAP-10
[**2156-5-5**] 04:00PM estGFR-Using this
[**2156-5-5**] 04:00PM ALT(SGPT)-43* AST(SGOT)-95* CK(CPK)-205* ALK
PHOS-249* TOT BILI-3.8* DIR BILI-2.3* INDIR BIL-1.5
[**2156-5-5**] 04:00PM LIPASE-112*
[**2156-5-5**] 04:00PM cTropnT-0.17*
[**2156-5-5**] 04:00PM CK-MB-4
[**2156-5-5**] 04:00PM ALBUMIN-2.5* CALCIUM-7.8* PHOSPHATE-0.6*#
MAGNESIUM-1.5*
[**2156-5-5**] 04:00PM WBC-5.5 RBC-3.62* HGB-11.9* HCT-36.7 MCV-102*
MCH-33.0* MCHC-32.5 RDW-20.0*
[**2156-5-5**] 04:00PM NEUTS-75* BANDS-0 LYMPHS-9* MONOS-16* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2156-5-5**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2156-5-5**] 04:00PM PLT COUNT-117*#
.
Discharge Labs:
.
.
Reports:
CXR [**5-5**] - AP upright and lateral views of the chest are
obtained.
Cardiomegaly is again noted with large tapering left pleural
effusion. Right lung is essentially clear and unchanged. There
is no evidence of
pneumothorax. Osseous structures reveal a compression fracture
in the upper- to-mid thoracic spine which is new since [**2156-1-19**].
CT head [**5-5**] - IMPRESSION: No hemorrhage, edema, or fracture.
US liver [**5-5**] - Moderate ascites with gall bladder wall
thickening and edema, unchanged from prior study, likely due to
third spacing. No evidence of acute cholecystitis. Echogenic
focus within the gall bladde possibley adherent sludge.
CT chest [**5-6**] - CONCLUSION:
1. No pulmonary embolism or aortic dissection. Extensive
atherosclerosis is present in the coronary arteries and there is
an aberrant origin of the right coronary artery which traverses
between the aortic root and the pulmonary artery.
2. Cardiomegaly, pleural and pericardial effusion as well as
ascites could
represent congestive cardiac failure. There has been significant
interval
increase in the right pleural effusion with almost complete
collapse/atelectasis of the left lung.
3. Enlarged mediastinal lymph nodes are unchanged since the
prior examination and may be assessed further to exclude
indolent lymphoma.
Echo [**5-13**] - A small secundum atrial septal defect is present
(cine loop #34). There is mostly left-to-right shunting, but
after injection of aerated saline into the right atrium,
right-to-left bubble transit is seen, as well. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal [**Month/Year (2) 7216**] septal motion/position consistent with right
ventricular volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets fail to
fully coapt. Severe [4+] tricuspid regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Dilated and hypokinetic right ventricle. Preserved
left ventricular systolic function. Moderate mitral
regurgitation. Severe tricuspid regurgitation secondary to
annular dilation. Small secundum ASD with bidirectional flow.
.
CT of head [**5-13**] - IMPRESSION: No acute intracranial
abnormalities. Old infarct of the left frontal lobe and insula
as well as the left thalamus.
.
CT chest/abd/pelvis [**5-13**] - IMPRESSION:
1. No acute intra-abdominal process is seen. There is no
evidence of
ischemic bowel.
2. Moderate free intraperitoneal fluid is seen.
3. Reflux of contrast into the hepatic veins and intrahepatic
IVC does
suggest right heart failure.
4. Dilated common bile duct without evidence of an obstructing
lesion. This has in fact progressed in diameter since a prior
torso imaging. Therefore, an MRCP is recommended for further
evaluation of this finding.
5. Bilateral pleural effusions, decreased in size since the
prior exam.
6. Areas of consolidation at the lung bases as detailed above.
7. Endotracheal tube extends into the main stem bronchus.
.
MRI/MRA brain [**5-13**] - MRI of the Brain: The [**Doctor Last Name 352**]-white matter
differentiation of the brain is well
preserved. The ventricles and extra-axial CSF spaces appear
normal. There are old lacunar infarcts in the centrum semiovale
bilaterally visualized with adjacent view of this. There is no
evidence of an acute infarct. There is no evidence of
intracranial edema, mass effect, shift of normally midline
structures, or hydrocephalus. The posterior structures appear
unremarkable. The major vascular flow voids are well preserved.
There is hyperintensity visualized in both mastoid air cells
suggestive of fluid within the mastoid air cells. There are
multiple susceptibility artifacts visualized in the left
temporal lobe, right aspect of the pons, and in both cerebellar
hemispheres, which may represent multiple cavernomas or
dystrophic calcifications. Visualized orbits and paranasal
sinuses appear normal.
.
MRA OF THE BRAIN: The anterior circulation including the
intracranial
internal carotid artery, anterior and middle cerebral arteries
bilaterally
appear normal. The vertebrobasilar system and both posterior
cerebral
arteries appear normal. There is no evidence of an aneurysm
(greater than 3 mm), flow-limiting stenosis, or occlusion.
.
CXR [**5-22**] - Increased consolidation of left lung, which could be
compatible with pneumonia or aspiration.
.
EEG [**5-25**] - IMPRESSION: Possibly normal EEG in an extremely drowsy
patient.
Whether this is related to sleep deprivation or medications that
the
patient is taking or represents an early encephalopathy cannot
be
determined from this record. No definitive epileptiform
abnormalities
were, however, seen.
.
US upper extremity [**5-27**] - IMPRESSION: No evidence of DVT in the
right upper extremity. - (done because had erythma around PICC
site.)
.
EKG [**6-1**] - Compared to prior tracing irregular sinus mechanism at
rate about 55 has
replaced atrial flutter. There are occasional atrial premature
beats
and ventricular premature beats. Generalized low voltage
remains. In
addition, there is Q-T interval prolongation consistent with
drug effect and also rightward axis. Anteroseptal myocardial
infarction of indeterminate age cannot be excluded in either
tracing.
Brief Hospital Course:
71 yo F with DM, ESRD on HD, GAVE, HTN, CHF w/ RV failure, who
p/w altered MS [**First Name (Titles) **] [**Last Name (Titles) **]. Admitted to the ICU, intubated
and on vasopressors. Was successfully extubated and had several
days of altered mental status, where she was uncommunicative and
unable to eat. She was refusing NGT and PEG was contraindicated
with her ascites. Improved, started taking PO. Had intact
mental status with some memory problems upon discharge.
.
After admission and ICU course:
Admitted to floor after dialysis [**12-27**] somnolence. Transferred to
MICU after only a few hrs [**12-27**] [**Month/Day (2) **]. Pt had a an ECHO in
the ICU that showed dilated, hypokinetic RV w/ 4+TR. Pt was
emperically treated w/ Vanc/Meropenem, then was switched to
cefepime for possible PNA (now s/p 10-D course). Pt also has a
L-sided chronic pleural effusion (exudative), pt is s/p
thoracentesis of 1.5 L w/ exudate, but no infection. Pt had a
possible seizure during thoracentesis, so she was intubated and
started on neosynepherine. Neuro was consulted and EEG showed
no seizure activity. LP was performed w/o evidence of bacterial
meningitis, however pt was placed on acyclovir. HSV PCR was
negative and acyclovir was stopped.. Pt has gone in and out of
aflutter, but was transfered to the floor in sinus rhythm with
2-3 beat runs of NSVT. Pt was on heparin ggt briefly but this
has been stopped. She was extubated on [**2156-5-16**], and has been
off pressors since [**2156-5-17**]. Pt has stayed in ICU [**12-27**] mental
status which waxes and wanes, and at best the pt is resposive to
only some simple commands. Has NGT and on tube feeds. Pt does
reportely have some baseline altered mental status, but is
signifcantly changed from baseline. Pt was transfered to the
medicine floor on [**2156-5-19**], with vitals of 113/45, 84 (sinus),
20, 99% on 2L.
.
On the floor, the patient continued to have significantly
altered mental status. She was uncommunicative and would follow
some simple commands. She improved quite quickly over several
days and returned close to baseline mental status according to
her family. Her major issue for most of her time on the floor
was nutrition status. She had pulled out her NG tube and kept
not cooperating for replacement. Family did not want to have to
restrain her to place it. She was unable to get a PEG tube d/t
ascites. When she woke up, she was able to take PO and start
repleting nutrition deficits. She had episodes of atrial
flutter with [**Date Range 13223**] into the 110s/120s. Pt also had c.diff
infection diagnosed. Please see below for specific details of
each problem...
# Altered mental status: At baseline pt able to walk from chair
to bathroom, and communicate. Pt's mental status declined while
in pt when she became hypotensive. The differential consists of
seizure (EEG x2 did not show seizure activity) or encephalitis
(HSV-but PCR was negative, and CSF studies WNL) or a global
hypoxia or a metabolic encephalopathy. Also possible is adrenal
insuffiency, therefore, tx with IV steroids, without change, so
stopped steroids. No radiologic evidence of intracranial
pathology. Pt believed to have seizure during thoracotomy as
stated above. Pt remained in stuporous state until approximately
[**5-24**] when her mentation started to improve. Likely cause of
mental status changes was multifactorial - including metabolic
derangements from kidney and liver disease. She was continued
on her home dose of Keppra her entire stay in the hospital. She
is leaving the hospital back at her baselin.
.
# [**Month/Year (2) **]: Unclear etiology, originally thought due to
possible pneumonia, as stated above, pt required pressers in
ICU. CTA negative for PE. Echo showed no pericardial effusion or
tamponade. Pt improved in the ICU and was successfully weaned
from pressors. She maintained appropriate blood pressures, and
all her antihypertensive medicines were held, and are still
being held upon discharge, SBPs are in 140s upon discharge, but
often drop lower after [**Month/Year (2) 13241**]. She will be on no
antihypertensive medicines on discharge.
.
# Possible PNA, hypoxia: with coughs (though no leukocytosis, no
fever). CXR showed worsening pleural effusion and collapse of
LLL initially. Pt treated with empiric vancomycin and meropenem
(switched from imipenem due to lower seizure threshold from
imipenem)for 10 day course. Sputum cx was negative. Follow up
CXRs showed persisent effusions. Pt was breathing well on RA
upon discharge. No cough.
.
# Arrhythmia: In ICU pt had transient [**Month/Year (2) 13223**] which improved
with IVF, pt alternated between sinus tach and atrial tach.
Improved somewhat w/metoprolol, which was later stoped d/t
bradycardia into the 30s. [**Month/Year (2) **] most likely initially
reflected hypovolemia, but not compeletly clear. No PE on chest
CTA. Pt was monitored on telemetry and had intermitenty ectopic
beats, NSVT up to 3 beats, which may have been related to
hypokalemia. While on floor, patient converted into atrial
flutter with rates between 110 and 130. Pt was started on
metoprolol. Pt then converted to NSR with HRs in 60s.
Metoprolol was stopped at this time and she was not discharge
.
# Effusions: large left pleural effusion. Prior fluid analysis
showed exudative process, w/o identifiable cause, cytology
negative as well. Currently being followed by pulmonary, Dr.
[**Last Name (STitle) 2168**]. During this stay, thoracentesis was performed but
resulted in intubation as stated above. Pt continues to have
effusions, but not symptomatic. Pt breathing well on RA upon
discharge.
.
# Transaminitis: Likely due to congestive hepatitis in setting
of RV failure. Pt's LFTs trended down during her hospital
course. Pt does have elevated INR, likely d/t some liver
dysfunction. No evidence of liver pathology on any imaging
studies.
.
# Hyperlipidemia: statin was held in setting of transaminitis.
Still held on discharge.
.
# ESRD/HD: On HD MWF. HD was continued while in pt, pt on
Phoslo, and renal labs were closly monitored. Pt will need to
continue HD upon discharge MWFs for fluid status management.
Phoslo had been discontinued during admission. Upon discharge
phos level was low at 1.2. On the day of admission, pt was
given 4 packets of neutrapohs. The renal fellow was called
about her level and thought discharge was still appropriate. Pt
is scheduled for dialysis the day after discharge. Her phos
level will be checked there. Dr. [**Last Name (STitle) **], her nephrologist, will
be faxed the results and is aware of the problem.
.
# Hypoglycemia: Pt had several episodes of hypoglycemia in ICU,
likely in setting of NPO; got dextrose and FS improved after
adjusted RISS. Continued to have episodes of hypoglycemia while
on floor and there was no way to have nutritional support (no
NGT or PEG and somnelent). Was on D10W for several days and
still had blood sugars in 60s and 70s. Pt then started to have
improved mental status. She passed a speech/swallow test and
was started on ground food and thin liquids. She will go home
on a diet that remains ground. Per swallow team, she can have
repeat study with her denturs if she is to be made full diet.
Endocrine team was also following and ruled out insulinoma as
possible cause. Insulin level was low and c-peptide was likely
elevated because it is usually cleared by the kidney. Encourage
small and frequent meals to maintain blood sugar. Can use
glucose tabs if needed.
.
# DM: held all diabetic medicines due to hypoglycemia. See
above.
.
# C.diff - had diarrhea during most of her time on the floor.
Stool culture was positive for C.diff. On Flagyl PO tid. Needs
to complete 14 day course. Day 1 of antibiotics was [**2156-5-30**]. Pt
will be given prescription for rest of course upon discharge.
She was still having diarrhea at the time, but no white count,
fevers or abdominal pain.
.
# New thoracic compression fracture: pt asymptomatic, no
treatment.
.
# Megaloblastic anemia: B12 and folate levels are normal,
unclear etiology, was monitored and remained stable throughout
admission.
.
# Code: FULL. Had several family meetings during stay.
Palliative care was consulted and helped us coordinate the
meetings and discuss the patients prognosis. Family is aware of
her end organ failure and fragile state.
Medications on Admission:
Medications: from dc summary in [**1-24**]. Isosorbide Dinitrate 30 mg PO BID
2. Pantoprazole 40 mg Q24H
3. Metoprolol Tartrate 75 mg PO TID
4. Lisinopril 20 mg PO DAILY
5. Levetiracetam 250 mg PO BID ?? not on list from NH
6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
7. Hydroxyzine HCl 25 mg PO Q6H as needed.
8. Atorvastatin 20 mg PO DAILY
9. Cinacalcet 30 mg PO DAILY ?? not on list from NH
10. Gabapentin 300 mg PO QHD ?? not on list from NH
11. Citalopram 20 mg PO DAILY ?? not on list from NH
12. Acetaminophen 325 mg 2tbl PO Q6H as needed.
13. Glipizide 2.5 mg 24hr PO once a day.
14. Phoslo 667mg po TID with meals
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 tube* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Keppra 100 mg/mL Solution Sig: Two [**Age over 90 1230**]y (250) mg PO
twice a day: Please take 2.5 ml twice daily to get a dose of 250
mg [**Hospital1 **].
Disp:*150 ml* Refills:*2*
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 2X/WEEK (MO,TH) for 2 months.
6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day: Start after 2 months of 50,000u twice weekly is completed.
7. Outpatient Lab Work
Please check phosphate level at [**Hospital1 13241**] on [**2156-6-4**]
and fax result to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: fax ([**Telephone/Fax (1) 8387**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary Diagnosis:
1. Altered Mental Status of multifactorial etiology
2. chronic liver disease with ascites, likely secondary to R
heart failure
3. chronic kidney disease stage V
4. Pleural effusions of undetermined etiology
6. C.difficile colitis
Secondary diagnoses:
1. Siezure disorder
2. Anemia
3. Compression Fracture
4. GAVE syndrome with hx UGI bleed
Discharge Condition:
Pt was afebrile, stable vital signs. Pt was unable to ambulate
by herself, she was able to walk a short distance with the help
of physical therapy. She was A+Ox3. She was having diarrhea at
the time of discharge.
Discharge Instructions:
You were admitted for being somnulent after a dialysis session.
It was thought that you may have had a pneumonia, and there was
fluid in your lungs. The medical team tried to get the fluid
off of your lung with a procedure called a thoracentesis.
During this your blood pressure became very low and you had to
go to the ICU where they kept your blood pressure high with IV
medicine and helped you breathe with intubation. Your body
started to recover and you were brought to a regular medical
floor.
On the floor, you remained somnolent and confused. You were
unable to eat and we could not feed you through a tube.
Eventually you started to improve. You passed a swallow test
and started eating. We were worried because your blood sugar
kept dropping low, probably due to your kidney failure and poor
nutritional stores. You need to keep eating at regular
intervals to keep your blood sugars up.
You also had an irregular heart beat at times. Sometimes it was
too fast, and sometimes it was too slow. We monitored you on
telemetry because of that. When you left the hospital, your
heart rate was regular and going about 60 beats per minute (a
normal rate).
You also were diagnosed with an infection of your bowels call
c.diff. You need to take flagyl, an antibiotic for a total of
14 days to treat this infection.
We stopped some medicines you had been taking at home before
this hospitalization. Please see the discharge sheet for what
you will take now.
You must continue [**Hospital6 13241**] M, W, F or as your renal doctor
recommends.
You will continue physical therapy in rehab to try to regain
your strength.
Please call or return to the hospital for any chest pain,
shortness of breath, worsening diarrhea, or any other concerns.
You should see your doctor regularly. Call 911 for any
emergencies.
Followup Instructions:
Please make appointment with PCP for two weeks to follow up on
C.diff infections:
[**Last Name (LF) **],[**Known firstname **] L. [**Telephone/Fax (1) 7976**]
Please follow up with your renal doctor [**First Name (Titles) **] [**Last Name (Titles) 13241**]. You
need to go to dialysis tomorrow. Dr. [**Last Name (STitle) **], your nephrologist,
will continue to follow you.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2156-6-3**]
|
[
"357.2",
"486",
"537.83",
"518.81",
"424.0",
"287.5",
"733.13",
"250.62",
"585.6",
"511.9",
"403.91",
"345.90",
"428.0",
"250.82",
"348.30",
"789.59",
"285.21",
"428.32",
"573.3",
"008.45",
"785.50",
"427.32",
"250.42",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"34.91",
"96.71",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
21594, 21641
|
11464, 14145
|
349, 442
|
22054, 22272
|
4795, 4795
|
24146, 24675
|
3048, 3151
|
20528, 21571
|
21662, 21662
|
19876, 20505
|
22296, 24123
|
5789, 11441
|
3203, 4776
|
21938, 22033
|
255, 311
|
471, 1878
|
4812, 5772
|
21681, 21917
|
14160, 19850
|
1900, 2671
|
2687, 3032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,344
| 159,893
|
47651
|
Discharge summary
|
report
|
Admission Date: [**2204-5-17**] Discharge Date: [**2204-5-23**]
Date of Birth: [**2140-10-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
SOB, weakness x 1 week
Major Surgical or Invasive Procedure:
hemodialysis line placement
History of Present Illness:
63M with h/o ESRD s/p CRT '[**98**] w/ recently worsening renal
function, CAD s/p 3V CABG in '[**97**], moderate AS, DMII, dCHF
presents to the ER with 1 week of SOB and weakness. He reports
that his SOB has progressed over the past week - is worst when
trying to lie flat but also when trying to exert himself. He
finds it difficult to walk up steps or walk a block when he can
usually do these things. He has had a dry cough at night for the
past week. Also feels chest discomfort when lying flat (not w/
exertion) and endorses generalized weakness. He feels he has
been urinating a normal amount. + anorexia, + constipation, +
chills, + increased LE edema, endorses 3-pillow orthopnea
(stable), denies increased salt intake, + constipation. He tells
me he doesn't check his blood sugars at home - doesn't take
insulin; is on orals at home.
.
In the ED, initial VS were: 97.4 60 117/52 18 95% on RA.
Labs revealed Hct of 22.1 (bl 23-27 on Procrit), WBC 7.5 (92%
PMNs), Na 132, BUN 135, Cr 6.7 (up from 114/6.1 on [**5-2**]), bicarb
of 15; anion gap 21. Glucose was 352. BNP [**Numeric Identifier 100667**]. Trop 0.04. CXR
showed worsening pulmonary edema, L pleural effusion and small R
effusion (stable), LLL consolidation (atelectasis vs.
infection). EKG showed NSR at rate of 60, nl axis, prolonged Qtc
of 490 ms, TWF inferiorly (longer Qtc than priors). ?VBG showed
7.25/33/88 w/ lactate of 1.3. Blood cultures x 2 were sent. He
was initially started on an insulin gtt (7U + 7U/hr) and given
40 mEq K. He was also given 1g Vanc and 2g Cefepime out of
concern for pneumonia. Later, lytes showed gap of 19, glc 247.
Insulin gtt was stopped after discussion with the ER about his
prior acidosis from renal failure. He received 35U IV regular
insulin and 20U Lantus in total (takes no insulin at home).
Later on s/o, transfer VS were listed as AF 119/72 71 92% on
NRB. Discussion was held about involving renal and diuresing.
Renal recommended 150 mg IV Lasix bolus + gtt at 10 mg/hr and
2.5 mg metolazone.
.
Of note, he was admitted [**Date range (1) 7267**], in the ICU for pulmonary
edema in the setting of dietary indiscretion for diuresis with
[**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 that admission. During that admission he received
IV Lasix boluses. He initially responded well to IV diuresis but
UOP then slowed. He was transitioned to lasix PO 80mg [**Hospital1 **] at
discharge. He was ruled out for an MI. His glucoses were up to
the 400s prior to discharge.
.
On arrival to the MICU, VS 97.6 61 129/59 16 98% on NRB -->
97% on 3L nc. The patient is breathing comfortably and speaks in
full sentences. He is accompanied by his wife and daughter.
Past Medical History:
-ESRD secondary to DM and HTN. s/[**Name Initial (MD) **] AVF, CRT [**2199-7-19**] c/b delayed
graft function requiring intermittent HD, maintained on
tacrolimus; renal fn/acidosis recently worsening
-BK virus infection: treated with cidofovir pheresis,
leflunomide and cipro, last BK viral load [**2201-9-18**] 2170.
-Aortic Stenosis: echo [**3-/2204**] with [**Location (un) 109**] 0.9
-Coronary Artery Disease: s/p PCI in [**2-6**], NSTEMI, s/p CABG [**2197**]
LIMA to the LAD, SVG to D1, SVG to circumflex
-Hyperlipidemia
-HTN
-Diabetes Mellitus: c/b retinopathy
-Renal osteodystrophy
-Iron Deficiency Anemia
-Nephrotic syndrome with hypoabuminemia
-Bells Palsy
-History of Rhabdomyolysis
-History of left lower lobe pneumonia
-s/p Hydrocele repair
Social History:
Married, lives with wife. Previous history of tobacco - 1ppd x
9 years until age 21. No current use. Occasional EtOH. Denies
other drugs including IVDU.
Family History:
Mother: [**Name (NI) 3495**] Disease, Still Living at 80. Father: Died of
Prostate Cancer, age 85. No known family history of renal
problems.
Physical Exam:
Vitals: 97.6 61 129/59 16 97% on 3L
General: Alert, oriented, no acute distress; speaks in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to jaw, no LAD
CV: Regular rate and rhythm, 3/6 systolic murmur heard
throughout precordium
Lungs: diminished bs at L base; rales heard at both bases,
unlabored
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, [**12-5**]+ PE in bil LE; 1+ PE in
thighs
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
Pertinent Results:
ADMISSION
[**2204-5-17**] 12:40PM BLOOD WBC-7.5 RBC-2.38* Hgb-6.9* Hct-22.1*
MCV-93 MCH-28.9 MCHC-31.1 RDW-18.6* Plt Ct-159
[**2204-5-17**] 12:40PM BLOOD Neuts-92.4* Lymphs-3.6* Monos-2.6 Eos-1.4
Baso-0.1
[**2204-5-17**] 12:40PM BLOOD Glucose-352* UreaN-135* Creat-6.7*
Na-132* K-3.6 Cl-97 HCO3-14* AnGap-25*
[**2204-5-17**] 07:00PM BLOOD ALT-14 AST-13 CK(CPK)-35* AlkPhos-244*
TotBili-0.5
.
PERTINENT
[**2204-5-17**] 12:40PM BLOOD proBNP-[**Numeric Identifier 100667**]*
[**2204-5-17**] 12:40PM BLOOD cTropnT-0.04*
[**2204-5-18**] 02:32AM BLOOD CK-MB-3 cTropnT-0.03*
[**2204-5-17**] 07:00PM BLOOD CK-MB-3
[**2204-5-18**] 03:12AM BLOOD %HbA1c-8.0* eAG-183*
[**2204-5-18**] 02:32AM BLOOD tacroFK-4.7*
[**2204-5-19**] 09:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2204-5-19**] 09:12AM BLOOD HCV Ab-NEGATIVE
.
DISCHARGE
[**2204-5-23**] 05:35AM BLOOD WBC-5.1 RBC-2.99* Hgb-8.6* Hct-27.5*
MCV-92 MCH-28.6 MCHC-31.1 RDW-18.3* Plt Ct-178
[**2204-5-23**] 05:35AM BLOOD PT-14.3* PTT-33.3 INR(PT)-1.3*
[**2204-5-23**] 05:35AM BLOOD ALT-21 AST-26 AlkPhos-252* TotBili-0.5
[**2204-5-23**] 05:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.1
[**2204-5-23**] 05:35AM BLOOD tacroFK-8.1
.
MICRO
URINE CULTURE (Final [**2204-5-19**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
10,000-100,000 ORGANISMS/ML..
Blood Culture, Routine (Final [**2204-5-23**]): NO GROWTH.
.
CXR:
Interval worsening of moderate pulmonary edema. Bilateral
pleural effusions, moderate on the left and small on the right,
are relatively stable with persistent opacification of the left
lung base. This may reflect compressive atelectasis, though
infection cannot be excluded.
.
EKG: NSR at rate of 60, nl axis, prolonged Qtc of 490 ms, TWF
inferiorly (longer Qtc than priors)
.
RUE U/S: Small echogenic nonocclusive thrombus at the right
subclavian vein valves. The right subclavian vein is widely
patent
Brief Hospital Course:
Hospital Course:
Brief Hospital Course:
63M with h/o ESRD s/p CRT '[**98**] w/ recently worsening renal
function, CAD s/p 3V CABG in '[**97**], moderate AS, DMII, dCHF
presented to the ED with decompensation of diastolic heart
failure in the setting of progressive CKD. He was initiated on
HD with ultrafiltration and his shortness of breath improved.
.
# Shortness of Breath: Worsening pulmonary edema on CXR and
pitting edema in LE w/ dCHF/AS and worsening renal function make
volume overload most likely cause. Acute decompensation of
diastolic heart failure in the setting of progressive chronic
kidney disease likely etiology. Chest pain free. Cardiac enzymes
were negative. A trial of diuresis was attempted and the patient
was given 150mg of lasix x1, metolazone 2.5mg x 1 and started
briefly on a lasix gtt with poor urine output. An HD catheter
was placed in the left subclavian on HD and ultrafiltration was
performed on HD3. The patient tolerated this well and was
transitioned to the general medical floor. He continued to get
dialysis with volume removal and he symptomatically improved.
His dry weight was 68kg at the time of discharge. His sodium
bicarbonate, calcitriol and lasix were discontinued. He will get
dialysis at [**Doctor Last Name 15284**] Circle Dialysis starting this Friday.
.
# Hyperglycemia/DM: Presented with Glc of 352 to ER. On orals at
home and not checking blood sugars. Initially concern for DKA
given AG acidosis, however, urine ketones were negative and
acidosis ultimately felt to reflect uremia. His DM has been
poorly controlled at home, with A1C of 8.0. Patient was
maintained on SSI throughout his course. He was restarted on his
home hypoglycemics at discharge.
.
# ESRD with superimposed acute renal failure: Cr progressively
worsening with ongoing discussions regarding need for dialysis
and potential repeat [**Doctor Last Name **] per outpatient records. Patient
was acidotic and volume overloaded on admission and failed trial
of lasix. A catheter was placed for HD 2 and dialysis with
ultrafiltration initiated on HD3. He was continued on regular
dialysis and ultrafiltration until he achieved his dry weight of
68kg. His sodium bicarbonate, lasix, and calcitriol were
discontinued but the rest were continued. He was continued on
tacrolimus to preserve his remaining renal function. He will be
following up with [**Doctor Last Name **] nephrology after discharge to
discuss the possibility of peritoneal dialysis in the future. Pt
is PPD negative and HepBSAg negative.
.
# AS/dCHF: Recent TTE in [**3-15**] with valve area of 0.9. Worsening
valvular disease per recent echo likely contributing to
pulmonary edema and CHF exacerbation in setting of renal
failure. The patient's volume was managed with initiation of
hemodialysis.
.
# CAD: Based on history, initial presentation not concerning for
ACS leading to pulmonary edema. Cardiac enzymes were negative x
2. Continued regimen of aspirin 81 mg qday and coreg 25 mg [**Hospital1 **]
w/ holding parameters, pravastatin 20 mg qday.
.
# HTN: Continue coreg and nifedipine 30 mg ER [**Hospital1 **]
.
# Anemia: Hct near baseline likely [**1-5**] ESRD. With initiation of
HD, the patient was transfused pRBCs with HD as needed. He was
continued on aranesp.
.
# BK virus: He was continued on leflunomide.
.
Transitional issues:
-Follow-up with [**Month/Day (2) **] nephrology regarding dosing and
further taper of tacrolimus. Also will discuss possibility of
starting peritoneal dialysis.
-Needs Hepatitis B vaccination
Medications on Admission:
calcitriol 0.25 mcg qday
carvedilol 25 mg [**Hospital1 **]
aranesp 60 mcg qmonth
lasix 80 mg [**Hospital1 **]
glipizide 10 mg qday
leflunomide 50 mg qday
nifedipine ER 30 mg [**Hospital1 **]
pioglitazone 30 mg qday
pravastatin 20 mg qday
sevelamer 800 mg tid
bactrim SS qday
tacrolimus 3 mg [**Hospital1 **]
ASA 81 mg qday
NaBicarb 650 mg [**Hospital1 **]
Discharge Medications:
1. Pioglitazone 30 mg PO DAILY
2. GlipiZIDE 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. leflunomide *NF* 50 mg Oral daily
6. NIFEdipine CR 30 mg PO BID
7. Pravastatin 20 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 3 mg PO Q12H
11. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
60 mcg/mL Injection monthly
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic kidney disease
initiation of hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 8430**]. You
were found to have shortness of breath due to fluid build-up
from worsening kidney function. It was decided that your kidneys
were likely failing and that you need to go back on dialysis.
You tolerated dialysis well and your symptoms improved.
Continue your home medications with the following changes:
1. STOP taking sodium bicarbonate
2. STOP taking lasix
3. STOP taking calcitriol and vitamin D
You will follow-up with the kidney doctors to discuss potential
initiation of peritoneal dialysis.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2204-5-28**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2204-5-31**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2204-5-31**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17762**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"424.1",
"414.00",
"585.6",
"285.21",
"584.9",
"588.0",
"250.50",
"V45.81",
"403.91",
"272.4",
"428.0",
"250.40",
"362.01",
"428.33",
"514"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11110, 11116
|
6774, 10047
|
329, 359
|
11219, 11219
|
4823, 6711
|
11975, 13065
|
4052, 4195
|
10667, 11087
|
11137, 11198
|
10287, 10644
|
6751, 6751
|
11370, 11952
|
4210, 4804
|
10068, 10261
|
267, 291
|
387, 3085
|
11234, 11346
|
3107, 3864
|
3881, 4036
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,619
| 116,407
|
41635
|
Discharge summary
|
report
|
Admission Date: [**2180-10-9**] Discharge Date: [**2180-10-12**]
Date of Birth: [**2115-10-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Concern for cholangitis and need for urgent ERCP
Major Surgical or Invasive Procedure:
ERCP x2
History of Present Illness:
64 y/o M with PMH of CABG, DMII, and recent CCY on [**2180-9-24**] at
[**Hospital1 **] for biliary colic who was transferred to [**Hospital1 18**]
from [**Hospital3 **] with fever and concern for cholangitis. The
patient was initially discharged home following the CCY in
stable condition. On [**10-7**] he was eating breakfast when he
developed RUQ abdominal pain similar in character to his prior
biliary colic. Associated with N/V, loose stools and
diaphoresis. Not relieved by tylenol. He presented to [**Hospital1 **] on [**2180-10-7**] where initial labs revealed a
rising bili, elevated WBC and an elevated lipase. Diagnosed
with gallstone pancreatitis and started on unasyn. Seen by GI
team who recommended ERCP. On the morning of [**2180-10-8**], the
patient spiked a fever to 101.0. Decision was made to transfer
the patient to [**Hospital1 18**] for semi-urgent ERCP given concern for
developing cholangitis.
.
On arrival to [**Hospital1 18**] the patient appeared stable with initial
vitals 99.9 159/65 104 22 94%RA. He reports feeling generally
well and denies any pain at present.
Past Medical History:
- s/p CCY [**2180-9-26**]
- CAD s/p CABG [**2172**]
- DM
- HTN
- HL
- urinary retention s/p cyst removal
Social History:
Works part-time as a CPA. Lives at home with his wife. Former
[**Name2 (NI) 1818**] but quit 13 years ago. Occasional EtOH. No other drug
use.
Family History:
Father and brother with CAD. Brother had lymphoma. Father had
lung CA
Physical Exam:
ADMISSION EXAM:
Vitals: 99.9 159/65 104 22 94%RA
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, icteric sclera, 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, soft I/VI systolic
murmur
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Mild TTP in RUQ and
also in LUQ. Surgical wounds without surrouning erythema.
Skin: Jaundiced
Ext: No gross deformity or edema
Neuro: Awake, alert and oriented. CN II-XII intact, strenght [**4-13**]
throughout.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, icteric sclera, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, soft I/VI systolic
murmur
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly.
Skin: Jaundiced
Ext: No gross deformity or edema
Pertinent Results:
ADMISSION LABS:
[**2180-10-9**] 04:31AM BLOOD WBC-17.7* RBC-3.72* Hgb-11.9* Hct-34.6*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.6 Plt Ct-286
[**2180-10-9**] 04:31AM BLOOD Neuts-89.0* Lymphs-6.2* Monos-4.4 Eos-0.1
Baso-0.3
[**2180-10-9**] 04:31AM BLOOD PT-14.9* PTT-29.0 INR(PT)-1.3*
[**2180-10-9**] 04:31AM BLOOD Glucose-187* UreaN-14 Creat-0.9 Na-136
K-4.3 Cl-101 HCO3-24 AnGap-15
[**2180-10-9**] 04:31AM BLOOD ALT-239* AST-107* AlkPhos-198*
Amylase-397* TotBili-2.9*
[**2180-10-9**] 04:31AM BLOOD Lipase-642*
[**2180-10-9**] 04:31AM BLOOD Albumin-3.3* Calcium-8.2* Phos-1.8*
Mg-1.8
[**2180-10-9**] 08:44AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2180-10-9**] 08:44AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2180-10-9**] 08:44AM URINE RBC-4* WBC-16* Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
.
MICROBIOLOGY
[**2180-10-9**] 8:44 am URINE Source: CVS.
**FINAL REPORT [**2180-10-10**]**
URINE CULTURE (Final [**2180-10-10**]): NO GROWTH.
.
IMAGING:
LENI: IMPRESSION: No evidence of DVT.
.
CXR: FINDINGS: No previous images. Cardiac silhouette is at the
upper limits of normal in size in the patient with intact
midline sternal wires after CABG procedure. Opacification at the
right base medially most likely represents atelectasis and
fibrous scarring. However, the lower right heart border is not
sharply seen, and the possibility of supervening pneumonia would
have to be considered in the appropriate clinical setting.
Remainder of the study is within normal limits with no evidence
of vascular congestion.
.
ERCP [**10-10**]:
Impression: Normal Pancreatogram
A 4cm by 5FR pancreatic stent was placed initially to facilitate
cannulation. Cannulation of the bile duct was then successful.
The main bile duct appeared normal. The intrahepatic ducts
appeared to have smaller than expected caliber
Sphincterotomy was extended in the 12 o'clock position using a
sphincterotome over an existing guidewire.
Multiple stone fragments and sludge were extracted successfully
using a balloon. No pus noted.
The pancreatic stent was then removed by using a snare.
.
ERCP [**10-9**]:
Impression: Esophagitis was noted in the lower third of the
esophagus
Edema and distortion of the duodenal wall secondary to
pancreatitis was noted
An impacted stone was noted at distal CBD
Normal pancreatogram
Extremely stenotic papilla with impacted stone at distal CBD.
Therefore, a small precut sphincterotomy was performed. Drainage
of bile and small amount of sludge noted after sphincterotomy.
No pus noted.
Deep cannulation of bile duct was not achieved due to the edema
Otherwise normal ercp to third part of the duodenum
LE DOPPLER: No evidence of DVT.
DISCHARGE LABS:
[**2180-10-12**] 03:21AM BLOOD WBC-7.4 RBC-3.39* Hgb-10.8* Hct-30.9*
MCV-91 MCH-31.8 MCHC-34.9 RDW-13.4 Plt Ct-283
[**2180-10-11**] 04:15AM BLOOD Neuts-81.1* Lymphs-10.6* Monos-6.2
Eos-1.6 Baso-0.5
[**2180-10-11**] 04:15AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1
[**2180-10-12**] 03:21AM BLOOD Glucose-174* UreaN-11 Creat-0.6 Na-129*
K-3.3 Cl-95* HCO3-25 AnGap-12
[**2180-10-12**] 03:21AM BLOOD ALT-73* AST-34 AlkPhos-160* TotBili-1.3
[**2180-10-12**] 03:21AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 90500**] is a 64 y/o M with PMH of CABG, DMII, and recent
CCY c/b likely retained stone and gallstone pancreatitis who was
transferred to [**Hospital1 18**] due to concern for developing cholangitis
and need for urgent ERCP.
#. Abdominal pain - The patient most likely had a retained stone
following CCY that lead to gallstone pancreatitis. There was
initially some concern for developing cholangitis given fever to
101.0 and worsening LFTs; however he remained relatively pain
free, normotensive and without mental status changes making this
condition less likely. Pt had ERCP with sphincterotomy but was
unable to canulate bile duct due to edema. He had repeat ERCP
that showed only stone fragments and sludge. He was continued on
unasyn and his LFTs and WBC trended downward. He was discharged
on a course of augmentin for total 8 day antibiotic course.
#. CAD - Pt is on lisinopril, aspirin and statin at home. These
were initially held at the outside hospital and resumed here
following successful ERCP. He was also started on metoprolol
tartrate before transfer to ICU and this was continued while in
ICU at 50mg po TID for rate control. Unclear if he was on
metoprolol at home but given his CAD, he would likely benefit
from long term beta blocker and has remained stable with the
addition of this to his regimen. Recommend follow up with PCP.
# hypertension: resumed home meds. Also started metoprolol
tartrate 50mg po TID while in house to control heart rate and BP
and patient remained stable with this addition to his regimen.
Recommend follow up with PCP to cont to optimize HTN regimen.
#. Dysuria - Patient describes dysuria on ROS. Had [**Last Name (un) **] on
arrival to OSH which resolved with fluid resucitation. Initial
urine culture negative. Pt was on antibiotics for cholecystitis
so this would treat UTI as well.
# diarrhea: developed diarrhea on day of discharge. unable to
get stool sample before discharge. Thought to be secondary to
cholecystitis but recommended follow up with PCP
# hyponatremia: sodium low to 129 on day of discharge. thought
to be secondary to recent resumption of po intake and subsequent
water consumption. recommended recheck and follow up with PCP
#. DM II: held oral meds and managed with SSI while in house,
restarted home meds on discharge
TRANSITIONAL ISSUES:
1. follow up repeat sodium labs to evaluate hyponatremia
2. follow up BP now that pt has been started on metoprolol
3. follow up diarrhea
Medications on Admission:
amlodipine 5mg
glipizide 5mg [**Hospital1 **]
niaspan 100mg daily
lisinopril 10mg daily
ASA 81mg daily
fish oil
vitamin C
vitamin D
multivitamin
simvastatin 80mg
actos 45mg
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
9. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Gallstone pancreatitis
SECONDARY:
CAD
diabetes
HTN
hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 90500**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for pancreatitis, likely
caused by a gallstone and an infection in your biliary tract.
You had an ERCP which showed an impacted stone at the common
bile duct. We were unable to remove the stone initially, so you
had a repeat ERCP which showed that the stone had disolved. We
were able to advance your diet and you tolerated food well.
You've had some diarrhea which here, that we feel is likely due
to your recent cholecystectomy but you should be seen by your
PCP for [**Name9 (PRE) 702**]. Your sodium was slightly low on the day you
were discharged.
.
Please make the following changes to your medications:
1. START Amoxicillin-Clavulanic Acid 875 mg by mouth every 12
hours for 4 days.
Take all other medications as prescribed.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 33524**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
[**2180-10-13**] at 11:45 am
*** please have your electrolytes and blood counts check at this
appointment. Also, please inform your PCP about your diarrhea
***
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"401.9",
"788.1",
"799.02",
"276.1",
"272.4",
"V45.89",
"574.51",
"577.0",
"250.00",
"414.00",
"V45.81",
"787.91",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88",
"52.93"
] |
icd9pcs
|
[
[
[]
]
] |
9717, 9723
|
6238, 8571
|
363, 372
|
9849, 9849
|
2950, 2950
|
10874, 11401
|
1805, 1876
|
8955, 9694
|
9744, 9828
|
8757, 8932
|
10000, 10698
|
5723, 6215
|
1891, 2537
|
2553, 2931
|
8592, 8731
|
10727, 10851
|
274, 325
|
400, 1499
|
2966, 5707
|
9864, 9976
|
1521, 1628
|
1644, 1789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,143
| 141,175
|
33680
|
Discharge summary
|
report
|
Admission Date: [**2127-3-6**] Discharge Date: [**2127-3-8**]
Date of Birth: [**2054-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
carotid artery stenosis
Major Surgical or Invasive Procedure:
1. B/L internal carotid stenosis
2. Successful ptca and stent of the left ICA
History of Present Illness:
72 yo M hx CAD, hyperlipidemia who presented after a screening
carotid
ultrasound demonstrated bilateral carotid artery stenosis.
Initially ordered after routine physical demonstrated a carotid
bruit.
Pt patient notes somewhat poor energy for years, has chronic
dyspnea on exertion, no associated chest pain. He states as long
as he takes his time he is not limited in climbing up stairs.
He has had no neurological symptoms including no weakness,
numbness, speech difficulty, monocular vision loss.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Dyslipidemia
CAD, s/p multivessel stenting
Severe bilateral carotid disease
Probable Interstitial lung disease
Possible myelodysplastic syndrome with a history of pancytopenia
(s/p bone marrow biopsy [**10-24**])
BPH
Osteoarthritis
Remote Hydrocele repair
Wrist fracture, s/p surgery
Tonsillectomy
Cardiac Risk Factors: Dyslipidemia, smoking hx
Social History:
Patient smoked 4 ppd x 37 years, quitting 22 years ago. He is
widowed, lives alone, has three children.
Family History:
Father died from an MI at age 62, paternal uncle died of an MI
at age 62
Physical Exam:
VS: T 97.3, BP 150/75, HR 64, RR 14, O2 98% on 2L NC
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: no carotid bruit on R
CV: RRR nl s1, s2, no m/r/g
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits, R groin without hematoma or
bruit.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: 2+ DP and PT pulses b/l
Pertinent Results:
EKG demonstrated NSR at 71bpm, nl axis/intervals, no ST changes.
[**2127-2-25**]: Carotid u/s: Right: peak velocity 434cm/sec. Left: peak
velocity 415cm/sec.
CARDIAC CATH performed on [**2-21**] demonstrated: widely patent LAD
and D1 stents.
Carotid cath [**3-6**]:
1. Successful PTCA and stenting of the left ICA with an
[**7-23**] tapering self-expanding 40mm protege stent which was
post-dilated to 5.0mm. Final angiography revealed 10% residual
stenosis, no
angiographically apparent dissection and robust flow. The
patient left the lab pain fre and in stable condition (see ptca
comments)
2. Limited hemodynamic data revealed a central aortic pressure
of 152/79
3. Successful angioseal deployment in the right cfa arteriotomy
site.
[**2127-3-6**] 11:12PM CK(CPK)-108
[**2127-3-6**] 11:12PM CK-MB-4
[**2127-3-6**] 11:55AM INR(PT)-1.0
[**2127-3-6**] 11:55AM PT-13.3 PTT-32.3 INR(PT)-1.1
Brief Hospital Course:
72 yo M hx CAD presented with b/l carotid artery stenosis. On
HD1, pt went to cath lab where he was noted to have 80% right
ICA stenosis as well as 80% stenosis of the left ICA. He had
successful PTCA of his left ICA. He was maintained on
phenylephrine overnight for BP goal 140-160's systolic. On HD
2, he felt well, was ambulating and off of phenylephrine but
systolics dropping to 70s while ambulating and was therefore
kept overnight and given 750cc's of IVFs. The following morning
the pt was systolic 120 while lying in bed but again dropped his
bp when ambulating to as low as 80 systolic. The team wanted to
give him 500cc bolus and monitor him but pt refused and demanded
to leave with or without discharge instructions. Given that pt
was mentating while ambulating with these pressures he was
discharged AMA, and pt was fully aware of the fact that
hypotension may cause lightheadedness, syncope or even death.
Medications on Admission:
Ecotrin 325mg one tablet every morning
Plavix 75mg daily every morning
Diflunisal 500mg one tablet every morning
Repliva 21/7 one daily every morning
Imdur 30mg twice a day
Omeprazole 20mg one daily every morning
Crestor 10mg one daily every morning
Flomax .4mg one capsule every evening
Glucosamine/Chondroiton 500mg-400mg one capsule twice a day
neosynephrine 0.9mg/hr
Discharge Medications:
1. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO qam.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Diflunisal 500 mg Tablet Sig: One (1) Tablet PO qAM ().
4. Repliva 21/7 (New Formulation) 151-200-1-0.8 mg Tablet Sig:
One (1) Tablet PO QD ().
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
7. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Glucosamine-Chondroitin 500-400 mg Capsule Sig: One (1)
Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
b/l carotid artery stenosis s/p R internal carotid artery
stenting
.
Secondary Diagnosis:
Dyslipidemia
CAD, s/p multivessel stenting
Probable Interstitial lung disease
Possible myelodysplastic syndrome with a history of pancytopenia
(s/p bone marrow biopsy [**10-24**])
BPH
Osteoarthritis
Remote Hydrocele repair
Wrist fracture, s/p surgery
Tonsillectomy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for stenting of your R internal carotid
artery.
.
If you develop fever greater than 101F, chest pain, shortness of
breath, dizzines, lightheadedness, numbeness, tingeling or
weakenss in any part of your body or if you at any time become
concerned about your health please contact your PCP, [**Name10 (NameIs) 18**] at
[**Telephone/Fax (3) **] or present to the nearest ED.
.
Please take your medications as prescribed including restarting
Imdur only after you have touched base with your outpatient
physician.
.
Please go to your scheduled appointments listed below.
Followup Instructions:
Please call to be seen by your PCP [**Name Initial (PRE) 176**] 1-2 weeks. Please
touch base with your primary care physician regarding restarting
Imdur.
Please call Dr.[**Name (NI) 3101**] office to schedule an appointment
within 1 month ([**Telephone/Fax (1) 7236**].
|
[
"515",
"600.00",
"433.30",
"238.75",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.61",
"00.63",
"88.42",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
5720, 5726
|
3678, 4605
|
338, 418
|
6144, 6153
|
2751, 3655
|
6786, 7059
|
1962, 2036
|
5026, 5697
|
5747, 5747
|
4631, 5003
|
6177, 6763
|
2051, 2732
|
274, 300
|
446, 1455
|
5856, 6123
|
5766, 5835
|
1477, 1824
|
1840, 1946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,066
| 150,208
|
8114
|
Discharge summary
|
report
|
Admission Date: [**2108-9-16**] Discharge Date: [**2108-10-12**]
Date of Birth: [**2066-7-8**] Sex: F
Service:
ADMITTING DIAGNOSIS: Superior vena cava syndrome.
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant on [**2108-9-8**].
2. Superior vena caval syndrome.
3. Distal ureter necrosis.
4. Status post revision of ureter bladder anastomosis.
HISTORY OF PRESENT ILLNESS: At the time of admission the
patient is a 42 year old female with a history of diabetes
mellitus type 1, end-stage renal disease who was on
hemodialysis prior to cadaveric renal transplant done on
[**2108-9-8**]. The patient also has a history of
hypertension, hypothyroidism, and a left lower extremity deep
vein thrombosis. The patient has a history of a Perma-Cath
and three arteriovenous fistulae. The patient also was found
out to have a history of a right brachiocephalic and superior
vena caval venous stent.
The patient presented to the [**Hospital1 188**] in the Emergency Department on [**2108-9-16**], with
demonstrable edema of the bilateral upper extremities and her
head and neck. The patient was without other complaints.
The patient was highly concerning for superior vena caval
syndrome. The patient was admitted to the Surgical Service.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1.
2. History of end-stage renal disease.
3. Status post cadaveric renal transplant on [**2108-9-8**].
4. Hypertension.
5. Hypothyroidism.
6. History of left lower extremity deep vein thrombosis.
7. Status post Perma-Cath placement.
8. History of arteriovenous fistulae times three.
9. It is unclear when it was placed but patient also had a
history of a right brachiocephalic and a superior vena caval
stent.
10. The patient at the time of admission had a right IJ
Perma-Cath which was placed in the superior vena cava.
PAST SURGICAL HISTORY:
1. Right internal jugular Perma-Cath.
2. History of arteriovenous fistula times three.
3. Status post cadaveric renal transplant, as stated on
[**2108-9-8**].
HOSPITAL COURSE: The patient was admitted to the hospital
and at the time of admission, the patient was afebrile; blood
pressure was 143/53. The patient's admission laboratory
examination revealed a white blood cell count of 14.0,
hematocrit of 33, platelets of 151. Sodium 136, potassium
4.4, chloride 104, carbon dioxide of 16, BUN of 102,
creatinine of 5.1 which is down from a creatinine of 5.5 at
the time of discharge from her cadaveric renal transplant.
Glucose was well controlled at 56.
The patient underwent an ultrasound which showed dilation of
both of her internal jugular veins. The patient had an MRV
which demonstrated left IJ and bilateral brachiocephalic vein
and a superior vena caval thrombus. The patient also, on
chest x-ray, demonstrated a stent within her right
brachiocephalic and superior vena cava. It is unclear when
these were placed.
The [**Hospital 228**] hospital course included angiogram done on the
20th with thrombectomy. This did not completely remove all
of the clot. The patient was treated with repeat angiogram
on the 21st with stenting and thrombectomy of the clot from
the superior vena cava, brachiocephalic and internal jugular
with modest return of flow and removal of her Perma-Cath.
A few days later the patient was taken back down to angiogram
where the patient had recanalization of all of her central
veins in her neck with good return of flow, and the patient
had a dramatic clinical response with resolution of her upper
extremity swelling and edema. The patient was treated with
heparin and then Coumadinized.
The patient was also noted on her hospital stay to have a
large amount of fluid coming from her wound. The wound was
opened down to the level of the fascia. Creatinine in the
fluid was consistent with a urine leak. The patient was
taken down to Interventional Radiology where she had a
nephrostomy tube placed which demonstrated stricturing of the
distal ureter.
Of note, it should be stated at the time of the kidney
transplant, it was noted that the Transplant Team had
transsected a lower polar artery that was probably supplying
the bladder which was probably supplying the ureter and this
was the reason for the necrosis of the distal end of the
ureter.
Interventional Radiology had a stent placed through the
distal stricture and into the bladder. The patient was taken
to the Operating Room on the [**9-26**] for a upper
ureteral bladder anastomosis. At the time of the operation,
the previous ureteral anastomosis of the bladder was
identified. This was taken down sharply. Previously, the
necrotic and ischemic ureter was transsected. A new ureter
to bladder anastomosis was performed in good fashion.
The patient, postoperatively, did well. The large wound was
treated with a wound VAC which was changed every two to three
days. The [**Location (un) 1661**]-[**Location (un) 1662**] which was placed at the time of the
surgery decreased in output and once there was no further
evidence of leak, the [**Location (un) 1661**]-[**Location (un) 1662**] creatinine was normal.
The [**Location (un) 1661**]-[**Location (un) 1662**] was removed.
The patient was seen and evaluated by Physical Therapy. The
patient was ambulatory but could not meet reasonable goals
and therefore was felt to an adequate candidate for further
rehabilitation work at rehabilitation hospital.
The patient was tolerating a regular diet. The wound was
cleaning up nicely with a wound VAC. The patient was on
Coumadin, and the patient was placed back on therapeutic
levels of her immunosuppressants.
At the time of discharge, the patient had a repeat renal
duplex on the [**2108-10-8**]. Resistant indices at
0.7 with normal flow already in the veins. The patient's
creatinine which had risen, at the time of discharge was down
to 3.7, which is the lowest point it had been so far.
Therefore, discharge diagnosis included the following.
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant on the [**2108-9-8**].
2. Severe vena caval syndrome secondary to occlusion,
secondary to a Perma-Cath in the superior vena cava and
stent.
3. Status post angiographic thrombectomy of the central
veins of the neck.
4. Distal ureteral necrosis.
5. Status post revision of ureteral bladder anastomosis.
6. Opening of transplant wound treated with wound VAC.
DISCHARGE MEDICATIONS:
1. Coumadin 2 mg p.o. q. h.s.
2. Lanosolid 600 mg p.o. q. 12.
3. Zinc sulfate 220 mg p.o. q. day.
4. Lasix 40 mg p.o. twice a day.
5. Insulin sliding scale.
6. Metoprolol 75 mg p.o. twice a day.
7. Fancyclovir 450 mg p.o. q.o.d.
8. Pantoprazole 30 mg p.o. q. day.
9. Atorvastatin 10 mg p.o. q. day.
10. Gabapentin 100 mg p.o. three times a day.
11. Artificial tears o.u. p.r.n.
12. Synthroid 75 micrograms p.o. q. day.
13. Single strength Bactrim one tablet p.o. q. day.
14. Her immunosuppressant medications which include
Prednisone 10 mg p.o. q. day; Mycophenolate mofetil 100 mg
p.o. twice a day and Prograf 4 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. Wound therapy q. day. Dressings include a wound VAC
which should be changed every two days to the right lower
quadrant wound incision.
2. The patient's follow-up will include an appointment with
Dr. [**Last Name (STitle) 28924**] in the Transplant Office on Tuesday, the 18th.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 14369**]
MEDQUIST36
D: [**2108-10-12**] 15:45
T: [**2108-10-12**] 17:58
JOB#: [**Job Number 28925**]
|
[
"584.9",
"E878.0",
"996.74",
"E878.1",
"599.0",
"996.81",
"E879.8",
"250.01",
"459.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"38.93",
"96.6",
"39.50",
"39.95",
"96.72",
"96.04",
"55.03",
"56.74",
"38.95",
"88.41",
"38.91",
"86.09",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
5982, 6387
|
6410, 7054
|
2063, 5961
|
7078, 7614
|
1881, 2044
|
415, 1278
|
153, 183
|
1300, 1858
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,973
| 156,523
|
8159
|
Discharge summary
|
report
|
Admission Date: [**2149-8-6**] Discharge Date: [**2149-8-7**]
Date of Birth: [**2094-5-1**] Sex: M
Service: NEUROLOGY
Allergies:
Thymoglobulin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
large intracerebral hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt. is a 55 year old with brittle Type I DM, poorly
controlled hypertension, hyperlipidemia, CRI s/p renal
transplant, PVD s/p bilateral LE amputations, who presented to
an
OSH with nausea, vomiting and lethargy and quickly deteriorated
in their ED, found to have a large R hemispheric hemorrhage on
CT, transferred here for further management. History is per OSH
ED records and per pt's caretaker [**Name (NI) **] ([**Telephone/Fax (1) 29046**])
[**Doctor First Name **] reports that she had dinner with the pt. last night and
that he was in his normal state of health. When she got there
this morning at 8:00 he complained that he didn't feel well. He
vomited once. He said that he just wanted to go back to bed, so
she helped him in to bed and said she'd come back in a few
hours.
He seemed uncomfortable but not confused or lethargic at that
time. She came back at 12:30 and he wasn't feeling better and
told her to come back later. She visited again at 2:00 because
she was worried about him. She found him in bed with blood
stains on the sheets. He told her that he'd fallen while trying
to transfer himself back into bed from his wheelchair. He had
bruises and abrasions on his left arm. Apparently his mother
had
been able to help him up from the floor. He seemed somewhat
sleepy at that point, and his blood sugar was high at 363, [**First Name8 (NamePattern2) **]
[**Doctor First Name **] called EMS and he was transported to an OSH ED.
When the ED initially examined him at 3:10 he was per their
notes
lethargic but arousable to verbal stimuli. He quickly
deteriorated and by 4 PM was unresponsive and extensor posturing
and was intubated. Head CT was performed and showed a large R
hemispheric hemorrhage with shift (I do not see the report of
this CT in paperwork here) He was transferred here for further
work up.
Here he has been evaluated by Neurosurgery and felt not to be a
surgical candidate. He has received Mannitol IV and has been
started on a Labetalol drip.
Past Medical History:
Type I DM- brittle, several admissions to OSH for both DKA and
hypoglycemia
CRI, s/p deceased donor transplant 5 years ago
Pancreatic transplant, failed
PVD with R BKA and L foot amputation
Poorly controlled hypertension
Hyperlipidemia
Depression
Diabetic gastroparesis
Social History:
Lives with elderly mother, who has dementia, has a PCA who
visits from [**7-18**] every day, smokes 1 PPD per recent OSH d/c
summary ([**5-22**])
Family History:
Non-contributory
Physical Exam:
T- 97.8 BP- 200/90 HR- 73 RR- 18 O2Sat- 100% on CMV
Gen: Lying in bed, intubated, eyes open, in C collar
HEENT: NC/AT, moist oral mucosa
Neck: in C collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: R BKA, L foot amputation, well healed, no rashes
Neurologic examination:
Mental status: intubated, not responsive to voice or sternal rub
Cranial Nerves:
R pupil 5 mm, NR, L pupil 3 mm, NR. NO EOM with cold calorics.
No corneals. Weak gag with deep suction through ETT.
Motor/Sensory: Minimal extensor posturing RUE with pain, no
movement of LUE or bilateral LE with pain.
Reflexes:
Brisk thorughout. Could not test plantar responses.
Pertinent Results:
[**2149-8-6**] 08:15PM LACTATE-1.2
[**2149-8-6**] 07:50PM GLUCOSE-336* UREA N-50* CREAT-2.8* SODIUM-141
POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-17* ANION GAP-20
[**2149-8-6**] 07:50PM estGFR-Using this
[**2149-8-6**] 07:50PM CK(CPK)-65
[**2149-8-6**] 07:50PM cTropnT-0.03*
[**2149-8-6**] 07:50PM CK-MB-NotDone
[**2149-8-6**] 07:50PM WBC-3.3* RBC-2.49*# HGB-9.0* HCT-28.3*
MCV-114*# MCH-36.2*# MCHC-31.9 RDW-18.5*
[**2149-8-6**] 07:50PM NEUTS-75.2* BANDS-0 LYMPHS-16.8* MONOS-5.4
EOS-1.9 BASOS-0.7
[**2149-8-6**] 07:50PM PLT SMR-NORMAL PLT COUNT-359
Head CT ([**2149-8-6**]): There is a large intraparenchymal hemorrhage
involving much of the right hemisphere including the right
frontal, temporal and parietal lobes. Hemorrhage involves the
right basal ganglia and right thalamus. There is
intraventricular extension of hemorrhage with blood in the
frontal [**Doctor Last Name 534**] of the right lateral ventricle and layering in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle. Blood is also
noted within the fourth ventricle. There is significant mass
effect with subfalcine herniation indicated by approximately
14 mm leftward shift of the septum pellucidum. The right
suprasellar cistern is effaced concerning for uncal herniation
on
the right. Hypodensity surrounds the intraparenchymal
hemorrhage
compatible with vasogenic edema. The right lateral ventricle is
effaced by mass effect. Left lateral ventricle
is dilated consistent with hydrocephalus. There is no evidence
of subdural or epidural hematoma. No fracture is seen. There
is
mild mucosal thickening of the maxillary and ethmoid sinuses.
The mastoid air cells remain clear.
CT C-spine ([**2149-8-6**]):
1. No evidence of cervical spine fracture or malalignment.
2. Bilateral pleural effusions, large on the right and moderate
on the left.
CT torso ([**2149-8-6**]): IMPRESSION:
1. Bilateral pleural effusions, large on the right and moderate
on the left.
2. Limited evaluation of the abdomen without IV contrast.
Apparent wall
thickening of the ascending and transverse colon is concerning
for ischemic colitis.
3. Small amount of free pelvic fluid.
4. Evidence of prior granulomatous disease with small calcified
nodules of the right lung and spleen.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to the Neuro-ICU service for further
evaluation and management. Extensive imaging with CTs of the
head, C-spine, and torso were performed on admission. The CT of
the head was most notable. It showed a large right cerebral
parenchymal hemorrhage with associated edema, and mass effect
resulting in leftward subfalcine herniation and probable
right-sided uncal herniation. There was intraventricular
hemorrhage noted with hydrocephalus. The patient remained
intubated, with no improvement from his initial examination.
His mother and PCA came the following morning and we discussed
the patient's poor prognosis given the extent of the hemorrhage
and deficits on clinical examination. Since the patient's
mother suffers from dementia, a family relative, also with
health care proxy power, was contact[**Name (NI) **] and the case discussed
again. The relative agreed to place the patient on comfort
measures only. The patient was extubated with comfort measures
initiated on [**2149-8-7**]; he expired later that day.
Medications on Admission:
Paxil 40 mg a day
Bactrim SS QD
aspirin 81 mg
Lipitor 10 mg QD
Toprol-XL 50 mg a day
multivitamin one a day
Lantus 6 U QD
Humalog [**5-23**] U QD
Plavix 75 mg a day
Prednisone 5 mg QD
Imuran 75 mg QD
Rapamune 3 mg QD
Procardia 90 mg QD
Protonix 40 mg QD
Lisinopril 10 mg QD
Discharge Medications:
Not applicable (N/A)
Discharge Disposition:
Expired
Discharge Diagnosis:
Extensive right cerebral parenchymal hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"V42.0",
"443.9",
"401.9",
"536.3",
"V49.75",
"331.4",
"431",
"272.4",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7335, 7344
|
5883, 6965
|
304, 310
|
7435, 7444
|
3581, 5860
|
7496, 7613
|
2813, 2831
|
7290, 7312
|
7365, 7414
|
6991, 7267
|
7468, 7473
|
2846, 3168
|
233, 266
|
338, 2340
|
3274, 3562
|
3207, 3258
|
3192, 3192
|
2362, 2633
|
2649, 2797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,344
| 132,392
|
45374+58770
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-10-18**] Discharge Date: [**2146-10-28**]
Date of Birth: [**2076-3-26**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / doxycycline / aspirin / Heparin Agents
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Acute Dyspnea
Major Surgical or Invasive Procedure:
Arterial Blood Gas [**2146-10-18**]
IVC Filter Placement [**2146-10-20**]
History of Present Illness:
Recent History-
70 yr old female pt on coumadin for Afib, DM, CHF,
pacemaker/ICD, who presented to the ED on [**2146-10-9**] for evaluation
of questionable syncope and headaches x 4 days, no seizures, she
denied any recent fall or trauma to the head. Head CT showed a
large left acute on chronic SDH with midline shift. S/p
uncomplicated left craniotomy and hematoma evacuation [**2146-10-9**].
Neurologically intact post surgery. Started on anti-epileptics.
Subcutaneous heparin was initiated for deep vein thrombosis
prophylaxis on [**2146-10-10**]. [**2146-10-11**] transferred to floor and
subsequent discharge to rehab ([**Hospital3 1186**]), discharged on
Phenytoin and without anticoagulation. Instructed not to restart
her Coumadin for the afib untill seen by Dr. [**Last Name (STitle) **] on [**2146-10-21**]
since s/p surgery.
.
Today-
Patient is unable to recall exact details of her recent medical
developments or about her pmh. As per pt, she had sudden onset
of dyspnea (although states that she might of had it for [**1-31**]
days) at rest last night at the [**Hospital3 1186**]. Denies pleuritic
CP, denies leg pain. She was taken to [**Hospital 882**] Hospital where a
CTA Chest showed PE. She was transferred to [**Hospital1 18**] ED in light of
her recent surgery for management of PE.
.
[**Hospital3 1186**] MD Report-
Patient was doing very well in Rehab, great exercise tolerance
on Wednesday. Over the weekend, the staff began to notice
decreased exercise tolerance and SOB with exercise, described as
a dramatic difference. Also had flares of SOB where she would go
tachypneic and then return to normal. VS remained stable and O2
saturation was normal. No CP. She had a temp of 100.6 on Sunday
and WBC came back at 21 on Monday. They called the Neurosurgery
staff who explained that she is at risk for DVT/PE. Sent to
[**Hospital1 882**].
.
In the ED, initial vitals 98.2 92 110/64 20 100% 2L nc
The pt underwent a head CT minimally improved shift of midline
structures now measuring 4mm compared to 6 on prior.
Neurosurgery was consulted and recommended admission to medicine
for management of anti-coagulation in light of recent SDH.
Vitals prior to transfer: 98 90 107/63 20 98%
.
Currently, feeling tired. Unable to fully recall details of her
recent medical developments, however, can convey info given to
her after the surgery relating to her course. Remembers what
people have been telling her happened. States that her memory is
not great right now, however, AAOx3. Denies CP, leg pain, SOB.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
DMII (on Insulin)
Hypertension
Hyperlipidemia
Cardiomyopathy with an EF of 30-35%
CHF s/p PM/ICD (Denies CAD/MI history)
Atrial Fibrillation (on Coumadin)
Gout [**1-8**]
Arthritis
Tonsillectomy
Trigger finger release R hand [**7-9**]
Tubal ligation [**2104**]
Social History:
Was living at home prior to SDH. Discharged to [**Hospital3 1186**]
(Rehab) after surgery. Remote tobacco history. Denies EtOH and
illicits.
Family History:
Son had a PE at 47 y/o and has HIT.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 111/68 83 18 99RA
GENERAL - NAD, wd/wn, head staples
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR (does not appear to be irregular irregular on exam),
no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no calf tenderness or erythema
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-4**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait NONFOCAL
.
DISCHARGE PHYSICAL EXAM:
VS- 98.4 89/58-119/78 72-90 18 100% on RA, weight 203lbs
Gen- NAD, AAOx3
HEENT- No JVD, MMM, PERRLA
CV- normal S1S2 Irregular Irregular, Systolic murmur at LLSB, no
g/c/r
PULM- CTAB, no wheezes
ABD- Soft, nt/nd BS+
Ext- No c/c/e, no calf tenderness or erythema
Neuro- Nonfocal
Pertinent Results:
ADMISSION LABS
[**2146-10-18**] 04:00PM BLOOD WBC-12.4* RBC-5.24 Hgb-12.7 Hct-41.1
MCV-79* MCH-24.3* MCHC-30.9* RDW-15.8* Plt Ct-167
[**2146-10-18**] 04:00PM BLOOD PT-17.0* PTT-28.0 INR(PT)-1.6*
[**2146-10-18**] 04:00PM BLOOD Glucose-172* UreaN-43* Creat-1.6* Na-133
K-7.2* Cl-96 HCO3-27 AnGap-17 (hemolyzed)
[**2146-10-18**] 06:45PM BLOOD Glucose-198* UreaN-47* Creat-1.7* Na-137
K-5.4* Cl-98 HCO3-25 AnGap-19
[**2146-10-18**] 04:00PM BLOOD cTropnT-0.02* proBNP-6432*
[**2146-10-18**] 04:00PM BLOOD Calcium-8.8 Phos-3.1 Mg-2.3
[**2146-10-18**] 04:00PM BLOOD Digoxin-0.7*
[**2146-10-18**] 04:30PM BLOOD Type-ART pO2-147* pCO2-33* pH-7.51*
calTCO2-27 Base XS-4 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2146-10-18**] 04:30PM BLOOD Lactate-1.5
[**2146-10-18**] 05:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2146-10-18**] 05:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2146-10-18**] 05:00AM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-9
.
INTERVAL LABS
[**2146-10-18**] 04:00PM BLOOD cTropnT-0.02* proBNP-6432*
[**2146-10-18**] 04:30PM BLOOD Type-ART pO2-147* pCO2-33* pH-7.51*
calTCO2-27 Base XS-4 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2146-10-22**] 01:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2146-10-22**] 01:00PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2146-10-22**] 01:00PM URINE RBC-11* WBC-12* Bacteri-FEW Yeast-NONE
Epi-1
[**2146-10-20**] 02:05PM BLOOD HEPARIN DEPENDENT ANTIBODIES-positive
[**2146-10-21**] 09:15PM BLOOD SEROTONIN RELEASE ASSAY-positive
[**2146-10-20**] 10:43AM URINE Eos-NEGATIVE
[**2146-10-20**] 10:43AM URINE Hours-RANDOM UreaN-373 Creat-28 Na-69
K-15 Cl-56
[**2146-10-20**] 10:43AM URINE Osmolal-305
.
DISCHARGE LABS
[**2146-10-28**] 08:10AM BLOOD WBC-9.8 RBC-5.05 Hgb-12.2 Hct-39.3
MCV-78* MCH-24.1* MCHC-31.0 RDW-16.0* Plt Ct-370
[**2146-10-28**] 08:10AM BLOOD Glucose-109* UreaN-35* Creat-1.6* Na-136
K-4.4 Cl-93* HCO3-28 AnGap-19
[**2146-10-28**] 08:10AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
[**2146-10-26**] 07:50AM BLOOD calTIBC-247* Ferritn-712* TRF-190*
[**2146-10-28**] 08:10AM BLOOD PT-39.8* PTT-61.9* INR(PT)-3.9*
[**2146-10-28**] 12:55PM BLOOD PT-26.7* PTT-41.3* INR(PT)-2.6*
.
IMAGING
Multiple CT Head w/o Contrast x3
No new acute bleed or changes.
.
LENI [**2146-10-18**]
IMPRESSION: No evidence of deep vein thrombosis, either right
or left lower extremity.
.
Portable CXR [**2146-10-18**]
Pacemaker defibrillator leads terminate in the right ventricle.
Heart size is enlarged. Mediastinum is stable. Prominence of the
main pulmonary artery is consistent with pulmonary hypertension.
Vascular engorgement is noted, but no overt pulmonary edema is
noted on the current study. There is interval improvement of
left retrocardiac opacity which might be consistent with
resolution of atelectasis/infection. No interval development of
appreciable pleural effusion or pneumothorax is seen. Small
amount of pleural effusion, though cannot be excluded.
.
IVC Filter
FINDINGS:
Normal IVC anatomy without duplication or megacava. No filling
defects.
IMPRESSION:
1. Patent IVC without evidence of thrombosis.
2. Opti retrievable IVC filter placement infrarenally.
.
RENAL U/S
INDICATION: 70-year-old woman with CHF, PE and now persistently
elevated
creatinine. Please evaluate for any kidney abnormalities.
COMPARISON: None available.
TECHNIQUE: Grayscale and Doppler ultrasound images of the
kidney were
obtained.
FINDINGS: The right kidney measures 10.1 cm. The left kidney
measures 10.4 cm. There is no hydronephrosis, stones or masses.
Renal echogenicity and corticomedullary architecture is within
normal limits.
Incidentally noted is a gallbladder filled with sludge with no
evidence of gallbladder wall thickening. The bladder is only
minimally distended and cannot be assessed.
IMPRESSION:
1. Normal renal ultrasound.
2. Incidental note of gallbladder filled with sludge with no
evidence of
gallbladder wall thickening.
The study and the report were reviewed by the staff radiologist.
.
MICROBIOLOGY
MRSA Screen Positive
[**2146-10-22**] 12:49 pm URINE Source: CVS.
**FINAL REPORT [**2146-10-25**]**
URINE CULTURE (Final [**2146-10-25**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2146-10-27**] 1:11 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2146-10-28**]**
URINE CULTURE (Final [**2146-10-28**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Culture x 4 - pending
Brief Hospital Course:
70 y/o female with CHF/afib (off Coumadin since neurosurgery
[**2146-10-9**]), DMII, HTN, HLD, s/p SDH evacuation on [**2146-10-9**], presented
to ED from OSH with a PE on CTA Chest.
.
# hypoxia/tachycardia: Pt transferred to MICU on [**2146-10-18**] for
tachycardia and desaturation with movement a few hours after
reaching the floor on her day of her admission. Stabilized in
MICU with aggressive rate control and I/Os were kept even since
there was no evidence for volume overload, appeared dry on exam.
Episode likely multifactorial. Pt had afib with RVR and could
have also thrown another PE (although LENI earlier that day was
negative). Also has underlying cardiomyopathy/CHF with EF 30-25%
on last echo. ACS ruled out during this episode and a Stat CT
head was negative. Echo done in MICU showed markedly dilated w/
severe global LV hypokinesis and increased LV filling pressure.
LVEF= 20 %. RV cavity is dilated with depressed free wall
contractility. She was transferred back to floor after a couple
of days. She had no issues with tachycardia on the floor.
Oxygen was weaned, and she saturated in the high 90s on room air
toward the end of her hospital stay.
.
# Pulmonary Embolism: Patient is s/p recent surgery (off of
Coumadin for afib since surgery), was in rehab when she had
acute onset of SOB (no heparin ppx, but recieved after
neurosurgery while in house prior to discharge). OSH CTA Chest
showed PE. No overt signs of DVT on exam on day of admission but
recent immobilization and s/p surgery (LENI negative for DVT).
Also could be from a R atrial clot from her CHF/afib.
Anticoagulation was going to be readdressed when she followed up
with Neurosurgery on [**2146-10-21**]. Pt was started on heparin drip for
goal of PTT 40-60, as per neurosurgery. After being transferred
back to the medicine floor, it was noticed that the pt has had
platelets steadily decreasing while on heparin. We suspected HIT
and sent a platelet factor 4 which was positive, serotonin assay
sent. HIT could be the reason pt developed the initial PE and
possibly a recurrent PE when she was started on the heparin drip
at the beginning of this admission. Hematology was consulted. We
stopped the heparin drip and switched over to Argatraban drip.
IVC filter was placed with the plan to remove it within a year.
She was started on Coumadin. The Argatroban drip was stopped
once the platelets were above 100 and the INR had been around or
above 4 for 2 days. At 4 hours post Argatroban discontinuation,
the INR remained above 2 (2.6) and she was maintained on
Coumadin. Oxygen was weaned several days prior to discharge.
.
#HIT: Platelets trended down since introduction of heparin.
Thrombocytopenia could also have been caused by Phenytoin, but
it is a less likely cause. HIT ultimately could of caused her PE
as well. PF4 was positive, and serotonin assay was also
positive. The platelets dropped as low as 78, but increased once
the heparin drip was stopped. They were 370 at time of
discharge.
.
# Atrial Fibrillation: Coumadin was held after the SDH
evacuation. Was going to be addressed at her f/u appt with
neurosurgery. Has not been taking any medications for
anti-coagulation since surgery. Aggressive attempt at rate
control was done while on the floor on her first day of
admission and was unsuccessful, ultimately transferred to the
MICU. Digoxin was discontinued due to renal failure and was not
restarted as she was well controlled on the increased dosage of
beta blocker. We kept her on Metoprolol Tartrate 25mg PO QID
after being transferred back to the medicine floor. Her HR
remained well controlled on this regimen, HR <90. She was
anti-coagulated as above. No other episodes of afib with RVR
after being transferred back to the floor.
.
# [**Last Name (un) **] on CKD: EGFR in [**5-/2146**] with Cr 1.2 was 54 for
African-American. Currently Cr 1.9. BUN/Cr > 20. Pre-renal
picture could be secondary to being dry vs poor forward flow
given her cardiomyopathy. On exam prior to ICU transfer, she
looked slightly wet and therefore iv lasix 40 mg x1 was given.
Contrast exposure might be contributing as well but it's early
for contrast to cause renal injury (~ 24 hr so far) from the CTA
Chest. UOP slightly improved with small volume boluses. Once
transferred back to the floor, we sent urine lytes which had
FeNa of 4% and FeUrea of 40%, negative eos on urine smear. Pt
was gradually diuresed and eventually started on her home dose
of Torsemide and the creatinine slowly improved down to 1.3.
Creatinine bumped back up to [**2-5**] on [**2146-10-25**] and there was a
concern for post-renal since pt was complaining of difficulty
urinating. A bladder scan at the bedside was ~125ml (her
complaints likely due to UTI). Torsemide was held on [**2146-10-25**] to
see if we were over diuresing the patient leading to kidney
injury. The creatinine did not improve, and the patient had
increased pulmonary edema by exam, so we restarted diuresis,
which improved creatinine. Renal ultrasound showed normal
kidneys. The creatinine was 1.6 on discharge, and she was
euvolemic on exam.
.
#Urinary Freq/Leukocytosis: Had increased urine frequency, and
one episode of incontinence on [**2146-10-22**] AM. In light of
leukocytosis and recent foley (discontinued once transferred
back to floor from ICU), could have a UTI. Increased urinary
freq could also be due to ATN. Found to have UTI on UA. Started
on Bactrim. Urine Cx returned positive for staph aureus
coagulase positive, unclear if contamniate, but ordered blood cx
x2 to assess for bacteremia seeding (note pt was stable with a
slightly elevated WBC at 11 but no fevers). Three-day course of
Bactrim was completed. Repeat urine culture showed only
skin/genital flora. Four blood cultures had not grown anything
at the time of discharge.
.
# Transaminitis: Found to have transaminitis in MICU. Believed
to be secondary to decreased forward flow, ischemia. Steadily
improved on the medicine floor with IVF.
.
# SDH: Stable as per CT Head done in ER. Staples removed [**10-18**].
Neurosrugery was following, who recommended heprin drip for PE
and repeat CT when PTT is therapeutic. CT Head at therapeutic
range was negative for any new bleeds/changes. Patient was
non-focal on her exam during her stay, with q4h neuro checks.
Phenytoin 100mg PO TID was started after her surgery, we spoke
with Neurosurgery who said that seizure ppx with Phenytoin was
only needed for 7-10days s/p surgery. On [**2146-10-24**], the phenytoin
was discontinued. Phenytoin levels were borderline low
therapeutic while on the medication.
.
# CHF/HTN: Echo done in ICU showed worsening EF. Will most
likely need optomization of her CHF meds as an outpt. Weight 202
pounds on [**2146-10-24**] (pre-admission weight 226) and 204 on
discharge. Torsemide was held on [**2146-10-25**] for concern of [**Last Name (un) **].
Torsemide was restarted when creatinine worsened and patient was
wet on exam. Metoprolol dose was doubled during her hospital
stay, and digoxin was stopped. She was euvolemic on exam at
discharge.
.
# DMII: Continued Lantus but at 20 u QAM (decreased from 40u QAM
at home), with sliding scale during her admission.
.
.
Transitional Issues:
# Gall bladder sludge without wall thickening was seen
incidentally on renal ultrasound. If patient has abdominal
pain, RUQ ultrasound should be considered.
# Continue to follow renal function and consider ACE-I or [**Last Name (un) **]
for CHF when renal function stabilizes.
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Digoxin 0.125 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-31**] tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. Phenytoin Sodium Extended 100 mg PO TID
8. Torsemide 40 mg PO DAILY
9 Lantus 40u QAM, Sliding Scale
10. Senna
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Senna 1 TAB PO BID:PRN constipation
4. Torsemide 40 mg PO DAILY
5. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
heartburn
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Fleet Enema 1 Enema PR DAILY:PRN constipation
please administer if pt not having BM with other full bowel
regimen
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Warfarin 4 mg PO DAILY16
13. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Pulmonary Embolism, Heparin Induced Thrombocytopenia,
Acute on Chronic Kidney Disease, Atrial Fibrillation
Secondary: subacute on chronic subdural hematoma, chronic
systolic heart Failure, Hypertension, Hyperlipidemia, Type 2
Diabetes
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 732**],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You were admitted to [**Hospital1 18**] because you were found to have a
blood clot in your lungs at an outside hospital. We treated the
blood clot with a blood thinner called heparin. You were
transferred to the ICU for a couple of days when your heart rate
was difficult to control on the medicine floor. When you came
back to the medicine floor, we diagnosed you with
heparin-induced thromobocytopenia (HIT), which causes blood
clots to form when you take heparin, a medicine that normally
thins the blood. This may have been the cause of the blood clot
in your lungs because you had also received heparin when you
were hospitalized for the brain surgery. We placed a filter in
your inferior cava vein (a large vein in your abdomen) in order
to prevent new clots from going to your lungs. We treated you
with a different blood thinner called argatroban and eventually
transitioned you to warfarin (also known as Coumadin), which you
had been taking previously.
You had multiple CAT scans of your head while you were here and
none of them showed any new bleeding in your head or brain.
During your stay, you developed kidney injury, which we treated
with fluids. It is most likely due to the contrast you recieved
at the outside hospital for the CAT scan that was done to
diagnose the PE. Your kidney function should be followed at the
rehabilitation facility.
You were also found to have bacteria in your urine, which we
treated with an antibiotic called Bactrim.
Lastly, an ultrasound study done in the ICU showed that you have
"heart failure," which means that your heart does not pump as
strongly as it should. Because of this, you should weight
yourself every day and talk to you doctor if you gain more than
3 pounds. The rehabilitation facility may give you more of the
water pills (torsemide, furosemide, or Lasix) if you are
accumulating fluid in your legs or lungs.
You improved and were deemed ready to be discharged to rehab for
more intensive physical therapy in order to improve your
functional status.
Please keep the appointments made for you below.
Thank you for allowing us to take part in your care.
Followup Instructions:
Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**]
When: Dr. [**Last Name (STitle) 96871**] office is working on a follow up appointment
for you in 16-30 days after your hospital discharge. You will be
called with the appointment date and time. If you have not heard
from the office in 2 business days please call the office number
listed below.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Department: Hematology
When: The Hematology Department is working on a follow up
appointment for you in [**10-15**] days after your hospital discharge.
You will be called by the office with your appointment date and
time. If you have not heard from the office or have questions
please call the number listed below.
Phone: [**Telephone/Fax (1) 3062**]
Department: RADIOLOGY
When: MONDAY [**2146-11-14**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: MONDAY [**2146-11-14**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 43708**], MD [**Telephone/Fax (1) 2731**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 15257**]
Admission Date: [**2146-10-18**] Discharge Date: [**2146-10-28**]
Date of Birth: [**2076-3-26**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / doxycycline / aspirin / Heparin Agents
Attending:[**First Name3 (LF) 1472**]
Addendum:
After discharge, the following laboratory results were returned:
ALT 37, AST 52, AlkPhos 254, Tbili 0.6. As mentioned in the
discharge summary, the patient did have a transaminitis earlier
in the hospital stay, but alk phos had never been this high.
Patient is without abdominal symptoms, and the significance of
these results is unclear. However, the rehabilitation facility
should please repeat LFTs on [**2146-10-31**]. If they continue to be
abnormal, then other testing, such as RUQ ultrasound, may be
considered.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2146-10-28**]
|
[
"E947.8",
"289.84",
"428.0",
"584.5",
"250.00",
"428.23",
"425.4",
"403.90",
"V58.61",
"427.31",
"041.12",
"V58.67",
"V45.02",
"272.4",
"585.9",
"599.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
24148, 24372
|
10192, 17368
|
326, 402
|
19177, 19177
|
4845, 10169
|
21627, 24125
|
3674, 3711
|
18163, 18796
|
18910, 19156
|
17694, 18140
|
19360, 21604
|
3751, 4523
|
17389, 17668
|
273, 288
|
430, 3217
|
19192, 19336
|
3239, 3500
|
3516, 3658
|
4548, 4826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,194
| 146,921
|
13699
|
Discharge summary
|
report
|
Admission Date: [**2146-12-22**] Discharge Date: [**2146-12-27**]
Date of Birth: [**2086-7-2**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Nifedipine / Fentanyl / Ambien
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Shortness of breath, nausea
Major Surgical or Invasive Procedure:
right heart catheterization [**2146-12-23**]
History of Present Illness:
Mr. [**Known lastname 14966**] is a 60-year-old man with history of severe dilated
cardiomyopathy (EF 10-15%, non-ischemic, likely familial) status
post ICD implantation with a biventricular upgrade in [**12/2145**],
amiodarone induced pneumonitis, multiple DVTs, chronic atrial
fibrillation,HTN, HLD, DM2, who was recently discharged from
[**Hospital1 18**] [**2146-12-13**] for ICD firing/V.Fib, and after attempting
several anti-arrhythmics, was eventually discharged on
quinidine. Seroquel was discontinued at that time due to its
arrythmogenic potential.
.
He developed constant dyspnea soon after discharge (about 10
days ago) occurring at rest and limiting his mobility to just a
few steps. This was accompanied by 2-pillow orthopnea and
frequent nightly episodes of PND limiting sleep. He notes
consistent compliance with all his meds, including his
diuretics, and denies dietary indiscretions. His appetite was
rather limited, in actuality. He is on chronic home 02 at 2L,
which he increased to 3L He has had multiple admissions in the
past few years for CHF exacerbation, and notes that his current
symptoms feel similar.
.
He also endorses consistent nausea over the past 10 days which
had been progressive, limiting his appetite, and resulting in
[**1-29**] daily episodes of dry-heaving. His symptoms seem to have
improved within the past 2-3 days, corresponding to a decreased
dose of quinidine.
.
While he denies chest pain, he does endorse a several year
history of intermittent chest pressure, occuring once a month.
The sensation is substernally localized with a [**Doctor Last Name **] sign,
though dissipates within 20 seconds, and is unrelated to
exertion. It does not radiate, and is unacompanied by
diaphoresis, anxiety, or dyspnea. He is currently chest
pain-free.
.
He has a history of multiple PE and DVT, but denies calf
tenderness, pleuritic chest pain, palpitations, or lower
extremity edema.
.
In the ED, his vital signs were 98 82 130/81 100% on 2L. His
examination was significant for a lack of JVD, crackles, or
lower extremity edema. His CXR demonstrated no congestion,
though a BNP was elevated at 6655. EKG demonstrated only Afib,
ventricular paced with PVCs. BP was running low in the upper
90's after giving anti-hypertensives that were missed that
morning.
.
On arrival to the floor, his vital signs were T=100.3 BP= 97/55
HR= 81 RR= 22 O2 sat= 97%2L. He was comfortable in NAD.
Complaining only of some mild lower back pain.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
.
On general review of symptoms, he denies any prior history of
stroke, TIA, current myalgias, joint pains, cough, sputum,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Past Medical History:
Cardiac Risk Factors:
+Diabetes (from steroids for pneumonitis), +Dyslipidemia,
+Hypertension
.
Cardiac History:
-history of an acute myocardial infarction due to a small
embolic event in [**5-/2145**]
-Percutaneous coronary intervention, in [**2145-6-11**] anatomy as
follows: two vessel coronary artery disease. The LMCA was a
large vessel with no angiographically apparent disease. The LAD
was a large vessel with apical diffuse narrowing and an abrupt
termination. The Lcx had a 90% stenosis in the mid to distal
LPDA with probable filling defect. The RCA was small without any
angiographically apparent disease.
.
Pacemaker/ICD, in [**2141**] for primary prevention, upgrade to BiV
[**2145**]
.
Other Past History:
- Dyslipidemia
- Hypertension
- dilated cardiomyopathy, severely depressed EF (10-15%), s/p
ICD [**2141**] for primary prevention
- Afib
- polymorphic VT after dofetilide
- Amiodarone-induced hypersensitivity pneumonitis
- Diabetes, diagnosed after being on steroids for pneumonitis
- GI bleed on Coumadin [**2137**] possibly related to ischemic colitis
- OSA, not on CPAP
- multiple previous DVTs including DVT and PE in [**2126**] following
an ankle trauma, and second episode of PE in [**2137**]. IVC filter
placed [**2137**]. Also had a right brachial vein DVT in [**2139**].
.
PAST SURGICAL HISTORY
- lap cholecystectomy [**2-/2144**]
- IVC filter placement [**2137**]
- bilateral cataract surgery with residual right ptosis
Social History:
Social history is significant for the absence of current tobacco
use. Quit smoking 7 years ago after smoking for 40 years x
2ppd. He drinks no etoh. Lives with wife. Worked at chemical
plant making latex.
Family History:
There is family history of premature coronary artery disease in
patient's father, who had first MI at age 37. He had several
heart attacks, the second occuring in his 40s. Mother also has
dilated cardiomyopathy. Sister had ?[**Name2 (NI) 41267**] CMY (1 episode of
heart failure when very emotional and sad)
Physical Exam:
VS: T=100.3 BP= 97/55 HR= 81 RR= 22 O2 sat= 97%2L Wt 91.1kg
GENERAL: Patient is a fatigued-appearing gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MM were dry.
NECK: Supple with JVP to the jaw. No carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, rate normal, normal S1, S2. 1/6 systolic
ejection murmur heard best at second right ICS. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Scattered crackles at
the bases but generally quite clear to auscultation.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No lower extremity edema palpated. 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+
.
DISCHARGE PHYSICAL EXAMINATION:
WEIGHT: 87.6Kg
HEENT: JVP 10cm
PULM: CTAB, no crackles
CARDS: normal exam
Pertinent Results:
ADMISSION LABS:
.
[**2146-12-22**] 11:46AM PT-20.7* PTT-25.5 INR(PT)-1.9*
[**2146-12-22**] 11:46AM PLT COUNT-204
[**2146-12-22**] 11:46AM NEUTS-84.6* LYMPHS-7.5* MONOS-5.7 EOS-0.5
BASOS-1.7
[**2146-12-22**] 11:46AM WBC-6.6 RBC-5.20 HGB-15.1 HCT-46.0 MCV-89
MCH-29.0 MCHC-32.7 RDW-18.4*
[**2146-12-22**] 11:46AM proBNP-6655*
[**2146-12-22**] 11:46AM ALT(SGPT)-56* AST(SGOT)-40 LD(LDH)-436* ALK
PHOS-79 TOT BILI-1.7* DIR BILI-0.8* INDIR BIL-0.9
[**2146-12-22**] 11:46AM estGFR-Using this
[**2146-12-22**] 11:46AM GLUCOSE-118* UREA N-27* CREAT-1.1 SODIUM-135
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18
[**2146-12-22**] 11:57AM LACTATE-3.3*
[**2146-12-22**] 11:57AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2146-12-22**] 01:50PM LACTATE-2.3*
.
DISCHARGE LABS:
[**2146-12-27**] 07:10AM BLOOD WBC-7.3 RBC-5.54 Hgb-15.9 Hct-49.0 MCV-89
MCH-28.6 MCHC-32.4 RDW-18.1* Plt Ct-188
[**2146-12-27**] 07:10AM BLOOD Glucose-99 UreaN-26* Creat-1.0 Na-139
K-3.8 Cl-99 HCO3-32 AnGap-12
.
CARDIOLOGY:
[**2146-12-22**] 11:46AM cTropnT-<0.01
[**2146-12-22**] 09:05PM cTropnT-<0.01
.
EKG: Ventricular paced rhythm at 83 BPM. Compared to the
previous tracing of [**2146-12-13**] no
definite change.
.
RIGHT CARDIAC CATHETERIZATION [**2146-12-23**]:
1. Limited resting hemodynamics revealed elevated left and right
heart filling pressures. The RVEDP was 16mmHg. The mean PCW was
31 in a tracing with come PA pressure artifact. The cardiac
output was 4.0L/min and cardiac index 2.0 L/min/m2 using the
Fick method assuming arterial oxygen saturation from peripheral
oximetry and mean arterial pressure from cuff pressures. The
oxygen consumption was assumed. The SVR was 1320 dynes*sec/cm5
and PVR 180 dynes*sec/cm5. FINAL DIAGNOSIS: 1. Low output
congestive heart failure with elevated filling pressures.
.
IMAGING STUDIES:
.
CXR [**2146-12-22**]: Again seen is a left-sided pacer defibrillator
with leads ending in the expected location of the right and left
ventricle, unchanged. Lung volumes are normal. The lungs are
clear
bilaterally with no areas of focal consolidation. There is no
pleural effusion or pneumothorax. Cardiomegaly remains stable.
IMPRESSION: No acute intrathoracic process. Stable cardiomegaly.
Brief Hospital Course:
Mr. [**Known lastname 14966**] is a pleasant 60 year old man with h/o severe
non-ischemic cardiomyopathy with EF 10-15% s/p BiV ICD,
amiodarone-induced pneumonitis, coagulopathy with multiple
DVT/PE, chronic AF s/p ablation, HTN, DM2, HLD who presents with
progressive dyspnea and elevated PWP seen on right heart cath
consistent with worsening heart failure:
.
ACUTE ISSUES:
.
1. Acute on Chronic systolic heart failure: The patient
presented with progressive dyspnea since his last
hospitalization with an elevated BNP, though he appeared
relatively euvolemic on exam, only demonstrating anelevated JVP.
His CXR was clear. For further characterization of his cardiac
performance, he underwent right sided cardiac catheterization on
[**2146-12-23**] which demonstrated an elevated PCWP and depressed
cardiac index consistent with worsening heart failure. As he is
in late-stage HF, a swan [**Doctor Last Name **] catheter was placed in the right
IJ and he was transferred to the CCU post procedure for more
aggressive diuresis. He was begun on a lasix gtt and was
diuresed to a wedge pressure of 18 with significant improvement
of his symptoms. The gtt was stoppped secondary to hypotension
to 70s which resolved, though his pressures remained in the
mid-90s to low 100s for the rest of his hospitalization. He was
then transferred to the floor on [**12-25**] for optimization of his
HF regimen. He was transitioned to PO torsemide and maintained
adequate diuresis. He was started on lisinopril and digoxin,
and his beta blocker was transitioned to toprol XL. His
spironolactone was increased to 25mg QD. He was seen by Dr.
[**First Name (STitle) 437**] of the HF team and will follow up with him as an
outpatient. He was without SOB on discharge and achieved a dry
weight of 87.5 Kg.
.
2. Arrhythmia: He has A fib, with BiV/ICD in place. He
remained V-paced at 70-80s with intermittent PVCs. His quinidine
was stopped secondary to nausea, and he experienced a 20 beat
run of VT on [**12-25**]. He was asymptomatic and his ICD did not
fire. He was started on mexilitine and experienced one further
10 beat run VT prior to D/C. He will f/u with Dr. [**Last Name (STitle) 1911**]
as an outpatient.
.
3. Nausea: he presented with 10 days of nausea and dry-heaves,
which improved following a dose decrease in his quinidine. The
quinidine was eventually stopped in the CCU with resolution of
his symptoms.
.
4. [**Last Name (un) **]: His creatinine is elevated from 0.8-1.1 on admission.
Due to his symptoms of overload, he may have experienced
decreased cardiac output from dilation. His Cr imrpoved
slightly to 1.0 following diuresis.
.
INACTIVE ISSUES:
5. Coagulopathy: He has a history of multiple PE/DVT in the
past and is s/p IVC filter in [**2137**]. His fundaparinux was held
on the day of admission in anticipation of right-heart cath the
following morning but was restarted post-procedure.
.
6. DM2- He has steroid-driven DM2 and was continued on glargine
and ISS with satisfactory FSG.
.
7. HTN:BP was running somewhat low with SBP 90s-100s, which is
apparently at his baseline.
.
8. HLD: continued zocor
TRANSITIONAL ISSUES: none
Medications on Admission:
1. aspirin 81 mg Tablet, PO DAILY (Daily).
2. captopril 25 mg Tablet [**Hospital1 **]
3. cholecalciferol (vitamin D3) 1000mg QD
4. quinidine gluconate 324 mg Tablet Sustained Release PO Q8H
5. escitalopram 10 mg Tablet PO DAILY
6. fondaparinux 7.5 mg/0.6 mL daily
7. furosemide 100mg PO BID
8. multivitamin QD
9. methylprednisolone 5mg PO DAILY
10. metoprolol tartrate 200mg [**Hospital1 **]
11. mirtazapine 15mg Qhs
12. omeprazole 20 mg Capsule, 40mg [**Hospital1 **]
13. simvastatin 40 mg Tablet daily
14. spironolactone 12.5 mg QD
15. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for back pain.
16. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation every 4 hours () as needed for SOB,
wheezing.
17. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) Units
Subcutaneous once a day.
18. senna 8.6 mg Tablet [**Hospital1 **] PRN constipation
19. docusate sodium 100 mg Capsule [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
6. torsemide 100 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*5*
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. methylprednisolone 2 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
9. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*5*
10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day.
12. Zocor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
15. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4hours PRN () as needed for SOB.
16. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) units
Subcutaneous at bedtime.
17. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
21. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
1. Acute on chronic systolic heart failure exacerbation
2. Nausea/vomiting secondary to quinidine
3. Atrial fibrillation s/p BiV ICD with intermittent
self-terminating V-tach
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14966**],
You were admitted to the hospital with shortness of breath that
was likely caused by an exacerbation of your congestive heart
failure. You underwent a catheterization procedure to establish
this diagnosis, and you spent a few days in the cardiac ICU to
remove some excess fluid from your body with lasix. You were
then transferred back to the regular cardiology floor, where we
optimized your medications and finished diuresing you. Your
breathing improved greatly by the time of discharge.
You also experienced nausea and vomiting prior to your admission
and in the hospital. We suspect this was triggered by the
quinidine, so this was stopped. You were started on a new drug
to control your heart rhythm, called mexilitine.
The following changes were made to your medications:
1. STOP LASIX
2. START TORSEMIDE, a new diuretic which is absorbed more evenly
3. START MEXILITINE to help control your heart rhythm
4. STOP QUINIDINE, as it probably caused nausea and vomiting
5. START LISINOPRIL instead of captopril to protect your heart
6. STOP CAPTOPRIL
7. INCREASE SPIRONOLACTONE to 25mg daily
8. START TOPROL XL 100mg daily to protect your heart
9. STOP METOPROLOL TARTRATE
10. START DIGOXIN 0.125mcg daily to help your heart contract
harder
Please continue all other medications as prescribed by your
other doctors.
As always, please remember to weigh yourself daily, and call
your doctor if your weight increases more than 3 pounds.
Followup Instructions:
Your PCP has been notified of your admission and will call you
at home with an appointment to be seen soon.
You have an appointment to see Dr. [**Last Name (STitle) 1911**] in [**Location (un) **] to
treat your heart rhythm.
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: MONDAY [**2147-1-9**] at 11:20 AM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You have the following appointment to meet with Dr. [**First Name (STitle) 437**] of our
heart failure team to manage your CHF.
Department: CARDIAC SERVICES
When: MONDAY [**2147-1-30**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
|
[
"V12.51",
"584.9",
"428.23",
"327.23",
"425.4",
"249.00",
"427.31",
"V15.82",
"V45.02",
"458.29",
"272.4",
"401.9",
"412",
"787.02",
"E932.0",
"428.0",
"V58.67",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
14908, 14976
|
8782, 11434
|
333, 379
|
15198, 15198
|
6519, 6519
|
16858, 17948
|
5005, 5314
|
12978, 14885
|
14997, 15177
|
11971, 12955
|
8272, 8346
|
15349, 16835
|
7314, 8252
|
5329, 6400
|
6422, 6500
|
11939, 11945
|
266, 295
|
407, 3291
|
11452, 11918
|
6535, 7298
|
15213, 15325
|
3313, 4764
|
4780, 4989
|
8363, 8759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,739
| 194,799
|
37229
|
Discharge summary
|
report
|
Admission Date: [**2169-11-22**] Discharge Date: [**2169-12-6**]
Service: PLASTIC
Allergies:
Sulfur / Penicillins
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
left oral complex upper and lower lip and cheek defect, status
post resection
Major Surgical or Invasive Procedure:
1. right vertical rectus abdominis myocutaneous free flap to
left cheek and lip defect
2. autologous fat grafting to the superior thyroid as well as
internal jugular vein pedicle
3. harvest of the deep inferior epigastric artery and vein
pedicle
History of Present Illness:
89 year old female with history of having multiple resections
for left cheek and upper and lower lip carcinoma. She has had
multiple radiation therapies of this area and this area has
recurred with a bulky mass that has caused her pain, bleeding
and ulceration.
Past Medical History:
1. Type 2 diabetes.
2. Coronary artery disease.
3. Peripheral vascular disease.
4. Hypertension.
5. Hypercholesterolemia.
6. Aortic stenosis status post porcine aortic valve placement.
7. Aortic insufficiency.
8. Left bundle branch block.
Past Surgical History:
1. Cholecystectomy.
2. Cataract extraction bilaterally.
3. Aortic valve replacement.
4. Left lower extremity vascular surgery.
Social History:
single, retired having worked in the advertising industry
tobacco: 25 pack-year history, quit in [**2130**]
EtOH: glass of wine daily
Family History:
prostate cancer, stomach cancer, colon cancer, and breast cancer
Physical Exam:
upon admission:
General: NAD
HEENT: left buccal tumor, malocclusion of teeth secondary to
tumor
Chest: CTAB
CV: RRR, 3/6 systolic mumur appreciated
Abdomen: soft, nondistended, G-tube in place, mild epigastric
tenderness to palpation
Extremities: no edema appreciated
Pertinent Results:
[**2169-11-22**] 11:19PM TYPE-ART RATES-16/ TIDAL VOL-450 PEEP-5
O2-100 PO2-247* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1 AADO2-455
REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED
[**2169-11-22**] 11:19PM GLUCOSE-164*
[**2169-11-22**] 11:19PM O2 SAT-99
[**2169-11-22**] 11:19PM freeCa-1.16
[**2169-11-22**] 11:13PM GLUCOSE-175* UREA N-13 CREAT-0.5 SODIUM-135
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11
[**2169-11-22**] 11:13PM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.3*
[**2169-11-22**] 11:13PM WBC-12.7* RBC-3.13* HGB-9.5* HCT-27.7* MCV-89
MCH-30.3 MCHC-34.2 RDW-16.0*
[**2169-11-22**] 11:13PM PLT COUNT-163
[**2169-11-22**] 11:13PM PT-15.1* PTT-28.7 INR(PT)-1.3*
[**2169-12-5**] 06:35AM BLOOD WBC-9.7 RBC-2.83* Hgb-8.2* Hct-25.6*
MCV-91 MCH-29.0 MCHC-32.1 RDW-15.3 Plt Ct-331
[**2169-12-5**] 06:35AM BLOOD Glucose-100 UreaN-21* Creat-0.4 Na-142
K-3.9 Cl-106 HCO3-29 AnGap-11
[**2169-12-5**] 06:35AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2169-11-22**] and had a right vertical rectus abdominis
myocutaneous free flap to left cheek and lip defect, autologous
fat grafting to the superior thyroid as well as internal jugular
vein pedicle, harvest of the deep inferior epigastric artery and
vein pedicle. The patient tolerated the procedure well and was
transferred to the surgical intensive care unit (SICU)
post-operatively.
Neuro: Post-operatively, the patient continued on propofol in
SICU until extubation. Throughout her inpatient admission, she
maintained adequate pain control. Patient reported insomnia
during admission and geriatic consult recommended increasing
trazodone dosing from 25mg to 50mg on a temporary basis.
CV: The patient was known to have exisiting left bundle branch
block, vital signs were routinely monitored and patient had no
acute cardiac events during her inpatient admission.
Pulmonary: The patient developed a right lower lobe
consolidation on POD#2 and was started on vancomycin and
levofloxacin; vital signs were routinely monitored.
GI/GU: Post-operatively, her tube feeds were advanced when
appropriate, which was tolerated well. Foley was removed on
POD#9. Intake and output were closely monitored. After no
recorded bowel movements in the SICU, patient developed frequent
bowel movements after transfer to the floor, stool samples were
sent and negative for C. diff toxin x3. Patient is noted to
have urinary incontinence.
ID: Post-operatively, the patient was started on IV vancomycin,
levofloxacin, and clindamycin for fevers and a right lower lobe
consolidation. Vancomycin was continued for a total of 10 days
and ciprofloxacin prescribed for a total of 10 days. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#14, the patient was doing well
with stable flap post-operatively, neck and abdominal drains
removed during inpatient stay, she was afebrile with stable
vital signs, tolerating tube feeds, thin liquids, and pureed
solids, ambulating out of bed to chair with assistance, voiding
without assistance (incontinent), and pain was well controlled.
Medications on Admission:
protonix, simvastatin, plavix, detrol, aspirin, amitriptyline,
digoxin, lexapro, lisinopril, metformin, metoprolol, and roxicet
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for .
8. Oxycodone 5 mg/5 mL Solution Sig: [**12-9**] PO Q4H (every 4 hours)
as needed for pain.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Insulin Regular Human Injection
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: total of 10d course, course
complete on [**12-7**].
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] at [**Hospital1 8**]
Discharge Diagnosis:
left oral complex upper and lower lip and cheek defect, status
post resection
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:
* trachiostomy shall remain in place
* trazodone shall be for short term use only
* tube feeds to continue in addition to thin liquid and pureed
solids
* liquids by teaspoon only, NO cups or straw sips
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners.
* No strenuous activity
* Okay to shower, but no baths until after directed by your
surgeon
Followup Instructions:
please call Dr [**First Name (STitle) **] at [**Telephone/Fax (1) 6742**] to schedule a follow-up
appointment for the week of [**2169-12-11**]
please call Dr [**Last Name (STitle) 1837**] at [**Telephone/Fax (1) 41**] to schedule a
follow-up appointment for the week of [**2169-12-11**]
please call [**Hospital1 18**] Gerontology at [**Telephone/Fax (1) 719**] to schedule a
follow-up appointment
Completed by:[**2169-12-6**]
|
[
"780.52",
"486",
"275.3",
"250.00",
"426.3",
"414.01",
"V55.0",
"172.0",
"276.1",
"311",
"272.0",
"564.00",
"V43.3",
"426.11",
"433.30",
"433.10",
"458.29",
"145.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.89",
"27.42",
"31.1",
"40.41",
"96.72",
"85.74",
"86.74",
"97.23",
"83.49",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6993, 7058
|
2785, 5105
|
306, 554
|
7180, 7180
|
1807, 2762
|
8414, 8844
|
1437, 1503
|
5283, 6970
|
7079, 7159
|
5131, 5260
|
7357, 8391
|
1138, 1270
|
1518, 1520
|
189, 268
|
582, 845
|
1535, 1788
|
7194, 7333
|
867, 1115
|
1286, 1421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,919
| 161,998
|
47196
|
Discharge summary
|
report
|
Admission Date: [**2185-5-19**] Discharge Date: [**2185-6-6**]
Date of Birth: [**2145-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
tracheotomy
PEG
intubation
History of Present Illness:
The patient is a 39 yo man c hc of Prader Willi Sd , mental
retardation , Morbid Obesity, OSA and Chronic CO2 retainer, on
BIPAP. Recently discharged from this unit after treatment of
PICC line infection. Pt sent to ED from [**Hospital3 **]
today after pt had a questionable episode of SOB and was found
to be more somnolent than ususla. Denied CP , no n/v.
In ED he was found to be mildly somnolent. T 98.3 HR 156/76 RR
22 SpO2 100% 2 lt.ABGs c have a severe respiratory acidosis
ABGs 7.18/65/213/25 ( 2 lt NC). He was started on BIPAP 12/2.
His respiratory status did not show much improvement 2 nd ABGs
7.13/70/42/25.
A CxR showed no signs of infection. Lower extremity US c no
signs of DVT . Pt was started on IV Heparin drip and sent to
[**Hospital Unit Name 153**].
Past Medical History:
Prader Willi Syndrome
Morbid Obesity
DM II
CRI w/ baseline creatinine 1.8-2
OSA on home cpap
Mental retardation
Hypothyroidism
Social History:
Patient lived in group home, came from rehab this time. Patient
denies any smoking, ethanol or drug use. Intermittently
sexually active with a female partner.
Family History:
Positive family history for diabetes.
Physical Exam:
PE: Tm 98.3 rectal; ; 132/74 HR 80; 100 on BIPAP (16/6cm)
Gen: morbidly obese AAM lying flat in no distress, answers
questions a
HEENT: mmm
CV: distant heart sounds; rrr
Lungs: cta anteriorly
Abd: obese; + BS , no tenderness to palpation
Ext: massive LE edema with venous stasis changes and scaling
over R shin
Neuro: slow speech; answers simple questions; follows commands;
non focal exam
Pertinent Results:
CxR : Due to patient habitus, study severely limited in
evaluating for pneumonia. Right basilar opacity appears likely
to represent the right heart border. Failure to visualize the
left diaphragm is likely related to patient habitus and film
exposure.
.
[**6-3**] CXR: The PICC line overlies proximal SVC probably impinging
on its lateral wall with a recoil at its tip the tracheostomy
tube is 5 cm above the carina. Cardiomegaly and bilateral
pulmonary opacities unchanged since prior film of [**2185-6-2**].
No pneumothorax.
.
ECHO:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The inferior wall and
the basal portion of the LV are visualized; no wall motion
abnormality is seen. The distal half of the LV is not well seen.
3. The mitral valve leaflets are mildly thickened.
4. Compared with the prior study (images reviewed) of [**2185-5-3**],
there has been no significant change.
.
admit labs:
[**2185-5-19**] 07:00PM BLOOD WBC-13.4* RBC-4.04* Hgb-9.8* Hct-33.3*
MCV-83 MCH-24.2* MCHC-29.3* RDW-20.8* Plt Ct-220
[**2185-5-19**] 07:00PM BLOOD Neuts-74* Bands-1 Lymphs-19 Monos-4 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-11* Other-0
[**2185-5-19**] 07:00PM BLOOD Plt Smr-NORMAL Plt Ct-220
[**2185-5-19**] 07:00PM BLOOD Glucose-189* UreaN-92* Creat-2.5*# Na-141
K-5.6* Cl-104 HCO3-22 AnGap-21*
[**2185-5-19**] 07:00PM BLOOD CK(CPK)-69
[**2185-5-20**] 03:02AM BLOOD ALT-306* AST-540* LD(LDH)-795* CK(CPK)-63
AlkPhos-1041* TotBili-0.8
[**2185-5-19**] 07:00PM BLOOD cTropnT-0.55*
[**2185-5-19**] 09:25PM BLOOD cTropnT-0.55*
[**2185-5-20**] 03:02AM BLOOD CK-MB-3 cTropnT-0.56*
[**2185-5-20**] 03:02AM BLOOD Albumin-2.9* Calcium-7.4* Phos-7.2*#
Mg-1.9
.
discharge labs:
[**2185-6-6**] 04:47AM BLOOD WBC-13.8* RBC-3.63* Hgb-8.7* Hct-30.4*
MCV-84 MCH-24.1* MCHC-28.7* RDW-19.7* Plt Ct-321
[**2185-6-6**] 04:47AM BLOOD Plt Ct-321
[**2185-6-6**] 04:47AM BLOOD Glucose-279* UreaN-28* Creat-0.9 Na-140
K-4.9 Cl-100 HCO3-36* AnGap-9
[**2185-5-30**] 04:26AM BLOOD ALT-25 AST-20 LD(LDH)-279* AlkPhos-274*
TotBili-0.5
[**2185-6-6**] 04:47AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6
[**2185-6-5**] 04:32AM BLOOD TSH-14*
[**2185-5-20**] 03:02AM BLOOD TSH-33*
[**2185-5-20**] 03:02AM BLOOD Free T4-0.6*
[**2185-5-20**] 03:02AM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2185-6-3**] 07:52PM BLOOD Vanco-41.0*
[**2185-6-3**] 05:36AM BLOOD Type-ART Temp-37.6 Rates-/16 Tidal V-375
PEEP-15 FiO2-50 pO2-144* pCO2-60* pH-7.34* calHCO3-34* Base XS-4
Intubat-INTUBATED Vent-CONTROLLED
Brief Hospital Course:
The patient is a 39 yo M w/ Prader Willi, diabetes, and CRI who
presented with questionable episode of hypoxia and AMS at his
rehab facility. ABG c severe hypercarbia.
Resp distress: The patient was brought to the ICU for
hypercarbic respiratory failure. It is unclear if there was a
precipitating event. He was given doses of morphine for
abdominal pain that may have tipped him over; but per family
reports he has been having a downward course over the last few
months. He was intubated on the evening of admission for
respiratory failure w/ evidence of respiratory acidosis. He was
aggressively diuresed in the hopes that this would help to wean
him off the vent. He continued to have good RSBI's and pass
breathing trials but ABG's continued to show PCO2's in the 60's.
It was decided to proceed with a trach and thoracics was
consulted. Tracheostomy was completed without complications, and
he was maintained on PS 20/10 w/ Fi02 40% w/ intermittent PS
[**1-8**]. On discharge, pt was undergoing sprints of decreased
pressure support. He would use PS 12 c PEEP 10 for upto 5 hours
at a time. He should gradually be given less PS as his
respiratory muscular function improves.
Elevated LFTs - The patient complained of abdominal pain (per
family) a few days prior to admission. On admission, his
abdomen was non-tender and had a benign exam. Based on his
elevated LFT's, he likely passed a stone. His enzymes trended
down to normal during his first week of admission. RUQ u/s
showed cholelithiasis without cholecystitis or biliary ductal
dilatation. He was originally started on vanc/unasyn for
?cholangitis but this was d/c'ed on [**5-21**]. The patient remained
afebrile during the course of the admission until [**5-30**]. His
fevers at that time was attributed to VAP, and this will be
discussed in more detail below. His LFTs returned to [**Location 213**]
before discharge.
Fevers - Pt had temperature elevation to 102 during his hospital
course. Sputum from [**5-30**] grew MRSA, and he has had a hx of MRSA
bacteremia. Blood cx from same date w/ coag - staph from A line;
surveillance cultures NTGD. He was treated with ceftazidime and
vancomycin for presumptive VAP and will plan to treat for 12
days (to end [**6-10**]). He remained afebrile after starting
antibiotic therapy, and his WBC trended toward normal.
Acute on chronic renal failure - resolving quickly after
hydration.
Anemia: Unclear etiology of anemia; Chronic kidney disease
seemed unlikely given normal creatinine and EPO stopped here.
Should follow up with his PCP to address his anemia.
Insulin Dependent Diabetes: The patient was treated with lantus
and an ISS which was adjusted as needed. He should have his
lantus dose adjusted over the next several days depending on his
sliding scale need.
Hypothyroidism: The patient had a TSH 33 and his levothyroxine
was increased from 75 to 100mcg. Repeat TSH level later in the
hospital course was 14 which suggested a response to the change
in dosing. Will need continued follow-up as an outpatient.
During tracheotomy, surgeons, noted to have black, nodular
thyroid. Endocrine was consulted who advised that this was
nonspecific finding - he should have a follow up with
endocrinology to better understand this finding and to manage
his thyroxine dose.
FEN: The patient was started on TF's after intubation. There
was discussion of placing a PEG at the time of trach placement
but surgery felt that they would have to do an open PEG with was
more extensive and had an increased morbitidy associated with
it. We felt that the patient had a good chance of using a
pasi-[**Last Name (un) **] valve within a week of being trach'd and would be able
to swallow at that time and take PO intake so the PEG was
deferred initially. However, as the trach was delayed due to
elevated temps, CT [**Doctor First Name **] proceeded w/ trach and PEG at the same
time without complications. Tolerated procedures well, and able
to use PEG without difficulty.
Full code
Medications on Admission:
1. Aspirin 81 mg qd
2. Levothyroxine 75 mcg qd
3. Hydrochlorothiazide 25 mg qd
4. Ferrous Sulfate 325 mg qd
5. Epoetin [**Numeric Identifier 890**] tiw
6. Tamsulosin 0.4 mg hs
7. Calcium Acetate 2668 mg tid
8. Insulin 70/30; 40u qam, 15u qpm
9. Morphine 15 mg prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-31**]
Puffs Inhalation Q6H (every 6 hours) as needed.
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed for constipation.
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
11. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
15. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gm Intravenous Q8H (every 8 hours) for 2 days: last dose
[**6-8**].
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 2 days: last day [**6-8**].
17. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous qAM.
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
sliding scale Subcutaneous four times a day: per insulin
sliding scale; please titrate long-acting insulin appropriately
based on sliding scale needs over following 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
hypercarbic respiratory failure
VAP
ARF
anemia secondary to CKD
IDDM
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) **] if you continue to have fevers
>101.4, have difficulty breathing, increased cough or
secretions, persistent diarrhea or vomiting, chest pain,
dizziness or any other symptoms that are concerning to you. PEG
and tracheostomy care as per usual protocol. You should take all
your medications and keep all your appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2185-6-7**] 4:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8386**], M.D. Date/Time:[**2185-7-5**] 4:30
Follow up with Dr. [**Last Name (STitle) 978**] as needed for diabetes care - he is
at the [**Hospital **] clinic. You have to schedule an appointment with
the [**Hospital 1800**] Clinic to follow up on your thyroid disease -
[**Telephone/Fax (1) 9941**]
|
[
"759.81",
"278.01",
"496",
"780.57",
"482.41",
"458.9",
"518.81",
"680.2",
"285.21",
"V09.0",
"V18.0",
"244.9",
"574.21",
"112.2",
"424.0",
"403.91",
"584.9",
"428.0",
"790.7",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.04",
"93.90",
"33.22",
"43.11",
"96.6",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10810, 10883
|
4635, 8648
|
323, 352
|
10996, 11005
|
1976, 3791
|
11419, 11971
|
1508, 1547
|
8963, 10787
|
10904, 10975
|
8674, 8940
|
11029, 11396
|
3807, 4612
|
1562, 1957
|
276, 285
|
380, 1162
|
1184, 1313
|
1329, 1492
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,989
| 129,385
|
43833
|
Discharge summary
|
report
|
Admission Date: [**2137-8-26**] Discharge Date: [**2137-8-27**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Respiratory failure.
Major Surgical or Invasive Procedure:
thoracenthesis
History of Present Illness:
[**Age over 90 **] y.o w/ recently diagnosed bilateral malignant pleural
effusions, primary tumor unknown, transferred to [**Hospital1 18**] ED from
nursing home with respiratory failure. In the ED L sided
thoracenthesis performed w/ 1.2 liters of bloody fluid return,
following procedure, patient became hypotensive to 60/palp.
Initially responded to 1 L NS fluid bolus. However upon transfer
to the MICU, coninued with hypotension (MAPs in mid 40-low 50
range)with heart rate in 150s (A-fib). After discussion with
patients healthcare proxy/daughter [**Name (NI) **], pt code status
changed to DNR/DNI with comfort measures. She was maintained on
morphine drip for comfort. The patient expired at 5:55 am on
[**8-27**] from respiratory arrest.
Past Medical History:
1. Dementia
2. Urinary incontinence
3. Asthma
4. CVA (lacunar infarct L basal ganglia in [**2133**])
5. Hypothyroid
6. Osteoporosis
7. Recurrent UTIs
8. Adenocarcinoma (pleural fluid) unknown primary
Social History:
At baseline, patient ambulated with walker. She lives in
[**Hospital3 **]. She used to smoke but quit >16 years ago.
Patient's family is heavily involved in her care (daughter
[**Name (NI) **] [**Name (NI) 69523**] is health care proxy).
Physical Exam:
97, BP 64/20, rr 14, HR 146
GEN: obtunded
CV: irregularly-irregular
Pulm: bilat ronchi, decreased breath sounds L>R
Abd: ND/hypoactive bowel sounds
Ext: no edema
Pertinent Results:
[**2137-8-26**] 01:14PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2137-8-26**] 01:14PM K+-6.3*
[**2137-8-26**] 11:15AM GLUCOSE-126* UREA N-50* CREAT-3.1*#
SODIUM-141 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-28 ANION GAP-17
[**2137-8-26**] 11:15AM cTropnT-0.07*
[**2137-8-26**] 11:15AM CK-MB-3
[**2137-8-26**] 11:15AM CALCIUM-8.7 PHOSPHATE-7.2*# MAGNESIUM-2.8*
[**2137-8-26**] 11:15AM WBC-10.2 RBC-3.68* HGB-10.1* HCT-31.0* MCV-84
MCH-27.4 MCHC-32.5 RDW-16.0*
[**2137-8-26**] 11:15AM NEUTS-88.4* LYMPHS-5.4* MONOS-5.0 EOS-1.0
BASOS-0.3
[**2137-8-26**] 11:15AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MICROCYT-1+
[**2137-8-26**] 11:15AM PLT COUNT-290
[**2137-8-26**] 11:15AM PT-12.4 PTT-24.0 INR(PT)-1.0
Brief Hospital Course:
The patient was maintained on morphine drip. She died in the
morning of [**2137-8-27**] from respiratory arrest. Her
daughter/healthcare proxy was present at the bedside.
Discharge Disposition:
Home
Discharge Diagnosis:
Adenocarcinoma, Malignant pleural effusions, respiratory arrest
Discharge Condition:
expired
|
[
"733.00",
"493.20",
"V15.82",
"197.2",
"244.9",
"294.8",
"518.81",
"199.1",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
2692, 2698
|
2497, 2669
|
278, 294
|
2805, 2815
|
1747, 2474
|
2719, 2784
|
1564, 1728
|
217, 240
|
322, 1069
|
1091, 1292
|
1308, 1549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,762
| 114,936
|
41344
|
Discharge summary
|
report
|
Admission Date: [**2149-6-3**] Discharge Date: [**2149-6-13**]
Date of Birth: [**2091-10-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea x 3 days
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
57 year old man with history of DMII, IPF on prednisone 20,
chronic MRSA osteomyelitis since [**9-17**] after ankle fracture, PAF
on coumadin presents to [**Hospital3 **] ED on [**2149-6-3**] after 3
days of worsening dyspnea. The patient has a long and
complicated hospital course neatly outlined in previous
discharge summary. In brief, the patient was recently discharged
from [**Hospital1 18**] on [**2149-5-23**], admitted on [**2149-5-21**] for failed
osteomyelitis treatment on vanc and switched to daptomycin. His
bactrim PCP [**Name9 (PRE) **] was also discontinued for concern of worseing
CKD and after a 5 day gap was switched to dapsone on [**2149-5-27**].
The patient started noticing dyspnea on exertion, fatigue, and
increasing O2 requirement on [**2149-5-31**] up to 6LNC from his
baseline of 1-2LNC. On the day prior to admission he developed
an increasingly productive cough of clear/white sputum. He
decided to present to the ED.
.
In the [**Hospital3 **] ED he initially presented with the
following VS: 98 87 28 181/67 98% on NRB. He was switched
off to 6LNC, desated to 87% and replaced on NRB. Sent set of
blood cx and gave him Duonebs and Solumedrol 125mg IV ONCE. HCT
came back at 23. Pt then taken off NRB and satting 90-93% on
6LNC. Vitals at transfer were 98.4 81 182/69 22 93%6LNC. His
labs were notable for CO2 of 36, creatinine of 2.5, BUN of 91,
WBC 14.9, HCT of 23.3 (MCV 84), K 5.4, INR 3.2, Troponin <0.015.
Rectal exam was guiac negative.
.
In the ED, his vital signs were 97.8 84 160/80 20 92% 6L RA
initially. He was given gabapentin 400mg PO ONCE, vancomycin 1gm
IV ONCE, cefepime 2mg IV ONCE, azithromycin 500mg IV ONCE.
Past Medical History:
1) Interstitial lung disease on prednisone 20 daily
2) Diabetes II
3) Osteomyelitis of right ankle on daptomycin (s/p vanc failure)
4) HTN
5) HLP
6) PAF on coumadin
7) Provoked DVT in remote past
8) Obesity Hypoventilation syndrome on BIPAP
Social History:
Former businessman, on disability at present. Does not smoke,
drink, or use drugs. Good social support from wife.
Family History:
No family hx of lung disease. Mother with MI at age 48.
Physical Exam:
Admission Physical Exam
GEN: pleasant, morbidly obese, unable to complete full sentences
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions,
RESP: CTA b/l with good air movement throughout except bibasilar
rales
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c 3+ edema bl
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
Discharge Physical Exam
VS: 98.2 142-150/68-75 80-83 22-24 94%2LNC
I/O: 1500/3400
CBG:152/130/61/182
GEN: pleasant, morbidly obese, able to complete full sentences
HEENT: PERRL, EOMI, anicteric, MMM, OP clear without lesions
NECK: supple, unable to evaluate JVD given habitus
RESP: CTAB. No crackles or wheezing noted
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: +BS, obese, soft, nontender, nondistended, no masses or
hepatosplenomegaly, +pitting edema of skin
EXT: wwp, DP 2+ bilaterally, 3+ LE edema to the thighs
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2149-6-3**] 07:35PM BLOOD WBC-13.9* RBC-3.20* Hgb-8.6* Hct-27.9*
MCV-87 MCH-26.8* MCHC-30.8* RDW-17.1* Plt Ct-266
[**2149-6-6**] 03:32AM BLOOD WBC-14.9* RBC-3.04* Hgb-8.2* Hct-26.0*
MCV-86 MCH-26.9* MCHC-31.4 RDW-16.0* Plt Ct-274
[**2149-6-9**] 05:43AM BLOOD WBC-11.7* RBC-3.26* Hgb-9.0* Hct-28.2*
MCV-87 MCH-27.7 MCHC-32.0 RDW-16.9* Plt Ct-250
[**2149-6-12**] 05:59AM BLOOD WBC-12.8* RBC-3.23* Hgb-8.8* Hct-28.3*
MCV-87 MCH-27.2 MCHC-31.1 RDW-17.2* Plt Ct-244
[**2149-6-6**] 03:32AM BLOOD PT-28.2* PTT-27.3 INR(PT)-2.7*
[**2149-6-7**] 05:57AM BLOOD PT-21.4* PTT-25.4 INR(PT)-2.0*
[**2149-6-8**] 06:07AM BLOOD PT-18.9* PTT-23.7 INR(PT)-1.7*
[**2149-6-9**] 05:43AM BLOOD PT-16.5* PTT-23.2 INR(PT)-1.5*
[**2149-6-11**] 06:12AM BLOOD PT-17.5* PTT-22.6 INR(PT)-1.6*
[**2149-6-12**] 05:59AM BLOOD PT-20.0* INR(PT)-1.8*
[**2149-6-13**] 04:57AM BLOOD PT-22.4* INR(PT)-2.1*
[**2149-6-4**] 01:49AM BLOOD Ret Aut-2.7
[**2149-6-3**] 07:35PM BLOOD Glucose-139* UreaN-85* Creat-2.2* Na-141
K-5.2* Cl-96 HCO3-35* AnGap-15
[**2149-6-5**] 03:38AM BLOOD Glucose-321* UreaN-68* Creat-1.9* Na-142
K-4.2 Cl-94* HCO3-37* AnGap-15
[**2149-6-7**] 05:57AM BLOOD Glucose-191* UreaN-71* Creat-1.6* Na-141
K-4.4 Cl-96 HCO3-39* AnGap-10
[**2149-6-8**] 02:56PM BLOOD Glucose-216* UreaN-64* Creat-1.6* Na-139
K-4.4 Cl-95* HCO3-37* AnGap-11
[**2149-6-10**] 04:18AM BLOOD Glucose-217* UreaN-53* Creat-1.4* Na-140
K-4.9 Cl-97 HCO3-39* AnGap-9
[**2149-6-12**] 05:59AM BLOOD Glucose-297* UreaN-47* Creat-1.6* Na-138
K-4.8 Cl-96 HCO3-35* AnGap-12
[**2149-6-13**] 04:57AM BLOOD Creat-1.4* Na-141 K-4.5 Cl-96
[**2149-6-3**] 07:35PM BLOOD ALT-20 AST-16 LD(LDH)-390* AlkPhos-93
TotBili-0.3
[**2149-6-4**] 01:49AM BLOOD proBNP-1356*
[**2149-6-4**] 01:49AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2 Iron-22*
[**2149-6-4**] 01:49AM BLOOD calTIBC-244* Ferritn-253 TRF-188*
[**2149-6-4**] 03:34PM BLOOD B-GLUCAN-Test negative
TTE ([**2149-6-6**])
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved left ventricular
function. No pathologic structural valvular disease identified,
but views are limited.
CT Chest
1. The appearance of the lungs, while significantly obscured by
motion
artifact and extensive multifocal consolidations, is not typical
for
idiopathic pulmonary fibrosis as there is no evidence of basilar
reticulation
or honeycombing. The appearances are more in keeping with a
multifocal
pneumonia rather than an acute flare of pulmonary fibrosis. When
the patient's
clinical condition has improved, a HRCT may then be performed to
assess for
subtle pulmonary fibrosis.
2. Moderately severe pulmonary enlargement suggesting pulmonary
hypertension.
Brief Hospital Course:
57 year old man with history of DMII, IPF on prednisone 20,
chronic MRSA osteomyelitis since [**9-17**] after ankle fracture, PAF
on coumadin presents to [**Hospital3 **] ED on [**2149-6-3**] after 3
days of worsening dyspnea.
# Hypoxia/respiratory failure: Patient on home 2L 02 and
admitted with hypoxic respiratory distress and required full
face bipap (failed nasal CPAP) for the first 24-36 hours.
Etiology was unclear but felt likely multifactorial IPF (history
of this, on 20mg po prednisone) vs. Pneumonia (increased cough,
sputum production and leukocytosis) vs. CHF (bnp . He was
treated with high dose IV steroids (125 q6 for 48 hours) for ?
IPF flare, Vanc/Cefepime/Levoflox for HAP and he was diuresed
with IV lasix. Over the course of 3 days his respiratory status
improved so that he was satting 90-95% on 3-4L by NC, though he
desatted to the 80s every time he moved. He was net negative
almost 10 Liters over this time. His prednisone was decreased
to 60 then 50 then 40mg po. His antbiotics were continued for
an 8 day course. He was continued on full face Bipap overnight
rather than nasal Bipap. He was eventually transitioned to po
bumetamide and discharged home with physical therapy as he was
able maintained good oxygen saturation with ambulation on 3LNC.
# History of IPF: Patient's pulmonologist was on vacation when
he was admitted, but OSH records showed that patient was
initially admitted on [**4-/2148**] with bilateral pneumonia, and
during this admission he was bronch'd and infectious etiologies
were ruled out and he had a transthoracic biopsy which was used
to get the diagnosis of IPF. Since then the patient's steroid
requirement was as low as 10mg po daily but the he was
hopsitalized in [**State **] last [**Month (only) 205**] with respiratory failure and
since then has remained on 20mg prednisone and home 02.
Patient's CT scan here was not consistent with IPF and it is not
the usual standard here to diagnose IPF on transbronchial biopsy
(typically transthoracic). Patient was continued on Dapsone for
PCP [**Name Initial (PRE) 1102**] (concern at an earlier admission that he had
renal failure from Bactrim). Vitamin D, Calcium, and a PPI were
initially for his steroid course.
# [**Last Name (un) **]: Patient's creatinine 2.2 on admission, up from 1.6
recently. After significant diuresis the kidney function
improved to baseline at 1.6, likely poor forward flow from CHF.
# Anemia: HCT down to 25 from baseline 30, normocytic, guiac
negative. Hemolysis unlikely with nl bili and other hemolysis
labs normal. Initially concerned for GI bleed still in ddx esp
with INR of 3.5 but patient guiac negative and had no BRBPR.
Patient's iron studies showed iron deficiency.
# PAF: Anticoaggulated for remote DVT, PAF, and immobility with
osteo. INR supratherapeutic, so his warfarin was initially held
which led to it being subtherapeutic. Coumadin was increased to
7.5 mg to maintain goal INR [**3-13**].
# Chronic osteomyelitis: Patient on Daptomycin, which was held
when he was treated for HAP. Daptomycin was subsequently
restarted after he completed 8 days of his HAP regimen.
# DM: Exacerbated by steroids at present. He was maintained on
Lantus 70 QAM, 60 QPM plus SSI. [**Last Name (un) **] was consulted with
eventual lantus of 75 qam and 55 qpm upon discharge.
# HTN: His home antihypertensives were initially held and were
subsequently restarted.
Follow up for PCP
1. Please check electrolytes and kidney function at the next
visit and decide whether to decrease bumetamide to qdaily
instead of [**Hospital1 **] based on volume status and kidney function.
2. Please discuss with pulmonologist regarding further
evaluation of IPF
3. Please check INR and adjust coumadin dose according.
Follow up for ID
1. Please check kidney function and ajdust Daptomycin dose
frequency accordingly.
Medications on Admission:
1) Daptomycin 1300mg Q48H since [**6-2**]
2) Neurontin 400mg PO TID
3) Nortryptaline 50 PO BID
4) Prednisone 20mg PO daily
5) Coumadin 5mg PO daily
6) Norvasc 10 daily
7) Coreg 25mg PO BID
8) Paxil 40mg PO daily
9) Bumex 3mg PO BID
10) Lantus 70 units QAM, 60 units QPM
11) SSI
12) Dapsone 100mg PO daily
13) Metolazone 5mg PO BID
14) Pantoprazole 40mg PO Daily
Discharge Medications:
1. daptomycin 500 mg Recon Soln Sig: 1300 (1300) mg Intravenous
once a day.
Disp:*30 doses* Refills:*0*
2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. nortriptyline 50 mg Capsule Sig: One (1) Capsule PO twice a
day.
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
9. bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. insulin glargine 100 unit/mL Solution Sig: Seventy Five (75)
units Subcutaneous qam.
11. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55)
units Subcutaneous qpm.
12. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis: Multilobar pneumonia, Acute on chronic
diastolic heart failure, Acute on chronic kidney injury
Secondary Diagnosis: OSA, obesity hypoventilation syndrome,
Hypertension, Type 2 Diabetes
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:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for shortness of breath and increasing oxygen
requirements. CT scan revealed a multilobar pneumonia. You
were started on IV antibiotics for a total eight day course.
In addition, you had an exacerbation of your diastolic heart
failure. Your heart is slightly stiff as a result of high blood
pressure. It is not as effective at pumping the fluid through
your body. You were given IV diuretics to help remove this
fluid and eventually transitioned to bumetanide orally.
Your steroids were increased while in the ICU, but a taper was
initiated thereafter. Please discuss your steroid course with
your outpatient lung doctor.
The following changes were made to your medication regimen:
INCREASE PRENDISONE to 40 mg by mouth once a day. Please discuss
your steroid course with your outpatient lung doctor.
INCREASE COUMADIN to 7.5 mg by mouth once a day. Please discuss
with your primary care doctor next week about continuing on
current dose or decreasing the current dose.
START BUMETANIDE 2 mg by mouth twice a day. Please discuss with
your primary care doctor next week about continuing on current
dose or decreasing the current dose.
STOP METALOZONE 5 mg by mouth once a day
INCREASE your morning lantus to 75 units while DECREASING your
pm lantus to 55 units
Followup Instructions:
Name: BROWN,[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: FAMILY MEDICINE ASSOCIATES
Address: [**State 90014**], [**Location **],[**Numeric Identifier 14085**]
Phone: [**Telephone/Fax (1) 14086**]
Appointment: Tuesday [**2149-6-17**] 9:45am
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2149-7-10**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2149-7-10**] at 12:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You have also been placed on a cancellation list. The office
will contact you if a sooner appointment becomes available.
Department: INFECTIOUS DISEASE
When: [**Hospital Ward Name **] [**2149-6-23**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: [**Hospital Ward Name **] [**2149-6-23**] at 11:10 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2149-7-10**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"427.31",
"584.9",
"327.23",
"401.9",
"272.4",
"280.9",
"250.00",
"V58.61",
"V58.65",
"041.12",
"278.03",
"428.33",
"730.17",
"428.0",
"515",
"486",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12113, 12176
|
6772, 10635
|
289, 297
|
12424, 12424
|
3653, 6749
|
14005, 15850
|
2407, 2464
|
11047, 12090
|
12197, 12197
|
10661, 11024
|
12607, 13982
|
2479, 3634
|
233, 251
|
325, 1995
|
12332, 12403
|
12216, 12311
|
12439, 12583
|
2017, 2259
|
2275, 2391
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,450
| 114,966
|
3356
|
Discharge summary
|
report
|
Admission Date: [**2193-7-2**] Discharge Date: [**2193-7-26**]
Date of Birth: [**2129-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
Placement of PICC line
Removal of PICC line
History of Present Illness:
64 y/o Male with PMHx sig for Chronic diarrhea w/
hypoalbuminemia, h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent
hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who p/w 2
days of nausea, vomiting, diarrhea.
Patient had a recent h/o left PICA infarct in [**2193-4-8**] after
which he was started on anticoagulation. He then presented in
[**2193-5-9**] with SOB and was found to have PE based on a high
probability VQ scan w/ DVT within superficial femoral vein
extending to common femoral origin. He was continued on
anticoagulation and sent to [**Hospital1 **]. Patient then developed
vomiting with nausea and continued intermittent diarrhea with
cramping abdominal pain. He had [**12-10**] episode of vomiting in the
weeks prior to admission with intermittent nausea which worsened
2 days prior to admission. There was no change in his frequency
of diarrhea. Of note, the patient had been on TPN at [**Hospital1 **].
He did not have any hematemesis, [**Last Name (un) 15557**], hemactoschezia. He
denied any chest pain, dizziness, shortness of breath,
palpitations. He did have generalized weakness which he has had
for several months now.
He has a chronic history of diarrhea (likely some kind of
protein losing enteropathy) with persistent hypoalbuminemia.
Also he has small bowel enteroscopy which showed ersions in
stomach/duodenum with ulcerations in jejunum and a mass in the
distal bulb. Biopsy of the mass showed extensive gastric
foveolar mucous cell metaplasia in duodenum but no evidence of
lymphoma anywhere in the GI tract.
In the ED, the patient was found to have a pulmonary embolism in
the superior branch of the right main pulmonary artery. He also
had trop elevation without significant EKG changes. He was given
325 mg Aspirin, started on a Heparin gtt and transferred to
MICU. His vitals were stable on presentation to MICU.
Past Medical History:
1. Acute left PICA territorial infarct involving the inferior
aspect of the left cerebellar hemisphere, with thrombosis of the
distal basilar artery [**2193-5-3**]
2. Reactivation Hepatitis B, on entecavir
3. Complex atheroma in descending aorta seen on TEE in [**2-11**].
4. Left-to-right shunt across a small secundum atrial septal
defect seen on TEE in [**2-11**].
5. Central retinal artery occlusion in right eye - [**10-10**] likely
an embolic event.
6. Lymphoma - lymphoplasmacytoid lymphoma; treated with
fludaribine, five cycles in [**2187**]. Since then has been seen by
Dr. [**Last Name (STitle) 410**] and has not required further therapy.
7. Insulin Dependent Diabetes - has had for many years. Treated
with humalog-lente combination 16 u AM, 22 u PM. Has had
multiple DM complications including left eye retinopathy,
gastroparesis, peripheral neuropathy complicated by several
bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0
8. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over
last several years. Question of possible nephrotic syndrome; may
be related to diabetes but unclear.
9. [**Name2 (NI) 167**] acoustic schwanoma - treated with gamma knife
radiation.
10. Gastritis, duodenitis: significant UGI bleed after received
lytics for recent embolic CVA
[**97**]. Peripheral vascular disease status post right below knee
amputation [**2-11**].
12. Hypertension
13. Anemia that is a combination of iron deficiency and anemia
of chronic inflammation.
14. Chronic malnutrition and 2 months of diarrhea, on TPN,
multiple GI ulcers, no lymphoma seen on biopsies, but still
undergoing work-up.
15. B12 deficiency on IM replacement
16. Depression
Social History:
He is married with 2 children. Primary language is Russian. He
has a remote 35 pack year smoking history. He drinks
occasionally. He is a retired dentist.
Family History:
Father died in [**2185**] after amputation for gangrene (unclear
origin).
Mother died [**2191**] unclear reason, had [**Name (NI) 11964**].
Physical Exam:
Vitals: Temp 96.5, HR 108, BP 119/68, O2sat 95/3L NC
Gen: appears confortable, AOx3
HEENT: Glossitis, PERLA, EOMI, MMM
Neck: JVD not appreciable
Skin: no cyanosis, rash, erythematous changes over knee joints
Heart: ditant heart sounds, tachycardic, no murmurs appreciable
Lungs: good bilat air movement, CTAB
Abdomen: distended, tympanic w/ flank dullness, fluid thrill+,
no hepatosplenomegaly appreciated, no caput medusae
Ext: R BKA, 2+ pitting edema bilaterally upto knee, R>L
GU: guaiac positive
Neuro/Psych: mild right facial deviation, 3/5 strength in both
UE/LE, mild tremors, mood appears normal
.
Pertinent Results:
[**2193-7-1**] WBC-8.8 RBC-3.51* Hgb-10.1* Hct-30.1* MCV-86 MCH-28.8
MCHC-33.5 RDW-15.6* Plt Ct-252# Neuts-49.2* Bands-0
Lymphs-47.1* Monos-3.1 Eos-0.1 Baso-0.5
[**2193-7-2**] WBC-11.8* RBC-3.05* Hgb-8.8* Hct-25.7* MCV-84 MCH-28.8
MCHC-34.2 RDW-15.9* Plt Ct-258 Neuts-54 Bands-10* Lymphs-29
Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2193-7-3**] 02:10AM BLOOD WBC-10.0 RBC-2.83* Hgb-8.1* Hct-24.1*
MCV-85 MCH-28.7 MCHC-33.7 RDW-16.1* Plt Ct-238 Neuts-64
Bands-12* Lymphs-21 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1*
Myelos-0
[**2193-7-4**] 01:38AM BLOOD WBC-9.0 RBC-2.30* Hgb-6.6* Hct-19.6*
MCV-85 MCH-28.8 MCHC-33.8 RDW-15.8* Plt Ct-197
[**2193-7-4**] 04:37PM BLOOD WBC-16.7*# RBC-3.55*# Hgb-10.4*#
Hct-29.5*# MCV-83 MCH-29.2 MCHC-35.1* RDW-15.6* Plt Ct-199
[**2193-7-5**] 03:45AM BLOOD WBC-11.0 RBC-3.47* Hgb-10.1* Hct-29.1*
MCV-84 MCH-29.3 MCHC-34.8 RDW-15.7* Plt Ct-169 Neuts-66
Bands-8* Lymphs-21 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1*
Myelos-0
[**2193-7-6**] 02:40AM BLOOD WBC-7.2 RBC-3.19* Hgb-9.4* Hct-26.6*
MCV-84 MCH-29.6 MCHC-35.4* RDW-15.6* Plt Ct-135*
[**2193-7-7**] 03:20AM BLOOD WBC-5.1 RBC-3.22* Hgb-9.3* Hct-27.3*
MCV-85 MCH-28.8 MCHC-34.0 RDW-15.6* Plt Ct-136*
[**2193-7-8**] 03:10AM BLOOD WBC-5.3 RBC-3.05* Hgb-8.7* Hct-25.9*
MCV-85 MCH-28.6 MCHC-33.7 RDW-15.6* Plt Ct-139*
[**2193-7-8**] 09:11PM BLOOD Hct-20*
[**2193-7-9**] 05:00AM BLOOD WBC-8.0# RBC-3.33* Hgb-9.5* Hct-28.2*#
MCV-85 MCH-28.4 MCHC-33.6 RDW-16.1* Plt Ct-146*
[**2193-7-9**] 03:30PM BLOOD Hct-29.2*
.
[**2193-7-1**] 10:26PM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2193-7-7**] 03:20AM BLOOD PT-12.0 PTT-71.5* INR(PT)-1.0
[**2193-7-8**] 03:10AM BLOOD PT-12.5 PTT-67.5* INR(PT)-1.1
[**2193-7-9**] 05:00AM BLOOD PT-12.2 PTT-50.7* INR(PT)-1.0
.
[**2193-7-1**] UreaN-62* Creat-0.7 Na-133 K-5.3* Cl-108 HCO3-19*
AnGap-11 Albumin-1.4* Calcium-7.1* Phos-4.5 Mg-2.2
[**2193-7-9**] Glucose-109* UreaN-31* Creat-0.5 Na-139 K-4.0 Cl-111*
HCO3-22
[**2193-7-2**] Glucose-109* UreaN-68* Creat-1.1 Na-135 K-5.7* Cl-110*
HCO3-17*
[**2193-7-4**] Glucose-125* UreaN-61* Creat-1.1 Na-136 K-4.6 Cl-109*
HCO3-18*
[**2193-7-9**] 05:00AM BLOOD Albumin-1.2* Calcium-7.8* Phos-2.9 Mg-1.9
.
[**2193-7-1**] 02:15PM BLOOD ALT-20 AST-22 AlkPhos-172* Amylase-46
TotBili-0.1
[**2193-7-5**] 03:45AM BLOOD ALT-17 AST-24 LD(LDH)-327* AlkPhos-150*
TotBili-0.2
[**2193-7-8**] 03:10AM BLOOD ALT-13 AST-18 LD(LDH)-210 AlkPhos-432*
TotBili-0.2
[**2193-7-9**] 05:00AM BLOOD ALT-13 AST-16 LD(LDH)-221 AlkPhos-454*
TotBili-0.2
.
[**2193-7-1**] 02:15PM BLOOD CK-MB-11* MB Indx-33.3* cTropnT-0.15*
[**2193-7-1**] 11:45PM BLOOD cTropnT-0.13*
[**2193-7-2**] 06:45AM BLOOD CK-MB-11* MB Indx-23.9* cTropnT-0.17*
[**2193-7-4**] 01:38AM BLOOD CK-MB-6 cTropnT-0.17*
[**2193-7-4**] 04:37PM BLOOD CK-MB-NotDone cTropnT-0.12*
.
[**2193-7-2**] 06:45AM BLOOD Triglyc-125 HDL-22 CHOL/HD-4.9 LDLcalc-60
.
[**2193-7-2**] 09:44PM BLOOD Type-ART Temp-37.0 FiO2-100 O2 Flow-15
pO2-27* pCO2-37 pH-7.32* calTCO2-20* Base XS--7 AADO2-666 REQ
O2-100 Intubat-NOT INTUBA Comment-NEBULIZER
.
[**2193-7-1**] 02:25PM BLOOD Lactate-1.4
[**2193-7-4**] 11:17AM BLOOD Lactate-2.8*
[**2193-7-5**] 12:20AM BLOOD Lactate-1.8
.
KUB [**7-1**] SUPINE AND LATERAL ABDOMINAL RADIOGRAPHS: An NG tube
is seen with the tip positioned in the stomach. Air can be seen
within the stomach and colon, and scattered loops of small
bowel, without any evidence of dilatation. The study is limited
secondary to large body habitus; however, no definite free
intraperitoneal air is identified. The soft tissue and osseous
structures are stable.
IMPRESSION: Air is seen within the stomach and colon, without
definite
evidence for small bowel obstruction.
.
[**7-1**] Abd/Pelvis CT: TECHNIQUE: MDCT acquired contiguous axial
images were obtained from the lung bases to the pubic symphysis.
Multiplanar reconstructions were obtained.
CONTRAST: Oral contrast and 130 cc of IV Optiray contrast were
administered due to the rapid rate of bolus injection required
for this study.
CT OF THE ABDOMEN WITH IV CONTRAST: Moderate-size bilateral
pleural effusion, increased on the right, new on the left, is
accompanied by a small pericardial effusion. Aside from
associated relaxation atelectasis, the lungs are clear.
A filling defect in the anterior branch of the right main
pulmonary artery is a new, likely acute pulmonary embolus.
A large amount of ascites and the nodular cirrhotic liver are
unchanged. The portal vein is patent. The gallbladder, spleen,
kidneys, adrenal glands, and atrophic pancreas are stable in
appearance. The bowel is normal, without wall thickening or
dilatation. No free intraperitoneal air is seen. Atherosclerotic
calcification involves the aorta and its major branches. A stent
has not migrated from the origin of the right common iliac
artery. Scattered retroperitoneal and periaortic and aortocaval
lymph nodes are not appreciably changed.
CT OF THE PELVIS WITH IV CONTRAST: A large amount of free fluid
is seen
within the pelvis. Mild thickening of the sigmoid colon is
stable. The
bladder is normal.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. There is spondylolysis of L5.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. Acute right upper lobe pulmonary embolus.
2. No bowel obstruction.
3. Increasing small to moderate pleural and small pericardial
effusions
probably due to cirrhosis and large volume of ascites.
4. Stable sigmoid colon wall edema or inflammation.
.
[**7-1**] CXR: Moderate sized pleural effusion with elevated
hemidiaphragm and associated atelectasis.
.
[**7-2**] Bilateral Lower Extremity Ultrasound:
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 867**] of the right and left common femoral, superficial
femoral, and left popliteal vein was performed. There is
occlusive thrombus, which is hypoechoic and expanding the right
common femoral and superficial femoral vein throughout its
course. On the left side, there is echogenic nonocclusive
thrombus at the origin of the greater saphenous vein at this at
the saphenofemoral junction. The left common femoral,
superficial femoral, and popliteal veins are patent.
IMPRESSION:
1. Occlusive thrombus, which appears acute, within the right
common femoral and superficial femoral veins.
2. Nonocclusive thrombus at the origin of the left greater
saphenous vein, at the saphenofemoral junction.
.
[**7-5**] CXR:
1. New right upper and right middle lobe consolidations, most
probably
aspiration and/or pneumonia.
2. Mild pulmonary edema, new.
3. Distended stomach.
.
[**7-19**] CT Chest
1) Necrotizing pneumonia in right upper lobe posteriorly with
foci of gas and probable evolving abscess formation.
2) Moderate right pleural effusion, decreased in size from prior
CT.
3) Marked ascites.
4) Resolution of left pleural effusion.
5) Persistent pericardial effusion.
.
[**7-20**] ECHO
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is difficult to assess but is normal
(LVEF>55%).
3. The aortic root is mildly dilated.
4. The aortic valve leaflets are mildly thickened.
5. The mitral valve leaflets are mildly thickened.
6. There is a small pericardial effusion.
7. No obvious vegetations are seen.
8. Compared with the prior study (images reviewed) of [**2193-7-2**],
there is
probably no significant change.
.
[**7-23**]
IMPRESSION: AP chest compared to [**7-17**] through 13:
Lung volumes remain low marked due to the markedly elevated
diaphragm.
Longstanding consolidation or atelectasis at the right lung apex
and
atelectasis at the right lung base are unchanged. Mild
pulmonary edema has recurred. Heart size is normal.
Mediastinal vascular engorgement is
longstanding and stable. Tip of the right subclavian line
projects over the junction of the right subclavian and jugular
veins. No pneumothorax.
Brief Hospital Course:
64 y/o Male with PMHx sig for Chronic diarrhea w/
hypoalbuminemia, recent h/o CVA, Hep B, Lymphoma, IDDM, HTN,
recent hospitalization in [**Month (only) **] for pulmonary embolism w/ DVT who
presented with 2 days of nausea and vomiting, found to have
Pulmonary Embolism in Right main PA and troponin elevation
likely in setting of PE.
.
Pulmonary Embolism: Mr. [**Known lastname 15558**] was at high risk for pulmonary
embolism given his history of malignancy, prolonged
immobilization, and recent PE w/ DVT. Although the patient was
on Coumadin, his INR was subtherapeutic on admission. CT on
admission shows PE in superior branch of R PA. He remained
hemodynamically stable on presentation. He was placed on
Heparin drip and coumadin was started on [**7-8**]. Bilateral lower
extremity ultrasound showed DVT in right lower extremity. IVC
filter was placed as pt had PE on anticoagulation. Coumadin and
heparin were stopped and the patient was started on lovenox sc.
He remained stable on this regimen and his INR trended down.
.
E coli bacteremia: The patient developed an elevated white count
and fevers and blood cultures from [**7-3**] grew Escherichia coli.
Possible sources include either spontaneous bacterial
peritonitis vs a pulmonary source given an infiltrate seen in
the RUL/RML (see below). Aspiration pneumonia was also
considered. He was started on Cefepime on [**7-4**] and Flagyl on
[**7-5**] (as concern for aspiration). Flagyl was stopped on [**7-6**]
and Cefepime was changed to ceftriaxone. ID was consulted and
the patient was restarted on vancomycin and cefepime. IV flagyl
was also added for concern for aspiration as above. Patient
also has ascites, thought possibly to have predisposed to SBP
and subsequent E. Coli sepsis. Surveilance cutures since
initial bacteremia have been negative for bacteria. Patient did
not receive tap at that time [**1-10**] to anticoagulation. The
patient was doing well and transferred from MICU to floor on
[**7-11**].
.
Fungemia: After being tranferred to the floor on [**7-11**]/2 blood
cultures grew [**Female First Name (un) **] albicans in the setting of TPN, for which
the patient was initially placed on Voriconazole, then
ultimately fluconazole. His PICC line was d/c'd and tip cultures
was negative, all subsequent cultures were negative and PICC
line was replaced on [**7-16**]. A TTE was performed to r/o
endocarditis and showed no vegtations. TEE was not pursued,
instead antibiotics will be continued for a total of 4 weeks.
Ophthalmology was consulted and found no evidence of fungal
infection in the eyes.
.
Nosocomial PNA: A CXR revealed a necrotizing pneumonia with air
fluid level in RUL confirmed by chest CT on [**7-19**]. He was seen
by infectious disease and started on cefipime, vanco, flagyl,
and was r/o'd for TB, by 3 negative AFB. Thoracic surgery
evaluated him and felt there was not collection to be drained
and recommended antibiotics and repeat imaging.
.
Hypotension: On the morning of transfer to the MICU, patient's
SBP dropped to the 60s/40s. He did complain for some chest pain
and SOB through the Russian interpreter and he was tachypeneic
with ABG 7.51/23/71. He recieved 1 liter NS and appeared more
comfortable, was mentating and BPs came up to 80's/50s and then
denied CP or SOB. He was afebrile and satting 95-98% on 4.5 L
NC. He was tranferred to the MICU for closer monitoring. On
admission the patient had a lactate of 2.7 which decreased to
1.6 with volume resuscitation and ongoing abx. The etiology for
the patient's hypotension was likely multifactorial including
intrasvascular volume depletion given persistent hypoalbunemia
and potential sepsis. The patient was noted to have a
persistenly elevated white count despite broad spectrum
antibiotics. C. Diff has been negative. Sputum cultures are AFB
negative x 3. The patient's Hct decreased from 29.6 to 24 in the
setting of volume resuscitation without evidence of acute
bleeding. The patient was transfused 2U PRBCs to help oncotic
pressure given decreased albumin. He reponded to the PRBC well
and remained normo to hypertensive for the remainder of his
hospitalization. He was transferred back to the floor prior to
discharge.
.
# CVS:
** CAD: The patient has high risk for CAD, now with elevated
Troponins and Ck-MB fraction. No EKG changes. The elevated
troponin was likely in the setting of acute PE, due to demand.
He was continued on medical management with ASA, restarted on
Lipitor. His beta blocker was held after an episode of
hypotension which sent him to the MICU. The beta blocker may be
restarted once medically stable.
.
** Rhythm: sinus Tachycardia, likely from PE
.
** Pump: ECHO from [**2-11**] shows EF of 55%, mild sym LVH, no
WMA. he seems intravscularly dry. SBP around high 90s. had SBP
in 70s. was treated with fluid boluses. SBP responded and
remained stable.
.
** HTN: based on previous records, but not on any
antihypertensives as outpatient, on [**Hospital1 **] metoprolol. BP normal
and stable
.
# GI Bleed: The patient's MICU course was complicated by a GI
bleed in the setting of Heparin gtt. The GI bleed resolved,
although patient continues to be guaiac positive. likely
chronic from stomach/duodenal erosion w/ jejunal ulceration,
especially in the setting of anticoagulation. Grossly positive
stools early in his hospitalization, but now guaiac positive
brown stools. GI was consulted, but given the risks of
EGD/colonoscopy in the setting of ulcerations and
anticoagulation the
decision was made to hold off on this for now. There was a
thought to give him IVIg for the ulcerative jejunoileitis but
was not given due to lack of enough evidence that it would
benefit. The patient's hematocrit trends down slowly and will
need to be followed closely.
.
Anemia: Anemia of chronic disease worsened by GIB. Patient
received transfusions to maintain Hematocrit > 28. GI was
consulted as above.
.
Chronic Diarrhea: Consulted GI, but still unclear as to the
cause of this. TPN was continued. Albumin was monitored.
Stool studies were sent and were negative. Stool negative for
C.Diff toxin. TPN was altered to include branched chain amino
acids.
.
Recent h/o line sepsis: Staph epi from [**6-15**] in [**12-10**] sets at
[**Hospital1 **]. repeat Blood Cx from [**6-22**] w/ 1 set showing staph. Was
started on IV Vanco 1 gm until [**7-1**]. PICC line changed from L to
R arm on [**6-27**]. E. Coli bacteremia as above, but no further
cultures growing staph. He was on ceftriaxone for a week and
then stopped. was started on IV vanc and cefepime after the CT
chest [**Last Name (un) **] developing abscess, as above.
.
ARF: Patient with Creatinine elevated to 1.1 over baseline. It
was felt that patient was pre-renal and he was given IVF as
needed. Creatinine improved to 0.6. Remained stable.
.
DM: RISS, tight glycemic control
.
Gout: Continued Colchicine
.
Hep B: Continued Entecavir
.
FEN: Nutrition was consulted for TPN recommendations which was
continued during hospitalization. Patient was also taking small
amount of PO food. He was evaluated by speech and swallow who
felt that the patient was able to take soft solids with
thickened liquids.
Medications on Admission:
Lactinex 1 tab [**Hospital1 **]
Anusol cream
Vit C 500 mg
ASA 81 daily
Questran 0.4 mg [**Hospital1 **]
Colchicine 0.6 daily
Lomotil 2tabs daily
Entecavir 0.5 mg daily
Ferrous sulphate
Regular insulin SS
Prevacid 30 mg [**Hospital1 **]
Remeron 30 mg QHS
Vancomycin 1 gm IV daily (completed on [**2193-6-30**])
Coumadin 2 mg daily
Zinc oxide
Octreotide 100 mcg [**Hospital1 **]
Infantis (Lactic acid prod org)
Prednisone 5mg daily
Ritalin 5 mg po 9am + 2pm
Xenaderm daily to l heel
Maalox
Zofran PRN
Simethicone
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
3. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
4. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) 100mcg
Injection Q8H (every 8 hours).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
11. Haloperidol 1-2 mg IV HS:PRN agitation
12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
13. Morphine Sulfate 1-2 mg IV Q3-4H:PRN pain
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
15. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) as needed.
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
17. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for abdominal cramps.
19. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane QID (4 times a day) as needed.
22. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 21
days.
24. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 21
days.
25. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
26. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H
(every 8 hours) for 21 days.
27. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours) for 21 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
pulmonary embolism
deep venous thrombosis
E.Coli bacteremia
[**Female First Name (un) 564**] Albicans Fungemia
Nosocomial pneumonia
GI Bleed
Acute renal failure
Chronic diarrhea
Secondary:
PICA infarct
Hepatitis B
Lymphoma
IDDM
HTN
Gastritis
PVD
Anemia
Depression
Discharge Condition:
stable
Discharge Instructions:
Please take all the medications as prescribed. You have a
fungus in your blood and a pneumonia which needs to be treated
with antibiotics. You must complete the entire course of
antibiotics.
**You need to take 3 more weeks of Cefepime, Vancomycin, Flagyl,
and Fluconazole.
**You need to continue anticoagulation for the diagnosis of
pulmonary embolism.
Please keep all outpatient appointments as outlined below.
Please call your primary care physician or return to the
hospital if you experience chest pain, increasing shortness of
breath, abdominal pain, fevers, numbness, weakness or other
concerning symptoms.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 8682**], [**Telephone/Fax (1) 133**], on
[**Last Name (LF) 766**], [**7-29**].
Please be sure to follow up with infectious disease as an
outpatient. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
[**8-19**] at 9:30. She will help you to schedule a follow up
CT chest at that time.
Please follow the result of the anti-Tissue Transglutaminase
Antibody, IgA test
|
[
"579.8",
"584.9",
"112.0",
"112.5",
"428.0",
"567.29",
"276.0",
"070.32",
"513.0",
"507.0",
"250.60",
"V49.75",
"578.9",
"357.2",
"285.1",
"415.19",
"410.71",
"790.7",
"458.9",
"453.8",
"V10.79",
"263.9",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"99.04",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
23277, 23356
|
12901, 20087
|
330, 376
|
23674, 23683
|
4951, 12878
|
24348, 24826
|
4169, 4310
|
20648, 23254
|
23377, 23653
|
20113, 20625
|
23707, 24325
|
4325, 4932
|
274, 292
|
404, 2278
|
2300, 3976
|
3992, 4153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,142
| 131,847
|
1076
|
Discharge summary
|
report
|
Admission Date: [**2126-9-24**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2060-2-3**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Iodine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
R carotid stent placement;
CABG
History of Present Illness:
66 man with h/o hypercholesterol, HTN, CAD with MI x 2 and cath
[**2112**], PVD and CRF, TIAs, family history of CAD and stroke, who
presented to OSH [**9-22**] w/unstable angina, tx'd to [**Hospital1 18**] for cath.
Past Medical History:
PMH:
MI x2, cath [**2112**], hypercholesterol, HTN, s/p aorto-bifem bypass,
L atrophic kidney w/ CRF Cr ~2.0, thrombocytopenia, COPD,
Meniere's dz, GI ulcer
PSH:
Ao-fem bypass
cataract
Social History:
Smokes 2-2.5 pks per day x 50yrs. Denies EtOH. Now retired-used
to work at [**Company 2486**]. Lives with his wife. [**Name (NI) **] 5 children.
Family History:
Father: Stroke (age 60), EtOH abuse, MI at 62
Mother: Died after head trauma due to fall (young age)
Brother: Died of MI at 50
Sister: CAD s/p CABG
Physical Exam:
Gen: well nourished, well dressed male lying in bed, NAD
Skin: tatoos on UE
HEENT: dry MM, op clear
Neck: supple, no bruits, 1+ carotids
CV: rrr nl s1s2 no mgr, JVP flat
Lungs: cta b/l
Abd: soft, nt, nd, +bs
Ext:
Pulses: R DP not palp or dopp; R PT not palp but dopp; L DP not
palp but dopp; L PT 1+ palp
Neuro: A+Ox3; CN 2-12 intact; strength 5/5 in UE/LE bilaterally;
sensation grossly intact
Brief Hospital Course:
[**9-24**] Cath showed: LMCA 50% distal, LAD 70%, RCA TO, LCx 60-70%
origin, 60% prox, w/ moderate inc L filling pressures w/ LVEDP
29. No interventions were performed, workup was begun for
patient to undergo CABG with test results as follows:
[**9-25**] TTE: LV depressed function, anteroseptal and inferolateral
HK thinned aneurysmal basal inferior wall
[**9-26**] Fem U/S: Thrombus within right common femoral graft. No
evidence of DVT.
[**9-26**] MR of head: 1. Chronic small vessel infarctions involving
the periventricular white matter. 2. Lack of flow in the left
vertebral artery at the level of C-1. 3. Decreased flow seen
throughout the entire left internal carotid artery and left side
of the anterior portion of the circle of [**Location (un) 431**]. 4. Decreased
signal in the entire right internal carotid artery c/w proximal
stenosis.
[**9-27**] carotid dopppler study: Right sided plaque with an 80 to
99% carotid stenosis; left 60 to 69% carotid stenosis; also
likely right subclavian artery stenosis.
[**9-27**] Carotid angio:
RSC stenosis 90%; distal RSC flow from collaterals from the
superior laryngeal artery of the ICA/ECA; LSC 40% focal lesion
without gradient; LCCA nl, L ICA mild 30% focal lesion; L ICA
fills the ACA, MCA with crossfilling of the contralateral ACA,
MCA; good filling of the V-B art system with Rvert filling; RCCA
is normal; R ICA 95% lesion; R ICA fills via ipsi R MCA with
TIMI II flow. R ACA not seen.
***************
The patient was admitted to the CCU s/p his right carotid stent
for blood pressure management and obervation. In his first
overnight, his blood pressures were seen to vary from SBP 120s
to 160s, no pressors or nitro drip were required. On the AM of
his second day in the CCU, the patient had a headache that
developed while he was straining to have a BM. CT scan was done
which showed a right high intensity material tracking through
the sulci worrisome for SAH. His headache resolved on its own
and he had another CT scan which showed the same linear density,
which argued against SAH. The pt failed to show signs of
meningismus or increased intracranial pressure, so it was felt
he did not have SAH. However, given the non-emergent necessity
for his triple vessel disease, it was decided to wait for [**4-9**]
weeks before CABG surgery, to allow any potential SAH to heal.
He will follow up with Dr.[**First Name (STitle) **] in [**3-7**] weeks. He will have a
repeat head CT in [**2-5**] weeks.
The patient also complained of right lower extremity pain on
ambulation, this pain worsens with activity and is alleviated by
rest. This was deemed claudication, and bedside ABI's revealed
0.7 on the right and 1.2 on the left. The patient has hx
aorto-femoral bypass 10-15 years ago, and has residual
claudication since. However, the patient was described
worsening of this claudication in the last few days. 2
ultrasounds were done of the R common femoral area which
revealed thrombus. Given the patients other problems (i.e.
triple vessel CAD) it was agreed that he should first have CABG,
then have his PVD problems addressed. [**Name2 (NI) **] will be scheduled for
vascular surgery clinic.
Medications on Admission:
Meds: inpatient (meds also taken at home marked with *)
*Clonazepam 0.5 mg PO QD
*Digoxin 0.125 mg PO QD
Isosorbide Mononitrate (Extended Release) 30 mg PO QD
Acetaminophen 650 mg PO Q4H:PRN fever, pain
*Lisinopril 20 mg PO QD
Acetylcysteine 20% 600 mg PO
Lorazepam 0.5 mg PO Q4-6H:
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN
Nitroglycerin SL 0.3 mg SL Q5MIN:PRN
Albuterol-Ipratropium 2 PUFF IH Q6H
Oxycodone-Acetaminophen [**1-4**] TAB PO Q4-6H:PRN
Aspirin EC 325 mg PO QD
Pantoprazole 40 mg PO Q24H
*Atenolol 25 mg PO QD
Simethicone 40-80 mg PO QID:PRN
*Atorvastatin 40 mg PO QD
*Tricor *NF* 160 mg PO [**Name (NI) 244**]
(pt also on ranitidine 300mg qd at home, not in hosp)
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*50 Tablet, Sublingual(s)* Refills:*0*
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)).
Disp:*60 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in
the morning)).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis
Triple vessel coronary disease
Peripheral vascular disease
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
If you have these symptoms, call your doctor or go to the ER:
1. chest pain
2. shortness of breath
3. arm or jaw pain
4. dizziness
5. visual changes
6. severe headache
7. neck pain/stiffness
8. tiredness/lack of energy
9. cold left foot
10. color change in left foot
Completed by:[**2126-10-1**]
|
[
"272.0",
"287.5",
"411.1",
"996.74",
"433.10",
"414.01",
"440.21",
"593.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"37.22",
"99.20",
"39.90",
"88.56",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
6380, 6386
|
1551, 4731
|
302, 335
|
6506, 6512
|
968, 1117
|
5472, 6357
|
6407, 6485
|
4757, 5449
|
6536, 6965
|
1132, 1528
|
247, 264
|
363, 581
|
603, 790
|
806, 952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,606
| 109,684
|
7014
|
Discharge summary
|
report
|
Admission Date: [**2111-5-12**] Discharge Date: [**2111-5-18**]
Date of Birth: [**2052-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right loculated hydropneumothorax.
Major Surgical or Invasive Procedure:
[**2111-5-12**] Bronchoscopy, Right Thoracotomy, Decortication
History of Present Illness:
Mr. [**Known lastname 1968**] is a 59-year-old male with a history of recurrent
B-cell lymphoma and recurrent right-sided effusions. CT scan
suggested entrapped right lung
and loculated hydropneumothorax. It was felt that the patient
would need a decortication and would need open thoracotomy
versus VAT procedure.
Past Medical History:
CAD c/b MI x2 s/p PTCA/stent/CABG/AVR'[**97**],
Atrial fibrillations s/p pacemaker
RAS s/p renal stents x2,
Stage I Hodgkin's lymphoma s/p splenectomy & chemorad Rx to
chest/neck/abdomen,
B-cell lymphoma with pulmonary nodules s/p CHOP/CVP'[**03**],
Hypoetension, IDDM, Hypothyroidism, Upper GI bleed
Hypercholesterolemia, Renal Insufficiency
Social History:
Social: lives with wife, was a printer. Drinks ETOH
occasionally, does not smoke currently, was a 35ppy smoker.
Unknown asbestos exposure
Family History:
non-contributory
Physical Exam:
VS: 98.2 HR 60 BP 120/80 Sats 95% RA
General: 59 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: scattered rhonchi RLL, otherwise clear
GI: benign
Extr: warm no edema
Incision: Right thoracotomy site w/steri-strips clean dry intact
no erythema
Chest-tube sm-moderate serous drainage
Neuro: non-focal
Pertinent Results:
[**2111-5-17**] WBC-11.1* RBC-3.42* Hgb-9.6* Hct-29.8* Plt Ct-359
[**2111-5-12**] WBC-8.9 RBC-3.07* Hgb-8.2*# Hct-26.1* Plt Ct-341
[**2111-5-17**] Glucose-80 UreaN-35* Creat-1.3* Na-137 K-5.0 Cl-101
HCO3-28
[**2111-5-12**] Glucose-95 UreaN-23* Creat-1.5* Na-142 K-3.3 Cl-103
HCO3-28
[**2111-5-12**] URINE CULTURE (Final [**2111-5-13**]): NO GROWTH.
[**2111-5-12**] Blood cultures No Growth
[**2111-5-12**] 9:00 am PLEURAL FLUID ANTERIOR RIGHT.
GRAM STAIN (Final [**2111-5-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2111-5-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2111-5-18**]): NO GROWTH.
ACID FAST SMEAR (Final [**2111-5-13**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2111-5-12**]):
NO FUNGAL ELEMENTS SEEN.
CHEST (PA & LAT) [**2111-5-17**]
CHEST: The three chest tubes present on the prior ultrasound
have all been withdrawn. A localized hydropneumothorax is
present laterally in the mid zone. This was present before the
tubes removed. No significant pneumothorax is present.
IMPRESSION: Chest tubes removed. No significant pneumothorax.
Pleural cortex, right:
Fibroadipose tissue with chronic inflammation and granulation
tissue formation.
Clinical: Fibrothorax.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known firstname **] [**Known lastname 1968**]," the medical record number and "right pleural
cortex" and consists of multiple fragments of yellow fatty
tissue and tan pink granular appearing tissue that measure 13.5
x 12.5 x 4 cm in aggregate. The specimen is serially sliced to
reveal unremarkable cut surfaces. The specimen is represented
in A-B.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted on [**2111-5-12**] and underwent successful
Right thoracotomy, evacuation of right pleural effusion,
pleurectomy with decortication, flexible
bronchoscopy with therapeutic aspiration. He was transferred to
the SICU intubated, sedated on Propofol overnight. While in the
SICU his [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker was interrogated and found to be
within normal limits. The chest-tubes were to suction, his pain
was well controlled with a Bupivacaine & Dilaudid epidural
managed by the acute pain service. On POD #1 he was extubated
and his oxygen saturations were upper 90's on 2 Liters nasal
cannula and pulmonary toileting. On POD #2 he transferred to the
floor. The posterior chest-tube was removed, a regular diet was
initiated and he was resumed on his home medications. On POD #4
the epidural was removed and his pain was well controlled with a
Dilaudid PCA. The middle anterior chest tube was removed, his
foley was removed and he voided without difficulty. On POD #5
the remainder chest-tube was removed and his PCA was converted
to PO pain mediation. On POD #6 he continued to make steady
progress. He ambulated in the halls and was discharged to home.
He will follow-up with Dr.[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
levothyroine 137 mcg daily, toprol xl 50 mg daily, omeprazole 40
mg daily,
simvastatin 80 mg daily, glyburide 3.75 mg daily, aspirin 325 mg
daily, plavix 75 mg daily, amiodarone 200 mg Sun/Tues/[**Last Name (un) **]/Fri,
allopurinol 100 mg daily, furosemide 60 mg daily
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Aspirin 325 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.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*70 Tablet(s)* Refills:*0*
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO as directed.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
CAD s/p MI s/p PTCA/stent/CABG/AVR [**2097**]
Atrial Fibrillation s/p Pacemaker
RAS s/p renal stents x 2
Hypertension/Hyperlipidemia
Hodgkin's Lymphoma s/p chemo/rad, s/p pulmonary nodules
Diabetes Mellitus Type 2, Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased cough or sputum production
-Chest pain
-Incision develops drainage or redness: steri-strips remove if
stop to peel off.
-Chest-tube site cover with a bandaid until healed. Should site
begin to drain cover with a clean dressings and change as needed
to keep site clean and dry
You may Shower: No tub bathing or swimming for 6 weeks
No driving while taking narcotics: take stool softners with
narcotics
Followup Instructions:
Follow-up with Dr.[**Doctor Last Name 4738**] NPs [**Female First Name (un) **] or [**Location (un) 1439**] on [**6-2**] at
1:00pm in the [**Hospital Ward Name 121**] Building Chest Disease Center, [**Hospital1 **] I
Report to the [**Location (un) 470**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**]
Completed by:[**2111-5-19**]
|
[
"250.00",
"244.9",
"511.8",
"V45.81",
"V45.82",
"202.80",
"585.9",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.59",
"34.51"
] |
icd9pcs
|
[
[
[]
]
] |
6264, 6270
|
3598, 4924
|
328, 393
|
6544, 6553
|
1726, 2504
|
7122, 7569
|
1279, 1297
|
5244, 6241
|
6291, 6523
|
4950, 5221
|
6577, 7099
|
1312, 1707
|
2540, 2540
|
2573, 3575
|
253, 290
|
421, 739
|
761, 1106
|
1122, 1263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,450
| 109,437
|
51591
|
Discharge summary
|
report
|
Admission Date: [**2199-10-23**] Discharge Date: [**2199-10-28**]
Date of Birth: [**2124-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dypnea on exertion
Major Surgical or Invasive Procedure:
[**2199-10-23**] - Redo Sternotomy with Aortic Valve Replacement (23mm
[**Company 1543**] Mosaic Ultra Porcine Valve)
History of Present Illness:
75 year old male s/p CABG in [**2187**] now with increased dyspnea on
exertion and found to have significant aortic stenosis. He is
now admitted for surgical management of his aortic valve
stenosis.
Past Medical History:
CAD s/p CABG in [**2187**] and PTCA in [**2198**]
AS, acute systolic heart failure
Hyperlipidemia
HTN
IDDM
Transient Amnesia
Global CVA
Social History:
Retired. Lives with his wife. Denies tobacco or alcohol use.
Family History:
Sister died of CAD at age 65
Physical Exam:
Admission
On physical examination, his pulse is 60. Respirations are 14.
Blood pressure on his right is 130/72 and his left is 125/75.
He is 5'6" tall and weighs 192 lbs. In general, he is in no
acute distress. His skin is warm and dry without clubbing,
cyanosis, or edema. He has a well-healed sternotomy incision.
From HEENT standpoint, his examination is unremarkable. Neck is
supple with full range of motion. Lungs are clear to
auscultation bilaterally. Heart shows a regular rate and rhythm
with a III/VI systolic ejection blowing murmur which radiates to
his bilateral carotids. His abdomen is soft, nondistended, and
nontender with normoactive bowel sounds. Extremities are warm
and well perfused without edema. He does have left lower
extremity vein harvest of his entire leg which appears to be an
open incision. He has no varicosities noted on his right leg on
standing and neurologically, he is grossly intact. Pulses are
2+ throughout.
Discharge
VS T98.7 HR 80SR BP 120/72 RR 20 O2sat 95%-RA
Pertinent Results:
[**2199-10-23**] 03:37PM GLUCOSE-152* NA+-136 K+-4.2
[**2199-10-23**] 03:30PM UREA N-17 CREAT-0.6 CHLORIDE-113* TOTAL
CO2-21*
[**2199-10-23**] 03:30PM WBC-10.2 RBC-3.04* HGB-9.6* HCT-26.4* MCV-87
MCH-31.6 MCHC-36.3* RDW-14.9
[**2199-10-23**] 03:30PM PLT COUNT-132*
[**2199-10-23**] 03:30PM PT-17.8* PTT-39.9* INR(PT)-1.6*
[**2199-10-26**] 07:50AM BLOOD WBC-7.8 RBC-2.88* Hgb-9.2* Hct-25.1*
MCV-87 MCH-31.8 MCHC-36.5* RDW-15.1 Plt Ct-130*
[**2199-10-26**] 07:50AM BLOOD Plt Ct-130*
[**2199-10-23**] 03:30PM BLOOD PT-17.8* PTT-39.9* INR(PT)-1.6*
[**2199-10-26**] 07:50AM BLOOD Glucose-136* UreaN-24* Creat-0.8 Na-136
K-3.2* Cl-97 HCO3-31 AnGap-11
[**2199-10-23**] ECHO
PRE BYPASS The left atrium is moderately dilated. The left
atrium is elongated. No mass/thrombus is seen in the left atrium
or left atrial appendage. The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricle displays normal free wall
contractility. The ascending aorta is mildly dilated. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. The non-coronary cusp is immobilized. There
is severe aortic valve stenosis (area 1.0 cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. There is
normal left ventricular systolic function. There is a
bioprosthesis in the aortic position. It is well seated. The
leaflets are not well seen. No aortic insufficiency is
appreciated. There is a maximum gradient of 28 mm Hg and a mean
of 15 mm Hg across the valve at a cardiac output of 5.5 l/m. The
effective orifice area is about 1.6 cm2. The tricuspid
regurgitation is increased to mild. The thoracic aorta appears
intact.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 106928**] M 75 [**2124-8-4**]
Radiology Report CHEST (PA & LAT) Study Date of [**2199-10-27**] 8:38 AM
Final Report
PA AND LATERAL CHEST FROM [**10-27**]
HISTORY: Previous pleural effusion.
IMPRESSION: PA and lateral chest compared to [**10-23**] through
31:
Small bilateral pleural effusion right greater than left has
stabilized since [**10-25**], after increasing since [**10-24**].
Large post-operative
cardiomediastinal silhouette is stable. Azygos distention
suggests elevated central venous pressure or volume but there is
no pulmonary edema. Bibasilar atelectasis is mild and improved
since [**10-25**]. No pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SUN [**2199-10-27**] 11:36 AM
Brief Hospital Course:
Mr. [**Known lastname 54488**] was admitted to the [**Hospital1 18**] on [**2199-10-23**] for elective
surgical management of his aortic valve disease. He was taken
directly to the operating room where he underwent a redo
sternotomy with an aortic valve replacement using a porcine
valve. Please see operative note for details. Postoperatively he
was taken to the intensive care unit for hemodynamic monitoring.
Later that day, he awoke neurologically intact and was
extubated. Beta blockade, aspiriin and his statin were resumed.
On postoperative day two, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
Over the next several days his gradually improved in strength
and mobility. On POD 5 he was discharged to rehabilitation at
[**Hospital3 15644**] in [**Location (un) 47**].
Medications on Admission:
Plavix 75 mg daily, Atenolol 50 mg in the morning and 25 mg in
the evening, Insulin 70/30 20 units in the morning and 6 units
in the evening, a Multivitamin, Zocor 20 mg at bedtime, and
Aspirin 325 mg 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for stent.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 20units QAM/6units QPM units Subcutaneous twice a day.
11. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x5 days then 400mg QD x 7 days then 200mg QD.
13. Lorazepam 0.5 mg Tablet Sig: 0.5 mg PO HS (at bedtime) as
needed.
14. Potassium Chloride 20 mEq Packet Sig: Twenty (20) mEQ PO BID
(2 times a day): 20mEQ [**Hospital1 **] x 10 days then 20mEq QD.
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: 40mg
[**Hospital1 **] x 10days then 40mg QD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
CAD/AS s/p redo CABG/AVR
Hyperlipidemia
HTN
IDDM
Global CVA in past
Transient Amnesia
CABGx3 in [**2187**]
PTCA in [**2198**]
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name (STitle) 4640**] in [**2-26**] weeks. [**Telephone/Fax (1) 20221**]
Please follow-up with Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Completed by:[**2199-10-28**]
|
[
"250.00",
"V58.67",
"401.9",
"V45.81",
"428.0",
"272.4",
"V12.54",
"428.22",
"424.1",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8077, 8167
|
5256, 6210
|
341, 461
|
8337, 8346
|
2031, 5233
|
9124, 9426
|
943, 973
|
6469, 8054
|
8188, 8316
|
6236, 6446
|
8370, 9101
|
988, 2012
|
283, 303
|
489, 689
|
711, 849
|
865, 927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,477
| 134,613
|
16792
|
Discharge summary
|
report
|
Admission Date: [**2117-7-22**] Discharge Date: [**2117-7-23**]
Date of Birth: [**2048-7-4**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Patient was admitted for elective carotid stenting and
[**Hospital 47416**] transferred to CCU for blood pressure management
Major Surgical or Invasive Procedure:
Carotid catheterization, R ICA stent placement [**2117-7-22**].
History of Present Illness:
69 yo female with CAD, PVD, HTN, HPL who was admitted [**7-22**] for
elective right internal carotid angioplasty/steniting stent
procedure that was complicated by TIA manifesting with slurred
speech and LLE symptoms. She was transferred to CCU after her
procedure for neuro checks and blood pressure control.
**** ECHO [**2116-7-10**]
EF 45% E/A 1.38, small ASD, septal apical HK, apical HK, +1 TR
**** Carotid cath [**2117-7-22**]
cb slurred speech, left sided weakness
RCCA normal. [**Country **] 99% lesion after the bifurcation with the ECA
stented with Cypher stent.
Meds:
A/P:
1. TIA - symptoms have resulved
- Neuro checks q 1 hour; continue q 2 hours
- Neo titrate to goal BP >130 LUE and >160 aortic
- Hold BP meds
2. CAD/carotid stent
- ASA, Plavix, lipitor
- will hold ACEI and Beta-blocker for now
3. PPX bowel regimen, pneumoboots, cardiac low fat
Past Medical History:
1. CAD s/p 2 vessel CABG in [**2087**]; MI in [**2087**] and [**2114**] ([**10/2115**]
PTCA of SVG to LAD graft)
2. PVD
3. HTN
4. hyperlipidemia
5. cardiomyopathy EF 35%, on coumadin
6. R renal artery TO
7. s/p stent/PTCA celiac artery, SMA
8. s/p stent L subclavian
9. L inguinal hernia repair
10. TAH, age 29 secondary to vaginal bleeding
11. c. difficile colitis in [**2115**]
12. colon polyps, s/p resection [**2115**]
Social History:
Used to work in manufacturing of medical instruments (exposure
ot paints, chemicals). Widowed. Retired. Smokes currently 1 ppd,
trying to quit. Was able to stop smoking x 6 months in the past.
Denies alcohol or tobacco use.
Family History:
Mother died at age 59 from heart disease. Father died age 75
from "old age". She has 17 siblings. Three brothers died of
premature CAD (in their 40s). One brother died of intracerebral
hemorrhage.
Physical Exam:
97.6 HR 55 BP 128/30 O2sat 100%
General: [**Last Name (un) **] and oriented, NAD, resting comfortably
Neck: no elevated JVP, no carotic bruits
HEENT: NC, AT, sclera white, EOM intact, PERRLA
Pulm: CTA bilaterally
CV: regular, nl S1, S2, 2/6 SEM at LSB
Abd: soft, NT, ND, NABS
Extr: no c/c/e
Neuro: CN 2-12 intact, muscle strength 5/5 bilaterally in upper
and lower extremities
Pertinent Results:
[**2117-7-22**] 08:45AM INR(PT)-0.9
[**2117-7-23**] 05:46AM BLOOD WBC-10.1# RBC-3.41* Hgb-10.9* Hct-31.8*
MCV-93 MCH-32.0 MCHC-34.3 RDW-15.1 Plt Ct-190
[**2117-7-23**] 05:46AM BLOOD Plt Ct-190
[**2117-7-23**] 05:46AM BLOOD Glucose-100 UreaN-23* Creat-1.0 Na-137
K-5.2* Cl-107 HCO3-24 AnGap-11 (hemolyzed specimen)
[**2117-7-23**] 05:46AM BLOOD Mg-2.3
CT head [**2117-7-22**]:
Limited study secondary to motion artifact. No definite evidence
of acute infarct.
Carotic catheterization [**2117-7-22**]:
Carotid/vertebral arteries: The RCCA is normal. The [**Country **] has a
focal 99% lesion after bifurcation with the ECA. The ICA filled
the
ipsilateral ACA and MCA with cross filling of the contralateral
ACA.
The vertebral artery was patent. Successful stenting of the [**Country **]
was performed with a 8.0 x 30 mm. Precise stent, complicated by
slurring of speech and LLE weakness that improved but did not
resolve by the end of the case.
FINAL DIAGNOSIS:
1. Critical [**Country **] disease.
2. Stenting of the [**Country **] complicated by CVA.
Brief Hospital Course:
Following the catheterization procedure, the patient was
transferred to CCU.
1. s/p TIA - The patient had a head CT done which did not reveal
any evidence of acute stroke. The patient was observed closely
overnight. She did well overninght and her symptoms completely
resolved. The patient was seen and evaluated by Dr. [**Last Name (STitle) **] from
Neurology. In the CCU, the patient was started on Phenyephrine
drip for blood pressure control and the rate was titirateed to
keep left arm cuff systolic blood pressure 130 to 160. All her
home blood pressure meds were held. She was slowly weaned off
Phenylephrine drip. She received several 500 cc bolus of NS to
help keep her systolic blood pressure above 130. She was
discharged without her BP meds and was instructed to have her BP
checked in 3 days at Dr.[**Name (NI) 9654**] office and to consult Dr.
[**Last Name (STitle) 7047**]/or Dr. [**First Name (STitle) **] regarding whether she should resume her BP
medications.
2. CAD - She was continued on ASA, Plavix, lipitor. Her last
coumadin dose was on [**2117-7-19**]. The decision was made not to
resume her on coumadin.
3. PPX - while hospitalized she was started on bowel regimen,
pneumoboots for DVT prevention, and received cardiac low fat
diet.
4. Disposion - The patient was discharged [**Last Name (un) **] on ASA, plavix,
lipitor. She will consult Dr. [**Last Name (STitle) 7047**] on [**7-26**] regarding
restarting Atenolol, Lisinopril/Hctz, Imdur, Lasix, Digoxin. She
has BP machine at home and will be checking her BP as well. She
known that her goal is SBP >130 but not higher than 150 as she
had a recent TIA. Coumadin was stopped. The patient will follow
up with Dr. [**First Name (STitle) **] on [**10-5**] and will have carotid US done
on the same day. The patient was warned about symptoms of
TIA/CVA and heart failure and was instructed to call her
physican or go to the emergency room if necessary. On the day of
discharge, she was able to ambulate without any problems.
Medications on Admission:
ASA 325 po qd, Digozin 0.125 mg po qd, Plavix 75 mg po qd, Lasix
40 mg po qd, Imdur 60 mg po qd, Atenolol 75 mg po qd, Librium hs
prn, Coumadin 5 mg po qd.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 300 days.
Disp:*300 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Please do not restart the following medications until you see
Dr. [**Last Name (STitle) 7047**].
Lisinopril/HCTZ 20/12.5 mg po qd, Atenolol 75 mg qd, Digoxin
0.125 mg po qd, Lasix 40 mg po qd, Imdur 60 mg po qd.
Discharge Disposition:
Home
Discharge Diagnosis:
1. s/p internal carotid artery stent placement
2. hypertension
3. hyperlipidemia
4. cardiomyopathy
5. coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician, [**Name10 (NameIs) 2085**], or go to
the emergency room if you develop slurring of speech, vision
changes, one-sided weakness or other concerning symptoms.
Have your blood pressure checked on [**Last Name (LF) 766**], [**2117-7-26**] in
Dr.[**Name (NI) 9654**] office. Do not take your blood pressure medicines
until you see Dr. [**Last Name (STitle) 7047**]. He will let you know whether you
should resume your blood pressure medications.
Completed by:[**2117-7-24**]
|
[
"443.9",
"433.30",
"414.02",
"414.01",
"440.1",
"997.01",
"425.4",
"E879.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
6679, 6685
|
3824, 5831
|
459, 525
|
6855, 6861
|
2739, 3691
|
2121, 2319
|
6037, 6656
|
6706, 6834
|
5857, 6014
|
3708, 3801
|
6885, 7397
|
2334, 2720
|
295, 421
|
553, 1418
|
1440, 1864
|
1880, 2105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,598
| 180,249
|
42819
|
Discharge summary
|
report
|
Admission Date: [**2136-3-29**] Discharge Date: [**2136-4-6**]
Service: MEDICINE
Allergies:
diltiazem / atorvastatin
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Bradycardia, S/P Arrest
Major Surgical or Invasive Procedure:
Endotracheal Intubation and Mechanical Ventilation
History of Present Illness:
Ms. [**Known lastname **] is an 87 y/o female with a h/o systolic heart
failure with an EF of 35-40%, atrial fibrillation on coumadin,
MDS requiring monthly transfusions whose family called EMS
initially due to lethargy and somnolence. Last night at around
5pm her family noted that she was lethargic and sort of leaning
to one side, but initially left her alone because they thought
she was tired. However, later that night at around 11pm she was
much less responsive than usual, so the family called 911. She
lives with her grandson and has a full time nurse during the
day, yesterday she was complaining of an upset stomach and
having diarrhea. Additionally, her family says that she has had
poor po intake for the few days prior to admission.
.
On arrival EMS found her minimally responsive, they put her on a
monitor and found that she was bradycardic to the 30's, so they
put pacer pads on her. She then reportedly bradied down and
lost her [**Last Name (LF) **], [**First Name3 (LF) **] report was PEA. At that time she received 2
minutes of CPR and 1mg of epinephrine with ROSC, her heart rate
remained in the 30's and they began to externally pace her. She
was then taken to the [**Hospital3 **] ER. At the OSH ER she
was intubated due to significant pain associated with external
pacing, she was then started on a versed gtt for sedation which
caused her to become hypotensive so she was started on
peripheral neo. Labs at [**Location (un) 745**]-[**Location (un) 3678**] were notable for an INR
of 2.0, BNP of 285.1, K of 6.0, Cr of 2.5 (baseline 0.8-1.0),
BUN of 69, AST of 60, ALT of 40, t-bili of 1.4, WBC of 8 (24N,
12 band, 44L, 10M, 2E, 2atypical, 1myelo, 4 blast, 7NRBC's), HCT
of 32.4, plt of 84, troponin I of 0.11. With the mildly elevated
troponin she was briefly started on a nitro gtt, but after
discussion with our ER physicians since she was on peripheral
neo the nitro gtt was discontinued. A CT of her head was
negative.
.
In the ED, initial VS were: 36.3C, 81, 135/114, 93% on AC
16x400, PEEP of 5, FiO2 of 100%. On arrival to our ER she was
initially on a versed drip but was agitated and biting on her
tube, so she was transitioned to propofol for sedation. When
they went to transition her to the external pacer in our ER her
heart was in the 60's to 70's so she did not require external
pacing. Cardiology was consulted who felt that she did not
require treatment for an NSTEMI since her troponin was
indeterminate at the OSH, they recommended adission to the MICU
and they would see the patient in consultation. Labs were
notable for lactate of 6.9 that improved to 4.1, Cr of 2.3, INR
of 2.0, HCT of 31.4, plt of 94, CXR showed her ETT in the proper
position. VS on transfer: 70, 118/64, 24, 100% on AC 100%, PEEP
5, 420 x 18.
.
On arrival to the MICU, her initial VS were: 97.3, 67, 128/50,
96% on 18x400, she was awake and following commands. Denied any
pain, otherwise appeared comfortable.
.
Review of systems: unable to obtain as patient is intubated
Past Medical History:
- systolic heart failure EF of 35-40%
- atrial fibrillation, CHADS2 score of 3
- hypertension
- hyperlipidemia
- SVT
- dementia
- pseudogout
- anxiety/depression
- anemia - likely MDS, requiring monthly transfusions
- hx of breast cancer
- osteopenia
- carotid artery stenosis
- history of colonic polyps
Social History:
lives at home with her grandson and daytime nurse
- Tobacco: lifelong nonsmoker
- Alcohol: denies
- Illicits: denies
Family History:
Sis, died of panc ca
Sis died of colon ca
[**36**] sibs total, no other ca
Seven children alive and well
Physical Exam:
ADMISSION
Vitals: T: 97.9 BP:122/51 P: 93 R: 21 18 O2: 99% RA
General: thin ill appearing female in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to 8, no LAD
CV: irreg, irreg, [**2-14**] holosytolic murmur heard best at the apex
Lungs: Bilateral crackles L> R
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses. Diffuse petichae over legs,
R arm with edema relative to L, diffuse ecchymosis in the
anti-cubital fossa with firm palpable veins
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
PERTINENT LABS
CBC
[**2136-3-29**] 03:55AM BLOOD WBC-6.9 RBC-3.74* Hgb-9.6* Hct-31.4*
MCV-84 MCH-25.8* MCHC-30.7* RDW-20.3* Plt Ct-94*
[**2136-3-30**] 04:32AM BLOOD Neuts-51 Bands-14* Lymphs-28 Monos-5
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1*
.
COAGULATION STUDIES
[**2136-3-29**] 03:55AM BLOOD PT-21.5* PTT-32.0 INR(PT)-2.0*
[**2136-3-29**] 03:55AM BLOOD Fibrino-472*
[**2136-3-29**] 06:23AM BLOOD Ret Aut-1.9
.
CHEMISTRY
[**2136-3-29**] 03:55AM BLOOD Glucose-200* UreaN-63* Creat-2.3* Cl-97
HCO3-16*
[**2136-3-30**] 06:46PM BLOOD Glucose-188* UreaN-28* Creat-0.9 Na-139
K-4.3 Cl-103 HCO3-25 AnGap-15
.
LFTS
[**2136-3-29**] 03:55AM BLOOD ALT-35 AST-55* CK(CPK)-47 AlkPhos-109*
TotBili-1.4
[**2136-3-30**] 06:46PM BLOOD ALT-22 AST-21 LD(LDH)-225 AlkPhos-91
TotBili-1.9*
[**2136-3-30**] 06:46PM BLOOD ALT-22 AST-21 LD(LDH)-225 AlkPhos-91
TotBili-1.9*
.
CARDIAC ENZYMES
[**2136-3-29**] 03:55AM BLOOD CK-MB-4 cTropnT-0.11*
[**2136-3-29**] 06:23AM BLOOD CK-MB-5 cTropnT-0.13*
[**2136-3-29**] 03:37PM BLOOD CK-MB-4 cTropnT-0.09*
.
TOX SCREEN
[**2136-3-29**] 03:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-11
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
ABG
[**2136-3-29**] 04:51AM BLOOD Type-[**Last Name (un) **] Rates-/20 Tidal V-420 PEEP-5
FiO2-100 pO2-523* pCO2-33* pH-7.46* calTCO2-24 Base XS-1
AADO2-162 REQ O2-36 -ASSIST/CON Intubat-INTUBATED
.
LACTATE
[**2136-3-29**] 04:02AM BLOOD Glucose-200* Lactate-6.9* Na-135 K-5.8*
Cl-98 calHCO3-20*
[**2136-3-29**] 04:51AM BLOOD Lactate-4.1*
[**2136-3-29**] 07:15PM BLOOD Lactate-2.2*
[**2136-3-30**] 07:08PM BLOOD Lactate-2.4*
.
URINE STUDIES
[**2136-3-29**] 03:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2136-3-29**] 03:55AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2136-3-29**] 03:55AM URINE RBC-15* WBC-2 Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
LABS ON DISCHARGE:
[**2136-4-5**] 05:56AM BLOOD WBC-5.6 RBC-3.45* Hgb-8.8* Hct-29.5*
MCV-85 MCH-25.5* MCHC-29.8* RDW-19.9* Plt Ct-92*
[**2136-4-5**] 05:56AM BLOOD Plt Smr-LOW Plt Ct-92*
[**2136-4-5**] 05:56AM BLOOD Glucose-85 UreaN-32* Creat-0.8 Na-133
K-4.4 Cl-96 HCO3-28 AnGap-13
[**2136-4-5**] 05:56AM BLOOD CK(CPK)-18*
[**2136-4-5**] 05:56AM BLOOD CK-MB-3 cTropnT-0.01
[**2136-4-5**] 05:56AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.5
.
RUE US
IMPRESSION: No DVT
MICROBIOLOGY
URINE CULTURE (Final [**2136-3-30**]): NO GROWTH
Blood cultures-pending
C. difficile DNA amplification assay (Final [**2136-3-31**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
.
STUDIES
TTE [**2136-3-29**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is moderately depressed (LVEF= 35-40 %). The right
ventricular cavity is dilated with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-12**]+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Marked biatrial enlargement. Normal left ventricular
cavity size with mild symmetric left ventricular hypertrophy.
Moderately depressed global left ventricular systolic function.
Dilated right ventricle with borderline normal right ventricular
systolic function. Mild to moderate mitral regurgitation. Severe
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2136-1-31**],
the findings are similar
.
EKG- [**2136-3-29**]
Atrial fibrillation with controlled ventricular response rate of
66 beats
per minute. Q-T interval prolongation. Intraventricular
conduction delay
of left bundle-branch block type. Non-specific ST-T wave changes
in the
lateral and high lateral leads. Low voltage in the limb leads.
Compared to the previous tracing of [**2136-1-27**] the ventricular rate
is slower and the
intraventricular conduction delay is more pronounced
.
CXR [**2136-3-30**]
Moderate cardiomegaly is stable. Widened mediastinum is
unchanged consistent with vascular engorgement. Right apical
pleuroparenchymal scarring is chronic. Mild vascular congestion
is stable. Bibasilar opacities have increased consistent with
increasing atelectasis. If any, there is a small right pleural
effusion. NG tube tip is in the stomach, but is looped in the
stomach and the tip is at the fundus
.
KUB [**2136-3-30**]
IMPRESSION: No evidence of obstruction.
.
RUE US [**2136-4-1**]
FINDINGS: There is normal flow, compressibility, and/or
augmentation within
the right internal jugular, subclavian, axillary, brachial (x2),
basilic, and cephalic veins. No focal fluid collections are
seen.
IMPRESSION: No DVT.
CXR [**2136-4-2**]
IMPRESSION: Interval worsening of the left lower lobe
consolidation is
consistent with infection/inflammation likely secondary to
aspiration.
Interval resolution of right basilar consolidation suggests
atelectatic
etiology.
Brief Hospital Course:
Ms. [**Known lastname **] is an 87 year old F with a h/o cardiomyopathy, AF
on coumadin, MDS requiring monthly transfusions who was found
lethargic and bradycardic at home, had PEA arrest followed by
bradycardia requiring transcutaneous pacing and intubation and
transfer to [**Hospital1 18**] ICU.
ACTIVE ISSUES BY PROBLEM:
# PEA Arrest: prior to arrest she was bradycardic to the 30's,
received only 2 minutes of CPR and 1mg of epinephrine with ROSC
with bradycardic rate, requiring transcutaneous pacing. Her
bradycardia was likely due to beta blocker toxicity in the
setting of acute renal failure and metabolic acidosis. As her
renal failure and acidemia improved, her heart rate normalized
and on arrival to the [**Hospital1 18**] ER she no longer required external
pacing. Electrophysiology consult was obtained on arrival in
the ICU, who agreed that this was likely beta blocker toxicity,
and recommended holding all nodal agents and observing. They
felt there was no indication for pacemaker placement. She then
subsequently became tachycardic, so beta blocker was slowly
reinitiated for afib rate control. She was restarted on
metoprolol rather than bisoprolol, given that metoprolol is not
renally cleared (documented allergy to metoprolol succ is
fatigue, so proceeded cautiously). She tolerated this
medication well throughout her stay with no further bradycardic
events on telemetry. Because her blood pressures were slightly
low (90's systolic on [**4-5**]) prior to discharge, the metoprolol
is being held again.
# Hospital acquired pneumonia: patient was initially intubated
due to her inability to tolerate external pacing, and at that
time, CXR was clear with no evidence of pneumonia. She was
successfully extubated on [**3-30**] without incident. She then spiked
a fever on [**4-2**] and CXR demonstrated new LLL infiltrate
consistent with pneumonia. She was then started on vancomycin,
cefepime, and metronidazole (in case this was aspiration) on
[**4-2**]. She improved clinically the following day and was
afebrile, so vancomycin was stopped (MRSA swab negative from
earlier in the admission). A PICC line was placed and she was
discharged to rehab with a plan to continue cefepime IV and
metronidazole PO for 8 day course finishing on [**4-9**]. PICC should
subsequently be pulled.
#) Acute on Chronic Systolic Heart Failure: EF 35-40%. As
mentioned above, her bisoprolol was stopped on admission due to
toxicity and bradycardia in the setting of renal failure.
Enalapril also held due to hypotension. After being given many
liters of fluid resuscitation for her hypotension, she did have
some acute on chronc CHF decompensation, which signs of volume
overload on exam and hypoxia. She was diuresed and improved
clincally. Once her HR normalized, she was restarted on beta
blocker and transitioned to metoprolol 12.5 mg [**Hospital1 **] (no
significant renal clearance, compared to bisoprolol) with good
tolerance. As above, patient should be restarted on metoprolol
low dose (tartrate 6.25 [**Hospital1 **] to begin with). Enalapril will need
to be restarted as blood pressures tolerate.
.
# Hypotension: Patient noted to have asyptomatic hypotension
with SBP's high 80's to low 90's on [**4-5**]. No evidence of
infection. Orthostatics negative. SBP improved to 120's-130's on
day of discharge.
.
# Acute kidney injury: Cr up to 2.3 on admission from baseline
of 0.8-1.0. This improved to baseline with administration of
IVF.
.
# Atrial Fibrillation: on coumadin for anticoagulation and
bisoprolol for rate control on admission, however both were held
initially on admission given elevated INR and bradycardia. The
patient's heart rate improved and she was started on metoprolol
tartrate 12.5 mg [**Hospital1 **] which she tolerated well. Coumadin was
also restarted, however dose reduced to 1 mg daily given
concurrent use of antibiotics at discharge. This will need to
be further titrated as an outpatient based on INR. Next INR
check on [**4-8**].
.
# RUE edema: Patient was noted to have swelling of her right arm
with noticible overlying ecchymosis. A US was done which showed
no evidence of DVT or underlying fluid collection.
# Hyponatremia: Na 127 at lowest, up to 136 on discharge. Likely
due to dehydration, improved with gentle IVF. Has not been given
lasix since [**4-2**], but can likely be restarted 1-2 days after
discharge as long as Na remains >133 and patient is euvolemic.
# Toe pain: complained of bilateral pain at 1st MTP joints,
found to have redness and swelling concerning for pseudogout
flare (has history of pseudogout). Started on ibuprofen for
pain control and resolved prior to discharge.
# Torticollis: stopped donezepil (has been on this chronically
and likely no longer deriving benefit). Neck spasm drastically
improved on discharge.
# Dyspepsia: Patient with dyspepsia on [**4-5**]. Ruled out for MI,
EKG with no changes. Started on omeprazole 20mg daily, maalox
PRN.
CHRONIC, INACTIVE ISSUES:
# Myelodysplastic syndrome: platelet count remained low but
stable in the 90K range throughout her hospital stay, however
her hematocrit trended down, finally to 29.5 on the day of
discharge, requiring a PRBC transfusion.
.
# Dementia: Patient's home donepezil was held throughout this
admission.
.
TRANSITIONAL ISSUES
- restart Beta blocker and enalapril as BP tolerates (not
restarted due to frequent hypotension)
- Flagyl and cefepime through [**4-9**], then pull PICC line
- Donepezil stopped due to toricollis
- Coumadin/INR monitoring - decreased warfarin from 1.25mg to
1mg while on abx
- Patient made DNR/DNI during this hospitalization after lengthy
discussion with patient and family
Medications on Admission:
- escitalopram 20mg daily
- potassium
- lidocaine patch daily
- warfarin 1.25mg daily
- lasix 20mg daily
- pravastatin 10mg daily
- donepezil 10mg QHS
- Flaxseed
- vitamin D 1000units daily
- enalapril 20mg daily
- aspirin 81mg daily
- bisoprolol 5mg daily
- multivitamin daily
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): through [**4-9**] .
2. cefepime in D5W 2 gram/50 mL Piggyback Sig: One (1) dose
Intravenous every twelve (12) hours: through [**2136-4-9**].
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Maalox RS 600 mg (1.5 gram) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO four times a day as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. PEA arrest
2. Hospital acquired pneumonia
3. Bradycardia
4. Acute renal failure
5. Gout
SECONDARY DIAGNOSIS:
- chronic systolic heart failure EF of 35-40%
- atrial fibrillation, CHADS2 score of 3
- hypertension
- hyperlipidemia
- dementia
- pseudogout
- anxiety/depression
- anemia - likely MDS, requiring monthly transfusions
- history of breast cancer
- osteopenia
- carotid artery stenosis
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 **],
It was a pleasure to take care of you at [**Hospital1 **].
You were admitted to the hospital for a low heart rate and
cardiac arrest at home. We found that your kidneys were not
working well, which may have caused you to have an increased
level of bisoprolol in your blood, causing your heart to go very
slow. We held many of your medicines and gave you fluids to
help your kidneys recover.
While you were in the hospital, and we found that you have a
pneumonia. You were started on two antibiotics (metronidazole
and cefepime), which you will need to take for a total of 8
days.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
1. Stop donezepil.
2. Stop your lasix dose for the next 1-2 days, until assessed by
the rehabilitation doctors.
3. Stop taking bisoprolol.
4. Change your warfarin dose from 1.25mg daily to 1mg daily
5. Stop your enalapril for now
6. Start taking omeprazole daily as you had heartburn in the
hospital
7. Start taking maalox as needed for heartburn
8. Start taking flagyl and cefepime for a total of 8 days
(through [**2136-4-9**])
Followup Instructions:
Please schedule an appointment with your PCP upon discharge from
rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
[
"427.31",
"427.5",
"584.9",
"272.4",
"276.2",
"238.75",
"276.1",
"428.0",
"428.23",
"V10.3",
"425.4",
"294.20",
"427.89",
"486",
"733.90",
"E942.6",
"V58.61",
"275.49",
"300.00",
"518.81",
"V49.86",
"507.0",
"311",
"712.37",
"723.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
16829, 16930
|
9941, 14903
|
255, 307
|
17390, 17390
|
4622, 6502
|
18788, 18955
|
3823, 3930
|
15945, 16806
|
16951, 16951
|
15642, 15922
|
17573, 18765
|
3945, 4603
|
3300, 3343
|
192, 217
|
6521, 9918
|
335, 3281
|
17083, 17369
|
14920, 15616
|
16970, 17062
|
17405, 17549
|
3365, 3672
|
3688, 3807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,250
| 103,134
|
50869
|
Discharge summary
|
report
|
Admission Date: [**2194-7-26**] Discharge Date: [**2194-7-27**]
Date of Birth: [**2167-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
seizure and hypoglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 27 yo M with a past medical history significant for
ESRD secondary to HTN on HD, beginning in [**2192**]. He reports one
previous incident of seizure also in the setting of a
hypoglycemic episode following HD. He presents today with
hypoglycemia following a witnessed seizure in his cousin's car
after HD. HD today was uncomplicated, though he states that
more fluid was removed and faster than usual (3L in 2.5 hours).
He denies any recent illnesses or ingestions.
.
He states that before these seizures he experiences an aura in
which he "blacks out" and cannot see anything. He frequently
has these auras during or immediately after dialysis, but
without the seizures. He receives dialysis on Tues/Thurs/Sat at
[**Location (un) 105764**]. Kidney Center.
.
In the ED, his neuro exam was felt to be nonfocal. He was given
1 amp of D50 x 1 to which he responded from a FS of 57 to a FS
of 120. Following eating, however, his glucose began to drift
downwards once again to a nadir in the 60's, for which he was
given another amp of D50. He is admitted to the MICU for
frequent blood glucose monitoring and to initiate further
work-up for hypoglycemia in a non-diabetic.
Past Medical History:
HTN - diagnosed [**2191**] (?"small stroke" per [**State **] OSH)
ESRD - diagnosed [**2191**], felt [**2-15**] HTN (dx [**2191**] also). pt on
dialysis
since [**12/2192**] (kidney center, comme ave, [**Telephone/Fax (1) **],
nephrologist
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on transplant list, s/p failed R AVF, with L AVF
placed [**10/2192**], usual dialysis day Tu/Th/Sa).
seizure presumed to be [**2-15**] hypoglycemia [**1-20**] (seen by neuro, no
intervention)
Seizures as noted above
Social History:
worked in construction, now on disability, denies tobbacco,
alcohol, or IVDU.
Family History:
denies family history of premature cad, dm, htn, or seizures.
Father has psoriasis. Grandmother died of cancer, type unknown.
Physical Exam:
Vitals - T 98.4 BP 153/102 HR 76 RR 18 99%RA
GENERAL: laying in bed, NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition, supple neck, no LAD, no JVD
CARDIAC: regular rate. III/VI holosystolic murmur heard at the
LUSB, radiating up to clavicle on left, but not to carotids.
Breast: Left breast with subareolar mass, about 2x2cm, tender to
palpation, no discharge, no skin changes
LUNG: CTAB no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally. thrill over fistula L arm.
NEURO: CN II-XII intact, strength 5/5 bilaterally, sensation to
light touch in tact bilaterally. A&Ox3. Normal speech, prosidy,
cerebellar function. Normal gait.
Pertinent Results:
Admission Labs:
WBC-8.5 Hgb-14.3 Hct-44.8 MCV-94 MCH-29.9 Plt Ct-204
Neuts-67.2 Lymphs-25.6 Monos-4.8 Eos-1.9 Baso-0.6
UreaN-28* Creat-16.0*# Na-143 K-3.9 Cl-89* HCO3-17*
ALT-19 AST-31 AlkPhos-81 TotBili-0.4
Lipase-59
Calcium-9.7 Phos-5.5* Mg-3.1*
[**2194-7-27**] 02:54AM BLOOD Cortsol-18.0
[**2194-7-27**] 04:31AM BLOOD Cortsol-32.1*
.
Studies:
[**2194-7-26**] CT FINDINGS: Non-contrast head CT. There is no
intra-axial or extra-axial hemorrhage, mass effect, shift of
normally midline structures, or evidence of major vascular
territorial infarction. [**Doctor Last Name **]-white matter differentiation is
preserved. There is no hydrocephalus. Paranasal sinuses are well
aerated as are the mastoid air cells and middle ear cavities.
The surrounding calvarium and soft tissue structures are
unremarkable.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
27 yo M with history of ESRD on HD with history of seizures in
the setting of hypoglycemia, who presents with hypoglycemia
after a witnessed seizure.
.
1. Hypoglycemia: Unclear etiology, however he is clearly
symptomatic given seizure in this setting. Etiologies in a
non-diabetic include insulinoma, adrenal insufficiency, and
malignancy. Adrenal insufficiency is unlikely given high blood
pressures, cosyntropin stim test performed with good response.
His blood sugars remained entirely normal with q1 hour
fingerstick monitoring.
- c peptide checked and pending
- ultrasound of breast mass, as outpt.
.
2. Seizure: No further seizures following admission and thought
to have occurred in the setting of hypovolemia and hypoglycemia.
CT head was negative for bleed and mass. As below, he was
advised to eat prior to each dialysis session. Hypoglycemia
evaluation pending as above.
.
3. AG Metabolic Acidosis: Likely uremia exacerbated by s/p
seizure. Lactate normal at 1.3.
.
4. ESRD: Continue HD as outpatient. Patient advised to make
sure to eat prior to hemodialysis.
.
5. HTN: Home antihypertensives continued.
.
6. FEN: Low Na diet.
.
7. PPx: Heparin sc for DVT prophylaxis
Medications on Admission:
Labetalol 300 mg PO BID
Felodipine SR 2.5 mg PO QAM
Catapres 2 patch QWeek
Lisinopril 5 mg PO QD
Calcium Acetate 667 mg capsules, 2 PO TID
Acetaminophen prn
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Catapres-TTS-2 0.2 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hypoglycemia
Seizure
Hypertension
End-stage renal disease on hemodialysis
Discharge Condition:
Stable, normoglycemic.
Discharge Instructions:
You were admitted to the hospital because of a seizure
associated with a low blood sugar after hemodialysis. You were
monitored in the medical ICU with frequent blood sugar checks,
all of which were normal.
You should always eat something when you have hemodialysis.
Also, you should schedule an appointment with your physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to follow-up on the results of the tests that were
done while you were in the hospital. You should also make an
appointment to have the mass in your breast further evaluated.
You should continue to take your home medications, especially
your phosphate binders (Calcium acetate or Phoslo) as your
phosphate level is high. In addition, you should also take the
phosphate binder Sevelamer or Renagel.
If you have any additional seizures, low blood sugar, or other
concerning symptoms, you should contact your physician or return
to the hospital.
Followup Instructions:
You should schedule an appointment to see Dr. [**Last Name (STitle) **] within the
next week or two.
You should make an appointment to have the mass in your breast
evaluated as you were instructed when you were seen in the
Emergency Department a few days ago.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
|
[
"780.39",
"V16.9",
"V63.2",
"V45.1",
"251.1",
"403.91",
"276.2",
"585.6",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6150, 6156
|
4172, 5365
|
340, 348
|
6293, 6318
|
3297, 3297
|
7305, 7690
|
2218, 2347
|
5572, 6127
|
6177, 6272
|
5391, 5549
|
6342, 7282
|
2362, 3278
|
276, 302
|
376, 1561
|
3313, 4149
|
1583, 2106
|
2122, 2202
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,413
| 150,077
|
28630
|
Discharge summary
|
report
|
Admission Date: [**2191-8-12**] Discharge Date: [**2191-9-7**]
Date of Birth: [**2146-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Motrin / Toradol / Augmentin /
Dicloxacillin / Doxycycline / Banana
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transfer from OSH for further characterization of her
intersitial lung disease
Major Surgical or Invasive Procedure:
Minithoracotomy
Bronchoscopy
Central line
PICC
History of Present Illness:
This is a 45 yo woman who has h/o interstial lung disease
treated with steroids for 1.5 years. She was originally
admitted to [**Hospital 3844**] Hospital for shortness of breath and
was diuresed and her steroids were increased. She did not
improve so she was transferred to [**Hospital1 18**] on [**2191-8-12**] for biopsy of
her lungs for further characterization of her interstial lung
disease.
.
She originally underwent a planned VATS procedure but it was
converted to an open minithoracotomy with LUL and LLL wedge
resection due to left lung collapse. Her post-operative course
was further complicated by a right-sided pneumothorax that
requred a chest tube. Then she became tachyneic and hypoxemic
and was transferred to the MICU where she was intubated. It was
unclear whether her respiratory distress was from infection
(aspiration, pnuemonia) or from worsening of her primary
interstial lung disease. Broad spectrum antibiotics
(Levo/Vanv/Flagyl) was started. There was also a concern for
PCP given her high dose steroid course, so Bactrim was started
prophylactically. Brochoscopy samples did not grow out PCP
[**Name Initial (PRE) **]. She was eventually extubated and tranferred to the
regular medicine floors for further care.
.
Biopsy of her lungs revealed Bronchilitis Obliterans Organizing
Pneumonia.
Past Medical History:
ILD as outlined above
Ankylosing Spondylitis
DM
Obesity
Depression
Anxiety
HTN
Hypercholesterolemia
GERD
Social History:
Divorced x 6 years. Currently living with fiancee and 2
daughters in [**Name (NI) 3844**]. She was a nursing and medical
assistant, and most recently a teacher. She denies tobacco or
alcohol use.
Family History:
Two brothers with alcohol abuse.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.1, 102/60, 90, 20, 95%-4LNC
GEN: A+Ox3, NAD, looks lethargic, speaks softly, looks somewhat
SOB
HEENT MMM, OP clear
NECK: no JVD
COR: rrr, no mrg
PULM: bibasilar crackles 1/3 up, no rhonchi, wheezes
ABD: obese, soft, active bs
EXT: trace edema
NEURO: nonfocal, mobilizes all extremities spontaneously
Pertinent Results:
[**2191-8-12**] 04:41PM BLOOD WBC-12.0* RBC-3.46* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.3 MCHC-34.6 RDW-16.6* Plt Ct-346
.
[**2191-8-12**] 04:41PM BLOOD Neuts-92.1* Lymphs-6.0* Monos-1.7*
Eos-0.1 Baso-0.1
.
[**2191-8-12**] 04:41PM BLOOD PT-11.9 PTT-20.9* INR(PT)-1.0
.
[**2191-8-12**] 04:41PM BLOOD Glucose-288* UreaN-23* Creat-0.8 Na-138
K-4.5 Cl-93* HCO3-30 AnGap-20
.
[**2191-8-12**] 04:41PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0
.
.
CHEST X RAY ADMISSION:
IMPRESSION: Prominent diffuse scattered interstitial opacities
throughout
both lungs, of indeterminate acuity. Comparison with prior
films would help
to assess for any superimposed process. No pneumothorax or
effusion is
identified.
.
CHEST CT [**2191-9-2**]:
FINDINGS:
Extensive ground-glass opacity compromising all lobes is worse
in the right upper lobe, right middle lobe and right lower lobe,
and mildly improved in the left upper lobe. There is mild
bronchiectasis in the posterior basal segment of the right lower
lobe. The airways are patent to the segmental level. There is
no mediastinal, hilar or axillary lymphadenopathy; a few small
prevascular, paratracheal and axillary lymph nodes are stable.
The heart and great vessels are unremarkable. A
pleuro-parenchymal seroma is adjacent to the surgical sutures in
the left lower lobe measuring approximately 32 x 19 mm. There is
no pericardial effusion.
A calcified granuloma is in the right upper lobe (5:14).
There are no bone findings of malignancy.
The upper abdomen shows no abnormalities.
IMPRESSION:
Interval worsening of the interstitial lung abnormalities.
.
PATHOLOGY:
1. Lung, left upper lobe (biopsy) (A-F):
Bronchiolitis obliterans - organizing pneumonia (see note).
2. Lung, left lower lobe (biopsy) (G-H):
Bronchiolitis obliterans - organizing pneumonia (see note).
Note: In specimen one , intraalveolar fibrinous exudate is
present, which is unusual for BOOP (bronchiolitis obliterans -
organizing pneumonia).
Brief Hospital Course:
46 yo woman with BOOP s/p thoracotomy bx complicated by PTX s/p
chest tube and respiratory failure s/p MICU + intubation.
.
# BOOP - she was on Solumedrol 40mg IV BID, then switched to
Prednisone 60mg [**Hospital1 **]. She takes Bactrim for PCP prophylaxis and
she is on Nystatin Swish and swallow.
.
# INTERMITTENT RESPIRATORY DISTRESS - She was extubated and
transferred to the medical floors on nasal cannula. At rest,
her oxygen saturation is 95% on 4L NC. However, she frequently
desaturated from mucous plugging. She becomes tachycardic to HR
of 140 and her O2 saturations drops to 85%. She responded to
oxygen with facemask and albuterol/ipratroprium nebs. She was
given aggressive pulmonary toilet and frequent chest physical
therapy. She uses guaifensin three times a day for mucous and
mucumyst nebs as necessary. She was given an Acapela spirometer
for further therapy.
.
Of note, she was on home O2 for a few months after diagnosis of
her interstitial lung disease a year and a half ago: 2L NC at
rest and 4L NC with exertion. She was eventually weaned off but
her primary pulmonologist thinks she might have to go back on
again.
.
# BACTEREMIA - she had coag neg staph bacteremia and the central
line cath tip also grew coag neg staph. She completed 14 days
of IV vancomycin on [**2191-8-7**].
.
# DIARRHEA - she has intermitted diarrhea without abdominal
pain. Stool cultures were negative as well as Cdiff culture.
This may be related to her recent antibiotic course.
.
# DIABETES - she usees lantus 18u qhs and a sliding scale
provided by our consultants from the [**Hospital **] Clinic.
.
# HTN - controlled with metoprolol and lasix.
.
# DEPRESSION/ANXIETY - she is anxious which exacerbates her
repiratory distress with she has mucous plugging. She was on
klonipin 0.5mg PO TID with ativan for breakthrough anxiety.
Social work gave her some counselling regarding her medical
condition as she frequently became tearful on examination. She
is on escitalopram for depression.
.
# GERD - protonix
.
# FOLLOW-UP - she had a discussion with our primary medical
team and the pulmonology consult team and she decides to follow
up with Dr. [**Last Name (STitle) 24110**] who is her primary pulmonologist in New
[**Location (un) **]. She was given the phone number of our pulmonologist
and the attending pulmonologist who saw her as consultants here
at [**Hospital1 51816**].
Medications on Admission:
Prednisone 40 daily
Combivent Q6
Albuterol Neb Q4PRN
Montelukast 10 QHS
Diltiazem 60 [**Hospital1 **]
Lorazepam 0.5 Q6 PRN
Protonix 40 daily
Heparin 5000u TID
Insulin sliding scale
Tylenol
Colace
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) neb
Miscell. three times a day as needed for mucous.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q 8H (Every 8 Hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q8H (every 8 hours).
16. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO TID (3
times a day).
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
19. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q12H (every 12 hours) as needed.
23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
24. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
25. INSULIN SLIDING SCALE
Please give glargine 18u QHS and sliding scale per attached
sheet
Discharge Disposition:
Extended Care
Facility:
St [**Hospital **] Hospital Rehabilitation Unit - [**Location (un) 8117**], NH
Discharge Diagnosis:
Bronchilitis Obliterans Organizing Pneumonia
-----------------
Ankylosing Spondylitis
DM
Obesity
Depression
Anxiety
HTN
Hypercholesterolemia
GERD
Discharge Condition:
Hemodynamically stable, afebrile, ambulating
Discharge Instructions:
Please take all medication as prescribed. Keep all appointments
listed below. If you have any acute shortness of breath or
chest pain, please seek medical attention immediately. In
general if you have any medical questions or concerns, please
call your doctor or go to the emergency room.
Followup Instructions:
Please follow up with your PCP as soon as you can make an
appointment. [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63099**]
.
Our pulmonology team spoke with you and you have agreed to
follow up with your primary pulmonologist Dr. [**Last Name (STitle) 24110**] in New
[**Location (un) **]. Please make an appointment with him as soon as
possible. The pulmonoly team has given you their phone numbers
should you need to contact them in the future.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2191-9-7**]
|
[
"V58.65",
"516.8",
"518.5",
"996.62",
"250.00",
"720.0",
"790.7",
"515",
"530.81",
"V58.67",
"512.1",
"272.0",
"V64.42",
"278.00",
"300.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"33.24",
"96.6",
"34.04",
"38.93",
"33.28",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9516, 9621
|
4568, 6970
|
433, 482
|
9811, 9858
|
2597, 4545
|
10198, 10832
|
2198, 2232
|
7216, 9493
|
9642, 9790
|
6996, 7193
|
9882, 10175
|
2247, 2247
|
2269, 2578
|
315, 395
|
510, 1838
|
1860, 1966
|
1982, 2182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,463
| 133,946
|
18870
|
Discharge summary
|
report
|
Admission Date: [**2140-8-12**] Discharge Date: [**2140-8-15**]
Date of Birth: [**2082-8-9**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 57 year old man with a
history of smoking, hypercholesterolemia, who started
noticing some fluttering sensation in his chest over the past
several years but no chest pain, syncope or chest tightness.
About two weeks ago, the patient had a presyncopal episode
with exertion. Evaluation by his primary care provider
showed hypercholesterolemia. He was also sent for exercise
tolerance test on [**7-18**], which demonstrated inferior septal
apical ischemia. Following his exercise tolerance test he
was referred for cardiac catheterization, and on [**7-29**], the
patient underwent cardiac catheterization which showed 100%
proximal right coronary artery, 30% left main, 50 to 90% left
anterior descending, 60% proximal circumflex and an ejection
fraction of 61%. Following cardiac catheterization the
patient was referred for cardiothoracic surgery.
PAST MEDICAL HISTORY: Significant for smoking and
hypercholesterolemia.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION: Only Aspirin once a day.
SOCIAL HISTORY: Positive tobacco use, occasional alcohol
use, no intravenous or other drug use.
FAMILY HISTORY: No known coronary artery disease.
PHYSICAL EXAMINATION: Afebrile, heartrate 55, blood pressure
105/58, respiratory rate 20, oxygen saturation 97% on room
air. Head, eyes, ears, nose and throat, pupils equally round
and reactive to light with extraocular movements intact,
uninjected, anicteric. Mucous membranes were moist, no
erythema, no bruits. Neck was supple. Heart regular rate
and rhythm with some sinus irregularity. S1 and S2 with a
Grade II/VI systolic ejection murmur. Lungs, coarse
breathsounds on the left with no crackles. Abdomen was soft,
nontender, nondistended. Positive bowel sounds.
Extremities, decreased capillary refill bilaterally with
[**Doctor Last Name 6237**] test. No lower extremity edema. Feet are warm
bilaterally, 2+ dorsalis pedis pulses bilaterally.
Neurological, alert and oriented times three. Cranial nerves
II through XII grossly intact. Motor is [**5-9**] in the upper and
lower extremities. Sensation is intact bilaterally.
LABORATORY DATA: White count 9.4, hematocrit 37.5, platelets
253, sodium 134, potassium 3.7, chloride 102, carbon dioxide
24, BUN 20, creatinine 0.7, glucose 185, PT 12.8, PTT 28.2,
INR 1.0. Urinalysis is negative.
HOSPITAL COURSE: The patient was discharged home following
cardiac catheterization and returned as a postoperative admit
on [**8-8**]. At that time he was brought directly to the
Operating Room. Please see the operative report for full
details. He had coronary artery bypass grafting times three
with left internal mammary artery to the left anterior
descending, saphenous vein graft to the obtuse marginal and
saphenous vein graft to the posterior left ventricular,
bypass time was 127 minutes with a crossclamp time of 81
minutes. The patient tolerated the operation well and was
transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit. At the time of transfer the patient's
mean arterial pressure was 93. He was atrially paced at 88
beats/minute and he had Neo-Synephrine at 0.3 mcg/kg/minute
and Propofol at 10 mcg/kg/minute. The patient did well in
the immediate postoperative period. His anesthesia was
reversed. He was weaned from the ventilator and successfully
extubated. He remained hemodynamically stable throughout the
day of his surgery. On postoperative day #1 the patient
remained hemodynamically stable, however, he continued to
require Neo-Synephrine at 1 mcg/kg/min in order to maintain
adequate blood pressure. For that reason he remained in the
Intensive Care Unit. His chest tubes were discontinued on
postoperative day #1 as was his Foley catheter. On
postoperative day #2 the patient continued to be
hemodynamically stable. He had weaned off of his
Neo-Synephrine over the past 24 hours and he was transferred
to the floor for continuing postoperative care and cardiac
rehabilitation. After arrival on the Cardiothoracic Surgery
floor the patient was worked with by the nursing staff and
physical therapist. His activity level was gradually
increased. On postoperative day #4 he was noted to have a
single episode of atrial fibrillation with a heartrate up to
140. He was treated with intravenous Lopressor and converted
back to normal sinus rhythm. The patient continued to
gradually increase his activity level and on postoperative
day #7 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
revealed temperature 99.1, heartrate 66, sinus rhythm, blood
pressure 112/70, respiratory rate 20, oxygen saturations 96%
on room air. Weight preoperatively 88.6 kg, at discharge
82.6 kg. Laboratory data revealed white count 12, hematocrit
27, platelets 387, sodium 145, potassium 4.7, chloride 106,
carbon dioxide 29, BUN 17, creatinine 0.9, glucose 96,
magnesium 2.3. Neurologically alert and oriented times
three, moves all extremities, follows commands. Respiratory
clear to auscultation bilaterally. Heartsounds regular rate
and rhythm, S1 and S2, no murmurs. Sternum stable. Incision
with Steri-Strips, open to air, clean and dry. Abdomen soft,
nontender, nondistended with normoactive bowel sounds.
Extremities, warm and well perfused with no edema. Right
saphenous vein graft site incision with Steri-Strips open to
air, clean and dry.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass grafting times three with left internal mammary artery
to the left anterior descending, saphenous vein graft to the
obtuse marginal and saphenous vein graft to the posterior
left ventricular
2. Hypercholesterolemia
3. Low back pain
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
Aspirin 325 q.d.
Niferex 150 q.d.
Ascorbic acid 500 b.i.d.
Metoprolol 50 b.i.d.
Atorvastatin 10 q.d.
Lasix 20 q.d. times seven days
Potassium chloride 20 q.d. times seven days
Dilaudid 2 to 4 mg q. 4 hours prn
FOLLOW UP: The patient is to be discharged home. He is to
have follow up in the [**Hospital 409**] Clinic in two weeks, follow up
with Dr. [**Last Name (STitle) **] in four weeks and follow up with his
primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 51650**] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2140-8-15**] 11:29
T: [**2140-8-15**] 11:39
JOB#: [**Job Number 51651**]
|
[
"414.01",
"724.5",
"785.6",
"272.0",
"305.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.22",
"36.12",
"39.61",
"36.15",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1328, 1363
|
6003, 6214
|
5649, 5948
|
1187, 1213
|
2545, 5628
|
6226, 6768
|
1386, 2527
|
183, 1046
|
1069, 1160
|
1230, 1311
|
5973, 5980
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,955
| 149,931
|
43028
|
Discharge summary
|
report
|
Admission Date: [**2123-11-9**] Discharge Date: [**2123-11-15**]
Date of Birth: [**2059-4-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amiodarone / Quinidine
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ICD discharge
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
64 yo female with a history of a mixed dilated cardiomyopathy,
EF 40%, s/p VF arrest and ICD placement in [**2111**] (with a coronary
cath without obstructive CAD) who was admitted on [**2123-11-9**] for
her ICD firing. In the past, pt had ICD shocks and underwent
cath [**7-29**] with 70-80% RCA lesion that was stented with DES, with
no other coronary disease noted. On [**2123-11-9**], she had a repeat
coronary angiography which was negative for new obstructive
disease. She also underwent an EPS for VT with VT mapping.
Polymorphic VT and VF were induced, as well as a superiorly
directed monomorphic VT that did not
appear to originate from the endocardial region of scar by
voltage mapping (basal scar identified). As pt is also known to
have akinesis of mid anterior wall, as well as basal aneurysm,
this was thought to be a possible focus of her VT, thus was
planned for epicardial VT mapping. No ablation was attempted on
the first EP study.
.
Today, the patient underwent epicardial as well left sided VT
mapping and ablation under general anesthesia. Two types of VT
were induced during the procedure. During the procedure she
required dopamine infusion (up to 10mcg/kg/min) for hypotension,
which was changed to norepinephrine prior to transfer to the
CCU. She had a pericardial drain placed for the epicardial
procedure which continues to drain fluid, draining a total of
800ccs of blood. After this was noted the patient was given
protamine (total of 40mg) to reverse the heparin given in the
procedure. She was also transfused two units of PRBCs although
her Hct did not decrease dramatically.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Hypertension
2. CARDIAC HISTORY: Cardiomyopathy with EF 40%, mixed etiology
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p RCA DES [**2122**]
-PACING/ICD: VF arrest s/p AICD implant [**2111**], generator change
[**2120**]
.
3. OTHER PAST MEDICAL HISTORY:
Transgender operation approx [**2095**]-male to female
Asthma
Bronchitis
Recent URI-treated with Cipro
Acid Reflux
Face lift [**1-28**]
Recent sinus infections
Social History:
Lives alone on [**Hospital3 **]. Works as quality technician and
cashier Stop and Shop. ETOH on weekends (beer).
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
v/s: 97.0 - 64 - 16 - 130/93
Gen: A&O X 3; No chest pain, palipitations, DOE. Rare
transient lightheadedness when goes from sitting to standing
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. pericardial drain in place draining sanginous fluid
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, coarse breath
sounds bilaterally, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has
no hematoma, bruit or oozing.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2123-11-11**] 02:21PM BLOOD WBC-12.2*# RBC-3.53* Hgb-11.5* Hct-33.1*
MCV-94 MCH-32.5* MCHC-34.6 RDW-16.7* Plt Ct-238
[**2123-11-15**] 01:50AM BLOOD WBC-6.3 RBC-2.84* Hgb-9.5* Hct-27.3*
MCV-96 MCH-33.3* MCHC-34.7 RDW-15.9* Plt Ct-259
[**2123-11-11**] 02:21PM BLOOD PT-12.2 PTT-24.8 INR(PT)-1.0
[**2123-11-15**] 01:50AM BLOOD PT-11.2 PTT-27.8 INR(PT)-0.9
[**2123-11-11**] 02:21PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-142
K-4.5 Cl-111* HCO3-24 AnGap-12
[**2123-11-15**] 01:50AM BLOOD Glucose-143* UreaN-17 Creat-1.0 Na-143
K-4.4 Cl-108 HCO3-25 AnGap-14
[**2123-11-11**] 02:21PM BLOOD Calcium-7.2* Phos-5.0* Mg-1.6
[**2123-11-15**] 01:50AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7
[**2123-11-11**] 02:25PM BLOOD Type-ART pO2-185* pCO2-47* pH-7.34*
calTCO2-26 Base XS-0
[**2123-11-12**] 05:27AM BLOOD Type-ART pO2-132* pCO2-35 pH-7.42
calTCO2-23 Base XS-0
[**2123-11-15**] 07:40AM URINE Blood-TR Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2123-11-15**] 07:40AM URINE RBC-3* WBC-180* Bacteri-MANY Yeast-NONE
Epi-1 TransE-7
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
MRSA SCREEN (Final [**2123-11-14**]): No MRSA isolated.
[**2123-11-15**] URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S).
>100,000 ORGANISMS/ML..
[**2123-11-15**] BLOOD CULTURE: Pending.
+
+
+
+
+
+
+
+
+
+
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Cardiac Cath Study Date of [**2123-11-9**]
1- Selective coronary angiography of this right dominant system
showed patent ostial RCA stent, mild luminal irregularities to
the LMCA and LAD system with 20% tubular stenosis in the
proximal LCX (small vessel).
2- Diffisulty engaging the RCA ostium due to the stent "sticking
out" into the aorta. A LIMA catheter eventually engeged (after
several attempts and failure of JR4 and AR-1 catheters).
3- Normal systemnic arterial blood pressure.
4- An attempt to close the R groin with Perclose device was
aborted as the EP service requested preservation of arterial
access. The 5 French sheath was exchanged for a new 8 French
sheath.
FINAL DIAGNOSIS: Patent RCA stent and no occlusive CAD in the
rest of the coronary arteries.
.
ECG Study Date of [**2123-11-9**]
Sinus bradycardia. Intraventricular conduction delay. Compared
to the previous tracing of [**2123-8-4**] no diagnostic change.
.
Portable TTE (Focused views) Done [**2123-11-11**]
There is mild (non-obstructive) focal hypertrophy of the basal
septum. Overall left ventricular systolic function is mildly
depressed (LVEF= 45%). Right ventricular chamber size and free
wall motion are normal. The mitral valve leaflets are
myxomatous. There is moderate/severe mitral valve prolapse.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Overall mildly depressed left ventricular systolic
function. No signficant pericardial effusion.
.
CHEST (PORTABLE AP) [**2123-11-11**]
IMPRESSION: Orogastric tube placed successfully to reach below
the diaphragm in intubated patient with evidence of ICD device.
No previous chest examination available for direct comparison.
.
Portable TTE (Focused views) [**2123-11-12**]
The mitral valve leaflets are mildly thickened. The mitral valve
leaflets are myxomatous. There is a small anterior pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
.
Portable TTE (Focused views) [**2123-11-13**]
Overall left ventricular systolic function is severely depressed
(LVEF=20-30 %) although difficult to assess given rapid heart
rate. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2123-11-12**],
the pericardial effusion is smaller.
.
Portable TTE (Focused views) [**2123-11-15**]
The estimated right atrial pressure is 0-5 mmHg. The mitral
valve leaflets are mildly thickened/myxomatous with bileaflet
systolic prolapse. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2123-11-13**],
the findings are similar.
Brief Hospital Course:
In summary, Mrs [**Known lastname 92850**] is a 64 year old female with history
of mixed cardiomyopathy, VF s/p ICD with ICD shocks, and
inducible VT on [**Hospital **] transferred to the CCU following epicardial
VT mapping and ablation procedure.
.
#. RHYTHM: The patient has a history of polymorphic, monomorphic
VT as well as VF. She is now s/p epicardial mapping with
ablation which appeared to be sucessful as she had no additional
episodes of pacemaker firing while in the hospital. During the
procedure she required pressor support and returned to the ICU
on pressors, intubated and with pericardial drain in place given
that a sternal approach was required for the procedure. After
the procedure, the pericardial drain was removed and there was
no evidence of further fluid accumulation. Additionally, she
was started on propafenone, then transitioned to dronedarone, to
help control her arrhythmia as she did have several runs of NSVT
as well as afib while on tele in the unit. Afib responded to IV
doses of metoprolol and she was in sinus rhythm for the majority
of her hospitalization. Digoxin and PO metoprolol were also
started for rate control and continued on discharge. Patient
refused to take warfarin at discharge and given the stable
nature of her condition and the recent pericardial drain
placement, it was decided that she will meet with her
cardiologist, Dr. [**Last Name (STitle) 92851**], to discuss the use of warfarin in
two weeks.
.
#. PUMP: The patient has a history of a mixed picture of
cardiomyopathy with an EF documented at 40% in [**Month (only) 547**]. TTE on
discharge showed resolution of pericardial effusion that
persisted after ablation procedure.
.
# CORONARIES: This admission coronary catheterization shows
patency of RCA DES. No other occlusive coronary artery diease
was present. She was continued on ASA and plavix, and also
starting on a statin on discharge.
.
# Hypertension: Hx of hypertension prior to admission, however
given her hypotension on admission, her home diovan was held.
Could restart as an outpatient if needed for BP control.
.
# Respiratory: The patient was electively intubated for the
procedure and general anesthesia however she was able to be
extubated one day after the procedure and had no further
respiratory issues while in the hospital.
.
# UTI: on the day of discharge, patient reported foul smelling
urine and report that she usually contract UTI after foley
placement. UA and Ucx showed evidence of UTI. She was given
Bactrium DS and was send home on a 7 day course. Sensitivity
were not back at the time of discharge and will require follow
up as outpatient.
.
# Transgender operation: Premarin was held out of concern for
increased risk of cardiac disease with high levels of estorgen
use.
.
# Depression: Lexapro continued
.
# GERD: Zantac continued as an inpatient
.
# Chronic sinus problems: Flonase was restarted after
extubation.
Medications on Admission:
Rythmol 325 mg [**Hospital1 **]
Lexapro 10 mg daily
Diovan 40 mg daily
ASA 325 mg daily
Oxazepam 15 mg qhs prn
Premarin 1.25 mg daily
Plavix 75 mg daily
Zantac 150 mg po prn
Flonase 1 spray each nostril prn
NTG SL prn
Discharge Medications:
...
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for anxiety.
8. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal PRN (as needed) as needed for nasal irritation.
10. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sort throat.
11. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
12. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*14 Tablet(s)* Refills:*0*
14. Toprol XL 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Tachycardia
Coronary Artery Disease
Ventricular Tachycardia
Non-ischemic Cardiomyopathy EF40%
ICD
UTI
Anemia
hypertension
transgender
depression
GERD
chronic sinusitis
Discharge Condition:
vss, afebrile, NAD, WNWD.
Discharge Instructions:
You had a cardiac catheterization to evaluate your coronary
anatomy following ICD discharge. You were found to have patent
vessels. You underwent an ablation procedure which was
successful as you did not have any subsequent firings, however
during the procedure we had to take a sternal approach. This
was complicated by a pericardial effusion which required
placement of a pericardial drain after the procedure. This was
removed without issue. You had a few episodes of short runs of
v.tach and Atrial fibrillation which was controlled on
dronedarone, metoprolol, and digoxin. You have been stable and
was transferred to the floor without issue.
You had a ventricular tachycardia (VT) ablation.
Please follow up with your PCP and cardiologist, specifically
for your medications adjustment, follow up for your UTI, and
discussion with Dr. [**Last Name (STitle) **] regarding the use of warfarin (this
is important as we have talked about the possible risk and
benefits with this medication. For now, as per your preference,
we are holding off until your visit with Dr. [**Last Name (STitle) **].
Please note we made the following changes to your medications.
stopped
1. diovan 40 mg by mouth daily
2. premarin 1.25 mg by mouth daily
3. Rhythmol (Propafenone) 325mg by mouth twice a day
started
1. Dronedarone *NF* 400 mg by mouth twice a day
2. Toprol XL 50 mg Tablet Sustained Release 24 hr by mouth
daily.
3. Digoxin 0.125 mg by mouth once a day
4. Bactrim 1 tab twice a day
If you experience any chest pain, shortness of breath, fever,
chills, cough, palptations, dizziness, syncope, or any symptoms
that is concerning to you, please come back to the emergency
room and call your doctors.
Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 46797**]
Specialty: PCP
Date and time: Monday, [**11-22**] at 2:45pm
Location: [**Street Address(2) 46802**], [**Location **],[**Numeric Identifier **]
Phone number: [**Telephone/Fax (1) 46798**]
Special instructions if applicable:
Appointment #2
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: Thursday, [**11-25**] at 9:00am
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 62**]
Special instructions if applicable:
|
[
"530.81",
"599.0",
"311",
"427.1",
"427.31",
"285.9",
"401.9",
"414.01",
"996.04",
"425.4",
"423.9",
"V45.82",
"473.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"37.34",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
13122, 13128
|
8533, 11459
|
313, 339
|
13352, 13380
|
4332, 5551
|
15132, 15868
|
3149, 3264
|
11727, 13099
|
13149, 13331
|
11485, 11704
|
6445, 8510
|
13404, 15109
|
3279, 4313
|
2604, 2809
|
260, 275
|
5580, 6428
|
367, 2520
|
2840, 3001
|
2542, 2583
|
3017, 3133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,172
| 181,252
|
16221
|
Discharge summary
|
report
|
Admission Date: [**2121-10-31**] Discharge Date: [**2121-11-13**]
Date of Birth: [**2087-7-16**] Sex: M
Service: MICU GREEN
HISTORY OF THE PRESENT ILLNESS: The patient is a 34-year-old
male with severe [**Hospital 46283**] transferred from the floor for
optimization of treatment for worsening hypoxemia. He was
diagnosed with IPF in [**2121-8-12**] by open lung biopsy,
treated with prednisone and azathioprine. His last set of
PFTs on [**2121-10-30**] showed an FEV of 35%, FVC 30%, home 02
requirement of [**4-17**] liters. He was recently put on the
transplant list at [**Hospital6 1708**]. He
presented to [**Location (un) 47**] ER with worsening dyspnea, a
nonproductive cough. He was given a steroid bolus and
transferred to [**Hospital1 18**].
HOSPITAL COURSE: Here, he had a CTA. There was no PE, new
ground glass opacities were seen. He was treated with
levofloxacin for seven days for a presumed pneumonia and
diuresed to the point of orthostasis. A bronch was negative.
All were without improvement of severe intermittent
hypoxemia.
The patient was taken to the unit for a PA catheterization
which showed a CVP of 10, PA of 28/12, and a CWP of 10, and
sent back to the floor. On the floor, he had repeated
episodes of tachypnea, rigors, and 02 saturations in the 70s
to 80% on a face mask nonrebreather. The patient was
returned to the MICU and intubated on [**2121-11-10**] for worsening
respiratory failure. He was treated with antibiotics for
another presumed infection which was also supported by a chest
CT scan. His white count responded. The patient was given
pressure support trials which he failed.
On the morning of [**2121-11-13**], the patient and his family
decided that they would prefer extubation and comfort
measures only. The patient was extubated on the evening of
[**2121-11-13**]. We were called to the bedside with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 496**], M.D., Pulmonary Fellow, to examine the patient
post extubation. The patient was cyanotic with no
respirations, no pulse, no heart beat, and no electrical
rhythm on the monitor. On examination, the pupils were
dilated. There were no heart sounds or breath sounds after
two minutes of auscultation. No pulses palpable. No
response to vigorous sternal rub. Time of death was called
at 8:52 p.m. The family was present and declined a
postmortem examination.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name6 (MD) 46284**]
MEDQUIST36
D: [**2121-11-13**] 09:11
T: [**2121-11-16**] 12:40
JOB#: [**Job Number 46285**]
|
[
"428.0",
"518.81",
"416.8",
"272.0",
"486",
"515",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"96.04",
"38.91",
"89.64",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
794, 2663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,312
| 142,616
|
10954
|
Discharge summary
|
report
|
Admission Date: [**2179-10-19**] Discharge Date: [**2179-10-21**]
Date of Birth: [**2118-9-24**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
white male with a history of coronary artery disease, status
post 5-vessel coronary artery bypass graft on [**2179-8-20**], who presents for elective right heart catheterization
and pericardiocentesis. The patient did well after his
coronary artery bypass graft.
On [**9-22**], the patient had a transthoracic
echocardiogram which revealed a new, moderate-to-large sized
pericardial effusion. The patient was asymptomatic at this
time, and the decision was made to monitor him and to start
him on Lasix. The patient had follow-up transthoracic
echocardiogram on [**10-13**] which revealed a slightly large
effusion. A few days later, on [**10-16**], the patient
began to develop dyspnea on exertion with normal activity.
He also noted a new two to three-pillow orthopnea and
paroxysmal nocturnal dyspnea.
On [**10-17**], he had an episode of acute shortness of breath
with chest pressure which he describes as different from his
typical angina with minimal exertion. The patient spoke with
his cardiologist who referred him for pericardiocentesis for
persistent and symptomatic pericardial effusion.
On right heart catheterization, the patient was noted to have
elevated right-sided and left-sided filling pressures with a
pulmonary capillary wedge pressure of 19 and a right atrial
pressure of 16. After 600 cc of serosanguineous pericardial
fluid was removed, the patient was noted to have a pulmonary
capillary wedge pressure of 9 and a right atrial pressure
of 2; indicating resolution of tamponade physiology.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post 5-vessel coronary
artery bypass graft on [**2179-8-20**]. Left internal
mammary artery to left anterior descending artery, saphenous
vein graft to left anterior descending artery to diagonal,
saphenous vein graft to right posterior descending artery,
and saphenous vein graft to first obtuse marginal.
2. Type 1 diabetes mellitus for 50 years.
3. Hypercholesterolemia.
4. Hypertension.
5. Chronic renal insufficiency with a baseline creatinine
of 1.1 to 1.4.
SOCIAL HISTORY: The patient has a positive tobacco history,
but he quit smoking over 20 years ago. He is married and
lives in [**Hospital1 1562**]. He has retired.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 50 mg p.o. q.d.,
Lipitor 10 mg p.o. q.d., baby aspirin 81 mg p.o. q.d., iron
sulfate 81 mg p.o. q.d., Lasix 40 mg p.o. q.d.,
Accupril 40 mg p.o. q.d., hydrochlorothiazide 12.5 mg p.o.
q.d., NPH insulin 18 units q.a.m. and 10 units q.p.m.,
Humalog sliding-scale q.a.m. and q.p.m.
PHYSICAL EXAMINATION ON PRESENTATION: The patient had a
temperature of 100.9. He had a blood pressure of 148 to
162/45 to 54. He had a heart rate of 85 to 87, breathing at
17 to 23, satting 100% on room air. In general, he was alert
and in no acute distress. His neck was supple without any
jugular venous distention. HEENT examination revealed his
pupils were equal, round, and reactive to light. His
extraocular movements were intact. His sclerae were
anicteric. His mucous membranes were moist. His oropharynx
was benign. Cardiovascular revealed a regular rate and
rhythm, heart sounds muffled, no murmurs. Respiratory
revealed bibasilar rales. Abdomen was soft, nontender, and
nondistended, positive bowel sounds. Extremities revealed
trace lower extremity edema, right greater than left, 2+
dorsalis pedis and posterior tibialis pulses. He had 2+
femoral pulses bilaterally. No hematomas were noted, but a
soft right femoral bruit was heard.
LABORATORY DATA ON PRESENTATION: The patient had a white
blood cell count of 9.5, a hematocrit of 34.5, a platelet
count of 194. His Chem-7 revealed sodium of 132, potassium
of 43, chloride of 97, bicarbonate of 28, BUN of 25,
creatinine of 1.3, glucose of 220. He had an INR of 1.1. A
calcium of 8.4, phosphate of 2.5, magnesium of 1.9.
Pericardial fluid analysis was consistent with an exudative
etiology.
RADIOLOGY/IMAGING: The patient had an electrocardiogram
with normal sinus rhythm at 70, normal axis, normal
intervals, low voltage in the limb leads.
Chest x-ray on admission revealed a large left pleural
effusion.
The patient had an echocardiogram on [**10-19**] which
revealed the following: Global left ventricular systolic
function appeared grossly preserved. Due to technical
quality a focal wall motion abnormality could not be fully
excluded. The aortic valve leaflets were mildly thickened.
The mitral valve leaflets were mildly thickened. There was a
large pericardial effusion (up to greater than 6 cm wide
anterior to the right ventricle). The right ventricle was
compressed.
HOSPITAL COURSE: The patient was transferred to the Coronary
Care Unit after his therapeutic pericardiocentesis. He was
hemodynamically stable and without any complaints. He was
continued on his home cardiac regimen, but was started on
indomethacin for post pericardiotomy syndrome. Over the
course of the night the patient drained an additional 400 cc
of serosanguineous fluid from his pericardial drain pouch.
By the next morning, the degree of drainage had decreased
considerably with only 60 cc drained over six hours.
The patient had a repeat transthoracic echocardiogram prior
to drain removal which revealed the following: A
trivial/physiologic pericardial effusion one day post
pericardiocentesis with no change from the study immediately
post pericardiocentesis. The pericardial drain was removed
without any difficulty. The pericardial fluid bag was
removed without any difficulty with the decision to monitor
the patient overnight and repeat the echocardiogram prior to
discharge.
The patient had an enlarged left pleural effusion which was
noted to layer on a lateral decubitus film. We decided to
perform a therapeutic thoracentesis. The patient was prepped
and draped in a sterile fashion, and 1150 cc of fluid were
drained. A chest x-ray was obtained post thoracentesis which
revealed a significant decrease in the size of the left
pleural effusion. No evidence of pneumothorax.
On the morning of admission the patient had a markedly
improved lung examination with increased air movement int he
left base. He denied any shortness of breath and had oxygen
saturations in the 90s on room air. He had a repeat
echocardiogram which revealed a trivial/physiologic
pericardial effusion. The patient was without any complaints
and remained stable.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged to home.
DISCHARGE DIAGNOSES:
1. Post pericardiotomy syndrome.
2. Status post pericardiocentesis.
3. Status post thoracentesis.
4. Type 1 diabetes mellitus for 50 years.
5. Coronary artery disease.
6. Hypercholesterolemia.
7. Hypertension.
8. Chronic renal insufficiency.
MEDICATIONS ON DISCHARGE: (Discharge medications include)
1. Indomethacin 25 mg p.o. t.i.d. for seven days.
2. Atenolol 50 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Baby aspirin 81 mg p.o. q.d.
5. Iron sulfate 81 mg p.o. q.d.
6. Accupril 40 mg p.o. q.d.
7. Hydrochlorothiazide 12.5 mg p.o. q.d.
8. NPH insulin 18 units q.a.m. and 10 units q.p.m.
9. Humalog sliding-scale q.a.m. and q.p.m.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary cardiologist, Dr. [**Last Name (STitle) **], within one week.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2179-10-21**] 12:02
T: [**2179-10-21**] 17:44
JOB#: [**Job Number **]
(cclist)
|
[
"511.9",
"429.4",
"593.9",
"272.0",
"276.1",
"401.9",
"V45.81",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"34.91",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
6760, 7011
|
7037, 7411
|
2479, 4842
|
4860, 6626
|
6641, 6739
|
7432, 7824
|
163, 1718
|
1740, 2246
|
2263, 2452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,383
| 185,709
|
34477
|
Discharge summary
|
report
|
Admission Date: [**2104-7-4**] Discharge Date: [**2104-7-22**]
Date of Birth: [**2051-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever, chills, rigors and increased white blood cell count prior
to elective surgery in an outside hospital.
Major Surgical or Invasive Procedure:
Surgical drainage of cervical spine abcsess on [**7-7**]
Interventional radiology drainage of lumbar para-spinal abcsess
on [**7-14**]
Surgical drainage of cervical fluid collection on [**7-19**]
PICC line placed on [**7-12**]
PICC line placed on [**7-21**]
History of Present Illness:
Mr. [**Known firstname 61893**] [**Known lastname **] [**Known lastname **] is a very nice 52 YO gentleman from
[**Male First Name (un) 1056**], with DM2, CKD, ICH s/p craniotomy (9 years ago),
PVD, b/l SFA stent placement (~1 mo ago) who is an IVDU (heroin,
last dose 08/03) and comes c/o fever, chills and increased in
WBC. Pt. started complaining of worsening of his claudication in
both calfs and was admitted to [**Hospital6 204**] on
[**2104-7-3**] for elective femo-[**Doctor Last Name **] bypass [**Last Name (un) **] placement. Then,
few hours later he was found to have an increased WBC of 19.4,
fever of 103.4 F and chills. Patient had MRSA in blood cultures,
and MRI of spine taht showed osteomyelitis at C3-C4 & C-4-C5
Patient received ancef, flagyl and vancomycin and was trasnfered
to [**Hospital1 18**].
Past Medical History:
HCV: treated with injections and pills (doesn't know more);
followed in [**Hospital1 189**].
Insulin Dependent DM
CRI Stage 3, baseline Cr 2.1
PVD s/p bilateral SFA stents
Intracranial hemorrhage s/p craniotomy after fall 9 years ago
Hypertension
Hyperlipidemia
Restrictive Lung Disease
Vitamin D Deficiency
Hernia Surgery
Social History:
Originally from [**Male First Name (un) 1056**]. Moved to US 17 yrs ago. Currently
unemployed, but former painter. Used to smoke 1 ppd x35 years,
but quit 8 months ago. Occasional etoh. Denies drugs. Lives in
[**Location **] with his brother. [**Name (NI) 4084**] married. Has a girlfriend. [**Name (NI) **] used
to work with birds (for 3 months) and in the aggriculture in New
Jerssey a few months ago.
Family History:
NC
Physical Exam:
Temp 101.6 F HR 84 BP 138/80 RR 16 SpO2 96% RA
.
General: NAD, A&O x3, sitting in bed, ready to walk, wearing
rigid collar
HEENT: PEERLA, normal eye movements, no icteric conjuntivae,
normal pharynx
Neck: Supple, no bruits, thyroid not palpable, pulses ok
Heart: RRR, no m/r/g
Lungs: ronchi, crackles bilaterally
Abdomen: non-tender, non-distended, decreased bowel sounds, no
signs of peritoneal irritation
Back: No CVA tenderness; pain on palpation of L3 & L4
supraspinal apofises
Extremities: Strenght [**3-31**], palpable pulses bilaterally, warm,
normal ROTs
Neurologic: Craneal nerves intact, A&O x3, normal ROTs in LE,
Patient able to walk with normal gait, can walk on heels and on
toes; normal senstaion and propiosception.
Pertinent Results:
On Admission:
[**2104-7-4**] 09:45PM WBC-17.6* RBC-4.27* HGB-12.9* HCT-36.9*
MCV-86 MCH-30.1 MCHC-34.9 RDW-13.5
[**2104-7-4**] 09:45PM NEUTS-77* BANDS-0 LYMPHS-8* MONOS-11 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2104-7-4**] 09:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2104-7-4**] 09:45PM PLT SMR-NORMAL PLT COUNT-272
[**2104-7-4**] 09:45PM GLUCOSE-148* UREA N-24* CREAT-1.4*
SODIUM-132* POTASSIUM-3.2* CHLORIDE-87* TOTAL CO2-32 ANION
GAP-16
[**2104-7-4**] 09:45PM ALT(SGPT)-30 AST(SGOT)-42* LD(LDH)-276* ALK
PHOS-131* TOT BILI-0.8
[**2104-7-4**] 09:45PM ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-1.7
MRI of the spine on [**7-6**]
Discitis, osteomyelitis from C3 through C5 with extensive
prevertebral
phlegmon and abscess. Tiny focus of epidural abscess as well as
the
predominant epidural phlegmon in the cervical spine.
Osteomyelitis in the lumbar spine, predominantly from L1 through
L3. There is abnormal enhancement in the right paraspinal
musculature abutting the facet
joint from L1 through L5. There is a left
prevertebral/paravertebral abscess at T12-L1. There is epidural
enhancement at L2-L3 on the right, which appears continous with
the paraspinal musculature enhancement. No convincing evidence
for epidural abscess in the lumbar spine is seen. There is also
prominent epidural enhancement within the left aspect of the
canal at L5-S1.
CXR: No acute cardiopulmonary process.
TTE: The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses and cavity size are normal.
There is mild global left ventricular hypokinesis (LVEF = 40-45
%). The estimated cardiac index is borderline low (2.1L/min/m2).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). 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 estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Normal biventricular cavity
sizes with mild global left ventricular hypokinesis c/w diffuse
process (toxin, metabolic etc. cannot exclude, but multivessel
CAD less likely). No valvular pathology or pathologic flow
identified.
MRI [**7-9**]:
1. Marked prevertebral soft tissue swelling with mixed signal
intensities. Post-operative changes and edema can have this
appearance. From an imaging
standpoint, it is difficult to rule out residual infection.
Followup MR [**First Name (Titles) **] [**Last Name (Titles) **] of the neck may be helpful to document
resolution of these changes.
2. Small abscess in the right paraspinal musculature, posterior
to L3 and L4 as described above. There are associated
inflammatory changes in the muscle, likely representing
myositis.
CT of neck [**7-16**]:
IMPRESSION: Extensive intercommunicating fluid collections with
numerous
suspended air bubbles at the surgical site in the neck, deep to
the right
sternocleidomastoid, as described. The collection overall
measures roughly
6.3 cm (AP) x 2.0 cm (TRV), 2:25, and extends over some 5 cm,
craniocaudally. Though direct comparison is somewhat difficult,
this process does not appear significantly improved and may, in
fact, be worse since the enhanced MR examination of [**7-9**]. This
process extends deep to the strap muscles, communicating with
the retropharyngeal and prevertebral spaces, and persistent
infected fluid collections cannot be excluded. There is marked
left lateral displacement of the laryngeal skeleton and cervical
airway, which remain patent.
MRI [**7-17**]:
1. Postoperative change in the cervical spine involving C3
through C5.
Persistent signal abnormality at C3 through C5 vertebral bodies
and
intervening disc is likely related to ongoing inflammation,
however, from an imaging standpoint, it is difficult to
differentiate between postoperative change and residual
infection. No epidural collection is identified.
2. Large fluid collection containing gas at the surgical site in
the neck
extending to the C3 through C5 anterior prevertebral space not
significantly changed from the postoperative MRI from [**2104-7-9**], and better evaluated on CT from [**2104-7-16**].
Laboratory Values Upon Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2104-7-22**] 05:05AM 7.2 3.22* 9.6* 28.4* 88 29.8 33.7 13.6
387
Source: Line-PICC
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2104-7-17**] 06:46AM 67.2 20.9 8.6 2.9 0.5
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2104-7-22**] 05:05AM 158* 20 1.5* 132* 4.1 94* 27 15
Brief Hospital Course:
Patient was feeling better on arrival and was complaining of
cervical neck pain. Pt was admitted to neurology. He had an MRI
done which corroborated the cervical spine abcsess and showed a
second one in the lumbar paraspinal muscles area (L3-L4, L4-l5).
Patient had vancomycin continued (1 g QD) as well as rifampin
300 mg PO QD, cefazolin (1g IV q12 hrs) and flagyl (500 mg IV
q8hrs). Pt had vancomycin trough in AM which was 5.0, had blood
cultures, neurosurgery consult, TTE and had pain medication. ID
was consulted.
TTE did not show any valvular or abnormal flow suggesting
endocarditis. ID recommended stopping ancef and flagyl on [**7-6**].
Patient had surgery on [**7-7**] for abcsess drainage. Patient went
to ICU until [**7-11**], when he also had a PICC placed in right arm.
He was extubated on [**7-9**]. Patient was still febrile, and
started with a productive cough on [**7-11**]. Due to persistent
fever a repeat MRI was obtained as well as more blood cultures.
Repeat MRI showed a small paraspinal abcess in lumbar region
(L3-L4). Since patient still febrile, but not growing anything
on blood cultures, blood cultures were continued. Neck pain kept
increasing, so a CT scan of the neck was done, showing
recurrence of the spinal abcsess with a big collection of fluid
in the right cervical region. An MRI ruled out epidural abscess,
showed the same osteomyelitis seen in the priro MRI. Patient
undergo surgical abcsess drainage on [**7-18**]. He had a drain left
in place, which was removed on [**7-21**]. Patient has been afebrile
since surgery (max temp 100.4 without tylenol). Patient
currently is blood culture negative.
Pt grew gram negative non-fermenting bacteria pan-sensitive in
blood taken from the PICC placed in the right arm. So PICC was
retrieved and patient was continued with peripheral IV. Zosyn
was started, but when sensitivities came back, ID recommended
switching to ciprofloxacin PO. Patient to complete 14 day
course. New PICC was placed when patient afebrile >48 hours with
negative cultures on [**7-21**]. It can be pulled out when patient
finished 6-week antibiotic course and Ok with ID.
Patient had acute renal failure, which was contrast induced
after the CT scan. Creatinine went from his baseline of 1.2 to
1.8 on [**7-19**]. Right now patient trending down to 1.5.
WBC trending down, now 7.8 from a max of 18.2.
Patient was explained the risk of doing IVDU and was counseled
to quit. Patient was explained the severity of his disease in
english and spanish and was able to repeat to us. Patient is
being discharge to [**Hospital1 1501**] in [**Hospital1 189**] where he will finish his 6 week
course of antibiotic therapy.
Patient having Vancomycin trough on Friday, weekly CBC, Chem-7,
LFTs, CRP, ESR. ID is following results. Patient followed in 6
weeks by neurosurgey. Patient will need to use hard collar in
between.
Medications on Admission:
Plavix 75 mg daily
Enalapril 40 mg PO daily
Lantus 50 U SC daily
Robaxin 500 mg PO tid
Vitamin D 50,000 U PO twice weekly
Tylenol 650 mg daily
Ibuprofen 1 tablet PO q6hr
Robitussin DM prn
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a
day.
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Vancomycin 1,000 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 24H (Every 24 Hours) for 25 days.
Disp:*25 Recon Soln(s)* Refills:*0*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours)
for 7 days: On for 12 hours and then off for 12 hours.
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush for 25
days.
Disp:*30 ML(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
8. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) Injection
three times a day as needed for 25 days.
Disp:*25 Syringe* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
10. Insulin
Please follow your home regimen.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection PRN (as needed) as needed for line flush.
Disp:*25 Syringes* Refills:*3*
Discharge Disposition:
Extended Care
Facility:
Heritage Manor
Discharge Diagnosis:
Primary
MRSA sepsis with cervical abcsess and cervica osteomyelitis as
well drained paraspinal abscess in lumbar spine
Gram negative sepsis (not fermenter, not pseudomonas)
Secondary
Insulin Dependent Diabetes Mellitus
Chronic Renal Failure Stage 3, baseline Cr 2.1
Peripheral Vascular Disease
Intravenous drug use (last [**2104-6-29**])
Discharge Condition:
Stable, with PICC line in Left arm, breathing normally on room
air, comfortable and with pain controlled.
Discharge Instructions:
You were sent here from [**Hospital 189**] hospital due to fever, chills and
increase WBC before your elective surgery. You were admitted to
the neurology service and got a CT scan of your neck and spine.
2 Abscesess were found and you had the major one surgically
drained. You had an MRI later, which showed cervical
osteomyelitis (infection of the bone).
Since your fever persisted, as well as positive blood cultures
growing S aureus, you had another CT of the neck showing a
recurrence in the cervical abscess that was srugically drained
again.
You had a PICC line placed in your arm to give you antibiotics
for the infection in the bone. You will need 6 weeks at least.
This type of infections are associated with intravenous drug
use, such as heroin. Please stop doing drugs. We are happy to
provide you with help. However, you need to be constant in your
appointments and good with your treatment.
Intravenous drug use also has risks for multiple infections,
including HIV and other hepatitis.
Please stop smoking, since it is very bad for your health and
increases your risk for lung diseases and cancer.
If your neck pain persist, you have fever, chills, rigors or
anything else that concerns you please come back to the ER.
Followup Instructions:
Please arrange for follow up in the neurosurgery clinic with Dr
[**Last Name (STitle) 739**]; Office number: [**Telephone/Fax (1) 1669**].
Please USE HARD COLLAR all the time (but to shower) until seen
by Dr. [**Last Name (STitle) 739**].
Please obtain an appointment with the infectious disease doctor
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8496**]) within 3 weeks at: ([**Telephone/Fax (1) 4170**]
Follow up with your primary care as needed.
You will need a vancomycin trough level this Friday [**2104-7-15**];
then you will need weekly (every tuesday) vancomycin trough,
CBC, Chem-7, LFTs, ESR, CRP. Please fax results to the
infectious disease clinic at [**Telephone/Fax (1) 432**]. You can have your
PICC line retrieved after the last vancomycin dose. If you want
to leave AMA, then you MUST have the PICC line removed before
that.
|
[
"584.9",
"272.4",
"585.3",
"443.9",
"038.11",
"730.08",
"250.00",
"324.1",
"V58.61",
"403.90",
"V09.0",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.95",
"80.51",
"83.09",
"03.02"
] |
icd9pcs
|
[
[
[]
]
] |
12497, 12538
|
7908, 10785
|
424, 684
|
12921, 13029
|
3088, 3088
|
14311, 15183
|
2316, 2320
|
11023, 12474
|
12559, 12900
|
10811, 11000
|
13053, 14288
|
2335, 3069
|
276, 386
|
7501, 7885
|
712, 1533
|
3102, 7485
|
1555, 1879
|
1895, 2300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,362
| 189,014
|
12225
|
Discharge summary
|
report
|
Admission Date: [**2127-9-22**] Discharge Date: [**2127-10-4**]
Date of Birth: [**2059-12-17**] Sex: F
Service: SURGERY
Allergies:
Vasotec / Bactrim
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
cadaveric renal transplant
Major Surgical or Invasive Procedure:
s/p CRT [**2127-9-22**]
History of Present Illness:
67 y/o female with a a history of ESRD on HD secondary to IDDM
and Hypertension -- presents for cadaveric renal transplant.
Past Medical History:
ESRD on HD Tue/Thurs/Sat
insulin dependent diabetes
hypertension
sigmoidectomy
vaginal hysterectomy
appy
knee arthroscopy
AVF
Social History:
n/a
Family History:
n/a
Physical Exam:
on discharge:
vitals: 98.9 BP 125-70 to 140/69 HR 70-85 99% on RA
CV: RRR
ABD: soft, NTND
EXT: no edema
Pertinent Results:
RADIOLOGY Final Report
PERSANTINE MIBI [**2127-10-1**]
PERSANTINE MIBI
Reason: CHEST PAIN.
HISTORY: Patient is s/p renal transplant and now with chest
pain.
SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min. Two minutes after the cessation of infusion, Tc-[**Age over 90 **]m
sestamibi was
administered IV.
INTERPRETATION:
Image Protocol: Gated SPECT.
Resting perfusion images were obtained with thallium-201.
Tracer was injected 15 minutes prior to obtaining the resting
images.
FINDINGS:
The image quality is good. Comparison was made to a prior
pharmacological
stress test dated [**2127-1-10**]. There is a moderate sized, reversible
inferior and
inferolateral wall perfusion defect which is a new finding when
compared to the
report from the prior examination. There are no fixed perfusion
defects
identified. Left ventricular cavity size is normal.
The study was interpreted using the 17-segment myocardial
perfusion model.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 49%.
IMPRESSION: 1) New, reversible, moderate sized inferior and
inferolateral
perfusion defect. 2) Normal left ventricular cavity size and
function.
/nkg
Approved: [**Doctor First Name **] [**2127-10-2**] 4:52 PM
____________________________________
EXERCISE RESULTS
RESTING DATA
EKG: SINUS, VOLTAGE FOR LVH WITH NSSTTW
HEART RATE: 84 BLOOD PRESSURE: 128/
PROTOCOL /
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
I 0-4 .142MG KG/MIN 91 [**Telephone/Fax (1) 38214**]
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 60
SYMPTOMS: NONE
INTERPRETATION: 67 yo woman (s/p renal tx) was referred to
evaluate
an atypical chest discomfort. The patient was administered 0.142
mg/kg/min of persantine over 4 minutes. No chest, back, neck or
arm
discomforts were reported during the procedure. During the
procedure,
and in the presence of prominent voltage, 0.5-1.5mm of slowly
upsloping/horizontal ST segment depression over baseline was
noted in
the lateral leads early in the postinfusion period. The rhythm
was sinus
with frequent aea noted during the procedure: frequent APD's,
intermittent atrial couplets and triplets. The patient reported
no
palpitations or fluttering. The hemodynamic response to the
persantine
infusion was appropriate. Three min post-MIBI, the patient was
administered 125 mg aminophylline IV.
IMPRESSION: ST segment changes that are probably nondiagnostic
in the
presence of baseline abnormalities; in the absence of anginal
symptoms. Nuclear report sent separately.
SIGNED: [**Last Name (LF) **],[**First Name11 (Name Pattern1) 177**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],[**First Name3 (LF) **]
____________________________________________
RADIOLOGY Final Report
RENAL U.S. PORT [**2127-9-24**] 9:43 AM
RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVIC
Reason: ?flow to transplanted kidney
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman with renal transplant [**9-23**]
REASON FOR THIS EXAMINATION:
?flow to transplanted kidney
INDICATION: Postop day 2 after renal transplant. Prior renal
ultrasound with no antegrade diastolic flow or discernible
venous outflow.
RENAL TRANSPLANT ULTRASOUND: Again identified is an 11.4 cm
transplanted kidney. The size is unchanged. There is no
hydronephrosis or perinephric collection.
Doppler evaluation of blood flow to the transplanted kidney
shows improved systolic upstrokes in the peripheral renal
arteries, with antegrade diastolic flow now present. Some of the
waveform measurements are limited, but resistive indices range
from 0.68 to 0.75. The main renal artery was not fully evaluated
due to technique. Good venous outflow is now seen from the
kidney, with a normal venous waveform present.
IMPRESSION:
Improvement in appearance of arterial waveforms, now with
antegrade diastolic flow. Venous outflow present from the
kidney, with normal-appearing renal vein waveform.
Results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the transplant
Fellow, at the time this study was performed.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2127-9-25**] 8:47 AM
_
_
_
_
_
_
________________________________________________________________
Brief Hospital Course:
This pleasant 67 y/o woman underwent a cadaveric renal
transplant -- please see operative note for further information
-- on [**2127-9-22**]. post-operatively she was admitted to the ICU for
management secondary to blood loss in the operating room. She
did have some small ischemic changes at this time, but had a
negative troponin. Patient was monitored and was started on a
low dose of lopressor (5mg IV x once) for cardioprotection.
Patient tolerated the dose. She initially continued to make
urine with improvement each day. renal ultrasound on [**9-23**] did
show a potential of a vein clot, but repeat ultrasound did not
illstrate any abnormalities and were able to visualize the vein
and artery without difficulty. She did get intermittent dialysis
while awaiting for the graft to fully function: HD: [**9-30**] 0.5L
[**9-25**] 3.0L [**9-24**] 0.5L. She was transferred to the floor and on
pod 6, she began to experience intermittent chest pain without
shortness of air or diaphoresis. Cardiology was consulted and in
light of creatine, though improving a cardiac cath was not an
option. A stress test performed after athe chest pain was
negative. She was ruled out and restarted on her imdur and
increased the dose to 60mg po bid. Patient was also started on
lopressor 12.5 mg po bid and increased to 25 mg po bid, she
tolerated the dose. However, she remains apprehensive about the
lopressor -- worried that it will make her weak. Though her
pressure and heart rate are better controlled she will need
additional management as an out patient. She was discharged to
rehab in good condidition -- she wishes to have cardiology care
here and will see the transplant office within the next week.
Her creatine on admission [**2127-9-22**] was 6.8 and discharge [**2127-10-4**]
was 4.3 with her last dialysis being [**9-30**].
Medications on Admission:
isosorbid mono 30", nephrocaps', allopurinol 300', verapamil
120', quinine 260' before HD, captopril 12.5'
Discharge Medications:
1. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*qs Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs ML(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*qs Tablet, Chewable(s)* Refills:*2*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Verapamil HCl 120 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*qs Suppository(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO twice a day:
take as directed by transplant surgery office.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p CRT [**2127-9-22**]
ESRD secondary to HTN and DM
chest pain with negative stress test
Discharge Condition:
Good
Discharge Instructions:
keep incision clean and dry. please call for fever >100.5,
chills, nausea, emesis or any other worrisome symptoms
Followup Instructions:
Please call the cardiology office to make an appointment
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-10-6**] 9:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-10-13**] 2:50
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-10-21**] 11:40
Completed by:[**2127-10-4**]
|
[
"276.7",
"403.91",
"250.40",
"E870.0",
"998.2",
"996.81",
"E878.0",
"427.31",
"285.9",
"786.50",
"276.2",
"998.11",
"459.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93",
"39.32",
"39.95",
"59.8",
"99.04",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
9164, 9243
|
5507, 7338
|
304, 330
|
9377, 9383
|
817, 3870
|
9545, 10230
|
669, 674
|
7496, 9141
|
3907, 3958
|
9264, 9356
|
7364, 7473
|
9407, 9522
|
689, 689
|
703, 795
|
238, 266
|
3987, 5484
|
358, 483
|
505, 632
|
648, 653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 147,469
|
15329
|
Discharge summary
|
report
|
Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
arterial line
History of Present Illness:
HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile
hypertension, RUE VTE on anticoagulation, recent facial swelling
who presents with hypertensive emergency. Patient developed
severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**]
on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea
and vomiting yellow/green liquid and BP cuff again not able to
obtain BP. Patient was last seen by VNA this past Friday with BP
130/70. Patient denies any CP, shortness of breath, abd pain.
Her facial swelling is slightly worse today. She denies any
weakness, dizziness, difficulty with speach, no numbness or
tingling. She says that she is compliant with all of her
medications. She denies any GU/GI complaints despite +UA in ED.
.
In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA.
Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1,
Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written
but patient did not take due to nausea. CT head showing no
hemorrhage but hypoattenuation in frontal area, which is change
from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with
INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K
5.6 ECG with ?hyperacute T waves, otherwise no changes, given
kayexalate only.
.
Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial
swelling and hypertensive emergency requiring ICU care. She was
also admitted [**Date range (1) 43498**] with similar complaints.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**]
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
to be due to the posterior reversible leukoencephalopathy
syndrome
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
PAST SURGICAL HISTORY:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA
Gen: swollen face L>R, alert and cooperative, NAD, snoring when
asleep but easily arousable
Heent: OP clear, swollen eye lids L>R, Left eye retracted with
prosthesis, anicteric, OP moist
Neck: supple, no JVD elevation, no meningismus
CV: nl S1 S2, RRR, [**1-15**] SM
Lungs: CTAB
Abd: obese, soft, NT, ND, BS+
Ext: dry, no c/c/e, diminished,
Neuro: Alert and oriented x 3, gets drowsy intermittently but
arousable, CN II-XII intact, strength 5/5 throughout, sensations
intact
Pertinent Results:
[**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis.
[**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high
bifrontal white matter, and subcortical hypoattenuation in the
left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white
differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying
focal lesion or possibly areas of new infarcts. An MRI head
without and with Iv conrast is recommended for further
characterization.
2. No evidence of intracranial hemorrhage.
[**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an
interval increase in retrocardiac opacity obscuring the left
hemidiaphragm. The right lung and the left upper lung zone are
clear. The right costophrenic angle is slightly blunted,
suggesting a very small right pleural effusion. The heart is
slightly enlarged, but the cardiomediastinal silhouette is
unchanged. There is no hilar enlargement. Soft tissue and bony
structures are unremarkable.
IMPRESSION: Interval increase in left basilar atelectasis with
pleural effusion. Superimposed pneumonia cannot be excluded.
Possible small right pleural effusion.
[**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the
head, the previously described low attenuation areas in the
parietal regions appear with hyperintensity signal on the FLAIR
sequence, mildly hyperintense on the diffusion-weighted
sequence, and also slightly hyperintense on the corresponding
ADC maps, these findings are nonspecific and may represent
posterior reversible encephalopathic changes, please correlate
clinically. There is no evidence of acute hemorrhage,
hydrocephalus, or midline shift. A low-attenuation area is
identified on the right occipital region, likely consistent with
chronic deposits of hemosiderin, please correlate with the prior
MRI dated [**2140-12-28**].
IMPRESSION: Limited examination secondary to motion artifacts.
On the FLAIR sequence, there is evidence of hyperintensity areas
in the parietal regions, left occipital lobe, which are
nonspecific and may represent possible posterior reversible
encephalopathic changes. The prior low-attenuation area of the
right occipital lobe is unchanged and may represent chronic
deposits of hemosiderin. There is no evidence of hydrocephalus
or midline shifting. Followup with MRI of the head with and
without contrast under conscious sedation is recommended if
clinically warranted.
Brief Hospital Course:
A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and
facial swelling p/w hypertensive emergency and delta MS
initially admitted to the [**Hospital Unit Name 153**].
In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home
medications. She had head imaging (MRI) with following results;
On the FLAIR sequence, there is evidence of hyperintensity areas
in the parietal regions, left occipital lobe, which are
nonspecific and may represent possible posterior reversible
encephalopathic changes. She was evaluated by neurology who
considered PRES, though she did not seize. She was started on
keppra as she has had seizures before, and will follow up with
them.
.
# HTN Emergency. She has had multiple admissions in the past
with neurological involvement, hemolysis in the past. SBP >300
in ED. Her BP was lowered slowly with a labetolol gtt in the
ICU. When it was stably below 180 she was transferred to the
medical floor on the [**Hospital Ward Name 517**]. She was continued on
clonidine TP, po labetalol, aliskiren. I/O goal was even. Her
BP remained between 120-170 before discharge, she no longer had
any headaches, or nausea. She was oriented times three.
Aliskiren was not covered by masshealth, and a prior auth was
faxed over. A supply from the pharmacy was sought but
unavailable. She was given a prescription for 5 pills to bridge
her to the time when the prior auth would have been approved in
order to facilitate her paying for the prescription. She was
also given hydralazine and instructed on how to take extra doses
when her blood pressure increased.
.
# Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive
changes on CT. AAO times three, no focal neurological signs
currently. Also likely component of OSA although this seems
chronic. No seizures although has had them in the past.
Neuro was consulted, and she was started on Keppra for question
of PRES, keppra for 6 weeks until f/u with neuro, has outpatient
MRI appointment as well. They will likely keep her on keppra
until the changes in her parietal regions have resolved.
.
#UTI-found on admission, was on Cipro-will complete course of 5
days
.
# VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o
other VTE [**2-11**] to lines in the past. Currently on coumadin. INR
2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures.
Her coumadin was restarted, has VNA set up and will be followed
by [**Hospital3 **].
.
# Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE
(brachiocephalic) vs. angioedema-pt now without swelling
.
# ESRD. Currently no on HD due to patient preference, awaiting
to start PD next week. Since patient has refused HD there was an
attempt to correct lytes and acid base with medications. Avoided
fluid overload with lasix, patient currently making urine. Lytes
- see below. She will commence PD as an outpatient (had issues
yesterday with catheter flushing)-still not working-will try
laxatives to relieve loops of bowel possibly wrapped around
catheter and she will follow up with renal on Monday. Her
ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was
administered.
.
# Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely
[**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated
in the past, likely some chronic hyerkalemia. She received
kayexalate 30 mg tid until K <5
Her electrolytes stabilized and she was continued on her home
regimen of sodium bicarb (650mg two tabs daily).
.
# SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some
point --Atovaquone to prevent hyperkalemia
Continued on prednisone 10mg (dropped from 15mg 2 weeks ago)
.
# Anemia-Hct and plts dropped on this admission but now stable
.
# HOCM. Avoid dehydration. Currently on Labetalol.
.
# PPX: systemically anticoagulated, getting kayexalate, PPI
# FEN: Electrolytes as above, no standing fluids I/Os goal even.
# Access: 2x PIV currently
# Code: Full
# Dispo: home
Medications on Admission:
Pantoprazole 40 mg daily
- Clonidine TP 0.3/24 hrs q wednesday
- Prednisone 10 mg daily (just decreased from 15 mg)
- Calcitriol 0.25 mcg daily
- Sodium bicarbonate 650 mg 2 tabs daily
- Vit D3 400 mg daily
- Vit D2 50,000 q wed, x 10 weeks
- Labetalol 300 mg po 3 tabs TID
- Nifedipine SR 90 mg [**Hospital1 **]
- Warfarin 2 mg daily
- Hydral 25 mg TID
- Lasix 40 mg [**Hospital1 **] (started friday)
- Benadryl 25 mg po prn
- Ativan 1 mg [**Hospital1 **] prn
- Colace 100 mg [**Hospital1 **] prn
- Morphine 15 mg po q 6 hrs x 14 days
- Diovan 320 mg daily
- Dilaudid prn
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
on alternating days with 15mg.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): please take as directed when blood pressure is above
180.
Disp:*90 Tablet(s)* Refills:*2*
8. 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*
9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
Disp:*405 Tablet(s)* Refills:*2*
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for hold for sbp < 130.
Disp:*10 Tablet(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Outpatient Lab Work
for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**]
please check INR once a week and have results faxed to
[**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**]
16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<130.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
-hypertensive emergency
-Lupus - [**2134**]. Diagnosed after she began to have swolen fingers,
a rash and painful joints.
-ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with
hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated
PTH/Metabolic Acidosis; PD Catheter placed [**5-18**]
-h/o seizures, ICU admissions; h/o two intraparenchymal
hemorrhages that were thought due to the posterior reversible
leukoencephalopathy syndrome, associated with LE paresis in [**2140**]
that resolved
-Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had
blood cleared and cataract removed as well as glaucoma.
-HOCM - per Echo in [**2137**]
-Mulitple episodes of dialysis reactions
-Anemia
-H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin
then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**],
[**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4
([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**],
[**8-/2140**])
-Facial and left breast swelling - attributed to angioedema vs
chronic L Brachiocephalic vein occlusion
-Thrombophilia ?????? likely related to SLE, h/o recurrent VTE
-Thrombocytopenia NOS
-TTP (got plasmapheresisis) versus malignant HTN
-History of left eye enucleation [**2139-4-20**] for fungal infection
Discharge Condition:
stable, afebrile, SBP 120's-170's
Discharge Instructions:
You were admitted with hypertensive emergency, your blood
pressure was extremely high. You had a head CT and MRI that
showed some changes concerning for PRES (posterior reversible
leukoencephalopathy syndrome), and neurology recommended
initiating Keppra. Your blood pressure was brought under
control in the intensive care unit and now you have a new
regimen of medications. In addition peritoneal dialysis was
attempted but there were difficulties with your catheter. This
will be further addressed by your outpatient nephrologist. You
will continue to have your INR drawn and sent to coumadin
clinic.
You should take all your medications as prescribed, you will be
taking the keppra until you follow up with a neurologist in
approximately 6 weeks. You will also be taking the Aliskiren
following discharge. You will be discharged on hydralazine
(which you will take three times daily EVERY DAY), as well as
when your blood pressure gets too high as follows;
if you blood pressure is above 180 please take an extra dose of
hydralazine, check your blood pressure in 10 minutes, if it is
still not take another dose and recheck your blood pressure in
another 10 minutes-if it is still elevated take another 25mg
hydralazine and recheck in 10 minutes-if it is still elevated
please call your doctor or go to the ER.
Continue taking your coumadin and having your INR sent to
coumadin clinic.
Please seek medication attention if you have any headaches,
chest pain, shortness of breath, dizzyness, nausea or any other
concerning symptoms.
Please follow up as outlined below.
Followup Instructions:
-Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**]
10:00
-Your renal team will contact you regarding follow up-you should
call CB for home teaching.
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2141-7-12**] 10:30
-MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building
-[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm
-Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP
for [**Name Initial (PRE) **] referral
-Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2141-6-19**]
|
[
"275.41",
"784.2",
"585.6",
"582.81",
"283.9",
"276.2",
"348.39",
"403.01",
"611.72",
"364.3",
"V12.51",
"287.5",
"V58.61",
"276.7",
"710.0",
"599.0",
"275.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13405, 13462
|
6796, 10827
|
302, 317
|
14963, 14999
|
4268, 6773
|
16624, 17709
|
3600, 3711
|
11452, 13382
|
13483, 14942
|
10854, 11429
|
15023, 16601
|
3208, 3372
|
3726, 4249
|
242, 264
|
345, 1875
|
1897, 3185
|
3388, 3584
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,506
| 148,523
|
33446
|
Discharge summary
|
report
|
Admission Date: [**2114-3-5**] Discharge Date: [**2114-3-14**]
Date of Birth: [**2049-1-28**] Sex: F
Service: SURGERY
Allergies:
[**Doctor First Name **]
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
65 yo F "found down" in vomit by family, altered mental status
Major Surgical or Invasive Procedure:
[**2114-3-9**] Tracheostomy
[**2114-3-9**] Percutaneous gastrostomy tube placement
History of Present Illness:
65 yo F "found down" in vomit by family, minimally responsive,
seen at OSH ([**Hospital **] Hospital), intubated, concern for pelvic
trauma/assault [**2-3**] vag bleeding, tx to [**Hospital1 18**] for treatment of
head bleed.
Past Medical History:
aspergillus originally thought to be t-cell lymphoma (underwent
chemo), depression, zoster, neuralgia, hyperlipidemia
Social History:
dtr states that pt lives in multi family house with her sister
and several other family members and has close supervision from
sister and dtr who lives
nearby and helps pt w/meds, errands, etc. Pt also has 3 sons who
all live out of state & are on their way in to [**Location (un) 86**]. Pt is
divorced, former husb lives in PA.
Family History:
noncontributory
Physical Exam:
INITIAL PHYSICAL EXAM
Vitals: T 101.3 F BP 148/79 P 80 RR 15 SaO2 100% on
vent
General: elderly, cachectic female
HEENT: alopecia, racoon eyes, bruising on scalp b/l in
frontotemporal areas, sclerae anicteric, dry MM, orally
intubated
Neck: C-spine collar in place
Lungs: coarse breath sounds
CV: regular rate and rhythm, no MMRG
Abdomen: softly distended, non-tender, bowel sounds present
Ext: cool, no edema, pedal pulses appreciated
Skin: scattered ecchymoses throughout
Neurologic Examination:
Mental Status:
Does not open eyes, even to noxious stimuli
Cranial Nerves:
No blink to threat b/l. Pupils: 4 mm on left and 6 mm on right,
both unreactive. Extraocular movements slowly roving
horizontally and conjugately. Facial symmetric at rest.
Spontaneously elevated shoulders bilaterally. Makes gagging
sound several times.
Sensorimotor:
Mild diffuse wasting. No adventitious movements noted. Lower
extremities extended, briskly withdraw from noxious. Upper
extremities in decerebrate posture bilaterally, pull toward
chest
with noxious at forearms.
Reflexes: B T Br Pa Pl
Right 1 1 1 3 0
Left 1 1 1 3 0
Toes were upgoing bilaterally.
Coordination and gait: unable
Pertinent Results:
IMAGING:
CT TORSO [**2114-3-4**]: 1. Left lower lobe consolidation is compatible
with atelectasis and/or aspiration. 2. No acute injury in the
abdomen of pelvis. 3. Tiny hypodensity at the upper pole of the
right kidney, too small to characterize, likely representing a
simple cyst.
CT HEAD [**2114-3-4**]: 1. Parenchymal hemorrhagic contusion within the
right frontal lobe, probable thombus adjacent to the septum
pellucidum, amd subarachnoid hemorrahge within the right
temporal lobe and the lateral aspect of the pons/midbrain, as
well as hemorrhage layering within the lateral ventricles, are
most suggestive of underlying traumatic etiology, although
underlying lesion less likely given the scattered,
multicompartmental nature of the bleeding. 2. Left temporal
laceration and left-sided periorbital soft tissue swelling. No
acute fracture.
MR HEAD [**2114-3-5**]: 1. Multiple hemorrhagic contusions suggest
assault with shaking mechanism. 2. Small hemorrhage in the
ventricular system. 3. Right paraseptal hematoma. 4. Right
occipital bone defect and right cerebellar hemisphere infarction
or resection with resulting gliosis.
5. No evidence of fracture.
MR [**Name13 (STitle) **] AND T-SPINE [**2114-3-5**]: 1. No evidence of cord
compression.
2. Degenerative changes throughout the cervical spine with
foraminal
narrowing at C4-C5 and C5-C6. 3. No significant spinal stenosis
R KNEE XR [**2114-3-5**]: Three views show no evidence of joint
effusion
or acute bone or joint space abnormality.
SPINAL FLUID [**2114-3-6**]: Cerebral spinal fluid (lumbar puncture):
NEGATIVE FOR MALIGNANT CELLS. Lymphocytes, monocytes and
abundant proteinaceous debris.Note: While the specimen is mildly
cellular, the lymphocytes are predominantly mature-appearing.
Clinical correlation is suggested. NO POLYMORPHONUCLEAR
LEUKOCYTES SEEN. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2114-3-12**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED
CRYPTOCOCCAL ANTIGEN NOT DETECTED
[**2114-3-5**]: MRSA SCREEN (Final [**2114-3-6**]): No MRSA isolated.
[**2114-3-5**] 01:58PM TYPE-[**Last Name (un) **] PH-7.44
[**2114-3-5**] 01:58PM freeCa-1.13
[**2114-3-5**] 01:27PM MAGNESIUM-2.5
[**2114-3-5**] 12:30PM TYPE-ART PO2-205* PCO2-41 PH-7.45 TOTAL
CO2-29 BASE XS-4
[**2114-3-5**] 12:30PM freeCa-1.07*
[**2114-3-5**] 10:13AM POTASSIUM-3.7
[**2114-3-5**] 10:13AM CK(CPK)-3342*
[**2114-3-5**] 08:49AM TYPE-ART PO2-191* PCO2-31* PH-7.47* TOTAL
CO2-23 BASE XS-0
[**2114-3-5**] 08:33AM URINE HOURS-RANDOM
[**2114-3-5**] 08:33AM URINE MYOGLOBIN-PRESUMPTIV
[**2114-3-5**] 08:33AM PT-12.3 PTT-22.3 INR(PT)-1.0
[**2114-3-5**] 08:33AM FIBRINOGE-515*
[**2114-3-5**] 05:46AM TYPE-ART PO2-169* PCO2-29* PH-7.51* TOTAL
CO2-24 BASE XS-1
[**2114-3-5**] 05:46AM LACTATE-1.9
[**2114-3-5**] 03:56AM TYPE-ART PO2-181* PCO2-33* PH-7.51* TOTAL
CO2-27 BASE XS-4
[**2114-3-5**] 03:56AM LACTATE-2.6*
[**2114-3-5**] 03:56AM freeCa-1.02*
[**2114-3-5**] 03:37AM GLUCOSE-214* UREA N-15 CREAT-0.7 SODIUM-139
POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-22 ANION GAP-19
[**2114-3-5**] 03:37AM CK(CPK)-3725*
[**2114-3-5**] 03:37AM ALBUMIN-4.0 CALCIUM-8.2* PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2114-3-5**] 03:37AM PHENYTOIN-17.4
[**2114-3-5**] 03:37AM WBC-14.8* RBC-3.53* HGB-11.0* HCT-31.8*
MCV-90 MCH-31.2 MCHC-34.6 RDW-12.7
[**2114-3-5**] 03:37AM PLT COUNT-190
[**2114-3-5**] 03:37AM PT-12.7 PTT-23.2 INR(PT)-1.1
[**2114-3-5**] 12:20AM TYPE-ART TEMP-38.5 RATES-0/15 TIDAL VOL-550
PEEP-5 O2 FLOW-100 PO2-485* PCO2-35 PH-7.48* TOTAL CO2-27 BASE
XS-3 -ASSIST/CON INTUBATED-INTUBATED
[**2114-3-4**] 11:05PM GLUCOSE-155* UREA N-19 CREAT-0.6 SODIUM-139
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
[**2114-3-4**] 11:05PM estGFR-Using this
[**2114-3-4**] 11:05PM CK(CPK)-2988*
[**2114-3-4**] 11:05PM CK-MB-44* MB INDX-1.5
[**2114-3-4**] 11:05PM WBC-10.9 RBC-3.71* HGB-11.8* HCT-33.8* MCV-91
MCH-31.9 MCHC-35.0 RDW-12.6
[**2114-3-4**] 11:05PM NEUTS-84.7* LYMPHS-8.9* MONOS-6.3 EOS-0
BASOS-0.2
[**2114-3-4**] 11:05PM PLT COUNT-165
[**2114-3-4**] 11:05PM PT-12.9 PTT-23.9 INR(PT)-1.1
[**2114-3-4**] 11:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2114-3-4**] 11:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2114-3-4**] 11:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-1
Brief Hospital Course:
On HD#0 ([**2114-3-4**]) The patient was admitted to the trauma SICU
with the history and exam as above. She sustained an unknown
trauma to her head and was "found down" in a pool of vomit by
her family. It is unclear whether she fell or possibly was
assaulted or exactly what was the mechanism of her trauma.
Her initial neurologic exam as documented above was
significant for a question of purposeful movement of her left
upper extremity, but otherwise was not responsive or following
commands. She was seen by the neurosurgery team and had the
exam as listed above. The pt had a SANE exam performed by the
SANE nurse given the ? of vaginal bleeding and the unknown
nature of her trauma. On [**3-6**] the pt was seen by OB-Gyn consult-
no vaginal lac seen at that time, but ? of vaginal lac seen on
SANE RN exam. No vaginal lacs or evidence of trauma seen by the
OB-Gyn consultant. Mild petechiae on labia minora, possibly
atrophy.
Social work followed the patient throughout her
hospitalization. The pt was weaned from sedation on [**4-12**] and
her neurologic exam remained the same. On [**3-6**] the patient had a
lumbar puncture which showed elevated RBCs, no evidence of
infection. On [**3-7**] the patient had a nutrition consult regarding
a tube-feeding regimen. Her nutrition recommendations are listed
in this document. On [**3-8**] the PICC team attempted to place a PICC
line but was unsuccessful x 3 attempts.
After discussion with the family with discussion of risks and
benefits and long-term prognosis, on [**3-9**] a Trach and PEG were
placed. The pt tolerated the procedure well and returned to the
ICU. The patient's vital signs remained stable and she was
transferred to the floor on [**3-10**]. On the floor the pt made
minimal change in her neuro exam; she occasionally
withdraws/localizes to pain. Her tube feeds were started through
her PEG tube on [**3-10**], and increased to goal with no
complications.
The pt was followed by case management and physical therapy,
and deemed appropriate for neuro rehab. She remained afebrile
and her vital signs and respiratory status remained stable for
her [**3-6**] day floor stay. The pt did have occasional low-grade
tachycardia to 108 on HD#10, but the patient's temperature and
other vitals were normal and the tachycardia may have been due
to receiving albuterol nebulizer treatment. On [**3-14**] (HD#10) the
pt was discharged to neuro rehab in stable condition.
Medications on Admission:
Oxycodone, Detrol, Lipitor, Cymbalta, ASA, Acetaminophen
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: hold
for loose stools.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
Disp:*60 injection* Refills:*2*
5. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO
Q8H (every 8 hours) for 2 days.
Disp:*qs * Refills:*0*
6. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*qs * Refills:*2*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Acetaminophen 160 mg/5 mL Solution Sig: [**1-3**] PO Q6H (every 6
hours) as needed.
Disp:*qs * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Multiple hemorrhagic brain contusions involving the white
matter of the left frontal, right frontal, and right parietal
lobes
Discharge Condition:
Stable
Discharge Instructions:
Please call your physician or go to the emergency room if you
develop chest pain, shortness of breath,fever greater than
101.5, foul smelling or colorful drainage from your incisions,
redness or swelling, severe abdominal pain or distention,
persistent nausea or vomiting, or any other symptoms which are
concerning to you.
Activity: You may resume activity as you are able and according
to the recommendations of the physical therapists.
Medications: Resume your usual home medications, as well as the
new medications prescribed to you in the hospital as listed. You
should take a stool softener with your pain medication.
Follow up with Dr. [**Last Name (STitle) **], with Trauma Surgery, as needed for
concerns regarding your tracheostomy or feeding tube. Please
call Dr.[**Name (NI) 12389**] office at [**Telephone/Fax (1) 6429**] for an appointment or
with any questions.
Follow up with Neurosurgery regarding your traumatic brain
injury. please call the neurosurgery clinic at [**Telephone/Fax (1) 1669**] with
any questions and for an appointment. You were seen by Dr.
[**Last Name (STitle) **] while in the hospital.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], with Trauma Surgery, as needed for
concerns regarding your tracheostomy or feeding tube. Please
call Dr.[**Name (NI) 12389**] office at [**Telephone/Fax (1) 6429**] for an appointment or
with any questions.
Follow up with Neurosurgery regarding your traumatic brain
injury. please call the neurosurgery clinic at [**Telephone/Fax (1) 1669**] with
any questions and for an appointment. You were seen by Dr.
[**Last Name (STitle) **] while in the hospital.
|
[
"202.70",
"518.81",
"272.4",
"851.80",
"E888.9",
"728.88",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"03.31",
"43.11",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
10461, 10531
|
6894, 9348
|
346, 431
|
10704, 10713
|
2442, 4366
|
11891, 12397
|
1189, 1206
|
9455, 10438
|
10552, 10683
|
9374, 9432
|
10737, 11868
|
1221, 1706
|
4399, 6871
|
244, 308
|
459, 686
|
1806, 2423
|
1745, 1790
|
1730, 1730
|
708, 827
|
843, 1173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,778
| 114,308
|
38859
|
Discharge summary
|
report
|
Admission Date: [**2187-7-5**] Discharge Date: [**2187-7-12**]
Date of Birth: [**2109-1-11**] Sex: F
Service: SURGERY
Allergies:
Augmentin / Vicodin / Zocor
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2187-7-5**] - open retroperitoneal abdominal aortic aneurysm repair
History of Present Illness:
Ms. [**Known lastname **] is a 78-year-old woman referred by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7047**] for evaluation of abdominal aortic aneurysm. She had
this detected several years ago and she has not had any symptoms
referable to this. She has a family history in that her mother
died from a ruptured abdominal aortic aneurysm. She also has a
sister with an abdominal aortic aneurysm and that is being
followed. Over the past year, it grew from 4.2 cm to 5.5 cm on
the ultrasound month ago and she had a CT today. She has
chronic back pain related to fibromyalgia but has not had
anything that has been different in her recent past. She has
coronary artery disease and aortic valvular disease. She is
status post CABG x2 plus AVR on [**2186-6-7**] by Dr. [**Last Name (STitle) **]. She is
a smoker. She has quit several times over the past several
years. She does not have a long history of hypertension but has
been hypertensive recently and has had medication adjustments
for this.
Past Medical History:
Borderline hyperlipidemia
Aortic stenosis
Psoriasis
Coronary artery disease
Osteoporosis
Gastroesophageal reflux disease
Fibromyalgia
Hepatitis treated in [**2143**]
Sleep apnea-does not use CPAP
4.2 cm abdominal aortic aneurysm
Ectopic pregnancy
Past Surgical History
[**2182**] Right total knee replacement
Tonsillectomy
Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: husband and daughter
Occupation: Retired
Tobacco: 50 pack years (1ppd until several wks ago)
ETOH: Occasional ETOH and denies illicit drug use.
Family History:
grandmother had "heart condition"
Physical Exam:
On physical examination on discharge, she is in no distress.
Pulse is 68. Respirations are 16. Blood pressure is 147/80.
HEENT is unremarkable. Neck is supple. Chest is clear. Heart
is regular. Abdomen is soft and nondistended. Her incision is
clean and intact, with small amounts of serous drainage. She
has palpable femoral and pedal pulses. The popliteal pulses are
not enlarged. She has psoriatic skin lesions in the lower
extremities. She has 1+ edema of b/l lower extremities
Pertinent Results:
[**2187-7-9**] 05:46AM BLOOD WBC-10.3 RBC-3.45* Hgb-10.6* Hct-30.2*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.6 Plt Ct-154
[**2187-7-12**] 06:50AM BLOOD Glucose-97 UreaN-14 Creat-1.0 Na-140
K-3.5 Cl-101 HCO3-24 AnGap-19
[**2187-7-12**] 06:50AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1
Brief Hospital Course:
On [**2187-7-5**], Ms [**Known lastname **] [**Last Name (Titles) 1834**] open repair of her abdominal
aortic aneurysm via a retroperitoneal approach. She was
transferred to the ICU intubated postoperatively due to the
large amount of fluid and colloid resuscitation she received
intraoperatively. However, she was extubated successfully the
next day, and transferred to the VICU in stable condition. She
was passing gas and having bowel movements by postoperative day
2. She began to tolerate a regular diet. She was actively
diuresed with lasix. Her appetite was decreased, which she has
had in the past while on narcotic pain medications, so she was
started on marinol and carnation instant breakfast supplements
were added to her diet. She was seen by physical therapy, who
recommended that she go to rehab. She was discharged to rehab
on [**2187-7-12**] in good condition.
Medications on Admission:
Omeprazole, Pravastatin, Metoprolol,Aspirin, and Losartan
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for bronchospasm.
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for bronchospam.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a
day).
14. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
17. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Abdominal aortic aneurysm
Hyperlipidemia
Fibromyalgia
Discharge Condition:
Good condition.
AAOx3
Ambulating with max assist
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-6**]
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 [**2-1**]
pillows or a recliner) every 2-3 hours
throughout the day and at night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low
cholesterol) to maintain your strength and assist in wound
healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound,
then place a dry dressing over the area that is draining, as
needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2187-8-8**] 2:15
Completed by:[**2187-7-12**]
|
[
"327.23",
"272.4",
"V43.65",
"V10.05",
"427.89",
"441.4",
"V45.81",
"401.9",
"305.1",
"729.1",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
5411, 5478
|
2899, 3786
|
312, 385
|
5576, 5627
|
2605, 2876
|
8254, 8436
|
2041, 2077
|
3894, 5388
|
5499, 5555
|
3812, 3871
|
5651, 7802
|
7828, 8231
|
2092, 2586
|
247, 274
|
413, 1445
|
1467, 1806
|
1822, 2025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,608
| 177,221
|
6424
|
Discharge summary
|
report
|
Admission Date: [**2159-9-27**] Discharge Date: [**2159-9-30**]
Date of Birth: [**2094-9-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
s/p Cardiac Arrest
Major Surgical or Invasive Procedure:
Arterial line placement
Intubation
History of Present Illness:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. He originally presented to hospital as outpatient
for planned [**Year (4 digits) **], which was cancelled due to tachycardia,
relative hypotension, and inability to find oxygen sat. Patient
then left the hospital to go home and had a witnessed Vfib
arrest with intubation in field and epi down ETT. Was shocked
out of Vfib. FS at that time was 132.
.
*per phone conversation with patient's wife*
In last few weeks patient had been complaining to his wife that
he was more short of breath with exertion. Wife reports that
patient acted like he had given up on life as he had no
motivation to do even the smallest thing like change his
underwear. She notes that he was sleeping through most of the
day. Patient also may have been a bit more confusion lately.
Patient finished 6.5 weeks of radiation therapy last week.
Patient has also finished multiple cycles of gemcitabine
chemotherapy. Of note, wife is very angry about the fact that
patient was released to home from GI procedure suite today. She
resports that she feels it was inappropriate to send a
"half-dead" man home.
.
In the emergency department, vitals at presentation were: T
96.6, HR 112, BP 125/32, and intubated with O2Sat 100%. Patient
had multiple impaging procedures including negative CT head, CT
abd/pelvis showing large simple ascites, CTA chest without PE
but did show multiple right rib fractures and sternal fracture.
Currently being cooled (target reached at 33 C) and on a
midazolam drip. EKG without concern for STEMI, and cardiology
feels this is close to his baseline EKG. Prior to transfer to
the ICU vitals were: T 92 98, HR , BP 101/58, RR 25, O2Sat 100%
on AC mode Vt 560, f 22, PEEP 5, FiO2 100%.
Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above
Social History:
Lives in [**Location 13360**] with wife. Retired IT tech. Has one son
age 31, one daughter age 35 with special needs. No current or
past EtOH use, no current or past tobacco use.
Family History:
Mother h/o Breast Ca at early age. Father CAD. Brother died
from lung Ca, heavy smoker. Sister has dementia.
Physical Exam:
VS: T 33 C, HR 99, BP 100/59, RR 22, O2Sat 100%
VENT: AC with Vt 560, f 22, PEEP 5, FiO2 100%
GEN: Intubated and sedated, appears cachectic
HEENT: Scleral edema, PERRL 3->2 mm
NECK: EJ IV catheter at right neck
PULM: Anterior chest bruising
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Largely obscured by placement of Artic Sun pads, though
BS+, soft, no grimace with palpation
EXT: Stage III ulcer on right heel, BLE with woody edema, BUE
[**11-25**]+ pitting edema
NEURO: Sedated, no rigidity of muscular tone
.
Pertinent Results:
Admission Labs
[**2159-9-27**] 11:17PM TYPE-ART TEMP-33 RATES-22/ TIDAL VOL-609
PEEP-5 O2-50 PO2-255* PCO2-22* PH-7.38 TOTAL CO2-14* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 11:17PM LACTATE-2.5*
[**2159-9-27**] 09:19PM TYPE-[**Last Name (un) **] PH-7.23* COMMENTS-GREEN TOP
[**2159-9-27**] 09:19PM LACTATE-2.6*
[**2159-9-27**] 09:19PM freeCa-1.04*
[**2159-9-27**] 09:07PM GLUCOSE-112* UREA N-33* CREAT-1.6* SODIUM-144
POTASSIUM-5.8* CHLORIDE-118* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 09:07PM CK(CPK)-352*
[**2159-9-27**] 09:07PM CK-MB-55* MB INDX-15.6* cTropnT-0.73*
[**2159-9-27**] 09:07PM DIGOXIN-0.2*
[**2159-9-27**] 09:07PM WBC-9.8 RBC-3.10* HGB-9.6* HCT-30.4* MCV-98
MCH-30.8 MCHC-31.5 RDW-21.7*
[**2159-9-27**] 09:07PM PLT COUNT-191
[**2159-9-27**] 09:07PM PT-16.9* PTT-33.6 INR(PT)-1.5*
[**2159-9-27**] 08:10PM GLUCOSE-107* UREA N-34* CREAT-1.6* SODIUM-140
POTASSIUM-8.6* CHLORIDE-117* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 08:10PM CK(CPK)-412*
[**2159-9-27**] 08:10PM CK-MB-53* MB INDX-12.9* cTropnT-0.63*
[**2159-9-27**] 08:10PM CALCIUM-7.7* PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2159-9-27**] 03:21PM TYPE-ART TIDAL VOL-520 O2-100 PO2-329*
PCO2-30* PH-7.30* TOTAL CO2-15* BASE XS--9 AADO2-362 REQ O2-64
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 01:55PM URINE HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE GR HOLD-HOLD
[**2159-9-27**] 01:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2159-9-27**] 01:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2159-9-27**] 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-9-27**] 01:38PM GLUCOSE-119* LACTATE-4.0* NA+-143 K+-5.7*
CL--118* TCO2-15*
[**2159-9-27**] 01:30PM UREA N-33* CREAT-1.7*
[**2159-9-27**] 01:30PM estGFR-Using this
[**2159-9-27**] 01:30PM estGFR-Using this
[**2159-9-27**] 11:59AM TYPE-ART PO2-294* PCO2-28* PH-7.39 TOTAL
CO2-18* BASE XS--6 INTUBATED-NOT INTUBA
[**2159-9-27**] 01:30PM FIBRINOGE-220
[**2159-9-27**] 01:30PM PLT COUNT-239
[**2159-9-27**] 01:30PM PT-16.4* PTT-33.4 INR(PT)-1.5*
[**2159-9-27**] 01:30PM WBC-6.7 RBC-3.38* HGB-10.4* HCT-33.3* MCV-99*
MCH-30.8 MCHC-31.3 RDW-21.8*
[**2159-9-27**] 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Discharge Labs
[**2159-9-30**] 05:43AM BLOOD WBC-10.6 RBC-2.76* Hgb-8.6* Hct-26.8*
MCV-97 MCH-31.1 MCHC-32.0 RDW-21.8* Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD WBC-8.8 RBC-2.98* Hgb-9.3* Hct-29.2*
MCV-98 MCH-31.0 MCHC-31.7 RDW-21.8* Plt Ct-169
[**2159-9-28**] 04:46AM BLOOD WBC-9.4 RBC-3.20* Hgb-10.0* Hct-30.8*
MCV-96 MCH-31.3 MCHC-32.5 RDW-21.5* Plt Ct-177
[**2159-9-28**] 04:46AM BLOOD Neuts-95.6* Lymphs-1.8* Monos-2.4 Eos-0.1
Baso-0
[**2159-9-30**] 05:43AM BLOOD Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD Plt Ct-169
[**2159-9-28**] 12:54PM BLOOD PT-17.0* PTT-113.2* INR(PT)-1.5*
[**2159-9-28**] 04:46AM BLOOD Plt Ct-177
[**2159-9-30**] 05:43AM BLOOD Glucose-120* UreaN-39* Creat-2.1* Na-139
K-4.9 Cl-113* HCO3-18* AnGap-13
[**2159-9-29**] 07:49PM BLOOD Glucose-120* UreaN-39* Creat-2.0* Na-138
K-5.0 Cl-113* HCO3-18* AnGap-12
[**2159-9-29**] 04:04PM BLOOD Glucose-124* UreaN-39* Creat-1.9* Na-140
K-5.0 Cl-114* HCO3-19* AnGap-12
[**2159-9-29**] 01:52AM BLOOD Glucose-256* UreaN-37* Creat-1.7* Na-142
K-5.2* Cl-113* HCO3-16* AnGap-18
[**2159-9-28**] 04:46AM BLOOD ALT-31 AST-64* LD(LDH)-370* CK(CPK)-372*
AlkPhos-132* TotBili-1.0
[**2159-9-27**] 09:07PM BLOOD CK(CPK)-352*
[**2159-9-28**] 04:46AM BLOOD CK-MB-62* MB Indx-16.7* cTropnT-0.67*
[**2159-9-27**] 09:07PM BLOOD CK-MB-55* MB Indx-15.6* cTropnT-0.73*
[**2159-9-27**] 08:10PM BLOOD CK-MB-53* MB Indx-12.9* cTropnT-0.63*
[**2159-9-30**] 05:43AM BLOOD Calcium-7.8* Phos-4.5 Mg-1.9
[**2159-9-29**] 07:49PM BLOOD Calcium-7.7* Phos-4.5 Mg-2.0
[**2159-9-29**] 04:04PM BLOOD Calcium-7.6* Phos-4.1 Mg-2.0
[**2159-9-29**] 01:52AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1
[**2159-9-30**] 05:43AM BLOOD Phenyto-9.0*
[**2159-9-29**] 07:49PM BLOOD Phenyto-8.8*
[**2159-9-27**] 09:07PM BLOOD Digoxin-0.2*
[**2159-9-27**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-9-29**] 08:32AM BLOOD Type-ART Temp-36.1 Rates-12/14 PEEP-5
FiO2-30 pO2-110* pCO2-35 pH-7.34* calTCO2-20* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2159-9-29**] 03:37AM BLOOD Type-ART Temp-35.0 Rates-[**10-25**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.3 pO2-92 pCO2-34 pH-7.33* calTCO2-19*
Base XS--6 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 01:57AM BLOOD Type-ART Temp-34.3 Rates-[**10-26**] Tidal V-450
PEEP-5 FiO2-30 pO2-89 pCO2-31* pH-7.33* calTCO2-17* Base XS--8
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 11:44PM BLOOD Type-ART Temp-33.6 Rates-[**10-29**] Tidal V-450
PEEP-5 FiO2-30 pO2-93 pCO2-28* pH-7.31* calTCO2-15* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 10:36PM BLOOD Type-ART Temp-33.3 Rates-[**10-27**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.2 pO2-132* pCO2-32* pH-7.27*
calTCO2-15* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 04:42PM BLOOD Lactate-1.8 Cl-114*
.
Reports
[**2159-9-27**]
Regular rhythm at 97 beats per minute. In leads V5-V6 there are
P waves so
this is probably sinus rhythm at 97 beats per minute. Marked low
voltage in the limb leads persists. The right bundle-branch
block pattern persists with a QRS duration which has widened to
158 milliseconds. There is poor R wave progression laterally and
low voltage in all leads. There are small Q waves in leads II,
III and aVF with ST segment elevation in those leads. Consider
acute inferior myocardial infarction.
.
[**9-27**] CT head w/o Contrast
IMPRESSION: No acute intracranial process.
.
[**2159-9-27**] Chest CT w contrast
. No central PE or dissection. Suboptimal evaluation of the
posterior
pulmonary circulation secondary to large bilateral pleural
effusions with
associated compressive atelectasis.
2. Focal small foci of gas in the anterior upper abdomen on the
last image of
non-contrast sequence. Free air cannot be excluded.
3. Large amount of abdominal ascites.
4. Multiple right and left rib fractures and a sternal fracture.
These may be
related to recent resuscitative efforts.
5. Ground-glass opacity in the right middle lobe may be a
pulmonary contusion
versus infection versus aspiration. This is new since [**2159-7-19**].
.
CT abdomen
Large volume ascites with no evidence of free air..
.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with near
akinesis of the inferior and inferolateral walls and hypokinesis
of the remaining segments. The anterior septum contracts best
(LVEF 25-30%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The estimated cardiac index is depressed
(<2.0L/min/m2). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is dilated with moderate global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic root is mildly dilated at the sinus
level. 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. Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2159-4-25**], the
estimated pulmonary artery systolic pressure is now highter.
.
[**9-29**] CXR
Cardiomegaly, large bilateral pleural effusions greater on the
right side with
associated atelectases are unchanged. ET tube, NG tube, and
right central
catheter remain in place. There is no pneumothorax.
Cardiomediastinal
silhouette is unchanged.
Brief Hospital Course:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. Is being cooled with Artic Sun.
#. Vfib cardiac arrest:
Most likely etiology was either new ischemia or automaticity
from old scar in setting of dilated ischemic cardiomyopathy with
LVEF of 25-30%. Patient's exam and history was consistent with
decompensated heart failure of at least several week duration.
Less likely cause of cardiac arrest would be digoxin toxicity
given patient recently started that medication and has history
of renal insufficiency. CTA chest was overall a poor study given
large pleural effusions, though no apparent PE or aortic
dissection. Patient fortunately had relatively rapid
defibrillation and [**Name (NI) **] during code. He was being cooled
followed by warmed on Artic Sun for neuro protection and has
reached temperature goal of 33 C. 48hr EEG showed possible
seizure activity consistent with ischemic injury; consult neuro
to evaluate EEG
Family meeting once warmed and off sedation to discuss goals of
care and prognosis, and it was decided to enact comfort care
measures.
.
#Hypotension: likely secondary to worsening heart failure in the
setting of fluid overload. N.epi and vasopressin as needed for
MAP > 60; phenylephrine PRN for additional pressure support
.
#. Acute on Chronic Kidney Injury:Most likely due to ATN in
setting of arrest
Mr [**Known lastname 4017**] wife and son decided they wanted to fully withdraw
care. Dr [**First Name (STitle) 1022**] met with them and answered all questions - pt was
extubated and all pressors were turned off. Placed on Morphine
for comfort. At approx. 12:45PM, I was notified by the nurse the
patient had passed away with his family at bedside.
.
[**2159-9-30**]
I examined the patient and he was not responsive to auditory or
tactile stimuli. I observed 1 minute of no breaths or
respiratory effort. I auscultated no breath sounds or heart
sounds for 1 minute. The patient did not have a corneal reflex
or pupilllary reaction to direct light bilaterally. I declared
the patient dead at 12:57 PM and notified his family who were in
the hallway outside the ICU. His wife and son denied a autopsy.
Medications on Admission:
per [**2159-9-4**] [**Hospital6 33**] discharge*
1) Atorvastatin 40 mg QHS
2) Lipase-Protease-Amylase 5,000-17,000-27,000 Capsule, TID
W/MEALS
3) Metoprolol Tartrate 25 mg PO DAILY
4) Trazodone 50 mg PO HS
5) Insulin Glargine 8 Units subcutaneous DAILY
6) Humalog 100 unit/mL 1-12 Units subcutaneous QID
7) Aspirin 81 mg PO DAILY
8) Pantoprazole 20 mg Q24H
9) Furosemide 40 mg Tablet PO DAILY
10) Digoxin 0.125 mg DAILY
11) Tamsulosin 0.4 mg DAILY
12) Ferrous gluconate DAILY
Discharge Medications:
Patient has passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient has passed away
Discharge Condition:
Patient has passed away
Discharge Instructions:
Patient has passed away
Followup Instructions:
Patient has passed away
|
[
"157.9",
"585.9",
"V58.67",
"428.23",
"348.1",
"427.41",
"584.5",
"428.0",
"600.00",
"414.01",
"785.51",
"518.81",
"427.31",
"414.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14738, 14747
|
11918, 14163
|
290, 326
|
14814, 14839
|
3649, 11895
|
14911, 14937
|
2982, 3096
|
14690, 14715
|
14768, 14793
|
14189, 14667
|
14863, 14888
|
2652, 2766
|
3111, 3630
|
232, 252
|
354, 2182
|
2226, 2629
|
2782, 2966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,476
| 150,619
|
47993
|
Discharge summary
|
report
|
Admission Date: [**2192-5-16**] Discharge Date: [**2192-5-28**]
Service: MED
Allergies:
Ativan / Haldol
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year old female with history of diabetes, severe peripheral
vascular disease, chronic toe ulcer with history of
osteomyelitis, and history of diverticulitis who initially
presented to the ICU with fever, white cell count of 24 with
31%bands, sepsis, and lactate of 5 that dropped to 2 after
receiving 750ml normal saline IVF. Abdominal CT showed striated
nephrogram in right kidney that may have been pyelonephritis or
an infarct. The patient has had a long history of a diabetic
foot ulcer with progression of an infection that resulted in
positive blood cultures. She developed endocarditis and an
infection in her right hand. This resulted in an abscess of her
PIP joint which was previously aspirated and sent for culture.
She also had a large abscess onthe dorsum of her hand as well as
on her wrist. An incision and drainage of all these areas was
successfully performed [**5-19**] and the patient returned to the
medicine floor on [**2192-5-21**]. She came back to the ICU on [**5-23**] with
respiratory distress on mask ventilation.
Past Medical History:
Diabetes
Periperheral Vascular Disease s/p bilateral femoral-popliteal
bypass
Wrist osteomyelitis
Right toe amputation
Chronic toe ulcer with osteomyelitis requiring debridement
h/o cerebrovascular accident
chronic obstructive pulmonary disease
coronary artery disease s/p myocardial infarction
hypertension
rheumatoid arthritis
h/o GI bleed with gastric ulcers
h/o bladder and breast cancer
h/o diverticulitis
h/o MRSA
h/o hip fracture s/p open reduction
Social History:
Active smoker, 50 pack year history. Past alcohol use. Came to
the hospital from rehab facility.
Family History:
Positive for coronary artery disease,peripheral vascular
disease, and diabetes.
Physical Exam:
The patient died [**2192-5-28**]. She was unresponsive and found to be
breathless, pulseless, and without heart tones, blood pressure,
and corneal reflexes.
Pertinent Results:
[**2192-5-27**] 05:30AM BLOOD WBC-48.9* RBC-3.04* Hgb-9.1* Hct-28.9*
MCV-95 MCH-30.0 MCHC-31.5 RDW-15.3 Plt Ct-257
[**2192-5-21**] 09:45AM BLOOD Fibrino-460* D-Dimer-5987*
[**2192-5-27**] 05:30AM BLOOD Glucose-231* UreaN-72* Creat-3.1* Na-143
K-3.6 Cl-110* HCO3-18* AnGap-19 Calcium-7.3* Phos-6.9*# Mg-2.3
[**2192-5-26**] 04:15AM BLOOD ALT-183* AST-189* LD(LDH)-539*
AlkPhos-121* Amylase-91 TotBili-0.7 Lipase-17
[**2192-5-27**] 05:13AM BLOOD Cortsol-36.0*
[**2192-5-19**] 12:20AM BLOOD RheuFac-79*
[**2192-5-27**] 01:22AM BLOOD Vanco-17.4*
[**2192-5-27**] 10:40AM BLOOD Lactate-2.6*
[**2192-5-27**] 01:22AM BLOOD Lactate-7.5*
[**2192-5-27**] 03:19AM BLOOD freeCa-1.04*
[**2192-5-24**] 04:36PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.010
Blood-LG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-22* WBC-31*
Bacteri-MOD Yeast-NONE Epi-<1 CastGr-6*
[**2192-5-24**] 04:36PM URINE Eos-NEGATIVE
[**2192-5-25**] 08:22PM URINE Hours-RANDOM Creat-110 Na-LESS THAN
[**2192-5-25**] 08:22PM URINE Osmolal-385
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2192-5-27**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
URINE CULTURE (Final [**2192-5-26**]): NO GROWTH.
BLOOD CULTURE: AEROBIC BOTTLE (Final [**2192-5-30**]): STAPH AUREUS
COAG +.
ANAEROBIC BOTTLE (Final [**2192-5-30**]): STAPH AUREUS COAG +.
STAPH AUREUS COAG +. OF TWO COLONIAL MORPHOLOGIES.
FINAL SENSITIVITIES.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ <=1 S
PORTABLE AP SEMI-UPRIGHT CHEST, [**2192-5-27**], 12:38 A.M.:
Compared to prior portable chest dated [**2192-5-24**], there are now
diffuse pulmonary patchy opacities and bilateral pleural
effusions.
ECHOCARDIOGRAM [**2192-5-25**]
IMPRESSION: Mitral valve structure attatched to the base of the
posterior
mitral leaflet with mobile components and a partial flail
segment. Findings
are consistent with endocarditis. Possible aortic valve
involvement without
significant aortic regurgitation. No perivalvular abcess seen.
Compared to the prior study from [**2192-5-18**] (tape reviewed), there
is a newly identifed mass (mobile components) at the base of the
posterior mitral valve
leaflet with severe eccentric mitral regurgitaiton
ABDOMINAL ULTRASOUND: The liver is normal in echotexture without
evidence of focal hepatic masses. The main portal vein is patent
and demonstrates normal hepatopetal flow. The gallbladder is
unremarkable without gallbladder wall edema, stones, or sludge.
There is no intra- or extrahepatic biliary duct dilatation. The
common bile duct measures 4 mm, which is normal in size. The
pancreas and spleen are within normal limits. Both kidneys
appear unremarkable without evidence of perinephric fluid
collection, hydronephrosis, or renal masses. The echotexture of
both kidneys appears within normal limits.
IMPRESSION:
1. No evidence of pulmonary embolism. There is moderate left
ventricular failure. Bibasilar collapse/consolidation represents
some element of aspiration.
2. Unchanged appearance of multiple wedge-shaped areas of
hypo-attenuation in the right kidney which likely represent
multiple infarctions. Other differentials include
pyelonephritis.
3. No evidence of bowel dilatation or wall thickening.
4. Stable appearance of the small left adrenal adenoma.
5. Extensive degenerative changes in the osseous structures.
Brief Hospital Course:
81 year old female with diabetes, severe peripheral vascular
disease, and chronic diabetic foot ulcer previously admitted to
ICU for MRSA bacteremia the transferred to the floor and
developed right hand tenosynovitis and endocarditis with flail
mitral valve. She was status post surgical irrigation of the
right hand and on vancomycin at presentation.
Infectious Disease: The patient presented with fever,
leukocytosis with bandemia, and high grade staph bacteremia. She
was treated with IV vancomycin without improvement. She had
multiple possible infectious sources: MRSA bacteremia, right
wrist osteomyelitis, new murmur and new multivalve endocarditis
of mitral and aortic valves with severe mitral valve
regurgitation due to flail leaflet with vegetation., likely
renal infarct, ischemic bowel, chronic foot ulcers. The patient
developed a very high white count and diarrhea due to C.
Difficile. She was treated with oral metronidazole. She was
followed closely by the infectious disease consult service. The
cardiology, plastic surgery, renal, and gastroenterology
services also provided expertise.
Cardiovascular: Clinically, she appeared to be in mild/moderate
heart failure with pulmonary edema, requiring 5L O2
supplementation. Over the hospital course, she'd developed a
new heart murmur with echocardiogram showing vegetations and
severe mitral valve regurgitation. Since she was not a good
surgical candidate per vascular surgery consult, gentle
afterload reduction if possible with nipride or hydralazine was
recommended by the cardiology consult service. Daily ECGs were
performed to monitor cardiac function and she had negative
cardiac enzymes [**2192-5-24**]. She was given her home regimen of
aspirin and beta blocker.
Respiratory Distress: This was likely a result of CHF
superimposed on COPD. She was given Lasix, Nitro gtt, and PPV
with improvement. She likely has both systolic and diastolic
dysfunction, requiring rate and blood pressure control. She was
given nebulizer therapy and oxygen supplementation to maintain
oxygen saturation in the setting of COPD and CHF. She was given
subcutaneous heparin for DVT prophylaxis.
Acute Renal Failure: The patient presented to the ICU with new
ARF starting 7/1or [**5-25**] (creatinine 0.9->3.0 over 4 days after
admission) that was likely secondary to a combination of low
effective cardiac ejection, ATN from IV contrast dye, ongoing
renal infarction, or infection. There was no indication for
hemodialysis. Urine output was closely monitored and the patient
was given gently IVF per recommendations by the renal consult
service.
GI: The patient had guiac positive stools and declining
hematocrit, which the GI service attributed to gut hypoperfusion
and likely ischemia. They determined that endoscopy was not
indicated. She also had transaminitis likely secondary to bowel
ischemia since RUQ ultrasound was negative for common bile duct
dilatation. She received proton pump inhibitor GI prophylaxis
throughout her ICU stay. HIT antibody was negative. TPN was
provided for nutrition.
Diabetes: The patient maintained glycemic control with
fingersticks and sliding scale insulin.
Delirium: The patient had a variety of factors contributing to
her delirium including metabolic, infectious, and medication
causes. She had been sundowning since admission to the ICU and
responded well to nighttime zyprexa.
Her 2 daughters, son, and husband were present for the family
decision to make the patient DNR/DNI with comfort measures only.
On [**2192-5-28**], the patient was unresponsive and found to be
breathless, pulseless, and without heart tones, blood pressure,
and corneal reflexes. The patient was pronounced dead and her
private physician and family were notified. They refused
anatomic gifts and autopsy.
Medications on Admission:
Lansoprazole 30 mg p.o. b.i.d.,
calcium carbonate 500 mg t.i.d., docusate 100 mg p.o. b.i.d.,
gabapentin 300 mg p.o. b.i.d., lisinopril 10 mg p.o. q.d.,
amlodipine 10 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d.,
vitamin D 400 IU q.d., Miacalcin nasal spray q.d. each
nostril, flurbiprofen 0.03% q.i.d. each eye, trazodone 50 mg
p.o. q.h.s. p.r.n., venlafaxine 75 mg p.o. b.i.d., aspirin 81
mg p.o. q.d., prednisone 5 mg p.o. q.d., NPH insulin 36 units
at breakfast and 10 units at dinner subcu.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis, MRSA
Endocarditis
Acute Renal Failure
Respiratory Failure
Congestive Heart Failure
Renal Infarct
Bowel Ischemia
C.difficile
Diabetes
Periperheral Vascular Disease s/p bilateral femoral-popliteal
bypass
Wrist osteomyelitis
Right toe amputation
Chronic toe ulcer with osteomyelitis requiring debridement
h/o cerebrovascular accident
chronic obstructive pulmonary disease
coronary artery disease s/p myocardial infarction
hypertension
rheumatoid arthritis
h/o GI bleed with gastric ulcers
h/o bladder and breast cancer
h/o diverticulitis
h/o MRSA
h/o hip fracture s/p open reduction
Discharge Condition:
The patient died.
Discharge Instructions:
none
Followup Instructions:
none
|
[
"518.82",
"250.01",
"427.31",
"410.71",
"038.10",
"711.09",
"584.9",
"707.15",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"80.13",
"38.93",
"88.72",
"80.14",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10196, 10202
|
5855, 9651
|
237, 243
|
10834, 10853
|
2204, 5832
|
10906, 10913
|
1930, 2012
|
10223, 10813
|
9677, 10173
|
10877, 10883
|
2027, 2185
|
178, 199
|
271, 1319
|
1341, 1798
|
1814, 1914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,066
| 129,632
|
49156
|
Discharge summary
|
report
|
Admission Date: [**2168-12-22**] Discharge Date: [**2168-12-26**]
Date of Birth: [**2115-4-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
asystolic arrest
Major Surgical or Invasive Procedure:
cardiac cath
TEE
History of Present Illness:
Source: Medical records, patient's wife, and ER physician from
[**Name (NI) 1474**] hospital
53 yo m with h/o AVR secondary to staph endocarditis,
polysubstance abuse, Hep C cirrohis, DM2, obesity,
hyperlipidemia, and atrial fibrillation transferred to [**Hospital1 **]
following asystolic arrest at [**Hospital1 1474**] ER. Earlier in the
morning around 6AM he awoke and told his wife that he was not
feeling well, was having chest pain and anxiety, and wanted to
call EMS to take him to the hospital. He was brought to the ED
in good condition, requested to go to the restroom to urinate,
walked back to the bed, was placed on telemetry, and became
bradycardic. Immediatly, he had an asystolic arrest at 8:07 AM,
CPR was initiated, he was intubated and recieved epinephrine,
atropine, Narcan, vecuronium, and Ativan. He regained a
perfusing rhythm at 8:16 AM. EGK done right after this showed V1
and V2 St elevations with ST depressions in V4 - V6. He was
started on heparin, given an ASA per NGT, and medflighted to [**Hospital1 **]
for urgent cardiac cathertization.
He entered the cath [**Hospital1 **] at 11:49AM. The cathertization revealed
coronary arteries without signficant athroscherotic disease and
no interveanable lesion. Hemodynamic analysis in the [**Hospital1 **] were:
wedge 48, RA 30, RV 77/16, PA 60, CP 3.8, CI 1.7 and low paO2 pn
100% FiO2 and Peep 10. IABP placed to assist in afterload
reduction, though no hypotension present. Intra-cath echo
revealed very poor LV fxn, ejection fraction of 20%, with mod MR
and mild AI. In the cath [**Hospital1 **] he recieved 80mg IV lasix.
Past Medical History:
1. Polysubstance abuse: Long history of heroin and cocaine abuse
currently taking methadone from a methadone clinic. His wife
says has not used illicit drugs for quite some time though
occasionally takes illicit Klonapin.
2.Alcoholism: Clinic notes report that the patient had recently
begun drinking heavily again. His wife [**Name (NI) 103128**] that he was
drinking a few beers a week and 1 pint of vodka a week.
3. Hep C.
4. Nodular Cirrosis due to Hep C and ETOH.
5. Aortic endocarditis: s/p porcine AVR in [**2164**] following MSSA
endocarditis c/b both left and right heart failure, septic
emboli to kidney and spleen.
6. s/p left axillary bypass [**2164**].
7. atrial fibrillation.
8. h/o suicide attempt though wife denies this.
9. depression/anxiety
10. DM2.
11. chronic back pain.
Social History:
Lives in [**Hospital1 1474**] with common law wife with who he has lived
with for 31 years. Has no children. He used to work in
construction but for the last 6 years has been on disability.
He has an extensive history of cocaine, heroin, and alcohol
abuse with multiple admissions here for detoxification. His wife
reports he has not used cocaine or herion for a long time and he
goes to a methadone clinic. He is drinking 1 - 2 beers per week
according to his wife, however clinic notes report that he has
been drinking more heavily than that.
Family History:
Brother has a history of herion abuse.
Physical Exam:
Vitals: T= 101.3, HR = 83 , BP = 144/88, AC, tidal V of 700,
Rate 24, FiO2 100% PEEP 10 92% wt 100 kg
General: Sedated well developed middle aged male
HEENT: Pupils minimally reactive, equal and round.
Normocephalic and atraumatic head, no nuchal rigidity, anicteric
sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: chest rose and fell with equal size, shape and symmetry,
lungs were clear to auscultation bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1; III/VI HSM and
II/IV soft diastolic murmur.
Abd: Normoactive BS, NT and ND. Liver hard, nodular and palpable
at 2 cm below costal margin. Spleen palpable
Ext: No cyanosis, no clubbing or edema with 2+ dorsalis pedis
pulses bilaterally. right groin line in without bruit or
hematoma.
Integument: no rash
Neuro: Not reactive to sternal rub. corneal reflexes absent. 2+
symmetric brachial, and patellar reflexes. Babinski absent.
Pertinent Results:
[**2168-12-22**] 11:00PM TYPE-ART PO2-104 PCO2-38 PH-7.47* TOTAL
CO2-28 BASE XS-3
[**2168-12-22**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-12-22**] 02:40PM PT-15.1* PTT-46.6* INR(PT)-1.4
[**2168-12-22**] 02:40PM WBC-21.7*# RBC-4.08* HGB-14.2 HCT-41.7
MCV-102* MCH-34.9* MCHC-34.1 RDW-13.6
[**2168-12-22**] 02:40PM NEUTS-90* BANDS-1 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-12-22**] 02:40PM ALBUMIN-4.0 CALCIUM-8.0* PHOSPHATE-3.1
MAGNESIUM-1.7
[**2168-12-22**] 02:40PM CK-MB-14* MB INDX-6.3* cTropnT-0.38*
[**2168-12-22**] 02:40PM ALT(SGPT)-72* AST(SGOT)-115* LD(LDH)-276*
CK(CPK)-222* ALK PHOS-88 AMYLASE-43 TOT BILI-1.2
[**2168-12-22**] 02:40PM GLUCOSE-302* UREA N-21* CREAT-1.3* SODIUM-139
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-19* ANION GAP-23*
[**2168-12-22**] 04:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
EKG:
s/p epi after cardiac arrest:
NSR 140, ST elevation in V1, V2; ST depression in V3-6, II, III,
F and I
PORTABLE AP CHEST: An endotracheal tube and nasogastric tube are
in satisfactory position. A swan ganz catheter is present, and
is coiling in the region of the right atrium. The cardiac
silhouette is enlarged, and there is evidence of congestive
heart failure with vascular engorgement, perihilar haziness, and
bilateral pleural effusions, right greater than left. No
pneumothorax is identified on this supine study.
Note is made of previous aortic valve replacement.
IMPRESSION
1. Coiling of swan ganz catheter in the right atrial region, as
discussed
with the clinical service caring for the patient.
2. Congestive heart failure.
Cardiac cath:
COMMENTS: 1. Selective coronary angiography revealed a
left-dominant system. The LMCA was angiographically normal.
The LAD
had a 30% mid-vessel lesion. The LCx was dominant and without
flow
limiting stenoses. The RCA had no angiographic evidence of
disease.
2. Left ventriculography was deferred.
3. Resting hemodynamics revealed severely elevated left and
right-sided
filling pressures (RA mean 29mHg, RVEDP 28mmHg, PCWP mean
46mmHg). The
calculated cardiac index was 1.71 l/min/m2. These findings were
consistant with cardiogenic shock.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe systolic and diastolic ventricular dysfunction.
CT Head:
FINDINGS: There is no acute intracranial hemorrhage, mass
effect, shift of the normally midline structures or
hydrocephalus. The [**Doctor Last Name 352**]/white matter differentiation is grossly
preserved. Osseous structures are unremarkable. There is
aerosolized fluid within maxillary and sphenoid sinuses and
ethmoid air cells.
IMPRESSION
1. No acute intracranial hemorrhage, mass effect, or edema.
2. Polynasal sinus disease.
TEE:
FINDINGS: There is no acute intracranial hemorrhage, mass
effect, shift of the normally midline structures or
hydrocephalus. The [**Doctor Last Name 352**]/white matter differentiation is grossly
preserved. Osseous structures are unremarkable. There is
aerosolized fluid within maxillary and sphenoid sinuses and
ethmoid air cells.
IMPRESSION
1. No acute intracranial hemorrhage, mass effect, or edema.
2. Polynasal sinus disease.
EEG:
FINDINGS:
ABNORMALITY #1: At 5 uV of sensitivity, a low voltage, [**2-5**] Hz
delta
frequency background was seen. With auditory and noxious
stimulation,
no change in the background was evident. At one point in the
tracing,
a burst of central [**10-14**] Hz alpha frequency activity was seen
that
appeared to be artifactual in nature. Replacement of the T1
electrode
appeared to correct this finding.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested to be done portably.
SLEEP: There were no normal sleep or wake transitions seen.
CARDIAC MONITOR: Revealed a generally regular rhythm of
approximately
72 bpm.
IMPRESSION: This EEG is consistent with a severe encephalopathy
of
toxic, metabolic, or anoxic etiology. No evidence of ongoing
seizures
was seen.
US ABD LIMIT, SINGLE ORGAN [**2168-12-26**] 8:08 AM
US ABD LIMIT, SINGLE ORGAN
Reason: PERSISTANTLY FEBRILE PATIENT, ? ASCITIES OR ABSCESS
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with h/o ETOH abuse and HCV cirrohsis admitted
after asystolic arrest, now persistantly febrile
REASON FOR THIS EXAMINATION:
eval for asicties, abscess
HISTORY: A 53-year-old man with cirrhosis admitted after
asystolic arrest.
Evaluate of ascites.
Ultrasound examination of the right upper quadrant, right lower
quadrant, left upper quadrant, left lower quadrant, and midline
reveals no evidence of ascites.
IMPRESSION: No ascites.
Brief Hospital Course:
1. Congestive heart failure/CAD: When the patient was admitted,
he was taken directly to the cath [**Hospital **] as it was thought that he
was having a large MI. His cath did not show significant disease
or thrombus. However, in the cath [**Hospital **], his wedge pressure was
markedly elevated to 50 with an EF that was 20%, dropped from
55% on an echo in [**Month (only) 116**]. His depressed cardiac function, elevated
troponins and Ck's, and EKG changes were thought to be due to a
stunned myocardium from the resuscitation. In the cath [**Last Name (LF) **], [**First Name3 (LF) **]
IABP was placed due difficulty oxygenating though he had a
normal SBP. He was aggressively diuresed with Lasix and Natrecor
during the first 2 days of his stay and he was nearly 5.6 liters
negative which improved his oxygenation. The balloon pump was
removed on [**12-24**]. At that time, since he was persistently
febrile and a large amount of insensible losses, further
diuresis was held.
2. Asystolic arrest - The patient had an asystolic arrest at the
OSH of unclear etiology. Since the patient has a history of
polysubstance abuse and suicide, overdose leading to coronary
spasm was high on the differential. However, his wife denied
that the patient had been using any illicit drugs and the
patient's urine and blood toxicology screen was negative (with
the exception of benzos which he received at the outside
hospital). There was also concern for new endocarditis related
abscess affecting his conduction system given that he had an
elevated white count, left shift, and was febrile. This was
investigated and can be found below. PE was also entertained,
however the patient had a high wedge pressure which is
inconsistent with PE and he was placed on heparin for his IABP
anyway.
3. Fever/ID: The patient was persistently febrile to 104 - 105
despite cooling blankets, Tylenol, and Motrin. This was felt to
be due to infection, medications, withdrawal, or most likely,
hypothalamic dysfunction from anoxic brain injury. The patient
was taken off of all unnecessary medications. He was maintained
on his equivalent methadone dose with fentanyl. Since the
patient had had a history of bacterial endocarditis it was
thought that he could have had a recurrence with an abscess
affecting his conduction system given his high white count, left
shift, and persistent febrile state. Blood cultures were
obtained and were negative. TEE performed and revealed no
valvular abnormalities and his AVR was in good position. A head
CT was preformed which showed a sinus infection. A sinus
aspirate was sent and was positive for Gram negative rods and
yeast. Infectious disease consult was obtained. An LP was
preformed and revealed no evidence of infection and cultures all
fungal cultures were negative. An abdominal US was preformed to
look for ascites causing SBP and the US was negative for free
fluid. The patient was maintained on broad spectrum antibiotics
throughout his stay and never broke his fever.
4. Neurology: When the patient was admitted, he had been sedated
earlier int he morning from the outside hospital code. He was
not reactive to sternal rub and did not have a corneal reflex. A
head CT was obtained which did not show any abnormalities.
Neurology was consulted for his mental status and recommended an
LP which showed increased WBC though cultures, including viral,
were negative. Also, an EEG was done which showed severe
encephalopathy of toxic, metabolic, or anoxic etiology. Sedating
medication were kept to a minimum so as not to cloud neurology
exam and only maintaince opioids were given to prevent
withdrawal. On [**12-25**], the patient had a seizure which terminated
with IV Ativan. Following the seizure, he was loaded with
dilantin and had no further. He had a head MRI in the morning of
[**12-26**] which was read as diffuse anoxic brain injury and signs of
watershed infarcts. It was felt at this time that the patient in
fact did have anoxic brain injury which occurred during his
cardiac arrest.
4. Respiratory failure: The patient was intubated at [**Hospital1 1474**] ED
during the code. Following diuresis, he oxygenation improved. He
was tried on PS and did well, however, his mental status
precluded extubation;
5. DM: He was placed on an insulin drip.
6. Polysubstance abuse/anxiety/depression: Story not likely
indicative of overdose given timeline and negative tox screen.
He was placed on fentanyl to prevent opioid withdrawal and
continued on sertraline and buspar.
8. Communication: The medical team was had daily communication
with the patient's wife and kept he updated on significant
events. Prior to the patient's death, the patient's wife
expressed understanding of the patient's grave condition and
brain injury.
9. Patient's death: On [**12-26**] at 10pm the patient became
hypotensive and had a PEA arrest. Rescsutation was initiated
with chest compressions, atropine, 3 shocks, epi, and
amiodarone. However the patient entered asystole and the code
was called after 15 - 20 minutes of resuscitative efforts. The
attending and the patient's wife was notified immediately.
Medications on Admission:
Lasix 40mg daily, Lipitor 20mg daily, Lisinopril 5mg daily,
ranitidine 150mg [**Hospital1 **], methadone 75mg daily, resperdol,
sertraline 200mg daily, toprol XL 25mg daily, wellbutrin (he had
recently stopped this according to his wife), ASA 81mg daily,
buspar 30mg [**Hospital1 **], clonidine 0.1mg q24 patch, glucophage 500mg
[**Hospital1 **], insulin, MVI, folic acid
Discharge Disposition:
Expired
Discharge Diagnosis:
atrial fibrillation
asystolic arrest
congestive heart failure
anoxic brain injury
DM
Hep CV
cirrohsis
seizure
Discharge Condition:
expired
|
[
"348.1",
"428.42",
"780.39",
"272.4",
"518.81",
"304.01",
"070.70",
"427.5",
"428.0",
"V42.2",
"571.5",
"427.31",
"250.00",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72",
"88.72",
"37.61",
"88.56",
"03.31",
"37.23",
"88.52",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
14799, 14808
|
9247, 14376
|
333, 351
|
14961, 14971
|
4465, 6724
|
3380, 3420
|
8772, 8884
|
14829, 14940
|
14402, 14776
|
6741, 6833
|
3435, 4446
|
277, 295
|
8913, 9224
|
379, 1985
|
6842, 8735
|
2007, 2801
|
2817, 3364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,568
| 167,226
|
42717
|
Discharge summary
|
report
|
Admission Date: [**2170-6-14**] Discharge Date: [**2170-6-22**]
Date of Birth: [**2110-5-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
acute renal failure, hypotension
Major Surgical or Invasive Procedure:
Placement of right IJ central line
Removal of right IJ central line
Placement of left IJ central line
Placement of right IJ dialysis line
Diagnostic paracentesis
History of Present Illness:
60 year old woman with CKD and HCV cirrhosis s/p OLT [**5-/2164**] c/b
recurrent HCV cirrhosis, who was transferred for hypotension and
acute renal failure. The patient initially presented to [**Hospital **]
Hospital on [**6-10**] with abdominal pain, N/V, worsening ascites, and
shortness of breath. She was hypotensive to the 80s so was
transferred to the ICU and started on phenylephrine as well as
empiric levofloxacin and flagyl. CXR with small right effusion
and elevated R hemidiaphragm but no pneuamonia. Diagnostic para
on [**6-10**] neg for SBP. She remained afebrile so the flagyl was
eventually stopped. Therapeutic para was performed on [**6-12**] with
removal of 4L (with albumin replacement). She was also noted to
have worsening acute on CKD. Admission Cr was 2.6 which rose to
3.3 on the day of transfer with associated hyperkalemia (K up to
6 without reported ekg changes) and oliguria. Renal was
consulted and diuretics were held and albumin challenge given,
with no improvement in renal function. It was felt likely due to
HRS so midodrine 7.5mg TID was started as well as a bicarb gtt
for the hyperkalemia. Also with thrombocytopenia to 39,000 so
patient received 2 units of platelets with increase to 114,000.
The patient's family requested transfer to [**Hospital1 18**] since Dr. [**Last Name (STitle) 497**]
is here and she is currently being [**Last Name (STitle) 6349**] for a repeat liver
transplant. VS prior to transfer were 99.0, 95/32, 70, 17, 96%
on 4LNC (uses 2L at home).
.
On arrival to the MICU, patient is somnolent but arousable and
answers questions appropriately. She arrived on phenylephrine 1
mcg/kg/min. She is reporting pain in her abdomen similar to her
chronic pain.
Past Medical History:
- HCV cirrhosis c/b variceal hemorrhage, ascites, hepatic
encephalopathy, and hepatopulmonary syndrome requiring TIPS, s/p
OLT [**2164-6-3**] at [**Hospital3 2358**]
-> recurrent HCV and graft cirrhosis treated with interferon and
ribavirin but unable to tolerate due to anemia and lack of
response
-> recurrent hepatopulmonary syndrome with a pO2 of 75 and
evidence of shunts on echo
-> progressive decompensated liver disease with refractory
ascites requiring large volume paracentesis (~6L) every two
weeks
-> currently undergoing liver transplant evaluation
- Chronic kidney disease (baseline Cr 1.5)
- Basal cell cancer removed from face requiring skin grafting
- Osteopenia
- Depression
- Anxiety
- COPD
- GERD
- S/p cataract surgery
Social History:
Currently lives in [**Location (un) 8973**]. She is married and has 3
children. Prior to becoming ill she worked as an LPN. She does
not smoke and does not drink any alcohol, but did smoke and
drink occasional etoh up until the time of her diagnosis of
hepatitis C.
Family History:
Unable to obtain due to patient's somnolence.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3, 72, 110/72, 12, 96% on 4L
General: Thin chronically ill-appearing. Somnolent but arousable
and oriented x3, though speech is slow. NAD.
HEENT: Sclera anicteric, dry MM, poor dentition but oropharynx
clear, EOMI, PERRL.
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at upper
sternal border, no S3/S4.
Lungs: Decreased breath sounds at both bases but otherwise
clear, no wheezes, rales, ronchi.
Abdomen: Mildly distended but soft. +TTP diffusely but no
guarding or rebound. NABS. Well healed surgical scar over RUQ.
GU: + foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. ? mild
asterixis though patient not cooperating with exam.
Skin: Multiple bruises thoughout.
.
DISCHARGE EXAM:
General: Chronically ill-appearing. Somnolent but arousable.
Appears comfortable.
HEENT: Sclera anicteric, dry MM, poor dentition but oropharynx
clear, EOMI, PERRL.
Neck: Central catheter in place in left IJ.
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at upper
sternal border, no S3/S4.
Lungs: Decreased breath sounds at both bases but otherwise
clear, no wheezes, rales, ronchi.
Abdomen: Distended but soft. NABS. Well healed surgical scar
over RUQ.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: Sedated, unable to perform exam.
Skin: Multiple bruises thoughout.
Pertinent Results:
ADMISSION LABS:
[**2170-6-14**] 09:45PM BLOOD WBC-10.5# RBC-3.01* Hgb-9.9* Hct-29.5*
MCV-98 MCH-32.8* MCHC-33.5 RDW-18.7* Plt Ct-124*#
[**2170-6-14**] 09:45PM BLOOD Neuts-79.0* Lymphs-9.1* Monos-9.2 Eos-2.4
Baso-0.3
[**2170-6-14**] 09:45PM BLOOD PT-21.4* PTT-40.2* INR(PT)-2.0*
[**2170-6-14**] 09:45PM BLOOD Glucose-126* UreaN-81* Creat-3.9*#
Na-129* K-5.8* Cl-100 HCO3-16* AnGap-19
[**2170-6-14**] 09:45PM BLOOD ALT-27 AST-60* LD(LDH)-232 AlkPhos-99
TotBili-3.7* DirBili-1.4* IndBili-2.3
[**2170-6-14**] 09:45PM BLOOD Albumin-4.4 Calcium-8.9 Phos-5.7*# Mg-2.2
[**2170-6-14**] 09:49PM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-47* pH-7.26*
calTCO2-22 Base XS--5 Intubat-NOT INTUBA
[**2170-6-14**] 09:49PM BLOOD Lactate-1.4
.
DISCHARGE LABS:
[**2170-6-21**] 04:29AM BLOOD WBC-2.5* RBC-2.59* Hgb-8.4* Hct-25.7*
MCV-99* MCH-32.5* MCHC-32.7 RDW-20.3* Plt Ct-14*#
[**2170-6-21**] 04:29AM BLOOD PT-22.5* PTT-64.9* INR(PT)-2.1*
[**2170-6-21**] 04:29AM BLOOD Glucose-71 UreaN-22* Creat-2.3* Na-136
K-4.1 Cl-101 HCO3-26 AnGap-13
[**2170-6-21**] 04:29AM BLOOD ALT-19 AST-42* AlkPhos-73 TotBili-4.3*
[**2170-6-21**] 04:29AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.8
.
MICRO:
[**2170-6-14**] Blood culture: no growth
[**2170-6-15**] Urine culture: no growth
[**2170-6-16**] Blood culture: no growth
[**2170-6-17**] Peritoneal fluid culture: no growth
[**2170-6-17**] Blood culture: no growth to date
[**2170-6-18**] CMV VL: not detected
[**2170-6-18**] Fungal blood culture: no growth
.
IMAGING:
[**2170-6-15**] Echo: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF 75%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The right
ventricular free wall thickness is normal. The right ventricular
cavity is moderately dilated with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. Compared
with the findings of the prior study (images reviewed) of [**2170-5-21**], the right ventricle is more dilated and the tricuspid
regurgitation is increased.
.
[**2170-6-15**] Renal U/S:
1. No hydronephrosis.
2. Echogenic kidneys, compatible with diffuse parenchymal
disease.
.
[**2170-6-16**] MRI Torso:
1. Small left basal pleural effusion with dependent atelectasis
noted in the lung bases bilaterally.
2. No evidence for abdominal aortic dissection or aneurysm.
3. Cirrhotic liver with sequela of portal hypertension including
ascites, splenomegaly and varices.
4. Sigmoid diverticulosis.
.
[**2170-6-20**] CXR: Line and tubes are in standard position. Mild
cardiomegaly is partially obscured by pleural effusions.
Bibasilar opacities likely on the left side are combination of
atelectasis and pleural effusions. There is mild vascular
congestion.
Brief Hospital Course:
60 year old woman with CKD and HCV cirrhosis s/p OLT [**5-/2164**] c/b
recurrent HCV cirrhosis, who was transferred for hypotension and
acute renal failure.
.
# Hypotension: There was initial concern for sepsis, and patient
empirically completed a 7-day course of vancomycin and zosyn.
However, no infectious source was ever identified. Blood
cultures, urine cultures, CXRs, and peritoneal fluid were all
negative. No diarrhea to suggest a C. diff infection. An
echocardiogram revealed a more dilated right ventricle and
worsening tricuspid regurgitation, however normal LVEF. She was
initially supported with pressors which were eventually weaned.
.
# Acute on CKD: Baseline Cr ~1.5. Creatinine upon admission to
OSH was 2.6 which peaked at 5.9. Renal was consulted and felt
that this is likely hepatorenal syndrome. Renal U/S was negative
for obstruction. A temporary dialysis line was placed in her
left IJ and she was started on CVVH.
.
# HCV cirrhosis: S/p liver transplant in [**2164**] with recurrence of
HCV cirrhosis in the graft. She was [**Year (4 digits) 6349**] by hepatology and
discussed at tranplant conference, however is not a candidate
for re-transplant.
.
# Anemia: HCT remained in the low to mid 20s throughout her
hospitalization. No evidence of GI or other bleeding. Hematology
was consulted and felt that this is likely due to her underlying
cirrhosis and multiple medical comorbidities.
.
# Thrombocytopenia: Platelets remained low and dropped to 14.
Again, likely to her underlying cirrhosis and multiple medical
comorbidities.
.
# Chronic pain: Patient reported severe full body pain
throughout the admission, worse in her back and abdomen. An MRI
torso was negative for any spinal or other acute process. The
pain service was consulted and her pain was managed with prn
narcotics and she was eventually started on a dilaudid gtt based
on her goals of care.
.
# Goals of care: After learning that she is not a candidate for
another liver transplant, and given her renal and liver failure,
the decision was made to focus on comfort. A dilaudid gtt was
started and she will be transitioned home with hospice.
Medications on Admission:
1. ergocalciferol 50,000 units weekly x 3 months
2. escitalopram 10 mg daily
3. Xalatan eyedrops 0.005% one drop in each eye once daily
4. lorazepam 1 mg by mouth at night
5. nadolol 20 mg at night
6. omeprazole 20 mg per day
7. rifaximin 550 mg twice daily
8. tacrolimus 0.5 mg once daily
9. lactobacillus
10. multivitamin daily
Discharge Medications:
1. Morphine Sulfate IR 5-10 mg PO EVERY 3-4 HOURS PRN pain
RX *morphine 10 mg/5 mL every 3-4 hours Disp #*1 Bottle
Refills:*0
2. Lorazepam 0.5-2 mg PO Q2H:PRN agitation, restlessness,
respiratory distress
RX *lorazepam 0.5 mg every 2 hours Disp #*60 Tablet Refills:*0
3. Evaluate and admit to hospice.
4. HYDROmorphone (Dilaudid) 0.5 mg IVPCA Lockout Interval: 15
minutes Basal Rate: 1.2 mg(s)/hour 1-hr Max Limit: 3.2 mg(s)
Basal rate range for PCA can be 1-3 mg/hour. Please start at 1.2
mg/hour.
5. Dilaudid PCA
Concentration: 1 or 2mg/mL
Quantity: 500mg x 6 bags
Basal rate: 1.2 mg/hour
Hourly rate: 0.5mg every 15 minutes
1-hour max: 3.2mg
Basal rate can be adjusted from 1-3 mg/hour
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2188**]
Discharge Diagnosis:
Liver failure
Renal failure
Anemia
Thrombocytopenia
Discharge Condition:
Intermittently alert and oriented
Discharge Instructions:
You were transferred to [**Hospital1 **] after you were
found to have renal failure and low blood pressures. We treated
you for a possible infection and supported your blood pressure.
You were started on dialysis for your kidneys. The liver doctors
[**Name5 (PTitle) 6349**] [**Name5 (PTitle) **] and unfortunately you are not able to have another
liver transplant. You and your family decided to focus on
comfort.
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2170-6-25**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2170-6-23**]
|
[
"338.29",
"785.52",
"530.81",
"276.1",
"293.0",
"584.5",
"496",
"276.7",
"789.59",
"518.81",
"287.5",
"996.82",
"V66.7",
"038.9",
"585.9",
"284.19",
"276.2",
"572.4",
"733.90",
"571.5",
"070.54",
"V10.83",
"724.5",
"789.09",
"995.92",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"54.91",
"38.91",
"38.95",
"38.93",
"96.6",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11294, 11344
|
8063, 10198
|
343, 507
|
11440, 11476
|
4895, 4895
|
11939, 12228
|
3313, 3360
|
10578, 11271
|
11365, 11419
|
10224, 10555
|
11500, 11916
|
5640, 8040
|
3375, 4255
|
4271, 4876
|
271, 305
|
535, 2250
|
4911, 5624
|
2272, 3013
|
3029, 3297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,517
| 138,156
|
39360
|
Discharge summary
|
report
|
Admission Date: [**2144-12-24**] Discharge Date: [**2145-1-1**]
Date of Birth: [**2072-3-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Chronic ventral hernia
Major Surgical or Invasive Procedure:
Ventral Hernia Repair with Component Separation and Surgimend
Mesh Overlay
History of Present Illness:
Mr. [**Known lastname 87011**] is a 72-year-old man who has previously suffered from
a bad appendicitis problem. This left him with multiple
operations and ultimately a big ventral hernia in a lower
midline incision which has progressed to generalized loss of
domain of the abdominal contents. He has a nonhealing scar
area over the middle aspect of the incision which has fistulized
in the past. He presented to Dr. [**Last Name (STitle) **] for definitive
management of his ventral hernia problem. [**Name (NI) 15110**] to its scope and
nature, the input of one of our plastic
surgeons, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was contact[**Name (NI) **] for co-management of
this problem.
Past Medical History:
PMH: HTN, Hyperlidedemia, squamous cell basal cell, TIA in the
year [**2134**]
PSHx: emergent appendectomy as well as incarcerated hernia, he
has had fistula in open abdomen and was treated with a VAC
sponge
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
NAD, A/Ox3
RRR
CTAB
soft, NT/ND, dsg clean, dry, intact, JP drains in place x5 - all
sites intact
WWP, no peripheral edema
Pertinent Results:
[**2144-12-24**] 02:05PM SODIUM-139 POTASSIUM-4.4 CHLORIDE-106
[**2144-12-24**] 02:05PM MAGNESIUM-1.8
[**2144-12-24**] 02:05PM HCT-39.2*
Surgical Pathology:
1. Small intestine and abdominal wall skin, resection (A-E):
A. Skin with dense underlying scar and superficial epidermal
erosion with neutrophils.
B. Small intestinal segment with fibrous adhesion to
overlying skin and scar; no mucosal abnormalities are noted.
2. Hernia sac, excision (F-G):
Fascia and mesothelial-lined fibroadipose tissue consistent
with hernial sac.
[**2144-12-26**] CT abd/pelvis:
1. No evidence for acute intra-abdominal hemorrhage.
2. Post-operative ileus versus early small bowel obstruction,
although, as
described above, no transition point can be identified and the
surgical
anastomosis of the small bowel appears grossly patent. If
obstruction is of clinical concern, oral contrast (gastrografin)
with repeat imaging could be performed.
3. Coiled appearance to the NG tube, terminating posteriorly
within the
stomach. Repositioning may be of benefit.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2144-12-24**], the patient underwent
Ventral Hernia Repair with Surgimend Mesh overlay as a joint
case with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] which went well without
complication (reader referred to the Operative Notes for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids and antibiotics,
with a foley catheter, and PCA for pain control. The patient
was hemodynamically stable. On POD 2 pt developed acute
respiratory distress on the floor necessitating transfer to the
ICU and intubation. CTA was negative for PE and aggressive
management with transient pressors and fluids and was clinically
stable and weaned to extubation on POD 4. On POD 5, pt was
transferred to floor for continued monitoring.
Neuro: The patient received PCA with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient was transiently hypotensive on admission to ICU,
but responded appropriately to shortterm pressor support which
was quickly weaned without effect. On POD 4 status post
extubation, pt was hypertensive requiring IV lopressor and
hydralizine, but was quickly transitioned to his home PO
antihypertention regimen.
Pulmonary: Pt triggered post-operatively for desaturation and
respiratory distress requiring intubation and ICU transfer for 4
day post-operatively. No radiographic findings suggestive of an
acute cardiopulmonary process or pulmonary embolism. Pt was
weaned to extubation on POD 4 and transferred to the floor where
he was started on standing nebulizers and worked with PT and
nursing staff for pulmonary rehabilitation. Early ambulation and
incentive spirometry were encouraged. Pt was
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. Wound care and JP drains
were managed by the Plastic and Reconstructive Surgery service.
No signs of infection were noted during this admission.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
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.
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.
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: do not drive or operate machinery while on
this medication.
Disp:*60 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 21 days: please continue antibiotics until your drains
are removed.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ventral Hernia
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-15**] 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Please wear abdominal binder at all times except when showering.
Followup Instructions:
Please call Dr.[**Name (NI) 27488**] office for an appointment in [**3-11**] weeks at
([**Telephone/Fax (1) 87012**] for follow-up and removal of your drains.
Please call Dr.[**Name (NI) 2829**] office for an appointment in [**3-11**] weeks
at ([**Telephone/Fax (1) 2363**].
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2145-12-23**] 1:00
Completed by:[**2145-1-1**]
|
[
"568.0",
"518.4",
"518.5",
"276.52",
"272.4",
"E878.6",
"998.83",
"553.21",
"276.0",
"401.9",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"96.71",
"45.62",
"53.61",
"54.59",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6528, 6603
|
2705, 5825
|
336, 412
|
6661, 6751
|
1622, 2682
|
9728, 10213
|
1447, 1464
|
5848, 6505
|
6624, 6640
|
6811, 7792
|
8418, 9705
|
1479, 1603
|
7824, 8403
|
274, 298
|
440, 1165
|
6766, 6787
|
1187, 1398
|
1414, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,850
| 167,393
|
9562
|
Discharge summary
|
report
|
Admission Date: [**2165-12-7**] Discharge Date: [**2165-12-18**]
Date of Birth: [**2129-8-16**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
hypernatremia
Major Surgical or Invasive Procedure:
Sigmoidoscopy [**2165-12-7**]
History of Present Illness:
Ms. [**Known lastname 32457**] is a 36 y/o woman primary sclerosing cholangitis
status post living unrelated liver transplant on [**2161-4-13**],
complicated by small for size graft with graft failure,
necessitating retransplantation on [**2161-4-19**], as well as as
permanent brain injury, recurrent primary sclerosing cholangitis
on liver bx, who was transferred from [**Hospital6 8432**]
Center on [**2165-12-7**] w/ hypernatremia & renal failure in setting
of diarrhea.
.
Prior to transfer to [**Hospital1 18**], while at EMMC, Mrs. [**Known lastname 32457**] was found
to have acute renal failure with Cr 3.8/BUN 164 and sodium 155.
She was treated with IVF. Sodium ranged from 154 up to 161. She
was covered empirically for C diff with metronidazole for
diarrhea.
Past Medical History:
* ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed leading to
cerebral edema necessitating second transplant in [**3-/2161**]
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o G tube placement (now removed)
* h/o seizures
* Ulcerative colitis
* Anoxic brain injury [**1-26**] respiratory arrest
* Hypothyroidism
* h/o dysphagia
Social History:
Living at rehab facility chronically following anoxic brain
injury in [**2161**]. Husband, [**Name (NI) **], very dedicated and involved in
her care.
Family History:
non-contributory
Physical Exam:
PE: T: 97.6 BP: 95/67 (90-120s/50-70s) HR: 108 (100-110s) RR: 24
O2 98% RA
Gen: Pleasant woman, appears younger than stated age
HEENT: OP clear, MMM, pupils small but reactive bilaterally
NECK: supple, no lad, evidence of prior trach
CV: tachycardic but regular, no murmurs
LUNGS: clear bilaterally, no wheezing
ABD: soft, slightly tender, no guarding, normoactive bowel
sounds
EXT: warm, well perfused, dp pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, talks softly in short phrases and tends to repeat
(such as "no no no no" or "hello hello hello"), face symmetric,
moving all extremities
Pertinent Results:
On Admission:
[**2165-12-7**] 01:40PM BLOOD WBC-10.0 RBC-3.62* Hgb-10.6* Hct-32.0*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.2* Plt Ct-104*
[**2165-12-7**] 01:40PM BLOOD PT-17.0* PTT-27.9 INR(PT)-1.5*
[**2165-12-7**] 05:36AM BLOOD Glucose-143* UreaN-86* Creat-1.7* Na-160*
K-3.1* Cl-140* HCO3-12* AnGap-11
[**2165-12-7**] 05:36AM BLOOD ALT-11 AST-14 LD(LDH)-249 AlkPhos-105
TotBili-0.3
[**2165-12-7**] 01:40PM BLOOD Albumin-3.0* Calcium-8.3* Phos-1.6*#
Mg-2.0
[**2165-12-7**] 01:40PM BLOOD tacroFK-3.2*
.
.
Labs On Discharge:
[**2165-12-18**] 04:27AM WBC 8.6 Hgb 11.0* Hct 32.5* Plt 408
[**2165-12-18**] 04:27AM PT 13.9* INR 1.2*
[**2165-12-18**] 04:27AM Gluc 105 BUN 18 Crt 0.9 Na 141 K 4.1 Cl
110 HC03 25
.
Stool for OVA + PARASITES (Final [**2165-12-13**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-12-11**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
CMV Viral Load (Final [**2165-12-11**]): CMV DNA not detected.
Performed by PCR.
.
URINE CULTURE (Final [**2165-12-10**]): ESCHERICHIA COLI. >100,000
ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
.
Imaging:
.
Lower extremity ultrasound: [**Doctor Last Name **] scale and Doppler son[**Name (NI) **] of
the
bilateral common femoral, superficial femoral and popliteal
veins was
performed. There is extensive clot in the left common femoral,
superficial
femoral and popliteal veins. There is normal compressibility,
flow and
augmentation of the right common femoral, superficial femoral
and popliteal
veins. IMPRESSION: Complete left lower extremity DVT.
.
GI biopsy: Sigmoid colon, biopsy:
1) Chronic active colitis.
2) No viral inclusions, granulomas or dysplasia. VIRAL CULTURE
(Preliminary): No Virus isolated so far.
.
[**2165-12-12**] BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and
Doppler son[**Name (NI) **] of the bilateral common femoral, superficial
femoral and popliteal veins was
performed. There is extensive clot in the left common femoral,
superficial
femoral and popliteal veins. There is normal compressibility,
flow and
augmentation of the right common femoral, superficial femoral
and popliteal veins. IMPRESSION: Complete left lower extremity
DVT.
Brief Hospital Course:
Brief Summary:
36 y/o W with PSC s/p liver transplantation X 2, anoxic brain
injury who is transferred with diarrhea, hypernatremia, and
acute renal failure. On arrival to [**Hospital1 18**], she was sent to the
MICU for treatment hypernatremia (Na 160) & renal failure. These
improved w/ IVF. Renal failure was thought to be pre-renal in
origin. She was noted to have frequent diarrhea, and underwent
sigmoidoscopy, which was suggestive of a UC flare. CMV viral
load & viral culture of sigmoid tissue were negative. The
patient was started on prednisone for presumed UC flare. She
was also found to have complete Left lower extremity DVT, and
was started on lovenox [**Hospital1 **]--she was tried on coumadin, but this
was discontinued after two doses as her INR rose to >17 after
only two doses.
Detailed Course by Problem:
# Hypernatremia: Due to hypovolemia from diarrhea + poor po
intake. At OSH, her sodium was as high as 160s. It improved
with continuous IVF. As diarrhea slowed & pt's PO intake
improved, IVF was discontinued and Mrs. [**Known lastname 32457**] was able to
maintain adequate PO intake with Na in the low 140s. Please
encourage po intake and have water available to her at all
times.
.
# Diarrhea: Patient had regular, non-bloody diarrhea. Cdiff X 2
negative, CMV viral load negative, O&P negative X 2, salmonella,
shigella, campylobacter negative. Biopsy showed active colitis.
She started on Prednisone for presumed UC flare (40 mg po qd for
2 weeks than taper 5 mg a week). She was continued on
Mesalamine DR 1600 mg PO TID for UC. Her diarrhea improved with
the prednisone, though she was still having up to 5 BM daily at
time of discharge. Ursodiol was held since it could worsen her
diarrhea, but it will need to be re-started once her diarrhea
slows. (She was started on vitamin D & calcium since she will be
on steroids for prolonged period.)
.
# L lower extremity swelling: She was found to have a large DVT
in her left lower extremity, despite being on DVT prophylaxis
with SC heparin. This DVT is her first known thrombotic event,
and it was felt to be due to her dehydration plus her immobility
during her acute illness. She was initiated on a heparin drip,
and then given coumadin. Following 2 doses of coumadin at a
dose of 2 mg, her INR increased to 17.6. No active bleeding was
found. The warfarin was discontinue and her INR was reversed
with 4 units FFP. Her INR improved to 2.4 and was stable. She
was also given Vitamin K 5 mg X 3 days. Hematology was
consulted. Her supratherapeutic INR was thought to be secondary
to low Vit K stores from her diarrhea, antibiotics, and
malnutrition. Her underlying hepatic dysfunction may have also
contributed to her elevated INR. She should not be given
coumadin given the unpredictability of her response to the
anti-coagulant. (Of note, she is not thought to be a rapid
metabolizer of the drug.) She should receive Lovenox therapy at
minimun for 6 months for her DVT.
.
# PSC/Liver Transplant: Her primary liver disease is primary
sclerosing cholangitis, which is treated with Ursodiol. This
was held as it could worsen her diarrhea, but it will need to be
re-started as outpatient. She was continued on tacrolimus
(Prograf) for immunosuppression, and the dose was adjusted based
on trough levels. Her discharge dose will be 1.5mg every twelve
hours.
.
# UTI: Mrs. [**Known lastname 32457**] was found to have a urinary tract infection.
Her Ucx grew Ecoli resistant to Cipro. She was given Cefazolin
1g q8hr, which she should receive for a total of 14 days, until
[**2165-12-24**].
.
# Anemia: Pt's Hct 23.7 on [**12-17**]. She has had a slow decrease
in her hct following an admission Hct of 32. Her stool was
repeatedly guaiac negative, and there was no evidence of gross
bleeding. Her drop in hematocrit may have been a reflection of
her baseline anemia (hct has reportedly w/ been in the upper-20s
at her nursing home) plus a dilutional component in the setting
of IVF. She was transfused 2units of packed red blood cells on
[**2165-12-17**]. Her discharge hematocrit was 32.5 on [**2165-12-18**].
.
# Cognitive deficits: Continued home medications, including
ritalin, escitalopram, and risperdal.
.
# Code Status: full code - confirmed by husband, [**Name (NI) **], who is
also her guardian.
Medications on Admission:
risperdal 0.25 mg daily
mvi daily
lexapro 5 mg daily
clonazepam 0.25 mg qhs
flonase [**Hospital1 **]
keppra 750 mg [**Hospital1 **]
asacol 1600 mg tid
Enlive supplement with meals
lactose ms/ tid between meals
ritalin 5 mg daily
ursodiol 600 mg [**Hospital1 **]
immodium 4 mg after each loose stool
synthroid 25 mcg daily
ibuprofen 200 mg up to four times per day prn
bisacodyl 10 mg prn
milk of mag prn
glycerin suppository prn
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day): 750mg twice daily.
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for apply to raw skin on bottom.
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO Bedtime as
needed for insomnia.
10. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO Q12H (every 12
hours).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Cefazolin in Dextrose (Iso-os) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q8H (every 8 hours) as needed for UTI
for 8 days: Last day [**2165-12-24**] for total 14 day course. .
15. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous [**Hospital1 **] (2 times a day).
16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Taper: 40 mg dose until [**2165-12-25**] for total 14 day
course. Then 5 mg reduction per week. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 32458**] Rehab
Discharge Diagnosis:
Ulcerative colitis
Deep vein thrombosis
Hypernatremia
Acute renal failure (pre-renal)
Primary sclerosing cholangitis
Anoxic brain injury
Anemia
Discharge Condition:
Fair
Discharge Instructions:
You were admitted for renal failure and high sodium. Both
improved with IV hydration. It is important you drink lots of
fluid.
You were having frequent diarrhea and are being treated on
prednisone for an ulcerative colitis flare.
You were found to have a blood clot in your left leg and started
on anticoagulation therapy called Lovenox - you will need to
take this for 6 months.
.
Please review your medication list closely. You are on a steroid
taper: 40 mg until [**2165-12-25**] then 5 mg reductions per week. Your
ursodiol was held due to possible diarrhea side effect. This
should be re-started when your diarrhea improves. You are being
discharged on Lovenox for anti-coagulation.
.
Attend all your follow up appointments.
.
Return to the ER if you experience fever, chills, nausea,
vomiting, diarrhea, bleeding or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care doctor in [**12-26**] weeks.
Please follow up with your liver doctor in [**1-28**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"584.9",
"576.1",
"996.82",
"041.4",
"345.90",
"244.9",
"263.9",
"599.0",
"453.40",
"556.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12111, 12164
|
5693, 10010
|
292, 324
|
12352, 12359
|
2499, 2499
|
13260, 13501
|
1829, 1847
|
10489, 12088
|
12185, 12331
|
10036, 10466
|
12383, 13237
|
1862, 2480
|
239, 254
|
3016, 5670
|
352, 1124
|
2513, 2997
|
1146, 1646
|
1662, 1813
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,160
| 190,330
|
28712
|
Discharge summary
|
report
|
Admission Date: [**2142-12-20**] Discharge Date: [**2143-1-9**]
Date of Birth: [**2075-7-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Severe subglottic tracheal stenosis, intrathoracic substernal
goiter
Major Surgical or Invasive Procedure:
Rigid and flexible bronchoscopies
Partial sternotomy with left total and right subtotal
thyroidectomy
Revision of tracheostomy
T-tube placement
History of Present Illness:
67 morbidly obese, diabetic female with a prior history of
coronary disease and congestive heart failure found to have a
large substernal goiter with substantial airway stenosis. There
is both intrinsic and extrinsic disease affecting the airway
which measures 5mm at the thoracic inlet. She has obvious
stridor and worsening airway compromise. After evaluation a
component of malacia as well as stenosis was found.
Past Medical History:
Mild-to-moderate bronchomalacia
multi-nodule goiter
HTN
Morbid obesity
CAD
CHF
s/p small bowel resection and ileostomy for strangulated bowel
DM2
COPD
Stable angina
H/o resp. failure s/p tracheostomy
Right adrenal and liver lesions
pericardial effusion
Social History:
She lives at [**Hospital1 **]. She is a former silk mill worker. She
denies tobacco and alcohol.
Family History:
Noncontributory
Pertinent Results:
1. Tracheal stoma (A-B):
a. Skin, and subcutaneous tissue with focal ulceration and
granulation tissue.
b. Fragments of skeletal muscle with focal degenerative changes.
c. Fibrovascular tissue with foci of thyroid tissue, no
malignancy identified.
2. Thyroid, left lobe, partial thyroidectomy (C-P):
a. Multinodular goiter with focal hurthle cell changes.
b. Multiple degenerative, fibrotic thyroid nodules, up to 1.5
cm.
3. Thyroid, right lobe, partial thyroidectomy (Q-R):
Multinodular goiter.
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to [**Hospital1 18**] from [**Hospital1 **] Commons on
[**2142-12-20**] for resection of an extrinsic source of airway
compression (i.e. substernal goiter) and underwent a
bronchoscopy with microdebridement, partial sternotomy with left
total and right subtotal thyroidectomy, and revision of her
longstanding tracheostomy (to allow better phonation and
communication) on [**2142-12-24**]. She tolerated the procedure well.
For details of the procedures, see operative dictations.
Post-operatively, she was transferred to the Cardiac surgery
recovery unit (CSRU) and was eventually weaned from the
ventilator on POD 2. A bedside swallow evaluation showed no
overt evidence of aspiration. Her diet was slowly advanced to a
regular dysphagia diet which was well-tolerated by discharge.
On POD 6, she was found to have a urinary tract infection
growing Klebsiella, Proteus and E.coli (resistant to
floroquinolones but sensitive to ceftriaxone and prescribed).
She was also febrile and found to have Coag pos., methicillin
resistant Staph. aureus grow from both anaerobic and aerobic
blood culture bottles for which she was eventually started on
vancomycin.
On POD 7, she underwent both rigid and flexible bronchoscopies
with placement of a T-tube in addition to a central venous line.
Post-operatively, she was re-cultured for fever and found to
have Coag neg. Staph. aureus. She was also noted to have a
suprasternal hematoma which was stable and not felt to be
clinically significant. She had been intermittently febrile
therafter but defervesced by POD 13. In anticipation of her
discharge, her CVL was removed after she had a PICC line placed
on POD 14 for continued antibiotic coverage. (CVL tip culture
still no growth and pending at discharge.) Lastly, on POD 14, a
sputum culture grew MRSA.
On POD 16, she was deemed stable and tolerating her regular
dysphagia diet. She was also afebrile for 48 hours. She was
therefore discharged to her Rehab facility in good condition
with recommendations to follow-up with Drs. [**Name5 (PTitle) **] (Thoracic
Surgery) in 2 weeks and [**Doctor Last Name **] (Interventional
Pulmonology) in [**5-17**] weeks. She is to maintain her intravenous
antibiotics for an additional 3 weeks and keep her T-tube capped
at all times, if possible. Lastly, a work-up for her adrenal
mass was negative to date for pheochromocytoma but will be
completed as an outpatient with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Endocrinology).
Medications on Admission:
Cymbalta 60 QDaily
Lasix 40 QDaily
Methimazole 10 QDaily
Lorazepam
Magnesium Oxide
Trazadone
Bisacodyl
Vicodin
Albuterol
Atrovent
Discharge Medications:
1. Lidocaine HCl 0.5 % Solution Sig: 2 mL MLs Injection Q1H
(every hour) as needed for cough.
Disp:*QS ML(s)* Refills:*0*
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for copd.
Disp:*QS 1* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for dvt prophylaxis.
Disp:*qs 1* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for copd.
Disp:*qs 1* Refills:*0*
6. Albuterol Sulfate 0.083 % Solution Sig: [**2-12**] Inhalation Q4-6H
(every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
7. Ipratropium Bromide 0.02 % Solution Sig: [**2-12**] Inhalation
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs 1* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. 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*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID PRN ().
Disp:*30 Tablet(s)* Refills:*2*
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
16. Hydroxyzine HCl 25 mg/mL Solution Sig: [**2-12**] Intramuscular
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
17. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO TID (3
times a day) as needed for t-tube care.
Disp:*qs ML(s)* Refills:*0*
18. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for cough ONLY.
Disp:*qs Tablet(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
20. Hydromorphone 2 mg/mL Syringe Sig: [**2-12**] Injection Q3-4H
(Every 3 to 4 Hours) as needed for breakthrough pain.
Disp:*qs 1* Refills:*0*
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*qs 1* Refills:*2*
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs 1* Refills:*2*
23. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
24. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
25. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Commons
Discharge Diagnosis:
Severe subglottic tracheal stenosis
Intrathoracic substernal goiter
MRSA Bacteremia (Coag pos. & neg., methicillin res. Staph.
aureus)
UTI (Klebsiella, Proteus, E. coli; resistant to floroquinolones,
sensitive to ceftriaxone)
MRSA Pneumonia (Sputum culture=Coag pos. Staph aureus)
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
Please take your antibiotics as prescribed. They shall be given
intravenously.
You may resume your diet as tolerated.
Take your medications as prescribed.
You may take showers.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in Thoracic Surgery in 2 weeks.
Call [**Telephone/Fax (1) 4741**] to schedule an appointment.
Please follow-up with Dr. [**First Name (STitle) **] in [**Hospital 1800**] clinic within 1
week of your discharge for your thyroid disease. Call
[**Telephone/Fax (1) 69423**] for an appointment.
Please follow-up with Dr. [**Name (NI) **] in Interventional
Pulmonology for your T-tube in [**5-17**] weeks. Please call
[**Telephone/Fax (1) 3020**] for an appointment.
|
[
"998.12",
"041.4",
"496",
"519.19",
"278.01",
"997.5",
"518.83",
"250.00",
"701.5",
"428.0",
"041.6",
"V09.0",
"241.1",
"482.41",
"V44.2",
"041.3",
"414.01",
"599.0",
"519.09",
"041.11",
"790.7",
"996.62",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"99.04",
"38.93",
"97.23",
"06.2",
"33.22",
"96.05",
"31.74"
] |
icd9pcs
|
[
[
[]
]
] |
7851, 7902
|
1906, 4445
|
342, 487
|
8226, 8233
|
1376, 1883
|
8823, 9343
|
1340, 1357
|
4625, 7828
|
7923, 8205
|
4471, 4602
|
8257, 8800
|
234, 304
|
515, 933
|
955, 1209
|
1225, 1324
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,156
| 170,135
|
655
|
Discharge summary
|
report
|
Admission Date: [**2171-12-2**] Discharge Date: [**2171-12-21**]
Date of Birth: [**2090-2-1**] Sex: F
Service: MEDICINE
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 81 year old Russian-speaking female with a
history of HOCM s/p septal EtOH ablation in [**2167**], CHF EF >70%,
nonobstructive CAD by cath '[**67**], mild dementia, CRI (baseline
1.9) , DMII who is admitted to the ICU on [**2171-12-2**] for suspected
pneumosepsis.
She had been recently hospitalized from [**Date range (1) 5008**] for a CHF
exacerbation in the setting of poorly controlled hypertension.
She was seen by cardiology who started her on lisinopril and
HCTZ. On her day of discharge she was given a influenza vaccine
which resulted in chills and myalgia but she was discharged home
regardless.
While at home she continued to have subjective fevers and
chills but per her daughter she had no measurable temperature.
She had worsening SOB despite taking all of her medications with
a productive cough. She denied CP but did feel some chest
tightness. She had poor appetite with mild nausea w/o vomiting,
and denied abdominal pain or dysuria. At 11pm the night prior to
admission, she could not even lay down to sleep so she called
her daughter who called 911.
In the ED she was hypertensive with SBP of 145 and her CXR was
read as mild CHF, no pneumonia with a pro-BNP of 13,431 (up
from 4107 during her recent hospitalization). She was given 20mg
IV lasix and dropped her SBP to the 85/54 from 142 with a fever
to 100.5.
A sepsis line was placed and she was given Vancomycin,
levofloxacin, and flagyl for empiric ? aspiration PNA coverage.
SBP improved to 100s with 500cc NS bolus so no vasopressors were
initiated. The ED staff was also concerned about ST dep inf on
ECG and started heparin gtt for ACS.
Her EKG showed SR 70s, LVH, increased voltage, downward sloping
ST segments V4-V6, I, AVL with TWI with 3 mm STE V1-V3 (old from
[**2168**]). No Q waves. Troponin was 0.04-0.02 on admission. CK
[**Telephone/Fax (3) 5009**] with an MB <10. She ruled out for an MI.
She was admitted to the [**Hospital Unit Name 153**] for further monitoring for sepsis.
They felt she was overdiuresed in the emergency department and
became tachycardic, which further exacerbated her tenuous
baseline volume status. She was maintained euvolemic in the ICU.
Her heart rate was controlled with diltiazem and metoprolol
with a goal rate in the 60s. On the night of admission, she had
a run of VT (60 beats?) with a right central line placement
which resolved spontaneously. Her electrolytes were buffed, and
the VT was thought to be secondary to stretch. Cardiology
followed her throughout her [**Hospital Unit Name 153**] stay.
She was started on ceftriaxone and vancomycin for a total of 14
days for pneumonia. She was also found to have a UTI which grew
pansensitive Klebsiella and E. Coli on Cx, which were covered by
her ceftriaxone.
She was continued on aspirin, beat-blocker, statin. Her ACE was
restarted on discharge from the ICU as her creatinine returned
back to baseline. She was ruled out for MI with three sets of
negative cardiac enzymes.
Regarding her HOCM, she was maintained on diltiazem 30 mg QID,
lopressor titrated up to 37.5 TID. She was transferred to [**Wardname 5010**]
for HOCM ablation on Friday.
At present, complains of shortness of breath and cough. Denies
any chest pain/pressure.
Underwent successful ETOH ablation of S1 on [**2171-12-13**] and
transferred to CCU post-procedure with temporary pacing wire for
close observation. The temp wire was removed without evidence of
CHB on [**2171-12-15**] without events.
Last echo prior to septal ablation was [**2171-12-5**] :
Left Ventricle - Peak Resting LVOT gradient: *96 mm Hg (nl <= 10
mm Hg). TR Gradient (+ RA = PASP): *78 to 85 mm Hg (nl <= 25 mm
Hg). Left Atrium *7.1 cm Right Atrium - *6.2 cm
Left Ventricle - Septal Wall Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
The left atrium is elongated. The right atrium is moderately
dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a severe
resting left ventricular outflow tract obstruction. The findings
are
consistent with hypertrophic obstructive cardiomyopathy (HOCM).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The
mitral valve leaflets are moderately thickened. There is severe
mitral annular
calcification. Severe (4+) mitral regurgitation is seen. The
mitral
regurgitation jet is eccentric. Moderate [2+] tricuspid
regurgitation is seen.
There is severe pulmonary artery systolic hypertension.
Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2171-11-22**], the
severity of
the mitral regurgitation has increased. The estimated pulmonary
artery
systolic pressures are markedly higher. The severity of
pulmonary
regurgitation has increased. The severity of tricuspid
regurgitation has also
increased.
.
Echo prior to septal ablation [**2171-12-13**]:
There is prominent symmetric left ventricular hypertrophy with
small cavity
and hyperdynamic systolic function (EF>75%). There is valvular
[**Male First Name (un) **] with a
severe (57mmHg peak) resting LVOT gradient. Right ventricular
cavity size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened.
The mitral leaflets are thickened. There is severe mitral
annular
calcification. There is systolic anterior motion of the mitral
valve leaflets.
Moderate to severe (3+) mitral regurgitation is seen.
.
Following injection of diluted Definity contrast into the sepal
artery, there
is prompt hyperenhancement of the RV side of the basal septum
and extending
into an RV band.
.
Post septal ablation on [**2171-12-13**]:
.
Following injection of 1cc of ethanol, there was prompt
hyperenhancement of
the basal septum, extending to a muscle band in the right
ventricle. The LVOT
gradient declined to a peak of 45mmHg. There was mild-moderate
mitral
regurgitation.
.
Following injection of another 0.5cc of ethanol, the peak LVOT
gradient
declined to 34mmHg. Valvular [**Male First Name (un) **] persisted with mild mitral
regurgitation.
Additional Doppler suggests mild mitral stenosis (possibly
related to MAC) and
mild aortic regurgitation
.
Furthermore, her cath on [**2171-12-13**] showed a right dominant system
with a patent LMCA, mid LAD and LCX with 70% calcified lesions,
RCA with 40% ostial disease.
C.CATH Study Date of [**2168-10-4**]:
COMMENTS:
1. Selective cine angiography of this right dominant system
revealed
mild to moderate single vessel coronary artery disease. The LMCA
was
free of angiographically significant stenosis. The LAD had a mid
40%
stenosis, otherwise rest of the LAD including the major diagonal
branch
were free of stenosis. The LCX had no significant stenosis. The
OM1 was
normal, OM2 had a 40% proximal stenosis, the OM3 was normal. The
RCA was
had no angiographcally significant stenosis. The PDA had a
proximal 50%
stenosis. The RPLV branch had no significant disease.
2. Resting hemodynamics revealed severe systemic hypertension,
moderate
to severe pulmonary hypertension and elevated left heart filling
pressures.
3. Left ventriculography in the [**Doctor Last Name **] projection revealed normal
LV size
and systolic function, 2+MR.
4. Successful ethanol ablation of the second septal perforator
with
decrease in the LVOT gradient from 90 mm Hg to 5-10 mm Hg post
ablation.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate mitral regurgitation.
3. Normal ventricular function.
4. Successful septal ethanol ablation.
.
Cath [**2171-12-13**]:
LVOT gradient of 60 mm Hg at rest.
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with patent LMCA. Mid LAD and LCX both had 70% calcified
lesions. The RCA had a 40% ostial disease.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed severely elevated pulmonary
pressures and a resting LVOT gradient of 60 mm Hg.
4. Successful ethanol ablation of the second subbranch of S1 was
performed.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Summetric left ventricular hypertrophy with LVOT gradient and
pulmonary hypertension.
3. Successful ethanol septal ablation.
Transferred to [**Hospital Ward Name 121**] 6 on [**2171-12-16**] without events or complaints.
ROS: No fevers, chills. Positive cough. Breathing stable but not
perfect. No chest pain.
Past Medical History:
1. hypertension
2. diabetes type II
3. hypercholesterolemia
4. coronary artery disease-nonobstruction
5. chronic renal failure -baseline creat 1.9
6.pulmonary hypertension-
7.left ventricle outflow tract obstruction,diastolic heart
failure-ejection fraction of 70%
8. gastro-esophageal reflux disease
9. pancreatic resection [**2155**], [**2166**]- required intubation with
10.history of delirium
11.resection of neuroendocrine tumor
12.HOCM with septal ablation [**2167**] and [**2171-12-13**]
13.Left leg pain/numbness
14.Spinal stenosis
Social History:
She is a high school school graduate w/ 2 years of college. She
is retired. She used to work as an engineer. She is married. She
lives with her husband. She does not smoke, she does not drink,
she denies any recreational drug use.
Family History:
Her mother died at 74 and has Alzheimer's. Her father died
young, she was only 4-month-old and she does not know the cause.
She has no sisters, had a brother who died in his 70s, he choked
after eating, and she has one daughter who is 53
years old, in good health. She has no sons.
Physical Exam:
T 97.0 HR 76 BP 150/70 RR 16 O2 sat 96% on RA
Gen- NAD, alert, Russian-speaking, speaks little English
HEENT-PERRLA, JVP 8 cm, MMM
Hrt-RRR, nS1S2, III/VI systolic ejection murmur at LLSB and
Grade II/VI holosystolic murmur at apex
Lungs- Minimal bibasilar crackles, otherwise clear
Abd- soft, nondistended, active BS, NT
Extrem-2+ rad and dp pulses, no [**Location (un) **]
Pertinent Results:
ECG [**2171-12-14**]:
NSR 71 bpm. 2 mm STE V1-V2, peaked T waves V3-V5. TWI AVL. NL
axis. LVH with prominent voltage.
.
ECG Study Date of [**2171-12-11**] 11:31:02 AM
Sinus rhythm
Left ventricular hypertrophy with ST-T wave changes
Anterior ST elevation, probably due to left ventricular
hypertrophy - clinical
correlation is suggested
Intraventricular conduction delay
Since previous tracing, no significant change
.
CHEST (PA & LAT) [**2171-12-11**] 10:15 AM
IMPRESSION: Interval improvement in CHF. No obvious pneumonia.
.
[**2171-12-5**] Echocardiogram: The left atrium is elongated. The right
atrium is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a severe resting left ventricular outflow tract obstruction. The
findings are consistent with hypertrophic obstructive
cardiomyopathy (HOCM). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is severe mitral
annular calcification. Severe (4+) mitral regurgitation is seen.
The mitral regurgitation jet is eccentric. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-11-22**], the
severity of the mitral regurgitation has increased. The
estimated pulmonary artery
systolic pressures are markedly higher. The severity of
pulmonary
regurgitation has increased. The severity of tricuspid
regurgitation has also increased.
.
[**2171-12-2**] 01:12PM CK-MB-9 cTropnT-0.04*
[**2171-12-2**] 01:12PM CK(CPK)-438*
.
[**2171-12-2**] Urine culture: Pansensitive klebsiella and e. coli
[**2171-12-2**] 09:15PM CK-MB-8 cTropnT-0.04*
[**2171-12-2**] 09:15PM CK(CPK)-369*
C.CATH Study Date of [**2168-10-4**]
1. Selective cine angiography of this right dominant system
revealed
mild to moderate single vessel coronary artery disease. The LMCA
was
free of angiographically significant stenosis. The LAD had a mid
40%
stenosis, otherwise rest of the LAD including the major diagonal
branch
were free of stenosis. The LCX had no significant stenosis. The
OM1 was
normal, OM2 had a 40% proximal stenosis, the OM3 was normal. The
RCA was
had no angiographcally significant stenosis. The PDA had a
proximal 50%
stenosis. The RPLV branch had no significant disease.
2. Resting hemodynamics revealed severe systemic hypertension,
moderate
to severe pulmonary hypertension and elevated left heart filling
pressures.
3. Left ventriculography in the [**Doctor Last Name **] projection revealed normal
LV size
and systolic function, 2+MR.
4. Successful ethanol ablation of the second septal perforator
with
decrease in the LVOT gradient from 90 mm Hg to 5-10 mm Hg post
ablation.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate mitral regurgitation.
3. Normal ventricular function.
4. Successful septal ethanol ablation.
.
C.CATH Study Date of [**2171-12-13**]
.
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA. Mid LAD and LCX both had 70% calcified lesions. The
RCA had
a 40% ostial disease.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed severely elevated pulmonary
pressures
and a resting LVOT gradient of 60 mm Hg.
4. Successful ethanol ablation of the second subbranch of S1 was
performed.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Summetric left ventricular hypertrophy with LVOT gradient and
pulmonary hypertension.
3. Successful ethanol septal ablation.
.
ECHO Study Date of [**2171-12-13**]
.
Conclusions:
There is prominent symmetric left ventricular hypertrophy with
small cavity and hyperdynamic systolic function (EF>75%). There
is valvular [**Male First Name (un) **] with a severe (57mmHg peak) resting LVOT
gradient. Right ventricular cavity size and free wall motion are
normal. The aortic valve leaflets are mildly thickened. The
mitral leaflets are thickened. There is severe mitral annular
calcification. There is systolic anterior motion of the mitral
valve leaflets. Moderate to severe (3+) mitral regurgitation is
seen.
.
Following injection of diluted Definity contrast into the
sepal artery, there is prompt hyperenhancement of the RV side of
the basal septum and extending into an RV band. The catheter
was then withdrawn, redirected, and diluted Definity was again
injected leading to hyperenhancement of some LV endocardial
portions of the basal septum.
.
Following injection of 1cc of ethanol, there was prompt
hyperenhancement of the basal septum, extending to a muscle
band in the right ventricle. The LVOT gradient declined to a
peak of 45mmHg. There was mild-moderate mitral regurgitation.
Following injection of another 0.5cc of ethanol, the peak LVOT
gradient declined to 34mmHg. Valvular [**Male First Name (un) **] persisted with mild
mitral regurgitation. Additional Doppler suggests mild mitral
stenosis (possibly related to MAC) and mild aortic
regurgitation.
.
C.CATH Study Date of [**2171-12-19**]
COMMENTS:
The lesion in the mid LAD was predilated with a 2.5 mm balloon,
stented
with a 3.0 mm cypher stent and post dilated with two 3.25 mm
balloons
with lesion reduction to 10%. The final angiogram showed TIMI
III flow
with no residual stenosis, no dissection, no perforation and no
embolisation. The patient left the lab in a stable condition.
FINAL DIAGNOSIS:
Successful stenting of the LAD (Drug eluting)
[**2171-12-2**] 09:15PM GLUCOSE-165* UREA N-41* CREAT-2.5* SODIUM-142
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2171-12-2**] 09:15PM CK(CPK)-369*
[**2171-12-2**] 09:15PM CK-MB-8 cTropnT-0.04*
Brief Hospital Course:
The patient is an 81 yo female with a history of HOCM s/p septal
ablation in [**2167**], severe MR/TR, CHF EF>75%, mild dementia, CRI
(1.8 baseline), and [**Hospital 2320**] transferred to s/p septal ablation of
S1 on [**2171-12-13**] with improvement in HOCM and MR and 70% LAD and
LCX disease on cath.
## CHF, EF >75%
- Appears overall euvolemic on exam.
- Repeat echo with EF >60%. Reduced MR.
- She was restarted on her home dose of lasix 20 mg PO QD which
was increased to lasix 40 mg PO QD on [**12-19**].
- Also started on lisinopril 10 in CCU.
.
## HOCM s/p septal ablation [**2171-12-13**]
- Repeat echo showed .
- Status post septal ablation without complication on [**2171-12-13**].
Had temporary pacing wires post cath without evidence of CHB.
- On Diltiazem XR 120 mg and Toprol XL 100 mg - Please stagger
to avoid hypotension.
.
.
## Severe MR/TR/PAH
- Decreased immediately post-procedure on [**2171-12-13**]. Repeat echo
to assess further,
- Continue Lisinopril 10 mg for afterload reduction.
.
## Rhythm
- H/o VT in [**Hospital Unit Name 153**] with manipulation during central line placement
- never recurred.
- Continue Toprol XL.
- Also had temp wire prophylactically post-procedure for concern
of CHB s/p septal ablation without events. Temp wire DC'd on
[**2171-12-15**].
- Repeat EKG.
.
## CAD
- Nonobstructive on cath in [**2167**].
-Cath on [**2171-12-13**] showed 70% mid LAD and 70% mid LCx lesions, the
LAD thought to be significant. Dr. [**Last Name (STitle) **] will consider a LAD
intervention after echo in a few days.
-Now s/p Cypher to LAD on [**2171-12-19**].
- Continue ASA 325, plavix , BB, ACE, lipitor 10 mg.
- The patient intermittently complains of chest pressure and
"not feeling so good" with SOB although her O2 sats are fine.
.
## ? Pneumonia: Started on ceftriaxone and vancomycin for a
total of 14 days in the [**Hospital Unit Name 153**]. Trasnsferred to [**Wardname 5010**] on day 9 of
both. Repeat CXR post-diuresis never showed pneumonia. Both
vanco/CTX were discontinued without evidence of infection.
- Not active issue.
.
## UTI: grew pansensitive bugs on Cx, which were covered by her
ceftriaxone. Her last urine culture was negative on [**2171-12-4**].
- Not active issue.
.
## Chronic renal failure: Baseline 1.9. Now 1.8-2.0.
- Continue to monitor.
- On ACE and small dose of daily lasix. Stable post-cath.
.
## DM2: SSI, FS QID
.
# Dementia
- Continue donepezil, memantine.
.
## FEN - Diabetic, cardiac diet, Monitor lytes
## FULL CODE
##Contact: Daughter [**Name (NI) 5011**] home #[**Telephone/Fax (1) 5012**]
Medications on Admission:
1. Furosemide 20 mg qd
2. Aspirin 325 mg qd
3. Atorvastatin 10 mg qd
4. Metoprolol Succinate 100 mg qd
5. Diltiazem HCl 120 mg qd
6. Memantine 5 mg Tablet [**Hospital1 **]
7. Pantoprazole 40 mg qd
8. Lisinopril 20 mg qd
9. Hydrochlorothiazide 25 mg qd
10. Aricept unknown dose
On Transfer from CCU:
Heparin 5000 UNIT SC TID
Sliding Scale Insulin
Acetaminophen 325-650 mg PO Q4-6H:PRN
Limit total daily dose Acetaminophen to <4000 mg.
Ipratropium Bromide Neb 1 NEB IH Q6H
Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
Lactulose 30 ml PO TID
Aspirin 325 mg PO DAILY
Lisinopril 10 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Metoprolol XL (Toprol XL) 100 mg PO DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Memantine *NF* 5 mg Oral [**Hospital1 **]
Clopidogrel Bisulfate 75 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Diltiazem Extended-Release 120 mg PO DAILY
Docusate Sodium 100 mg PO BID
Donepezil 5 mg PO HS
Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Furosemide 20 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Memantine 5 mg Tablet Sig: One (1) Tablet PO bid ().
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*3 * Refills:*2*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*12*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Hypertrophic Obstructive Cardiomyopathy
Coronary artery disease
Chronic renal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call your primary care physician if you experience any
chest pain, shortness of breath, or palpitations.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 147**] SPEC SURGERY- [**Doctor Last Name **] [**Doctor First Name 147**] SPEC (NHB)
Date/Time:[**2172-5-11**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2172-5-26**] 11:20
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in 1 week. You may call [**Telephone/Fax (1) 250**] to schedule an
appointment.
|
[
"414.01",
"428.30",
"272.0",
"995.92",
"287.4",
"425.1",
"401.9",
"486",
"416.0",
"038.9",
"584.9",
"585.3",
"397.0",
"250.00",
"599.0",
"424.0",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"37.78",
"37.34",
"00.66",
"37.23",
"88.56",
"38.93",
"00.40",
"00.45",
"99.20",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
21477, 21563
|
16643, 19223
|
294, 300
|
21699, 21708
|
10520, 13707
|
21969, 22518
|
9817, 10102
|
20261, 21454
|
21584, 21678
|
19249, 20238
|
16360, 16620
|
21732, 21946
|
10117, 10501
|
235, 256
|
328, 7985
|
9009, 9552
|
9568, 9801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,254
| 140,910
|
38221
|
Discharge summary
|
report
|
Admission Date: [**2179-6-3**] Discharge Date: [**2179-6-4**]
Date of Birth: [**2095-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
septic shock
pnemonia
Major Surgical or Invasive Procedure:
none, arrived intubated with CVL in place from OSH
History of Present Illness:
Chief Complaint: Respiratory failure
.
History of Present Illness (Of note, much of the hx is obtained
from family as the pt was intubated):
Mr. [**Known lastname **] is a 83 yo M with HLD, CAD s/p MI (unknown
intervention hx), and RCC metastatic to liver and ?bone, who
presented this morning to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital complaining of 1
day of nausea and vomiting. As per the patient's family, the pt
was found in the AM having had vomitted numerous times O/N. The
pt denied any cough or fever, but did endorse chills, fatigue,
and recent loss of appetite. The friend that found the pt noted
him to be quite pale, and brought him to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **]. At
the OSH ED, he was found to have a WBC of 14 with 40% bands, CXR
showed PNA. He was given levofloxacin 750 mg, azithromycin 500
mg, subsequently developed respiratory failure, was intubated,
given 4L NS and transfered to [**Hospital1 18**]. During his transfer his SBP
was low and he was started on norepinephrine.
.
In the ED, initial VS were: T 97, HR 73, BP 85/73, on a vent.
Patient's antibiotics were broadened to vanc/zosyn, a RIJ was
placed, he was given 500 mL NS and admitted to the CCU.
.
On the floor, the patient is intubated and unable to answer
questions.
Past Medical History:
Past Medical History:
HLD
CAD s/p MI (before the age of 40)
RCC metastatic to liver/bone marrow
Social History:
Social History (unable to obtain):
- Tobacco: Unknown
- Alcohol: Unknown
- Illicits: Unknown
Family History:
Family History (unable to obtain): Unknown
Physical Exam:
Physical Exam:
Vitals: T: BP: 98/59 P:93 R: 31 O2: 96% on vent
General: Intubated and sedated
HEENT: NCAT
Neck: RIJ c/d/i
Lungs: Coarse breath sounds and crackles noted R>L, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: cold, poorly perfused, 2+ pulses in femorals, unable to
feel pulses in radials and DPs, no edema
Neuro: Intubated and sedated, no response to noxious stimuli
Pertinent Results:
[**2179-6-3**] 10:23PM TYPE-ART RATES-24/16 TIDAL VOL-500 PEEP-5
O2-100 PO2-224* PCO2-45 PH-7.16* TOTAL CO2-17* BASE XS--12
AADO2-464 REQ O2-77 -ASSIST/CON INTUBATED-INTUBATED
[**2179-6-3**] 10:23PM GLUCOSE-156* LACTATE-6.0* NA+-134* K+-3.9
CL--106
[**2179-6-3**] 10:23PM HGB-9.0* calcHCT-27 O2 SAT-99 CARBOXYHB-0.9
MET HGB-0.3
[**2179-6-3**] 10:23PM freeCa-0.98*
[**2179-6-3**] 09:59PM PH-6.97* COMMENTS-GREEN TOP
[**2179-6-3**] 09:59PM GLUCOSE-60* LACTATE-7.8* NA+-141 K+-3.9
CL--108 TCO2-16*
[**2179-6-3**] 09:59PM HGB-9.8* calcHCT-29 O2 SAT-74 CARBOXYHB-1.8
MET HGB-0.2
[**2179-6-3**] 09:59PM freeCa-0.92*
[**2179-6-3**] 09:45PM UREA N-26* CREAT-2.6*
[**2179-6-3**] 09:45PM estGFR-Using this
[**2179-6-3**] 09:45PM ALT(SGPT)-38 AST(SGOT)-96* ALK PHOS-77 TOT
BILI-0.8
[**2179-6-3**] 09:45PM LIPASE-8
[**2179-6-3**] 09:45PM cTropnT-0.47*
[**2179-6-3**] 09:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2179-6-3**] 09:45PM WBC-19.8* RBC-3.44* HGB-9.1* HCT-30.0* MCV-87
MCH-26.5* MCHC-30.5* RDW-23.8*
[**2179-6-3**] 09:45PM NEUTS-68 BANDS-13* LYMPHS-7* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2179-6-3**] 09:45PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TARGET-1+
SCHISTOCY-1+ BURR-2+
[**2179-6-3**] 09:45PM PT-20.1* PTT-54.4* INR(PT)-1.9*
[**2179-6-3**] 09:45PM PLT COUNT-207
[**2179-6-3**] 09:45PM FIBRINOGE-319
Brief Hospital Course:
Mr. [**Known lastname **] is a 83 yo M with HLD, CAD s/p MI (unknown
intervention hx), and RCC metastatic to liver and bone marrow,
who presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital complaining of 2 days of
nausea and vomiting found to have PNA, who was transferred to
[**Hospital1 18**] for further management after developing respiratory
failure. His family arrived the following morning and goals of
care were shifted to comfort. Pressors [**Last Name (un) 8966**] discontinued and
the pt expired shortly thereafter. His family declined a
post-mortem examination.
.
#. PNA/ Respiratory failure: Patient found to have PNA at OSH,
subsequently developed respiratory failure, was intubated and
started on norepinephrine on transfer. Admission CXR revealed
large right mid-lower lobe consolidation. He was treated with
Vanco/Zosyn and mechanical ventilation was continued until he
expired.
.
#. Septic shock: Patient presented developed hypotension on
transfer from the OSH and started on norepinephrine. On
admission pH 7.16 and lactate of 7.8. Lactate improved with
fluid resuscitation. Pressors discontinued when goals of care
were focused on comfort.
.
#. Metastic RCC: Prior to pursuing comfort, confirmed pt's
previously guarded prognosis from an oncologic perspective with
his onocologist, Dr. [**Last Name (STitle) 1492**].
Medications on Admission:
Crestor
Sutent (sunitinib) 25 mg PO daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Lobar Pneumonia
Hypoxic Resp Failure
Septic Shock
Metastatic Renal Cell Carcinoma
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2179-6-7**]
|
[
"414.01",
"486",
"276.2",
"198.5",
"785.52",
"197.7",
"272.4",
"995.92",
"584.5",
"518.81",
"412",
"V70.7",
"189.0",
"427.5",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5557, 5566
|
4059, 5436
|
335, 387
|
5691, 5701
|
2587, 4036
|
5753, 5786
|
2025, 2069
|
5529, 5534
|
5587, 5670
|
5462, 5506
|
5725, 5730
|
2099, 2568
|
432, 1778
|
415, 415
|
1822, 1898
|
1914, 2009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,406
| 156,776
|
48103
|
Discharge summary
|
report
|
Admission Date: [**2110-11-2**] Discharge Date: [**2110-11-19**]
Date of Birth: [**2057-12-27**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Ace Inhibitors
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
ankle fracture, hypoxia
Major Surgical or Invasive Procedure:
endotracheal intubation
central line placement
History of Present Illness:
52F (limited history per chart from EMS and ED) w/ hx chf, COPD
p/w L ankle pain s/p fall while getting OOB, found on floor, no
other traumatic injuries noted. She complained of left ankle
pain. When the EMS arrive, she was found to have initial blood
sugar 30 on sulonfylurea, She received 1amp D50 and was continue
on D5 1/2 NS. HOwever, as the below ED course will show that she
became hypoxic and then hypercarbic over the next several hours.
She eventually was intubated for hypercarbic respiratory
distress.
.
Of note, patient was recently discharged on [**10-22**] and was
hospitalized for mental status changes, hyperkalemia in setting
of acute renal failure and hyponatremia.
.
ED course:
Initial VS T 97.6 P 63 BP 161/44 RR 16 O2 75 on RA (1pm)->
NRB(2:20pm) -> 97% on NRB,-> ABG 3:30pm 7.19/84/66-> ABG 4pm
7.16/90/82-> but patient became more somnolent at (4:30pm).
BiPAP was initiated-> Pt was yelling out and trying to get OOB
(5:30pm). Pt was intubated at 5:35pm.
Alb/atrovent
D50 1amp-> FS
solumedrol 125 mg IV
levaquin 500 IV
1L D5 1/2 NS
325 ASA
intubated w/ vecuronium and etomidate and propofol for sedation
Past Medical History:
- COPD/Asthma on home O2 (2.5L/min)
- Restrictive lung disease
- HTN
- CHF (diastolic, EF 55% in [**2109-2-2**])
- Moderate mental retardation
- CKD, baseline Cr 1.8
- DM2
- h/o hyponatremia
- Chronic LE edema
- Dementia
- IgA nephropathy
- hearing loss
- tobacco use
- chronic constipation
- hyperlipidemia
Social History:
tobacco - 1ppd x many years
alcohol - none
illicit drugs - none
occupation - not employed; currently living in group home
Family History:
FH: One older sister, does not know her health status. Mother
died when she was young, does not know what her father died of.
Physical Exam:
Vitals: P 70s BP 150/40 RR 14 O2 95% on PS PEEP 5 FiO2 40% TV
250s (spontaneous), Peak pressure 20s
weight 162.3 lbs (up 3 lbs from baseline)
Gen: Petite female, intubate and arousable
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP
clear, uvula midline, MM dry. Dentures in place.
Neck: No JVD, no LAD, no carotid bruits.
CV: RR, nl S1/S2, no m/r/g noted.
Lungs: coarese breath sounds bilaterally
Ab: Soft, NTND,+ BS, no HSM by percussion, no rebound or
guarding.
Extrem: No c/c/e. + wwp. 2+ radial, PT pulses bilaterally. No
point tenderness along her spine. No reproducible neck pain. LLE
in cast
Neuro: AAOx3, CN II-XII grossly intact.
Skin: No rashes. + SCC on scalp.
.
Pertinent Results:
At admission:
[**2110-11-2**] 01:25PM GLUCOSE-44* UREA N-63* CREAT-3.0* SODIUM-124*
POTASSIUM-5.2* CHLORIDE-89* TOTAL CO2-30 ANION GAP-10
[**2110-11-2**] 01:25PM ALT(SGPT)-68* AST(SGOT)-100* LD(LDH)-200
CK(CPK)-1774* ALK PHOS-190* AMYLASE-24 TOT BILI-0.3
[**2110-11-2**] 01:25PM CK-MB-46* MB INDX-2.6 cTropnT-0.06*
proBNP-[**Numeric Identifier 46788**]*
[**2110-11-2**] 01:25PM WBC-6.3 RBC-3.20* HGB-10.5* HCT-30.9* MCV-96
MCH-32.7* MCHC-33.9 RDW-16.6*
[**2110-11-2**] 01:25PM PLT COUNT-232
[**2110-11-2**] 03:50PM (pre-intubation) TYPE-ART PO2-82* PCO2-90*
PH-7.16* TOTAL CO2-34* BASE XS-0
.
[**2110-11-2**]: Ankle xray: There is a displaced comminuted overriding
distal fibular (lateral malleolus) fracture. There is also a
comminuted fracture of the medial and posterior malleolus
(tibial) with likely intra- articular involvement. There is
surrounding soft tissue swelling. The ankle mortise appears
symmetric.
.
[**2110-11-3**]: TTE: 1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular wall motion is normal.
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
6. There is a trivial/physiologic pericardial effusion.
7. Compared with the report of the prior study (images
unavailable for review) of [**2107-2-14**], there is probably no
significant change.
.
[**2110-11-4**]: CT chest (w/o contrast): 1. Multiple small discrete
peripheral pulmonay opacities. The appearance is nonspecific but
could be secondary to pulmonary infarctions from multiple
pulmonary emboli. This could be further evaluated with a chest
CTA. The mediastinal and right hilar adenopathy could also be
better evaluated with intravenous contrast.
2. Mild interstitial edema.
3. Slight over-distension of the endotracheal tube cuff.
.
[**2110-11-16**]: Chest xray: Endotracheal tube, central venous
catheter, and nasogastric tube remain in standard position.
Cardiac silhouette is enlarged but stable. There is persistent
vascular engorgement and perihilar haziness attributed to
congestive heart failure. The peripheral right hemidiaphragm is
partially obscured. This may be due to right effusion and/or
developing consolidation in the right lower lobe. Followup
radiographs are suggested to exclude developing infectious
pneumonia.
.
Brief Hospital Course:
A/P:52 year old COPD, CRI, HTN, anemia, p/w ankle fracture and
now intubated for hypercarbic respiratory distress.
.
#Hypercarbic respiratory distress - This is likely exacerbation
of her underlying COPD and CHF with questionable PNA. PCP
reports [**Name Initial (PRE) **] 15 lb weight gain over the last month although no
evidence of pulmonary edema on CXR. PNA is no evidence on CXR,
but there is significant secretion on suctioning as well.
Patient was treated with lasix in attempt to diurese, levaquin
and vancomycin for pna, albuterol, combivent, solumedrol for
COPD. Despite these efforts, patient was extubated
unsuccessfully and required reintubation and had an episode of
asystole. She then was reintubated for one more week. On
extubation, patient was made DNR/DNI and comfort measures were
started with morphine gtt. Patient died the next day [**3-6**]
respiratory failure.
.
.
#Ankle fracture
-comminitated fracture-> put in cast.
.
# CKD- Baseline Cr 1.7 - 2.4, and planned for starting HD at the
end of the year. Cr on admission was 4.1 and BUN 108. Attempted
aggressive diuresis. Creatinine improved down to high 2s.
Dialysis never started.
.
.
# CV
a)Pump: history of CHF. Patient had pulmonary edema on cxr and
had h/o weight gain. Attempted diuresis with bumex and
metalazone which was difficult given CRI.
.
b) ischemia-elevated CK likely in setting of fall and elevated
troponin likely in setting of renal failure. troponin is at
baseline.
-monitor on telemetry
-continue b-blocker and ASA
.
c)rhythmn-NSR w/1 AVB.
.
# HTN: Elevated over baseline likely in setting of stress
-Continued labetalol, nifedipine, bumex, imdur, hydralazine
-held valsartan given very limited renal status
.
# DM type II: FS QID with RISS for now. oral glycemic held in
setting of sulfonrea-related hypoglycemia.
.
# ANEMIA: Stable and at baseline.Will guaiac all stools and
monitor hct daily
.
# DEPRESSION: Continue home regimen of doxepin, carbamazepine
and remeron.
Medications on Admission:
Carbamazepine 800 mg [**Hospital1 **]
Doxepin 150 mg hs
Mirtazapine 30 mg hs
Labetalol 200 mg [**Hospital1 **]
Nifedipine 120 mg Tablet Sustained Release daily
Calcium Carbonate 1000 mg daily as needed
Cholecalciferol (Vitamin D3) 800 unit daily
Atorvastatin 20 mg DAILY
Multivitamin daily
Montelukast 10 mg daily
Pantoprazole 40 mg q24
Tiotropium Bromide 18 mcg Capsule daily
Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **]
Polysaccharide Iron Complex 150 mg daily
Albuterol Sulfate q6 prn
Atrovent q6 prn
Ammonium Lactate 12 % Lotion [**Hospital1 **]
Bumetanide 1.5 mg tid
Aspirin 325 mg daily
Colace
Polyethylene Glycol 3350 17 g (100%) daily
Calcitriol 0.25 mcg PO twice a week.
Glipizide 10 mg Q AM.
Glipizide 5 mg qhs
Melatonin 1 mg qhs.
Prilosec 20 mg Capsule daily
Metamucil 0.52 g daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased s/p respiratory failure
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"583.81",
"389.9",
"250.80",
"318.0",
"428.0",
"564.00",
"305.1",
"824.6",
"300.00",
"518.81",
"285.21",
"427.5",
"V66.7",
"250.40",
"583.9",
"307.9",
"493.20",
"585.9",
"E884.4",
"276.1",
"272.4",
"403.90",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.54",
"96.72",
"38.93",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8389, 8398
|
5528, 7500
|
318, 366
|
8474, 8484
|
2864, 5505
|
8537, 8680
|
2013, 2141
|
8360, 8366
|
8419, 8453
|
7526, 8337
|
8508, 8514
|
2156, 2845
|
255, 280
|
394, 1525
|
1547, 1857
|
1873, 1997
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,797
| 196,472
|
35905
|
Discharge summary
|
report
|
Admission Date: [**2165-3-13**] Discharge Date: [**2165-3-25**]
Date of Birth: [**2081-9-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
TPA administered
History of Present Illness:
HPI: Patient is a 83 year old RHM with hx of Afib on Coumadin,
DM, CAD, hypercholesterolemia, and mild dementia who was found
aphasic with vomitus at 9:40pm. His last known well time was
9:30 and when the EMS arrived around 9:50, he was found to be
not
talking and completely hemiplegic on right side. He was taken
to
[**Hospital3 **] where he was evaluated per telemed with
neurologist at [**Hospital1 2025**] who recommended IV tPA given that his INR was
1.3 and his significant deficits. IV tPA started at 12:10 am
(2hrs 40 mins after last known well time) and finished at 1:20
at
which point, he was transferred here for further evaluation and
care.
Patient arrived at 1:45 and upon evaluation, he was showing some
improvement with moving his right leg which was completely
plegic
per report.
NIHSS after IV tPA here in ED:
2 for LOC questions
1 for minor facial paralysis
4 for no movement of RUE
1 for drift of RLE
1 mild/mod sensory loss
3 for mute, global aphasia
2 for severe dysarthria
Total 14
Patient was taken for CTA/CTP which showed no hemorrhagic
transformation plus patent proximal vessels but did have
increased MTT and decreased CBV on reformatted images. However,
patient continued to make significant improvements including
almost full strength in RUE plus improvement of facial palsy as
well.
Per wife, patient was in his USOH until this evening. No
infectious symptoms and no report of chest pain. He was taking
all his meds including Coumadin. However, he did have a bout of
pneumonia 2 weeks ago hence was on levaquin for 10 days which
finished 5 days prior to admission.
Patient walks with a cane at baseline and has mild dementia but
still highly independent - he still drives, pays own bills and
takes own meds.
Past Medical History:
1. Atrial fibrillation on Coumadin
2. Hepatocellular carcinoma per biopsy ([**1-7**])
3. DM
4. HTN
5. Hypercholesterolemia
6. CAD s/p MI and CABG - LVEF 29%
7. OA
8. Depression
9. PVD and claudication
Social History:
SH: Lives with wife - highly independently functioning as noted
in HPI. Quit smoking 20 yrs ago and no EtOH. Retired grocery
store manager.
Family History:
No strokes
Physical Exam:
Exam on admission
.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam - follows
simple commands: opens and closes eyes, points to ceiling and
etc. Able to utter "good" and says his name but severe
dysarthria. Repetition not intact.
Cranial Nerves:
Small pupils bilaterally but reactive. EOMI without nystagmus.
Blinks to visual threats in all directions. Slight R facial
droop. Tongue midline and palate elevated symmetrically.
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. R pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] Grip IP H Q DF PF
R 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5
Sensation: Seems intact to LT and pin prick although unclear if
asymmetry present given aphasia.
Reflexes:
+2 and symmetric for UEs but trace for L patellar and none for R
and no Achilles. Toes upgoing bilaterally
Coordination: No dysmetria with FTN but had difficulty
comprehending the task.
Gait: Deferred.
Exam on discharge:
Gen: awake and alert, oriented to person, place, occasionally
date
HEENT: NCAT, anicteric, no injections, PERRLA, MMM
Cor: RRR s1s2 no mgr
Pulm: diminished at left base, transmitted upper airway sounds
Abd: +bs, soft, nt, nd
Extrem: no cce
Pertinent Results:
[**2165-3-14**] 04:56AM BLOOD WBC-7.4 RBC-3.39* Hgb-10.3* Hct-31.2*
MCV-92 MCH-30.4 MCHC-33.0 RDW-16.2* Plt Ct-255
[**2165-3-19**] 05:10AM BLOOD WBC-8.1 RBC-3.66* Hgb-11.3* Hct-34.0*
MCV-93 MCH-30.9 MCHC-33.2 RDW-16.4* Plt Ct-284
[**2165-3-19**] 05:10AM BLOOD PT-32.7* PTT-27.6 INR(PT)-3.4*
[**2165-3-14**] 04:56AM BLOOD PT-16.8* PTT-26.5 INR(PT)-1.5*
[**2165-3-19**] 05:10AM BLOOD Glucose-127* UreaN-39* Creat-1.3* Na-152*
K-3.7 Cl-113* HCO3-25 AnGap-18
[**2165-3-18**] 05:30AM BLOOD Glucose-131* UreaN-38* Creat-1.4* Na-149*
K-4.1 Cl-111* HCO3-26 AnGap-16
[**2165-3-17**] 08:05AM BLOOD Glucose-126* UreaN-33* Creat-1.3* Na-146*
K-3.6 Cl-109* HCO3-24 AnGap-17
[**2165-3-15**] 03:25AM BLOOD Glucose-92 UreaN-26* Creat-1.2 Na-145
K-4.2 Cl-108 HCO3-29 AnGap-12
[**2165-3-14**] 04:56AM BLOOD Glucose-109* UreaN-24* Creat-1.2 Na-143
K-4.3 Cl-107 HCO3-29 AnGap-11
[**2165-3-15**] 03:24PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2165-3-15**] 03:25AM BLOOD CK-MB-3 cTropnT-0.09*
[**2165-3-14**] 04:56AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2165-3-19**] 05:10AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
[**2165-3-18**] 05:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.7
[**2165-3-17**] 08:05AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.6
[**2165-3-15**] 03:25AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
[**2165-3-14**] 04:56AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.7 Cholest-101
[**2165-3-14**] 04:56AM BLOOD %HbA1c-6.6*
[**2165-3-14**] 04:56AM BLOOD Triglyc-58 HDL-41 CHOL/HD-2.5 LDLcalc-48.
[**2165-3-14**] 04:56AM BLOOD TSH-1.5
CT/CTA: 1. No acute intracranial hemorrhage.
2. The CT perfusion study demonstrates ischemia in the
distribution of the
inferior division of the left middle cerebral artery. It is not
clear whether the blood volume in the posterior temporal portion
of this territory is slightly reduced, i.e. whether an area of
infarction is also present. Questionable focal loss of
[**Doctor Last Name 352**]/white matter differentiation in the posterior left temporal
lobe on the non-contrast CT scan is also inconclusive with
respect to the presence of an acute infarction.
3. Extensive cervical and intracranial atherosclerosis.
Moderate, 50%
stenosis in the proximal left internal carotid artery. Mild
stenoses at the origins of both vertebral arteries.
4. Abrupt cut-off in a small distal branch of the inferior
division of the
left middle cerebral artery, likely related to embolic
occlusion.
5. Emphysema. Atelectasis. Not clear if pleural effusions are
present.
6. Cervical spondylosis.
MRI: 1. Several small diffusion abnormalities in the left
temporal and left basal ganglia consistent with acute infarct in
the posterior division of the left MCA.
2. No evidence of acute large hemorrhage, mass, or small
microvascular
hemorrhages.
3. Small vessel ischemic disease.
CT head negative for acute process done 1 week after stroke
CXR [**3-22**]: Large left pleural effusion and small right pleural
effusion are unchanged. Left lower lobe atelectasis is stable.
The upper lobes are clear. Cardiomegaly is partially obscured by
the pleuroparenchymal abnormalities. Patient is status post
CABG. There is no pneumothorax. No new lung abnormalities are
present.
Brief Hospital Course:
A/P: Patient is an 83 yo man with pmhx of DM, HTN, CAD, CHF with
EF 20%, Afib, HCC here with acute MCA stroke managed with [**Hospital **]
transferred to [**Hospital1 18**] for further management.
# MCA stroke: Patient is s/p TPA. Head CT without acute changes
[**3-20**]. Resolving defecits on exam and dysarrthria improved as
well on discharge. The stroke occured in the setting of a
subtherapeutic INR. Coumadin was restarted shortly after TPA
administration. Patient's INR climbed despite holding coumadin
to 8.6. 2.5 mg vitamin K which resulted in a trending down of
the INR to 2.3. The elevated INR was thought to be due to lack
of nutrition, antibiotics and liver disease (he has HCC). Given
the difficulty with his INR, lovenox was started when his INR
was 2.3. He should continue lovenox for his atrial fibrillation
and asa 81 mg daily. He has neurology follow-up. He needs to
work with PT. Speech and swallow initially thought he was an
aspiration risk because of his poor mental status, but as his
mental status improved, he was able to eat purreed food with
thickened liquids and per nurse was not aspirating at all. This
may be able to be advanced as he continues to improve and regain
strength so he will need repeat assessment at some point.
.
# Mental status changes: Patient was intermittently agitated and
somnolent. Repeat CT head was negative. He was noted to have a
UTI and was hypernatremic so these were the likely causes. We
treated the UTI with ceftriaxone and the hypernatremia with D5 W
and his mental status improved. He still has some short-term
memory problems but patient has early dementia at baseline.
Oriented to name and hospital and intermittently date. Will need
periodic labs to assess electrolytes especially if his po intake
declines.
.
# UTI: treated with ceftriaxone for 5 days, UA negative on
discharge so antibiotics were discontinued
.
# Hypernatremia: likely due to poor po intake when somnolent.
Resolved with D5W. Cont to monitor chem-7 every few days
.
# ARF: His creatinine climbed to 1.5 and his exam was volume
overloaded. We diuresed him with 40 mg IV lasix for 3 days and
diuresed several liters of fluid. On discharge his creatinine
was down to 1.1. UA without casts, rare urine eos.
.
# CHF with EF 15-20%: Patient received fluids after his stroke
and lasix was held. He became very overloaded with 2+ pitting
edema to his knees on exam and crackles on lung exam. Patient
received several 40 mg IV boluses of lasix and diuresed [**2-1**]
liters per day for 3 days. On discharge, his respiratory status
was improved and his LE edema was resolved. We also continued
asa, carvedilol and added 5 mg lisinopril once his creatinine
normalized. We continued him on 40 mg po lasix but his volume
status should be watched closely and this should be adjusted
based on his clinical exam.
.
# HTN: well-controlled, cont carvedilol and lisinopril
.
# DM: held rosiglitazone in setting of CHF. Covered with RISS.
Check fs qid.
.
# CAD: continued asa, statin, betablocker. Started AceI.
.
# AFib: rate controlled with carvedilol without any rvr, started
lovenox for anticoagulation once his INR was between [**3-5**] as his
INR was difficult to manage for the above reasons on coumadin.
.
# Hyperlipidemia: increased atorvastatin on this admission.
.
# HCC: inoperable per Dr. [**Last Name (STitle) **], patient declined other
treatment per wife. Prognosis per family is < 1 year. Lfts
elevated on this admission, no baseline to compare. Trending
down on discharge.
.
# Dementia: continued donepezil
.
# FEN: restarted pureed diet with thick liquids per s/s eval
[**3-22**] and per nurse, no aspiration events.
.
# Access: PIV
.
# Code: DNR/I- confirmed with his wife- HCP
Medications on Admission:
1. Lipitor 20mg daily
2. Bupropion 100mg [**Hospital1 **]
3. Coreg 12.5 [**Hospital1 **]
4. Cilostazol 100 [**Hospital1 **]
5. Aricept 5 daily
6. Avandia 4 daily
7. Coumadin 5 daily
8. ASA 325 daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Bupropion 100 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
8. 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.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day).
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: This
may need to be adjusted based on his volume status.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary
left mca ischemia s/p iv tpa
CHF
UTI
hypernatremia
Secondary
HTN
Afib
hyperlipidemia
dementia
Discharge Condition:
Stable
Discharge Instructions:
You were initially admitted because of a stroke. You received
medication in time to dissolve the clot which was causing the
symptoms. We also started you on lovenox for atrial fibrillation
to help reduce your risk of recurrent stroke. While you were
here, you became volume overloaded and received lasix and are
now improved. In addition, you became confused and were
diagnosed with a UTI and were hypernatremic. You were treated
for both of these issues and your confusion improved.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Please return to the ED if you experience any fever, chest pain,
difficulty breathing, abdominal pain or any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2165-5-27**] 1:30
Please follow-up with your PCP after leaving rehab.
|
[
"440.21",
"401.9",
"V45.88",
"294.8",
"790.92",
"434.91",
"584.9",
"412",
"293.0",
"311",
"276.0",
"599.0",
"428.23",
"V45.81",
"427.31",
"715.90",
"V58.61",
"155.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
12231, 12303
|
6973, 10692
|
290, 308
|
12450, 12459
|
3811, 6950
|
13223, 13462
|
2491, 2503
|
10942, 12208
|
12324, 12429
|
10718, 10919
|
12483, 13200
|
2518, 2538
|
230, 252
|
336, 2090
|
2797, 3531
|
3550, 3792
|
2577, 2781
|
2562, 2562
|
2112, 2315
|
2331, 2475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,083
| 175,357
|
45475
|
Discharge summary
|
report
|
Admission Date: [**2176-12-26**] Discharge Date: [**2177-1-16**]
Date of Birth: [**2103-8-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Aspirin / Compazine / Nifedipine /
Morphine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sudden onset of left sided weakness at 11.00 am today.
Major Surgical or Invasive Procedure:
IV tPA
PEG tube placement
Nasal packing for epistaxis
History of Present Illness:
73 year old RH female with past medical history significant for
atrial fibrillation (not on Coumadin), severe CHF, and
hypertension, who awoke this morning at 6AM asymptomatic. At
10AM, she talked to her sister on the phone and was normal.
Patient states that around she slipped in the bathroom, looked
at her watch, which said 11AM, and activated life alert. Her
son says that at 11:45AM, he heard the life alert voice go off
saying that they were on their way. He went downstairs and
found that she had fallen out of bed (not the bathroom). EMS
states that the life alert was actually activated at 12:50PM.
She was ten transported to [**Hospital1 18**] ED.
At arrival to [**Hospital1 **], she had a dense left hemiparasis, left
hemisensory loss, in addition to a left neglect. A head CT was
done, which confirmed a right MCA stroke and she was given tPA
at 3PM. Repeat examination 30 minutes later was relatively
unchanged.
In review of systems, she does not have fever, cough,
rhinorrhea, chest pain, shortness of breath, abdominal pain,
dysuria, or rash. She does not have diplopia or blurred vision
or dysphagia.
Past Medical History:
1. Pulmonary hypertension
2. Severe [4+] tricuspid regurgitation
3. Atrial fibrillation--on Plavix. Had been on Coumadin, but
developed hemoptysis in the setting if supratherapeutic INR of
22
requiring intubation and bronchoscopy in [**4-2**].
4. TIA ([**2166-1-28**])
5. Hypertension
6. SLE with joint involvement, malar rash
7. Chronic Pain syndrome
8. Fibromyalgia
9. OSA on CPAP--compliant. Uses 2L O2, but does not know
pressures.
10. GERD
11. IBS
12. Gout
13. Anemia: Iron deficiency anemia with negative upper and lower
endoscopy
14. H/o falls
15. Congestive heart failure, last echo [**4-2**], EF>55%, mod PA
hypertension.
Social History:
Lives on her own, son in same building. Daughter moved out
recently. Smoked in the past but unable to tell us how much,
rare alcohol use, occasional drug use.
Family History:
Hypertension, CAD, Cancer. Both parents died of CHF.
Physical Exam:
T- 99.6 BP- 155/88 (180/90 with EMS) HR- 71 RR- 18 O2Sat 97
2L
Gen: Lying in bed with head turned to the right
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruits
CV: Irregularly irregular
Lung: Clear to auscultation bilaterally, no wheezes
Abd: +BS soft, nontender
Ext: Some edema at the ankles
NIH STROKE SCALE: 17
1a. LOC: alert(0)
1b. LOC questions: answer question correctly(0)
1c. LOC commands: closed eyes and gripped with **(nonparetic)
hand (0)
2. Best gaze: Forced deviation to right(2)
3. Visual: complete hemianopia(2)
4. Facial Palsy: partial paralysis(2)
5a. Left arm: no movement(4)
5b. Right arm: no drift (0)
6a. Left leg: no movement(4)
6b. Right leg: no drift (0)
7. Limb ataxia: not done
8. Sensory: severe sensory loss on left arm and left leg(2)
9. Language: no aphasia, normal (0)
10. Dysarthria: mild dysarthria (1)
11. Extinction/inattention: (0)
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and not date. Attentive
with exam. Speech is fluent with normal comprehension. Follows
2 step commands. Dysarthric. Able to read and name.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields with questionable left visual field
loss (vs neglect), eyes cross midline when looking left but not
fully. Sensation decreased to LT on left V2-3 areas. Left UMN
facial droop. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Trap [**3-31**]. Tongue midline.
Motor:
Normal bulk bilaterally. Tone decreased in left upper and lower
and lower extremity. Good strength in right upper and lower
extremity. 0/5 in left upper and lower extremity.
Sensation: Intact to light touch throughout trunk and
extremities on right but not on left upper and lower and left
side of face.
Reflexes:
2 on right upper extremity, 1 on left side upper extremity, 0 at
patella and achilles.
Toes downgoing on right, upgoing on left.
Coordination and gait deferred.
Pertinent Results:
[**2176-12-26**] 01:44PM BLOOD WBC-7.1 RBC-4.99 Hgb-14.6 Hct-44.7 MCV-90
MCH-29.3 MCHC-32.7 RDW-15.7* Plt Ct-215
[**2176-12-27**] 08:36AM BLOOD PT-14.8* PTT-30.5 INR(PT)-1.3*
[**2176-12-26**] 01:44PM BLOOD PT-13.3 PTT-28.6 INR(PT)-1.1
[**2176-12-27**] 08:36AM BLOOD Glucose-163* UreaN-20 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2176-12-26**] 01:44PM BLOOD ALT-16 AST-25 LD(LDH)-205 AlkPhos-199*
TotBili-0.9
[**2176-12-26**] 01:44PM BLOOD CK-MB-5 cTropnT-<0.01
[**2176-12-27**] 08:36AM BLOOD CK-MB-5 cTropnT-<0.01
[**2176-12-27**] 08:36AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 Cholest-PND
[**2176-12-26**] 01:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-12-26**] 01:47PM BLOOD Glucose-133* Na-140 K-4.1 Cl-93*
calHCO3-33*
.
HCT:
Large acute infarct of the right MCA territory. Hyperdense right
MCA indicates acute thrombus. No hemorrhage is seen.
.
EEG: Abnormal EEG due to the marked interhemispheric asymmetry
with the right hemispheric slowing in evidence both anteriorly
and posteriorly. No frank discharging features were seen.
.
Transesophageal echocardiogram:
The left atrium is dilated. Moderate to severe spontaneous echo
contrast (smoke) is seen in the body of the left atrium. Severe
spontaneous echo contrast is present in the left atrial
appendage and presence of thrombus formation can not be excluded
due to severity of dense smoke. The left atrial appendage
emptying velocity is borderline depressed ( There is symmetric
left ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta and at least simple
atheroma in aortic arch (compex atheroma can not be excluded).
Sponteneous echo contrast is also seen in descending aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Presence of dense spontaneous echo contrast in left
atrium and left atrial appendage. Thrombus in formation in LAA
can not be excluded. Complex aortic atheroma and spontaneous
echo contrast in the descending thoracic aorta.
.
RUE ultrasound
No evidence for DVT, right upper extremity.
Brief Hospital Course:
Ms. [**Known lastname **] [**Last Name (Titles) **] a 73 year old woman with a PMH s/f atrial
fibrillation off of coumadin, diastolic CHF, and HTN who was
initially admitted on [**12-26**] with sudden onset of left sided
weakness. A head CT confirmed the presence of a right MCA
stroke, and she was given tPA. She was initially admitted to
the neuro-SICU for monitoring, and upon doing well she was
admitted to the neurology service. Her residual deficits
included left hemiparesis, left facial droop, and dysarthria. A
TEE confirmed the presence of a left atrial thrombus, and her
stroke was thought to be embolic secondary to afib off of
coumadin. On [**1-3**] she was noted to be hypotensive to a SBP of 58
in the setting of a fever to 101.4, leukocytosis, EKG changes,
and CK's peaking to 2500. She was transferred to the MICU for
pressure support with neosynephrine, fluids and intubation. The
MICU team felt her shock picture was more consistent with septic
shock, and initially covered her with vancomycin, meropenam, and
flagyl. Cardiology was consulted for her cardiac picture and it
was felt that this was likely a NSTEMI secondary to demand, and
the patient was medically managed without anticoagulation. Her
cultures later revealed pan sensitive enterococcus and
klebsiella in her urine, and MRSA on her bronchoscopy washings.
She was started on a 10 day course of IV zosyn and a 7 day
course of IV cipro. A PICC line was placed on [**1-7**] for long
term abx, and a PEG tube was placed for tube feeds in the
setting of severe dysphagia. Coumadin was re-started in the
setting of her atrial thrombus confirmed on TEE, as her stroke
was likely embolic in nature. We discussed this decision with
both neurology and her PCP as she has a history of severe
pulmonary hemorrhage in the setting of an INR of 22 in the past.
As she is going to rehab and will be closely monitored we are
comfortable with this decision. Current active issues include:
1. New fevers and leukocytosis off of cipro- A UA was positive
in this setting. Foley catheter was removed and cipro
re-started. She defervesced. She will complete a 10 day course
for a presumed foley-associated UTI. Cultures will need to be
followed up.
2. Volume overload: After a 5liter volume resuscitation she
became short of breath. She resoponds to lasix 80mg IV, and
atrovent nebs. She may need to be restarted on her home regimen
of po furosemide when she is euvolemic.
3. AFR: creatinine is elevated in the setting of intravascular
depletion and lisinopril. Lisinopril often induces ARF in this
patient, so it is held.
Medications on Admission:
1. AMBIEN 5 mg qhs
2. CLONAZEPAM 0.5 mg qhs prn insomnia
3. FERROUS SULFATE 325 mg [**Hospital1 **]
4. IPRATROPIUM BROMIDE 0.2 mg/mL one nebulized solution QID
5. LASIX 80 mg [**Hospital1 **]
6. LIDODERM 5 % (700 mg/patch) apply for 12h eachday
7. LISINOPRIL 10 mg daily
8. METOPROLOL TARTRATE 100 mg TID
9. PERCOCET 5 mg-325 mg prn
10. PLAVIX 75 mg daily
11. PRILOSEC 20mg daily
12. ULTRAM 100mg TID prn
13. Vitamin D 800 units daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Apply for 12 hours each day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
8. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
15. PICC line care per protocol
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
- Cardioembolic right MCA stroke
- Left atrial thrombus
- NSTEMI
- MRSA pneumonia
- Klebsiella / Enterococcal UTI
- Epistaxis
.
Secondary:
- Atrial fibrillation
- Diastolic heart failure
- Pulmonary hypertension
- Cor pulmonale
- Massive hemoptysis in setting of supratherapeutic INR
- TIA
- Hypertension
- SLE
- OSA
- GERD
- Gout
- Iron deficiency anemia, (-) upper/lower GI workup
Discharge Condition:
Left hemiplegia.
Discharge Instructions:
You were admitted for left sided weakness and found to have a
large right sided stroke. We also diagnosed a pneumonia and a
urinary tract infection for which you are getting IV
antibiotics.
.
Please take all of your medications as directed.
.
Please follow up as indicated below.
.
Return to the emergency department if you develop any concerning
symptoms such as shortness of breath, chest pain, new lower or
upper extremity weakness, bloody or tarry stools.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2177-1-13**] 4:15
.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 12454**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2177-1-22**] 4:00
|
[
"280.9",
"518.81",
"995.92",
"038.49",
"784.5",
"V15.82",
"427.31",
"410.71",
"327.23",
"787.20",
"416.8",
"038.0",
"276.0",
"530.81",
"784.7",
"786.3",
"402.91",
"428.33",
"429.79",
"785.52",
"781.94",
"428.0",
"599.0",
"V09.0",
"424.2",
"710.0",
"470",
"342.92",
"434.11",
"274.9",
"719.90",
"584.9",
"794.01",
"V17.49",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.71",
"99.04",
"99.10",
"99.19",
"33.24",
"96.6",
"96.04",
"99.21",
"38.93",
"43.11",
"21.01",
"89.14"
] |
icd9pcs
|
[
[
[]
]
] |
11499, 11570
|
7062, 9669
|
382, 438
|
12006, 12025
|
4576, 7039
|
12534, 12853
|
2440, 2496
|
10155, 11476
|
11591, 11985
|
9695, 10132
|
12049, 12511
|
2511, 3450
|
287, 344
|
466, 1593
|
3707, 4557
|
3465, 3691
|
1615, 2247
|
2263, 2424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,426
| 199,509
|
27559
|
Discharge summary
|
report
|
Admission Date: [**2189-8-24**] Discharge Date: [**2189-9-8**]
Date of Birth: [**2140-10-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Sternal debridement and bilateral pectoral flaps and omental
flap
History of Present Illness:
48 yo M s/p Bentall procedure presented to PCPs office with
SOB/fevers/sternal wound erythema and drainage.
Past Medical History:
Prior history of Hypertension although patient states he has not
been on meds and was recently normotensive
Hyperlipidemia
Deviated septum, Bronchospastic lung disease
Depression
GERD
Excision of a salivary gland due to stones
Social History:
Patient is single and lives alone. He works as a
plumber.
Drinks a 12 pack of beer per week.
Family History:
Paternal side of family with CAD. Grandfather
died at age 65 from an MI. Father with rheumatic fever.
Physical Exam:
Diaphoretic 100.4 92 152/74 24 92% on RA
Lungs CTAB
RRR with audible valve click
Crepitus from Nipples to clavicle left chest > right
Abdomen soft/NT
[**1-5**]+ peripheral edema
Pertinent Results:
[**2189-9-7**] 04:55AM BLOOD WBC-15.3* RBC-3.26* Hgb-10.1* Hct-29.4*
MCV-90 MCH-31.0 MCHC-34.3 RDW-15.7* Plt Ct-541*
[**2189-9-6**] 05:17AM BLOOD WBC-16.2* RBC-3.16* Hgb-9.9* Hct-29.0*
MCV-92 MCH-31.4 MCHC-34.3 RDW-15.6* Plt Ct-535*
[**2189-9-8**] 10:56AM BLOOD PT-20.6* PTT-32.0 INR(PT)-2.0*
[**2189-9-7**] 04:55AM BLOOD PT-20.7* PTT-26.6 INR(PT)-2.0*
[**2189-9-6**] 05:17AM BLOOD PT-23.8* INR(PT)-2.4*
[**2189-9-5**] 07:15AM BLOOD PT-25.6* PTT-29.8 INR(PT)-2.6*
[**2189-9-4**] 05:02AM BLOOD PT-31.2* PTT-31.5 INR(PT)-3.3*
[**2189-9-3**] 02:50PM BLOOD PT-35.5* PTT-30.9 INR(PT)-3.9*
[**2189-9-6**] 05:17AM BLOOD UreaN-16 Creat-1.0 K-4.1
[**2189-9-4**] 05:02AM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-29 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname **] was taken to the operating room the day of
admission for a mediastinal reexploration, washout. His chest
was left open postoperatively. He was seen in consultation by
plastic surgery for potential flaps. His OR cultures grew out
enterococcus and he ws started on linezolid. He was taken to the
operating room again on [**2189-8-27**] where he underwent bilateral
pectoral advancement flaps and omental flap performed by Dr.
[**First Name (STitle) **] with plastic surgery. He was seen in consultation by
infectious diseases for continued management. His linezolid was
changed to vanocmycin after it was determined that the
enterococcus was not VRE. He self extubated on [**2189-8-29**] and
remained extubated. He was transferred to the floor on [**2189-8-31**].
He was anticoagulated for his mechanical valve. He was ready for
discharge on [**2189-9-8**].
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours) for 5 weeks: 6 weeks from [**8-28**].
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: Heparin Flush PICC (100
units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift. .
8. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day).
14. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Sternal wound infection
secondary:
Ascending aortic aneurysm s/p Bentall (Mechanical)
AS
Obesity
HTN
lipids
deviated septum
depression
GERD
bronchospastic lung disease
s/p excision of salivary gland [**2-5**] stones
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
[**First Name8 (NamePattern2) 7618**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2189-10-13**] 10:30
Suite GB LMOB
Plastic Surgeon Dr. [**First Name (STitle) **] 1-2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] after d/c from Rehab
Weekly CBC, BUN/Creatinine, vanco trough
INR PRN
Completed by:[**2189-9-8**]
|
[
"998.31",
"423.9",
"519.2",
"278.00",
"272.4",
"998.59",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"86.74",
"00.14",
"77.61",
"34.1",
"38.93",
"54.74",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
4314, 4387
|
1987, 2871
|
328, 396
|
4647, 4655
|
1229, 1964
|
4911, 5277
|
911, 1015
|
2894, 4291
|
4408, 4626
|
4679, 4888
|
1030, 1210
|
282, 290
|
424, 533
|
555, 784
|
800, 895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,433
| 194,129
|
13898+56491
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-9-7**] Discharge Date: [**2130-9-12**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] YO Russian speaking woman BIBA from [**Hospital 100**] Rehab due to
decreaesed energy and deteriorating ability to ambulate;
laboratory workup at HR was sig for worsening renal failure vs.
baseline and bicarb of 7. Per pt, she has felt more fatigued
over the past few days, with decreased appetite; denies
dysuria/frequency or decreased urine output; denies CP/SOB/F/C
N/V diarrhea/constipation or any other complaints. She denies
medication changes, or increase in medications including pain
relievers. She does have chronic b/l knee pain.
Past Medical History:
PMH:
1. CRI (baseline Cr 1.5-1.7)
2. A-Fib
3. OA (Bil Knee Pain)
4. Chronic Constipation
5. Remote BRCA s/p mastectomy and radiation therapy
6. HTN
7. Right Foot Plantar Spur
8. Anemia
.
PSH:
Left Mastectomy
Social History:
SH: From [**Hospital 100**] Rehab, Daughter (Feni Gurevick, [**Telephone/Fax (1) 14943**]);
Second contact is granddaughter [**First Name5 (NamePattern1) **] [**Name (NI) 41636**],
[**Telephone/Fax (5) 41637**])
Family History:
FH: N/C
Physical Exam:
Vitals: 69.2 72 106/50 20 99RA
.
Gen - NAD
HEENT - PERRLA/EOMI, lids/conj clr, anicteric schlera, nares
clr, OP clear w/o exudate/erythema, nares clear bilaterally
Neck - supple, ntn, FROM, no tender [**Doctor First Name **], no JVD
Chest - s/p L mastectomy, irreg irreg S1S2 w/o MGR
Lungs - CTAB, good air movement bil bases
Abd - NABS, soft, ntn, no guarding/rebound, large soft nontender
midline ventral hernia
Exts - LUE diffusely edematous, 2+ [**Hospital1 **]-pedal edema, no pedal
wounds
Neuro - CNII-XII intact, moving exts x4 nonfocally, unable to
tolerate ambulation w/o significant assistance
Skin - no rashes or lesions
Pertinent Results:
EKG [**2130-9-7**] - irreg irreg VR 72, NA, NI (QRS, QTc), no ST
changes, T wave flattening inferiorly (II, III, aVF) and
laterally (I, aVL)
.
CXR [**9-7**]
No prior studies for comparison. The heart size is not well
assessed AP technique. The thoracic aorta is tortuous. There is
a vague curvilinear calcification overlying the medial left
heart, which may relate to valvular calcifications. The lungs
are clear without
consolidation, pneumothorax, or pleural effusion, though the
lung apices are suboptimally assessed. No evidence of congestive
heart failure. The visualized bony structures are normal.
.
[**9-7**] Renal U/S
No prior studies. The kidneys are slightly small and echogenic
within normal limits for patient age. The right kidney measures
8.6
cm and the left kidney measures 8 cm. There is no hydronephrosis
or focal renal lesions, with the exception of a small 2-cm
simple cyst in the upper pole of the left kidney. No perinephric
collections. The bladder is not optimally distended but
demonstrates no abnormalities. No hydronephrosis.
.
Echo [**9-9**]
Conclusions: 1. The left atrium is mildly dilated. 2. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. 3. The aortic valve leaflets are mildly thickened. No
aortic regurgitation is seen. 4. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
[**2130-9-7**] 06:38PM LACTATE-1.2
[**2130-9-7**] 08:20PM PT-12.1 PTT-24.3 INR(PT)-1.0
[**2130-9-7**] 08:20PM PLT COUNT-264
[**2130-9-7**] 08:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
[**2130-9-7**] 08:20PM NEUTS-76.1* LYMPHS-16.4* MONOS-4.9 EOS-1.9
BASOS-0.7
[**2130-9-7**] 08:20PM WBC-11.0 RBC-3.29* HGB-10.1* HCT-29.1* MCV-88
MCH-30.6 MCHC-34.6 RDW-16.7*
[**2130-9-7**] 08:20PM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-4.8*
MAGNESIUM-2.7*
[**2130-9-7**] 08:20PM LIPASE-46
[**2130-9-7**] 08:20PM ALT(SGPT)-14 AST(SGOT)-11 CK(CPK)-66 ALK
PHOS-124* AMYLASE-50 TOT BILI-0.4
[**2130-9-7**] 08:20PM GLUCOSE-115* UREA N-57* CREAT-4.0* SODIUM-133
POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-9* ANION GAP-20
[**2130-9-7**] 11:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-MOD
[**2130-9-7**] 11:00PM URINE RBC-<1 WBC-[**5-13**]* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2130-9-7**] 11:00PM URINE HOURS-RANDOM UREA N-239 CREAT-37
SODIUM-32 POTASSIUM-7 CHLORIDE-39 TOTAL CO2-LESS THAN
Brief Hospital Course:
Ms. [**Known lastname 41638**] is a [**Age over 90 **] yo Russian-speaking woman sent in from
[**Hospital 100**] Rehab on [**9-7**] due to decreased energy, found to be in
acute on chronic renal failure (creatinine on admission 4.0).
She was initially admitted to the floor, but later transferred
to the MICU for systolic blood pressure in the 80's, believed to
be secondary to overtreatment of hypertension for a prolonged
period of time. The nephrology team was consulted. She had muddy
brown casts in urine, and renal felt that a prolonged period of
hypotension may have led to ARF at the time of admission. She
received 2L of NS and her BP increased appropriately. Sepsis was
considered as a source of her hypotension, but no white blood
cell count and no fevers. Concern for a UTI (few bacteria, [**5-13**]
white cells) prompted a three day course of ciprofloxacin.
.
Her renal failure improved with hydration. She was acidemic with
a low bicarb, which corrected with her renal function
improvement and with fluids containing bicarb.
.
Shortly after her transfer from the MICU to floor, she developed
atrial fibrillation with rapid ventricular response up to the
130's-140's. Her blood pressure was stable. She denied chest
pain, shortness of breath, palpitations, dizziness, or
lightheadedness. EKG did not reveal ischemic changes. Her blood
pressure did not tolerate high enough doses of
metoprolol/diltiazem to control her atrial fibrillation, so
digoxin was loaded and continued at a dose of 0.125mg every
other day with good effect; her heart rate was 80's-90's
thereafter. She should have an EKG and digoxin level drawn
approximately 7 days after it started ([**9-19**]).
.
On [**9-9**], her urine culture was positive for 10,000-100,000 CFU
of Strep bovis. The patient is afebrile, without a white count,
and with no urinary symptoms. A repeat U/A on [**9-10**] was
completely negative. She should be monitored clinically for
infection.
Medications on Admission:
Tylenol
ASA 325 qd
Diltiazem CD 240 qd
Colace 100 [**Hospital1 **]
FeS 325 [**Hospital1 **]
Protonix 40 qd
Ducolax 10 PR prn
Paxil 10 qd
Lactulose 40 qPM
HCTZ 25 qd
Lisinopril 5 qd
Metoprolol XL 100 qd
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet
PO once a day.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Not to exceed 4g per day.
5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): If patient not ambulating.
12. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
13. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
14. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) mL
Injection QMOWEFR (Monday -Wednesday-Friday).
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute renal failure on top of chronic renal insufficiency
Hypotension
Atrial fibrillation with rapid ventricular response
Anemia
Discharge Condition:
Stable, satting well on RA, HR well-controlled, normotensive.
Discharge Instructions:
You were admitted for fatigue; you were found to have acute
renal failure on top of your chronic renal insufficiency. Please
take all of your medications as prescribed. If you experience
any pain, chest pain, shortness of breath, nausea, vomiting, or
other concerning symptoms, please seek medical attention
immediately.
Followup Instructions:
Please follow up with your doctors at the [**Name5 (PTitle) 100**] Rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
Name: [**Known lastname 7511**],[**Known firstname **] Unit No: [**Numeric Identifier 7512**]
Admission Date: [**2130-9-7**] Discharge Date: [**2130-9-12**]
Date of Birth: [**2039-2-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7513**]
Addendum:
The patient was discharged on 0.0625mg digoxin every other day
instead of 0.125mg as noted in the original discharge summary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7514**] MD, [**MD Number(3) 7515**]
Completed by:[**2130-9-13**]
|
[
"276.2",
"585.9",
"715.36",
"403.90",
"584.5",
"V10.3",
"427.31",
"599.0",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9411, 9635
|
4483, 6433
|
226, 233
|
8285, 8349
|
1976, 4460
|
8718, 9388
|
1299, 1308
|
6686, 8023
|
8133, 8264
|
6459, 6663
|
8373, 8695
|
1323, 1957
|
179, 188
|
261, 822
|
844, 1054
|
1070, 1283
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,586
| 145,340
|
5204
|
Discharge summary
|
report
|
Admission Date: [**2152-9-23**] Discharge Date: [**2152-9-28**]
Date of Birth: [**2126-2-2**] Sex: F
Service: MEDICINE
Allergies:
Cogentin / Benadryl
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
ASA overdose
Major Surgical or Invasive Procedure:
Tracheal Intubation
Central Venous Catheter for hemodialysis
History of Present Illness:
26F with history of depression, borderline personality disorder,
PTSD, took [**3-8**] bottle (estimated 250 tabs of 325 mg) ASA
(unknown if enterically coated) at 10pm last night.
.
In the ED, initial vs were: T100.8, P84, BP 120/76, R16, O2 sat
100% RA. Per ED, c/o abdominal pain, unclear if other concerning
sx. Voicing SI. patient drowsy, otherwise neurologically intact.
Noted increased work of breathing. Patient was given 50 grams
charcoal (threw it up and gave again). No NGT in place. Bicarb
running. Initial ASA level 63, then up to 96 on recheck.
.
In the MICU, patient initially became obtunded, responded to
more bicarb and stimulation. Set up for HD line placement
aborted due to patient agitation. Patient urgently intubated in
order to perform line placement safely (required IM ketamine for
sedation [**2-7**] loss of IV access). Intubated, CVL, Aline placed.
Preparing for HD line placement and urgent HD.
.
Review of systems:
(+) Per HPI
(-) Unable to obtain
.
Past Medical History:
Past Medical History:
borderline personality disorder
[**Name (NI) 7350**]
PTSD
h/o severe self injury and multiple suicide attempts ([**Month (only) 956**]
[**2152**] 60 diet supplements of hydroxycut, discharged from [**Hospital1 **] 4
on [**2152-9-6**] after 1 week stay for "dissociating")
asthma
anemia
headaches
Social History:
lives in group home in [**Location (un) 686**], attends [**Location (un) 18750**] program through
[**Hospital **] [**Hospital 4189**] Health Center. PER [**Name (NI) **] pt has h/o physical and
sexual abuse from age [**2-13**], has 11th grade education. Per [**Name (NI) **] pt
has h/o substance abuse.
Family History:
mother with EtOH abuse and bipolar disorder
two sisters with bipolar disorder. Her mother has diabetes,
hypertension, and coronary artery disease.
.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated and sedated, nonresponsive on sedation
HEENT: Sclera anicteric, MMM, ETT in place, charcoal on face.
Neck: supple, JVP appears flat, no LAD
Lungs: Mildly rhonchorous bilaterally, no wheezes or crackles.
CV: Tachy, regular, no m/r/g appreciated
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Healed UE marks from cutting.
Pertinent Results:
LABS ON ADMISSION:
7.34/33/37 (venous)
UA negative
Utox negative
asa level initially 63, repeat pending
serum tox negative
138 | 107 | 15
----------------100 AG:15
4.6 | 16 | 1.1
.
9.2>34.4<430 59N, 35L, 4M, 2E
MCV82
.
INR 1.1
.
EKG: NSR at 86, NANI, QTc 400, QRS 74
.
Aspirin levels:
[**2152-9-23**] 01:35AM BLOOD ASA-63* Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-9-23**] 03:20AM BLOOD ASA-94*
[**2152-9-23**] 04:50AM BLOOD ASA-105*
[**2152-9-23**] 07:25AM BLOOD ASA-91*
[**2152-9-23**] 09:30AM BLOOD ASA-58*
[**2152-9-23**] 11:25AM BLOOD ASA-38*
[**2152-9-23**] 01:16PM BLOOD ASA-15
[**2152-9-23**] 05:37PM BLOOD ASA-7
[**2152-9-23**] 10:51PM BLOOD ASA-17
[**2152-9-24**] 03:11AM BLOOD ASA-31*
[**2152-9-24**] 05:45AM BLOOD ASA-38*
[**2152-9-24**] 08:03AM BLOOD ASA-34*
[**2152-9-24**] 11:21AM BLOOD ASA-27*
[**2152-9-24**] 03:46PM BLOOD ASA-21
[**2152-9-24**] 07:50PM BLOOD ASA-14
[**2152-9-24**] 11:40PM BLOOD ASA-9
[**2152-9-25**] 03:28AM BLOOD ASA-NEG
[**2152-9-25**] 08:27AM BLOOD ASA-NEG
[**2152-9-25**] 02:56PM BLOOD ASA-NEG
Brief Hospital Course:
Assessment and Plan: 26F with history of depression, PTSD,
borderline personality; admit with large ASA overdose.
.
# ASA overdose: Pt reports taking 250 325mg tablets = 80grams.
Became obtunded upon arrival to MICU, which improved with
subsequent agitation. Need for dialysis given very high levels
(>100). HD line placed and pt dialyzed x1. Pt required
intubation for airway protection and was hyperventilated to
avoid acidemia in setting of asa overdose. Maintained on sodium
bicarb until ASA level nondetectable on [**2152-9-25**], at which point
sodium bicarb fluids d/c'ed. Patient self-extubated. Acid-base
disorder stabilized.
.
# Anemia: Pt had a HCT trend down to 23 in the ICU, with BRBPR
and hard stools. GI conult felt due to ASA gastritis vs
hemorroidal bleed mostly. She gives a history consistent with
GERD. Was tranfused 1U x PRBC, HCT to 28 --> 30. She is on PPI
prophylaxis given gastritis potential for ASA and h/o consistent
with GERD. An outpatient EGD was recommended to evaluate for
Barrett's.
.
# Hypotension/tachycardia. Following intubation. ?meds vs.
positive pressure ventilation vs. infection vs. hypovolemia vs
just effects from overdose itself. Briefly required
phenylephrine, however, this quickly resolved and BP is stable
off of pressors or support. Patient has baseline BP in the 90s
w/o symtpoms, and this was documented in recent otpt PCP visit
[**2152-8-5**].
.
# Fever. Resolved. Likely [**2-7**] overdose. Also concerned for
infection. She was apyrexic when discharged from ICU and not on
antibiotics and with no signs of active infection at this time.
.
# Suicidal attempt. Long history of depression and SI/suicidal
behavior with multiple attempts in the past (drug overdose,
cutting, swalling glass). Psychiatry is following. On 1:1
sitter. Currently back on home psych meds, pending transfer to
inpatient facility. Patient medically stable and cleared to go
to psych facility.
# Mild liver injury - resolving. Mildly elevate INR, AST, LDH
trending down. Normal to elevated fibrinogen (acute phase
reactant), normal haptoglobin (not low) do not suggest
hemolysis. This likely related to ingestion event and should be
self limited.
.
# FEN: full diet
# Contacts: Lives @ [**Last Name (NamePattern1) **] Group Home in [**Location (un) **] [**Telephone/Fax (1) 21280**]
Psychiatrist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ MMHCTR {[**Telephone/Fax (1) 21273**]}
She also works with Dr. [**First Name4 (NamePattern1) 7810**] [**Last Name (NamePattern1) 21274**] @ MMHCTR {pg [**Numeric Identifier 21275**]
thru [**Hospital1 18**] pager{[**Telephone/Fax (1) 9521**]}
Medications on Admission:
Medications (per discharge from [**2152-9-6**]) :
- Chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
- Chlorpromazine 25 mg Tablet Sig: Two Tablet PO 2PM & 5PM
- Bupropion HCl 300 mg Tablet SR Two Tablet Sustained Release PO
QAM
- Fluticasone 50 mcg/Actuation Spray, One DAILY
- Loratadine 10 mg Daily
- Docusate Sodium 100 mg [**Hospital1 **]
- Naproxen 250 mg Two (2) Tablet PO QAM
- Naproxen 250 mg One (1) Tablet PO QPM
- Omeprazole 20 mg [**Hospital1 **]
- Simvastatin 10 mg QHS
- Clonazepam 1 mg Tablet [**Hospital1 **]
- Chlorpromazine 100 mg QAM
- Chlorpromazine 100 mg [**Hospital1 **] as needed for agitation/anxiety.
- Topiramate 100 mg Two (2) Tablet PO DAILY
- Propranolol 10 mg Three (3) Tablet PO BID
- Prazosin 1 mg - Two (2) Capsule PO QPM
- Desmopressin 0.1 mg Tablet Four (4) Tablet PO QHS
Discharge Medications:
1. Chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
2. Chlorpromazine 100 mg Tablet Sig: 0.5 Tablet PO AS DIRECTED
().
3. Chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO BID PRN
() as needed for anxiety/agitation.
5. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
8. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO QHS (once a day
(at bedtime)).
9. Propranolol 10 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Units Injection TID (3 times a day): if not regularly
ambulatory.
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]-[**Hospital1 **] 4
Discharge Diagnosis:
Depression with Suicidal attempt
Aspirin Overdose
Anemia, NOS
Gastritis
GERD
Discharge Condition:
Improved
Discharge Instructions:
You were admitted for aspirin overdose. You required intubation
for airway protection and hemodialysis to remove the salicylate
from your blood. You had mild liver injury which is healing on
its own. You had mild blood loss likely as a result of chronic
GERD and mild gastritis made worse by aspirin ingestion. You
were transfused one unit of red blood cells for this, and placed
on a medication to protect the lining of your stomach. As
explained to your by GI team, you will need an outpatient
endoscopy to fully evaluate your stomach and esophagus for
continue gastritis or precancerous changes which can occur with
chronic GERD. You are being discharged to an inpatient
psychiatric facility to further address your psychiatric issues
of depression and suicidal ideation. You should refrain from
any aspirin or NSAID products.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2152-10-12**] 9:10
You need to follow-up with your PCP (Dr [**Last Name (STitle) 21281**] with Dr. [**Last Name (STitle) **] at
[**Company 191**] [**Hospital1 18**]) when you are discharged from psychiatric inpatient
care. You will need an upper endoscopy.
|
[
"285.9",
"V62.84",
"296.33",
"301.83",
"E950.0",
"458.9",
"276.8",
"401.9",
"493.90",
"535.41",
"309.81",
"287.5",
"564.09",
"965.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.95",
"39.95",
"38.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8583, 8783
|
3776, 6427
|
292, 355
|
8904, 8915
|
2691, 2696
|
9798, 10170
|
2044, 2195
|
7322, 8560
|
8804, 8883
|
6453, 7299
|
8939, 9775
|
2210, 2672
|
1328, 1365
|
240, 254
|
383, 1309
|
2710, 3753
|
1409, 1707
|
1724, 2028
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,134
| 174,214
|
10988
|
Discharge summary
|
report
|
Admission Date: [**2203-6-26**] Discharge Date: [**2203-6-30**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / ORENCIA / Remicade
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Central venous catheter placement
History of Present Illness:
Mr. [**Known lastname 17385**] is a 39 yo M with complex medical history,
significant for psoriatic arthritis c/b steroid dependence.
Patient had been tapering his prednisone and his dose was
recently changed from 8mg/day to 7mg/day on [**2203-6-18**]. He reports
feeling more malaise, lethargy and somnolent, but his BP was
doing ok at home (pt checks it 3 times daily). On [**2203-6-25**],
patient noticed that his evening SBP was down to 100 (baseline
of 120-130). On rechecks, it ultimately came down to 50s/40s.
Patient reports 1 episode of vomiting and 3 falls during that
evening, last of which prompted him to call EMS. His falls were
thought to be from hypotension. He hit his head multiple times
on surrounding furniture during these falls as well.
.
He was brought to [**Hospital3 20284**] Center. BP was initially 70/33
at OSH where he received 6 L NS and was placed on levophed. Labs
significant for BUN 39, Cr 2.8, WBC 8.4, H/H 11.4/34.9, Plt 303
Bands 12% N 79% L 3% M 5% myelocyte 1%. He received vancomycin
1 g IV, zosyn 3.375 g IV, and hydrocortisone 100 mg before
transfer. Labs were significant at 4:35 [**2203-6-26**] for BNP 105,
CPK-MB 0.6, troponinI < 0.015, Lactic acid 2.9, phosphorous 5.9,
Cr 2.8, BUN 39. CXR with no acute cardiopulmonary process. At
this time, he was transferred to [**Hospital1 18**] for further management.
.
In the ED at [**Hospital1 18**], initial vs were: 96.4 72 109/61 18 100% 2L
NC, levo @ .11 mcg/kg/min. A RIJ central line was inserted, and
he was continued on levophed to SBP > 100. He was given
potassium chloride 40 mEQ IV. Initial ER labs are likely a
mistake, given repeat labs have normalized. WBC 8.3 with N 79.8,
L 11.6 with no bands, INR 1.2, Cr 1.6 (baseline ~ 1.2), CK-MB
3, cTropnT < 0.01, lactate 1.3. UA clean. Urine and blood
cultures pending.
.
When he was admitted to the ICU, he gave very detailed history
as above. He complained of an occipital headache that is similar
to his typical headaches. He was given compazine and dilaudid.
Past Medical History:
# Psoriatic arthritis c/b steroid dependence with exogenous
steroid-associated [**Location (un) **] syndrome, relative adrenal
insufficiency
# vitamin D deficiency
# abnormal thyroid function tests.
# Left gastrocnemius abscess and bacteremia growing MSSA ([**Month (only) 958**]
[**2201**]).
# History of MRSA infection status post eradication in [**2195**].
# Morbid obesity.
# Obstructive sleep apnea, autoset CPAP 14-18cmH20 with CFlex 2
# Irritable bowel syndrome.
# Hypertension.
# Diabetes mellitus type 2 on insulin
# Hyperlipidemia.
# Peripheral neuropathy.
# Nonalcoholic fatty liver disease secondary to previous
methotrexate treatment.
# Keratoconus status post bilateral corneal transplant ([**2186**],
[**2190**]).
# Status post four anal fistulotomies.
# Status post tonsillectomy x2 and adenoidectomy.
# Degenerative joint disease, status post L4/L5 discectomy.
# Patellofemoral syndrome, status post arthroscopic surgery for
both knees x3 each.
Social History:
Patient lives with his wife and children. He is currently on
disability, previously teacher for autistic children.
Tobacco: never
ETOH: occasional
Family History:
Mother: Ulcerative colitis, hypertension, hypercholesterolemia,
and bipolar disorder.
Father: Non smoking-induced COPD and hypertension.
Brother: Dermatologic psoriasis and ulcerative colitis.
Sister: Hypertension, hypercholesterolemia.
Paternal aunt: Crohn disease and sarcoidosis.
Physical Exam:
ON ADMISSION:
General Appearance: Overweight / Obese
Head, Ears, Nose, Throat: Normocephalic, buffalo hump
Cardiovascular: distant heart sounds
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Warm, various small cysts/boils, non of which seem
particularly actively infected
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal, some midline
neck discomfort; limited neck ROM similar by patient report to
chronic state
.
ON DISCHARGE:
VITALS: Tm 98.4; Tc 98.4; BP 130/P; P 73; RR 18; O2 99% RA
GENERAL: Pleasant man, NAD. Cushingoid appearance, looks older
than his stated age
HEENT: NC/AT, OP clear, MMM. Thick neck with buffalo hump.
CV: Faint heart sounds but nl S1/S2, without m/r/g. +tender
gynecomastia
Lung: CTAB, no crackles or wheezes
ABDOMEN: Purple striae throughout abdomen, obese, nontender to
palpation. +BS
EXT: Both knees with well healed surgical scars, L leg with well
healed calf surgical scar. DP/PT pulses 2+ bilaterally. 1+
edema.
NEURO: Grossly intact. Conversant.
Pertinent Results:
ADMISSION LAB:
[**2203-6-26**] 11:19PM GLUCOSE-224* UREA N-21* CREAT-1.3* SODIUM-142
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
[**2203-6-26**] 11:19PM CK(CPK)-278
[**2203-6-26**] 11:19PM CK-MB-3 cTropnT-<0.01
[**2203-6-26**] 11:19PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2203-6-26**] 11:19PM WBC-9.7 RBC-3.90* HGB-11.4* HCT-33.2* MCV-85
MCH-29.1 MCHC-34.3 RDW-15.5
[**2203-6-26**] 09:14PM LACTATE-1.4
[**2203-6-26**] 03:33PM CK-MB-3 cTropnT-<0.01
[**2203-6-26**] 03:33PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2203-6-26**] 03:33PM HAPTOGLOB-296*
[**2203-6-26**] 03:33PM CORTISOL-8.8
[**2203-6-26**] 11:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
.
DISCHARGE LAB:
[**2203-6-30**] 08:25AM BLOOD WBC-7.5 RBC-3.90* Hgb-11.2* Hct-32.4*
MCV-83 MCH-28.7 MCHC-34.5 RDW-15.9* Plt Ct-254
[**2203-6-30**] 08:25AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2203-6-30**] 08:25AM BLOOD CK(CPK)-51
[**2203-6-28**] 03:18AM BLOOD ALT-14 AST-14 LD(LDH)-251* AlkPhos-38*
TotBili-0.2
[**2203-6-30**] 08:25AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3
====================
IMAGING:
[**6-26**] CXR: The lungs are low in volume which results in crowding
of the bronchovascular structures. No [**Month/Day (4) **] pulmonary edema. The
cardiac silhouette is enlarged. The mediastinal silhouette
remains widened, compatible with mediastinal lipomatosis as
noted on prior CT. Hilar contours are unchanged. No focal
consolidation, pleural effusion or pneumothorax is present.
[**6-26**] CT-Cervical Spine: Slightly limited eval of lower cervical
spine due to pt size. No acute fx or malalignment. If concern
for ligamentous or cord injury, MRI should be obtained.
[**6-26**] NCHCT: No acute intracranial abnl.
======================
MICROBIOLOGY:
[**6-26**] BCx NGTD, UCx negative
[**6-26**] MRSA screen negative
[**6-29**] C diff toxin A &B negative
Brief Hospital Course:
Assessment and Plan:
39M with complex history including psoriatic arthritis on
chronic steroid therapy presents with hypotension requiring
pressors.
# Shock (adrenal insufficiency & hypovolemia): Patient
presented to [**Hospital **] Hospital with malaise and falls for the past
week. The day prior to presenation he took his BP meds
(CARVEDILOL - 12.5 mg and Torsemide 100 mg) despite SPBs in the
40s, and fell several times. He remained hypotensive in the 90s
systolic at the OSH despite fluid resucitation, stress-dose
steroids, and vasopressors. Concern was for hypovolemic shock in
the setting of fluid restriction and increased diuretic doses
versus septic shock given his immunosuppressed state versus
adrenal insufficiency given his chronic steroid usage. MI was
ruled out with serial enzymes. Cultures were negative at [**Hospital **]
Hospital, so antibiotics were stopped. Endocrine was consulted
who felt that adrenal insufficiency was likely contributing to
his hypotension but was not the primary cause. Vasopressors
were stopped in the MICU and his blood pressures were stable on
transfer. His blood pressure remained stable while his stress
steroid was tapered down and he was started on 10 mg of PO
prednisone daily. He will be discharged home with a rescue dose
of 4 mg IM dexamethasone.
# Syncope with trauma: The patient had several falls prior to
admission. He struck his head several times with enough force
to damage a wall and break a piece of furniture, which raised
concern for head or neck injury. Head and C-spine CT were
negative for acute injury. He had some pain at the trauma site
which were treated with tylenol.
# Chest pain: Symptoms correlated with hypotension and resolved
with normalization of blood pressure. Initial biomarkers at OSH
and BIMDC not suggestive of ACS. Troponin was <0.01 x2 at this
hospital. No complaint of chest pain at the time of discharge.
# Acute renal failure: Cr was 2.8 at OSH with trend to 1.2 with
volume resuscitation. This was likely pre-renal in etiology. By
the time of discharge, it had downtredned back to his baseline
Cr of 0.8.
# Steroid-induced fluid retention: Patient appears obese with
edema likely from underlying steroid-induced fluid retention. He
has been previously evaluated by cardiology with no apparent
cardiac, renal, or hepatic etiologies of fluid. His
spironolactone and torsemide were held in the setting of his
hypotension. His torsemide was started at 50 mg daily on [**6-30**]
given his increasing peripheral edema. Patient was instructed to
continue taking 50 mg torsemide daily for 3-4 days after
discharge while monitoring blood pressure. He was also
instructed to increase the dose to 100 mg torsemide daily
(torsemide) afterwards if peripheral edema worsened.
# Psoriatic arthritis: Azathioprine and ustekinumab were held
in the acute setting. Azathioprine was restarted on [**2203-6-28**] per
rheumatology recommendation.
# Diarrhea: pt developed diarrhea night of [**6-29**], characterized by
crampy abdominal pain relieved with defecation, typical of his
IBS flare. Stool sample was sent for c diff toxin and was
negative. Donnatal was ordered for symptom relief. Patient will
follow up with Dr. [**First Name (STitle) 2643**] for his IBS as outpatient.
# Hypertension: His carvedilol and diuretics were initially
held in the setting of hypotension. Carvedilol was restarted at
half dose after his blood pressure normalized given his
ventricular ectopy. He will follow up with his PCP and primary
cardiologist to adjust carvedilol dose as needed.
# DM2: was put on 70% home dose of lantus with an NPH sliding
scale while NPO. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained in order to
allow the patient to do carb counting like he does at home. His
lantus dose was changed to 20 unit in AM and 29 unit in PM. He
continued premeal carb counting with adequate control of his
blood glucose. He will go home with increased lantus dose and
continue carb counting at home.
# HL: Atorvastatin was initially held in the acute setting. It
was restarted in the ICU and continued on the floor. He will
continue the medication at home at full 80 mg daily dose, as he
has tolerated this dose in the past, does not have any
interacting medication and has normal ALT/AST and CK.
# Peripheral neuropathy: nortriptyline, pregabalin, tizanidine
were initially held in the acute setting. They were restarted
on [**2203-6-29**] at home dose, and he will continue those at home.
# Prolonged QTc: Etiology unknown as no overt QTc prolongating
drugs, but was seen on previous studies. Patient received
serial EKGs and [**Hospital1 **] lytes, both of which normalized. He was
monitored on tele which showed known ventricular ectopic beats
and prolonged QTc. Both of them remained stable. He will follow
up with Dr. [**Last Name (STitle) **] after discharge.
# OSA: continued on home CPAP
# Normocytic Anemia: OSH Hgb 11.4, Admission Hgb 6.4 (likely
due to drawing labs off a vein with fluids running in) with
repeat 11.7. [**Month (only) 116**] be marrow suppresion from azathioprine and
underlying chronic inflammation. His hemoglobin remained stable
between 10.1 and 11.7.
Medications on Admission:
-ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs po
four times a day
-ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth
once a day
-AZATHIOPRINE - 50 mg Tablet - TWO(2) Tablet(s) by mouth in the
morning, THREE(3) at night
-CARVEDILOL - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth twice
a day
-CLOBETASOL - 0.05 % Ointment - AAA body twice a day use for up
to 2 weeks only, then as needed
-ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 capsule
by mouth q month
-INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) -
Dosage uncertain
-INSULIN DETEMIR [LEVEMIR] - (Prescribed by Other Provider) - 20
qAM and 24 qHS
-LIDOCAINE [LIDODERM] - (Prescribed by Other Provider) - 5 %
(700 mg/patch) Adhesive Patch, Medicated - to ankle/knee 12
hours on and then 12 hours off prn
-NORTRIPTYLINE - (Prescribed by Other Provider) - 25 mg Capsule
- 1 Capsule(s) by mouth at bedtime
-PHENOBARB-HYOSCY-ATROPINE-SCOP - (Prescribed by Other Provider;
Dose adjustment - no new Rx) - 16.2 mg-0.1037 mg-0.0194
mg-0.0065 mg Tablet - 1 to 2 Tablet(s) by mouth four times a day
as needed
-PREDNISONE - 5 mg Tablet - 1 tablet by mouth daily in addition
to 1mg tabs taken separately
-PREDNISONE - 7 mg Tablet PO qd
-PREGABALIN [LYRICA] - 75 mg Capsule - 1 Capsule(s) [**Hospital1 **]
-SPIRONOLACTONE - 200 mg Tablet by mouth daily
-TIZANIDINE - 4 mg Tablet - 2 Tablet(s) by mouth at night, may
take 1 [**Hospital1 **] PRN for severe pain and spasm
-TORSEMIDE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
-USTEKINUMAB [STELARA] - 90 mg/mL Syringe - 90 mg Sub-Q Weeks 0
- 4; then every 12 weeks
.
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet - one Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - 500 mg (1,250 mg)-400 unit Tablet, Chewable -
1 (One) Tablet(s) by mouth once a day
FERROUS SULFATE - (OTC) - 325 mg (65 mg Iron) Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation four times a day.
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. azathioprine 50 mg Tablet Sig: Three (3) Tablet PO in the
evening.
4. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO in the
morning.
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
6. insulin aspart Subcutaneous
7. insulin detemir 100 unit/mL Insulin Pen Sig: Twenty (20) unit
Subcutaneous in the morning.
8. insulin detemir 100 unit/mL Insulin Pen Sig: Twenty Nine (29)
unit Subcutaneous at bedtime.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical on for 12 hours and off for 12 hours as
needed as needed for pain.
10. prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
11. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg Tablet
Sig: 1-2 Tablets PO up to 4 times a day as needed as needed for
diarrhea.
13. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. tizanidine 2 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
15. Stelara 90 mg/mL Syringe Sig: One (1) syringe Subcutaneous
every 12 wks.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
17. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
18. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
19. clobetasol 0.05 % Ointment Sig: enough to cover affected
area Topical as needed.
20. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. torsemide 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
22. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1)
mL Injection once as needed for for low blood pressure: Please
draw this up in with syringe and needle and inject it into your
thigh muscle.
Disp:*4 mg* Refills:*0*
23. syringe with needle (disp) 3 mL 25 x 1 Syringe Sig: One (1)
syringe Miscellaneous once.
Disp:*1 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypotension secondary to relative adrenal insufficiency
Secondary: Hypovolemia, irritable bowel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 17385**], it was a pleasure to take care of you during
this hospitalization at [**Hospital1 **]. As you know, you
came into the hospital with low blood pressure and falls. You
were admitted into the ICU and received intravenous fluid,
stress dose (high dose) hydrocortisone and pressors for your low
blood pressure. Your blood pressure improved after these
medications and the pressor was stopped. You were then
transferred to the regular medicine floor. Your carvedilol and
torsemide were restarted at half dose after your blood pressure
returned to [**Location 213**]. Your stress dose hydrocortisone was tapered
off and you were transitioned to a higher dose of oral
prednisone. While these medications were changed, your blood
pressure remained normal.
.
You also had some diarrhea that you thought were similar to IBD
flares. Your stool was checked for toxin from c. diff and it was
negative.
.
After you go home, please continue to monitor your blood
pressure as you were doing. Also, please weigh yourself daily to
monitor for fluid retention.
.
These changes were made to your medications:
CHANGE prednisone to 10 mg by mouth daily
CHANGE detemir to 20 units in the morning and 29 units in the
evening
CHANGE carvedilol to 6.25 mg by mouth twice daily
CHANGE torsemide to 50 mg by mouth daily for 3-4 days. If you
notice increased swelling in your legs, you can increase
torsemide back to 100 mg by mouth daily.
STOP spironolactone
NEW: dexamethasone 4 mg rescue syringe. Please use this if your
blood pressure becomes too low.
.
Followup Instructions:
.
Department: RHEUMATOLOGY
When: FRIDAY [**2203-7-1**] at 9:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: PAIN MANAGEMENT CENTER
When: TUESDAY [**2203-7-5**] at 1:40 PM
With: [**Name6 (MD) 8673**] [**Last Name (NamePattern4) 8674**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: DIV OF GI AND ENDOCRINE
When: FRIDAY [**2203-7-15**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Name: [**Last Name (LF) 3240**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: INTERNAL MEDICINE
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Appointment: Tuesday [**8-5**] at 9:45AM
.
Department: CARDIAC SERVICES
When: MONDAY [**2203-8-15**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.69",
"356.9",
"584.9",
"272.4",
"276.52",
"250.52",
"E932.0",
"721.90",
"786.50",
"571.8",
"719.46",
"401.9",
"V58.67",
"794.31",
"278.01",
"362.01",
"255.0",
"V58.65",
"V42.5",
"564.1",
"255.41",
"458.8",
"696.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
16479, 16485
|
7099, 12339
|
300, 336
|
16642, 16642
|
5109, 7076
|
18382, 20010
|
3544, 3828
|
14329, 16456
|
16506, 16621
|
12365, 14306
|
16793, 18359
|
3843, 3843
|
4535, 5090
|
248, 262
|
364, 2375
|
3857, 4521
|
16657, 16769
|
2397, 3361
|
3377, 3528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,727
| 115,868
|
47888+59038
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-5-5**] Discharge Date: [**2112-5-16**]
Date of Birth: [**2056-6-11**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
woman with metastatic breast cancer on Xeloda and Herceptin
who presents with nausea and diarrhea. The patient has also
been complaining of lightheadedness. In addition, the
patient also reports having very little p.o. intake over the
past two to three days and, in fact, vomited the day of
admission and several days prior to admission. As part
treatment for this the patient started taking Imodium and
noted a decreased frequency of diarrhea from four bowel
movements a day to two bowel movements a day, but they were
still liquidly in consistency. She has also had increased
dry heaves and crampy abdominal pain and is not even able to
tolerate juice.
REVIEW OF SYSTEMS: Negative for chest pain, upper
respiratory infection symptoms, dyspnea, dysuria, cough. She
has had extreme fatigue over the past several months.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer first diagnosed in [**2101**] status
post auto bone marrow transplant in [**2104**], metastatic to
bone, liver, and lungs, status post multiple cycles of
chemotherapy. Currently on Herceptin, Xeloda, and monthly
Zometa.
2. Anemia of chronic disease.
3. Status post TRAM flap.
MEDICATIONS ON ADMISSION: Zantac q. day.
ALLERGIES:
1. Intravenous contrast.
2. Sulfa.
PHYSICAL EXAMINATION: On exam patient's temperature is 98.1,
pulse 102, BP 135/61, respiratory rate 20, satting 100
percent on room air. In general, she is in no acute distress
but uncomfortable. Neck veins are flat. Neck is supple.
Lungs: Clear to auscultation bilaterally. Her heart is
tachycardiac and regular. There is normal S1 and S2 and no
murmurs, rubs, or gallops. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities have
no cyanosis, clubbing, or edema.
LABORATORY DATA: White count of 1.9, hematocrit 0.6,
platelets 95. Her sodium was 132, potassium 4.5, chloride
99, bicarbonate 12, BUN 21, creatinine 1.0, glucose 94. ABG
was drawn. It was 7.34/22/14. Lactate was 1.9.
SUMMARY OF HOSPITAL COURSE:
1. Diarrhea: The time course fits well with Xeloda toxicity.
However, the differential diagnosis was still broad and
stool studies were sent and were essentially negative.
The patient on night of admission spiked a temperature of
104.3. Given concern for a possible infectious diarrhea
she was started on Levofloxacin.
In addition, the patient was given bicarbonate repletion and
intravenous fluids to improve her metabolic acidosis.
The following day the patient was given broad antibiotic
coverage as her neutrophil count was continuing to fall from
the chemotherapy. She was on ampicillin, Levofloxacin, and
Flagyl for gut protection.
As will be detailed below, the patient suffered a ventricular
tachycardia arrest and was briefly in the Intensive Care
Unit. Following that transfer the patient was called out to
the floor. Patient was given a peripherally inserted central
catheter line and started on TPN for parenteral nutrition.
Her diet was fully advanced from sips to clears, which she
generally tolerated, although she had a few episodes of
emesis towards the end of her stay. The patient was started
on Imodium for control of her bowel movements and over the
course of her admission both the frequency and amount of
stool declined significantly. At the time of this dictation
she was having just one to two bowel movements per day.
1. Ventricular tachycardia arrest: On the second day of
admission the patient was talking to the nurse and then
abruptly lost consciousness. The patient had been on
telemetry due to abnormalities in the EKG and it was seen
on tele as being monomorphic or polymorphic ventricular
tachycardia leading to a VT arrest. A Code was called.
Right before the patient was shocked she reverted back to
sinus rhythm. At this point she was intubated and brought
to the Intensive Care Unit for closer observation over the
next three days. The patient was extubated within 12
hours and her electrolytes continued to improve.
A Cardiology consult was obtained and they noted that her QT
interval was significantly prolonged possibly due to
Levofloxacin, and so she was initially changed to Cipro and
then her antibiotic coverage was changed altogether. She was
on telemetry for the duration of her admission, and there
were no further telemetry events.
In addition, she was started on low-dose beta blocker as VT
prophylaxis. She will have this followed up as an outpatient
with Dr. [**Last Name (STitle) 284**]. Moreover, while in the ICU she had an
echocardiogram that was essentially negative for any
structural disease.
1. Fluids, electrolytes, and nutrition: As mentioned
previously, the patient has had decreased p.o. intake over
the past several weeks. She was initially started on sips
of clears and then graduated to thin liquids and then to
full liquids, which she tolerated exceptionally. She
would occasionally have an episode of nausea, but these
were generally self-limited and she was started on total
parenteral nutrition or additional nutrition while her gut
continues to recover. Hopefully, she will not need to be
maintained on TPN for that much longer.
1. Breast cancer: The patient had a torso CT to help stage
her malignancy. The CT torso showed interval increase in
the size of a left hepatic lobe metastasis and diffuse
osseous metastatic disease. In addition, the patient was
noted to have this questionable tracheal compression on a
chest film, so she had a CT trachea which showed widely
patent airways, more extensive osseous metastatic disease,
and pleural thickening in the right hemithorax likely also
looked metastatic disease. Further treatment of her
breast cancer will be discussed with her primary
oncologist, Drain. Come.
1. Heme: During her Intensive Care Unit stay her INR was as
high as 2.1 likely possible secondary to poor nutrition.
It rapidly corrected with subcutaneous vitamin K.
1. Code: Patient is a Full Code at time of the of this
dictation.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Metastatic breast cancer.
2. Xeloda toxicity.
3. Ventricular tachycardia arrest.
4. Anemia of chronic disease.
DISCHARGE MEDICATIONS:
1. Toprol XL 25 mg p.o. q.d.
2. Ambien 5 mg q. h.s. p.r.n.
3. Protonix 40 mg p.o. q.d.
4. Phenergan 25 mg p.o./IV q.6 hours p.r.n. nausea
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 101050**]
Dictated By:[**Last Name (NamePattern1) 6997**]
MEDQUIST36
D: [**2112-5-16**] 11:51:33
T: [**2112-5-16**] 12:44:50
Job#: [**Job Number 101051**]
Name: [**Known lastname 16225**], [**Known firstname 1194**] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 16226**]
Admission Date: [**2112-5-5**] Discharge Date: [**2112-5-19**]
Date of Birth: [**2056-6-11**] Sex: F
Service: OME
This will serve as a discharge summary addendum to the
previously dictated discharge summary.
ADDENDUM: FEN: The patient was started on clear liquids
earlier in this admission and progressed to full liquids and
ultimately to house diet with Boost supplements. She had a
calorie count at the end of her admission which showed she
was taking in excess of 300 calories per day orally. The key
to her nutrition was Boost supplements which she would take
b.i.d. She preferred chocolate shakes.
In addition, the patient developed phlebitis around her left
arm and the peripherally inserted central catheter site.
Ultimately, it will be detailed below. The PICC needed to be
removed. She was on PPN for approximately one day. However,
by the next day her calorie count was completed and it was
clear she did not need parenteral nutrition. She will be
discharged with an oral diet that should include Boost
supplements t.i.d. between meals.
Upper extremity deep venous thrombosis: The patient
developed erythema and tenderness around her PICC insertion
site. The left upper extremity was subsequently imaged with
a Doppler ultrasound which showed a nonocclusive thrombus
around the PICC line.
At this point the PICC line was removed. The following day
the patient had another image of her left upper extremity
which showed residual clot. Given the fact that the patient
had no symptoms of either local swelling or PE, the patient
was not anticoagulated. The patient should have repeat
ultrasound at some point next week to follow improvement of
the clot.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES: Xeloda toxicity.
VT arrest.
Metastatic breast cancer.
Left upper extremity deep venous thrombosis.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Loperamide 2 mg p.o. q.i.d. p.r.n. diarrhea.
3. Toprol XL 300 mg p.o. q.d.
4. Keflex 500 mg one capsule p.o. q. 6 hours times three more
days.
5. Sarna lotion one application q.i.d. p.r.n.
6. Reglan 5 mg q.i.d. a.c. and h.s. p.r.n. nausea.
7. Multivitamin one cap p.o. q.d.
8. Subq Heparin 5000 units subq q. 8 hours.
9. Phenergan 25 mg p.o. q. 6 hours p.r.n. nausea.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 16227**], [**MD Number(1) 16228**]
Dictated By:[**Last Name (NamePattern1) 5583**]
MEDQUIST36
D: [**2112-5-19**] 11:45:22
T: [**2112-5-19**] 13:31:13
Job#: [**Job Number 16229**]
|
[
"999.8",
"198.5",
"288.0",
"V42.81",
"427.1",
"197.7",
"276.5",
"427.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.05",
"38.93",
"96.71",
"38.91",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6302, 6340
|
8841, 8944
|
8967, 9644
|
1389, 1453
|
2211, 6280
|
1476, 2183
|
8780, 8819
|
873, 1021
|
164, 853
|
1043, 1362
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,477
| 169,498
|
16791
|
Discharge summary
|
report
|
Admission Date: [**2115-11-7**] Discharge Date: [**2115-11-13**]
Date of Birth: [**2048-7-4**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old
woman with known coronary artery disease status post coronary
artery bypass graft in [**2048**], hypertension,
positive family history and history of tobacco use who
presented to an outside hospital with two days of chest pain
reported as 10 out of 10 on the day of admission with
electrocardiogram changes suggestive of anterior ST
elevation myocardial infarction. The patient was transferred
from the outside hospital to [**Hospital1 188**] for cardiac catheterization. On arrival the patient
was intubated and sedated. History was obtained from the
chart and the patient's daughter. The patient reported to
the EMTs that she had been having two days of substernal
chest pain radiating to a left arm and back. The patient's
nitroglycerin tablets at home were old and not effective.
When EMTs were finally called the patient's pain was 10 out
of 10. She was found to be hypertensive at 230/120. She was
given three aspirins at 81 mg each, nitroglycerin spray and
morphine followed by sublingual nitroglycerin times two at
which time she became hypotensive, apneic and obtunded. She
was intubated on arrival to [**Hospital3 417**] in [**Hospital1 1474**]. The
patient's electrocardiogram with ST elevations in V1 through
V3, atrial enlargement, T wave inversions in V5 and V6. She
was not responsive to Narcan on arrival to [**Hospital1 1474**]. She was
started on a nitro drip at which time she became hypotensive
again and nitro drip was turned off. Heparin drip was
started as was Integrilin and the patient was transferred to
[**Hospital1 69**] for catheterization.
Cardiac catheterization revealed cardiac output of 2.98,
cardiac index of 1.74 by the Fick method, wedge pressure was
22, RA pressure 11 and PA pressure 27/18 with a mean of 22.
Coronary angiography revealed a right dominant system with a
50% left main osteal lesion, totally occluded left anterior
descending coronary artery, mild diffuse disease in the left
circumflex, mild diffuse disease in the right coronary artery
and occlusion of the saphenous vein graft to left anterior
descending coronary artery as well as an ostial saphenous
vein graft occlusion of the saphenous vein graft to the left
circumflex. The catheterization was complicated by failed
initial attempts of access from both femoral arteries. The
guidewire was unable to be passed through the iliacs.
Therefore the procedure was done from a right radial
approach. She underwent successful percutaneous transluminal
coronary angioplasty and stenting of the saphenous vein graft
to left anterior descending coronary artery and final
angiography revealed normal flow without dissection and 0%
residual stenosis. The patient was then transferred to the
Coronary Care Unit for further management.
PAST MEDICAL HISTORY:
1. Status post coronary artery bypass graft in [**2087**] with
saphenous vein graft to left anterior descending coronary
artery and saphenous vein graft to left circumflex as above.
2. Hypertension.
3. Peripheral vascular disease.
4. Left inguinal hernia.
MEDICATIONS ON ADMISSION: Inderal 40 mg, Dipyridamole 25 mg,
Lipitor 10 mg, Trental 400 mg, aspirin, sublingual
nitroglycerin and multivitamins.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is an active smoker. She admits
to drinking alcohol and has a history of narcotic use per
report.
PHYSICAL EXAMINATION ON ADMISSION TO THE CORONARY CARE UNIT:
The patient was intubated and sedated, but arousable to
verbal stimuli. She was initially on AC at 550 by 20 with an
FIO2 of 50% and 10 of PEEP. Her lungs had few rales
anteriorly and laterally. Her heart examination had a normal
S1 and S2 without murmur. Her abdominal examination was
benign. Her extremities were cool, though her skin was not
modeled on the feet. Pulses were only localized by doppler.
LABORATORIES FROM OUTSIDE HOSPITAL: Hematocrit of 51.4 with
a white blood cell count of 15.6. Chem 7 was significant for
BUN and creatinine of 15 and 1.3 respectively. CK was 248
with an MB fraction of 20 and an MB index of 8.1, troponin
was measured at 5.79. Coags on admission revealed a PT of
15.2 and INR of 1.5. Lipids from [**2115-6-27**] revealed
cholesterol total of 170, HDL 50, LDL of 98. Blood gas on
admission to the Coronary Care Unit was 7.40 with a PCO2 of
40 and a PO2 of 244.
HOSPITAL COURSE: 1. Cardiovascular: The patient was
continued on aspirin, Plavix and Integrilin for 18 hours
following catheterization. Beta blockers and ace inhibitors
were held initially, because of the patient's recent
hypotension as well as her poor cardiac output and index
coming from the catheterization laboratory. Her CKs were
cycled to follow for a peak, which was found to be 1564. A
Swan-Ganz catheter was left in place to evaluate
hemodynamics. On the night of admission the patient
experienced two episodes of chest pain without
electrocardiogram changes, which were relieved with titration
of her nitro drip. The pain was associated with 9 out of 10
arm pain, though on further questioning this was found to be
due to the patient's infiltrated intravenous in that arm.
With inprovement of her hemodynamics, her Swan-Ganz catheter
was discontinued. Her hematocrit was found to drop from 29.3
down to 24 after persistent oozing from the groin site where
the Swan-Ganz catheter was located. She was transfused 1
unit of packed red blood cells with the development of
pulmonary edema at which time her respiratory rate rose to
the 30s and her O2 sats fell to 79 to 83% on 4 liters of
nasal cannula.
By this time (see next problem - respiratory) the patient had
been extubated. Her blood pressure was elevated to 180s to
90/100s. The patient received 40 mg of intravenous Lasix and
was started on a nitro drip and placed on a nonrebreather.
Arterial blood gas on the nonrebreather was pH of 7.19, PCO2
of 68 and PO2 of 86%. Electrocardiogram revealed sinus
tachycardia at 135 with a normal axis and intervals, [**Street Address(2) 4793**]
depressions in the lateral leads, .[**Street Address(2) 1755**] depressions in the
inferior leads and [**Street Address(2) 5366**] elevations in the anteroseptal
leads, which were increased when compared to the
electrocardiogram from [**11-8**]. The patient received multiple
doses of intravenous Lopressor for persistent sinus
tachycardia in the setting of hypertension. She diuresed
over 300 cc in 30 minutes. A Foley catheter was replaced to
better monitor Is and Os. After resolution of this event
another electrocardiogram was checked, which was sinus rhythm
at [**Street Address(2) 47412**] 1 mm depressions in the lateral
leads and [**Street Address(2) 2051**] elevations anteroseptally unchanged from
the electrocardiogram from the prior day.
Following the event the patient was chest free and no further
episodes of pulmonary edema were noted. The patient was
started on a beta blocker of Lopressor at 12.5 mg b.i.d. and
on [**2115-11-10**] Captopril was added at 12.5 mg t.i.d. Her beta
blocker and ace inhibitor were titrated as tolerated by her
blood pressure. On [**2115-11-8**] an echocardiogram had been
performed, which revealed an ejection fraction of 35%. The
left atrium was mildly dilated. There was mild symmetric
left ventricular hypertrophy. Left ventricular cavity size
was normal with moderate regional systolic dysfunction.
Resting regional wall motion abnormalities included anterior
and septal akinesis, RV chamber size and free wall motion
were normal. For the patient's decreased ejection fraction
and anterior akinesis, the patient was begun on
anticoagulation of Lovenox and Coumadin. Her ace inhibitor
and beta blocker were changed to once daily doses of Atenolol
and Lisinopril for easier dosing in preparation for
discharge. Prior to those changes, however, the Lopressor
has been titrated as high as 75 mg t.i.d. and Lisinopril up
to 20 mg po q day. These higher doses lead to an episode of
hypotension with a blood pressure of 100/50 while the patient
was at rest. Upon standing she did experience symptoms of
lightheadedness. For these reasons her doses were decreased
with Lopressor being changed to 25 mg t.i.d. and Lisinopril
to 20 mg q day prior to discharge. She was continued on 40
mg of Lasix po b.i.d. as well as aspirin, Plavix and her
Lipitor. At the time of discharge her INR was 1.8. She had
continuing treatment with Lovenox and Coumadin with a goal
INR of 2 to 3 and was set up for close follow up with the
[**Hospital 197**] clinic for further management of her INR. On the
day of discharge [**2115-11-13**] the patient had an INR [**Location (un) 1131**] of
1.0. This was felt to be a spurious laboratory result, which
was rechecked, which was returned at 1.9.
2. Respiratory: The patient was admitted to the Coronary
Care Unit still intubated, but arousable to verbal stimuli
and able to communicate her wishes. In having a discussion
with her daughter she revealed to us that the patient had not
wished to be intubated in the future and that after
extubation in talking with the patient she was able to convey
that if the need arose for her to be reintubated that she
would not want that. Weaning parameters were checked and
were very good. The patient was extubated shortly after her
admission to the Coronary Care Unit without complications.
3. Hematology: The patient had persistent oozing from the
groin site where the Swan-Ganz catheter was placed. As above
her hematocrit fell from 31 at admission to a low point of
23.9. She was transfused on [**2115-11-9**] and at the time of
discharge her hematocrit was back up to 36.1 and stable.
4. Renal: On admission the patient's creatinine was noted
to be elevated at 1.3. The following day with diuresis the
patient's creatinine improved to 0.9 and at the time of
discharge was back to her baseline of 0.7.
5. Code status: As above the patient expressed her wishes
of not wanting to be intubated and following extubation
discussion was held with the patient and her daughter at
which time the patient decided she wanted to be DNR/DNI
status. The order was placed and assigned by the attending
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft in [**2087**] admitted with acute myocardial
infarction status post percutaneous transluminal coronary
angioplasty of saphenous vein graft to left anterior
descending coronary artery.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS: Metoprolol 25 mg po t.i.d.,
Lisinopril 10 mg po q day, Isosorbide mononitrate 30 mg po q
day, Lovenox 60 mg subQ q 12 hours, Warfarin 5 mg po q day,
aspirin 325 mg po q day, Plavix 75 mg po q day to complete a
thirty day course, Trental 400 mg po q day, Lasix 40 mg po
b.i.d., Lipitor 10 mg po q day. Atenolol 50 mg po q day and
Ranitidine 150 mg po b.i.d.
DISCHARGE CONDITION: Stable.
FOLLOW UP: The patient had an appointment to be seen the day
following discharge by her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 47413**]
in [**Hospital1 1474**]. In addition, her primary care physician had
planned to arrange for a primary cardiologist for the patient
at [**Hospital1 1474**] as well. [**Hospital6 407**] services
were arranged for home visits for help of the administration
of Lovenox as a bridge to Coumadin becoming therapeutic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Doctor Last Name 26904**]
MEDQUIST36
D: [**2115-12-23**] 02:38
T: [**2115-12-24**] 09:42
JOB#: [**Job Number 23515**]
|
[
"414.01",
"401.9",
"410.01",
"V45.81",
"996.72",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"36.01",
"99.20",
"88.55",
"88.52",
"96.04",
"96.71",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
11151, 11160
|
10448, 10746
|
10770, 11129
|
3250, 3408
|
4528, 10427
|
11172, 11921
|
161, 2940
|
2962, 3223
|
3425, 4510
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,182
| 104,834
|
39346
|
Discharge summary
|
report
|
Admission Date: [**2103-11-6**] Discharge Date: [**2103-12-9**]
Date of Birth: [**2041-12-27**] Sex: M
Service: SURGERY
Allergies:
Gluten
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
free air
Major Surgical or Invasive Procedure:
EGD x2
exlap, small bowel resection x2 with primary reanastamosis
exlap, small bowel resection, jejunal stoma formation, mucous
fistula formation for anastomotic breakdown
percutaneous cholecystostomy tube placement
percutaneous drainage of perihepatic fluid collection
bilateral chest tube placement
History of Present Illness:
Mr. [**Known lastname 496**] is a 61 M with a medical history notable for
celiac disease. Of note, he was recently admitted to [**Hospital1 18**] from
[**2103-9-10**] to [**2103-9-19**] for worsening GI symptoms thought to be
related to his difficult-to-control celiac disease. He was
started on budesonide, loperamide, and TPN. An endoscopy
performed during that admission revealed duodenitis.
He reports feeling well at dischcarge on the TPN and was even
able to travel on [**Hospital3 **]. However, approximately 3 weeks ago
he noted marked fatigue and dyspnea on exertion. He is currently
very weak and unable to perform basic activities around his
house. His abominal cramping has also increased and his diarrhea
has returned. His bowel movements are "muddy" with rare bright
red blood (usually with straining), but no melena. No NSIADs or
recent alcohol use.
Since discharge he was started on prednisone and started on
mercaptopurine on [**11-5**]. He was seen in [**Hospital **] clinic on [**11-5**].
After his routine laboratory studies returned with worsening
anemia he was referred to the ED.
Vital signs on arrival to [**Hospital1 18**] ED: T 98.2, P 100, BP 129/76,
100% RA. His evaluation in the ED was notable for a HCT of 22.5,
guaiac positive stool, and a negative gastric lavage. In the ED
he received pantoprazole 40mg IV, morphine, 1 unit of packed red
blood cells, and IV fluids.
On [**2103-11-7**] he underwent EGD showing friable duodenal mucosa
with contact bleeding. Since the procedure he has had worsening
abdominal pain, and was found to have copious free air on CXR
and KUB. We were contact[**Name (NI) **] to evaluate him for possible
perforation.
Past Medical History:
Hypertension
Celiac disease diagnosed in [**2097**] after work-up for osteoporosis
Social History:
Patient lives with his wife. [**Name (NI) **] is a retired history teacher. He
has two children. Patient reports smoking a pipe occassionally
and previously drank wine on occasions but none recently.
Family History:
He is adopted and has no family history of sprue of which he is
aware. Has two healthy children.
Physical Exam:
Vital Signs: T 99.3, P 83, BP 132/83, 96% on RA. Current pain
[**4-23**].
Physical examination prior to EGD by GI on [**2103-11-7**]:
- Gen: Thin male, appears chronically ill.
- HEENT: Pale conjunctiva. Oropharynx clear w/out lesions.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP
<5 cm.
- Abdomen: Normal bowel sounds. He is diffusely tender
throughout his abdomen with no rebound or guarding.
- Extremities: 1+ ankle edema to the knees bilaterally.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal.
- Psych: Appearance, behavior, and affect all normal.
Upon surgical evaluation after the EGD:
96.8 127 128/74 22 99% 2L
uncomfortable, anxious
no respiratory distress
abdomen distended, tympanytic +rebound +guarding
no scars, no hernias
Pertinent Results:
[**2103-11-5**] 09:44AM WBC-20.6* RBC-3.01*# HGB-8.0*# HCT-25.8*#
MCV-86 MCH-26.7* MCHC-31.2 RDW-15.6*
[**2103-11-5**] 09:44AM NEUTS-95* BANDS-0 LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2103-11-5**] 09:44AM CRP-126.1*
[**2103-11-5**] 09:44AM TOT PROT-4.8* ALBUMIN-2.1* GLOBULIN-2.7
CALCIUM-7.3* PHOSPHATE-2.1*# MAGNESIUM-2.2
[**2103-11-5**] 09:44AM ALT(SGPT)-37 AST(SGOT)-18 LD(LDH)-183 ALK
PHOS-209* TOT BILI-0.6
CXR [**2103-11-7**]: In comparison with the study of [**11-6**], there is a
substantial amount of free intraperitoneal gas beneath the
hemidiaphragms. Atelectatic change with possible effusion again
seen at the right base.
CTAP [**2103-11-8**]: 1. Extraluminal oral contrast seen adjacent to a
loop of mid jejunum in the lower mid abdomen, presumably
representing a site of small bowel perforation with resultant
pneumoperitoneum and fluid in the abdomen. 2. Small bowel mural
thickening, presumably related to known diagnosis of celiac
sprue. 3. Large area of mesenteric adenopathy and 'mistiness'.
This finding is unchanged since [**2103-9-11**] and though it
may be related to reactive changes from the known celiac
disease, lymphoma is another consideration and ongoing followup
is recommended as per the previous study. 4. Distended
gallbladder
PATHOLOGY SMALL BOWEL RESECTION [**2103-11-8**]: 1) Small bowel, at 110
cm, resection (A-B, Q-AB): Small bowel segment with multiple
perforations and associated full thickness ulceration, exudative
inflammation and extensive granulation tissue. Adjacent intact
mucosa with extensive villous blunting with increased
intraepithelial lymphocytes consistent with prior history of
refractory celiac disease. Atypical lymphoid infiltrate, refer
to part 2 for further characterization. 2) Small bowel,
resection (C-P, AC-AJ): Small bowel segment with multiple
perforations and associated full thickness ulceration, exudative
inflammation and extensive granulation tissue. Adjacent intact
mucosa with extensive villous blunting with increased
intraepithelial lymphocytes consistent with prior history of
refractory celiac disease. Atypical lymphoid infiltrate, see
note.
PATHOLOGY SMALL BOWEL RESECTION [**2103-11-17**]: Small bowel, resection:
1. Small intestinal segment with acute and chronic
inflammation, patchy ulceration, focal anastomotic site mucosal
necrosis, prominent submucosal edema, and extensive serositis;
no definitive perforation identified. 2. Viable margins with
marked edema, focal mucosal ulceration and mild active
inflammation. 3. Increased intraepithelial lymphocytes, villous
shortening, and crypt hyperplasia, consistent with involvement
by patient's known celiac disease; Paneth cells do not appear
overall decreased in viable mucosal areas. See hemepath note.
4. One unremarkable lymph node.
CT Torso [**2103-11-27**]: 1. Bilateral pleural effusions, increased
compared with previous study. 2. Diffuse anasarca and diffusely
abnormal small and large bowel wall thickening consistent with
mucosal edema. Given the diffuse involvement this likely
represents third spacing. 3. Diffuse mesenteric fat stranding
and mesenteric lymphadenopathy. 4. Moderate amount of free fluid
in the pelvis and both paracolic gutters. No discrete localized
fluid collection seen however infection cannot be excluded. 5.
Interval formation of bilateral stomas. 6. Lower abdominal wound
dehiscence. 7. Distended gallbladder. 8. Left inguinal hernia
containing fluid.
CT guided percutaneous cholecystostomy tube placement [**2103-11-29**]:
Technically successful percutaneous cholecystostomy tube
placement. Sample sent for microbiology analysis. A total of 200
cc of dark green turbid bile were aspirated.
CT guided percutaneous abdominal fluid collection drainage
[**2103-11-29**]: Technically successful aspiration and drainage
catheter placement right upper quadrant ascitic fluid pocket as
above. 200 cc clear straw-colored fluid were aspirated to bag.
CT Torso [**2103-12-5**]: 1. Stable bilateral pleural effusions. 2. New
diffuse bilateral ground glass opacities, infectious vs.
aspiration. 3. Thickened small and large bowel with surrounding
mesenteric stranding and fluid, relatively unchanged from prior.
4. Stable midline wound with interval resolution of associated
free air and contrast extravasation. Interval resolution of
anterior abdominal fluid collection in the right upper quadrant,
with interval placement of a peripherally placed percutaneous
drain. GJ-tube in place. 5. Cholecystomy drain in place with
surrounding decompressed gallbladder. 6. Stable pelvic fluid
collection with stable adjacent enhancement of peritoneum.
RUQ U/S [**2103-12-6**]: 1. No intrahepatic biliary ductal dilatation.
2. 3-mm CBD containing echogenic material, most likely
representing sludge or pus. 3. Catheter within the gallbladder,
which appears collapsed. 4. No ascites. 5. Right pleural
effusion
Cholangiogram through percutaneous cholecystostomy tube
[**2103-12-6**]: free flow of contrast into the duodenum
Brief Hospital Course:
Mr. [**Known lastname 496**] is a 61 yo gentleman with severe, medically
refractory celiac disease who underwent push endoscopy on
[**2103-11-7**] with multiple biopsies. After this procedure, he
developed significant abdominal pain and a chest xray and KUB
showed massive free air. Follow up CT scan of the Abdomen
revealed contrast extravasation from the bowel lumen indicative
of perforation. For this reason, he was taken emergently to the
OR on [**2103-11-8**] and underwent bowel resections x2 (over 160 cm of
small bowel in total) with two primary reanastamoses.
Unfortunately, these anastamoses broke down over the ensuing
days likely secondary to his baseline poor nutrition as well as
the inherent friability of his intestines secondary to his
severe, medically refractory sprue. He ultimately required
reoperation on [**2103-11-17**]. During this operation, a further 20 cm
of bowel were resected and a jejunal stoma as well as a mucous
fistula were created. The patient continued to do poorly overall
and ultimately was transferred to the ICU on [**2103-11-28**] for
respiratory distress and was intubated and later found to have
developed a hospital acquired pseudomonal pneumonia. During the
next 11 days, the patient developed a new fascial dehiscence
with enterocutaneous fistula which was controlled with bag
drainage. He also underwent percutaneous cholecystostomy tube
placement for a distended gallbladder and a drain placed
percutaneously into a perihepatic collection but this did little
to alleviate his problems. [**Name (NI) **] further developed an acutely
dropping hematocrit and underwent EGD which showed a fresh clot
but no active bleeding in his stomach. This was treated with a
pantoprazole drip. Concurrently, he developed worsening hepatic
failure with cholestasis and a bilirubin rising to 18.0 and
worsening coagulopathy indicative of liver failure. In a last
ditch effort to identify a source of his sepsis and worsening
organ failure, bilateral chest tubes were placed which drained
serous fluid. In discussions with his family, it was decided to
make him Comfort Measures Only on [**2103-12-9**]. He was terminally
extubated and passed soon thereafter.
His hospital course is summarized below by system:
Neuro: His pain was controlled throughout his hospital stay on a
combination of IV or PO medications. At the time of his terminal
extubation, he was placed on a fentanyl and versed drip to
ensure sufficient treatment of his pain, dyspnea, and anxiety.
CV: For most of his hospital stay, he remained, in general,
hemodynamically stable. In the last days of his hospitalization,
he had an ever-worsening pressor requirement and was ultimately
on levophed, neosynephrine, and vasopressin at the time of his
extubation. After extubation, his demise was so quick that the
pressors had not yet even been turned off.
Pulm: For the most part, the patient did well from a pulmonary
perspective. However, on transfer to the unit on [**11-28**], he had
begun to develop respiratory failure and was intubated for
hypoxemic respiratory failure thought to be secondary to
pseudomonal pneumonia. He grew out numerous colonies of P.
aeruginosa, most of which were resistant to numerous
antibiotics. During his last few days, chest tubes were placed
bilaterally to see if this would improve his pulmonary mechanics
and function. After his terminal extubation, he quickly
developed worsening hypoxemia and hypercarbia whereupon he
passed away quickly.
GI/FEN: After his endoscopy, he required emergent operation for
bowel perforation. At his first operation, at 7 enterotomies
were discovered in two different segments of bowel starting
approximately 110 cm from the ligament of Treitz. These two
areas of bowel (approximately 150 cm and 10 cm respectively)
were resected with primary reanastamoses. Initially, he seemed
to have tolerated the procedure as well as could be expected.
However, he soon developed serous drainage from the superior
portion of his wound and it was noted that he had a developing
fascial dehiscence. He went back to the OR and had the
intervening 20 cm of small bowel resected and the proximal end
of his bowel was brought out in the LLQ as a jejunal stoma. The
distal portion was brought out in the RLQ as a mucous fistula. A
gtube was also placed to help with feeds. His abdomen was again
reapproximated and retention sutures were left in place. His
initial high output from his jejunal stoma was treated with
tincture of opium as well as immodium and psyllium wafers
without much improvement in the total output. Ultimately, his
wound dehisced again along with the development of an
enterocutaneous fistula which was controlled with a large ostomy
appliance to the wound. He began growing pseudomonas from this
wound as well. In addition, in order to rule out and treat other
possible sources of his sepsis, he underwent percutaneous
cholecystostomy tube placement as well as drainage of a
perihepatic fluid collection. This proved to be futile. Although
earlier in his course he was able to take some POs, his gut did
not appear to tolerate any enteral nutrition either through the
Gtube or PO. The patient had been on TPN prior to his
hospitalization and this was continued in house due to concern
over the ability of his gut to absorb nutrition as well as over
his poor nutritional status in general. His albumin levels
remained low accordingly and he required lots of colloid and
crystalloid resuscitation as well as blood product transfusion,
when indicated, in order to maintain intravascular volume
although he developed progressively worsening anasarca
indicative of his overall poor nutritional status and inability
to tolerate enteral feeds. In the last week of his
hospitalization, as part of his overall septic picture, he
started to develop worsening liver failure with elevated
bilirubin, progressive coagulopathy which was complicated by an
UGIB as noted on repeat EGD. This was treated with transfusions,
vitamin K, as well as a pantoprazole drip.
GU: He had a foley in place for most of his hospital stay for
urine output monitoring. At some point he also grew out
pseudomonas from his urine as well. This infection was treated
concurrently with his pneumonia with broad-spectrum antibiotics.
Endo: After his initial surgery, he was given stress-dose
steroids and then was tapered off the steroids completely due to
concerns that they were adversely impacting his ability to heal
his wounds. Due to concerns for adrenal insufficiency, he
underwent a cortisol stimulation test which showed a normal
response in his adrenal glands. Blood sugars were monitored and
treated appropriately.
Heme: Due to his many surgeries and critically ill state, the
patient's white count and hematocrit were closely monitored.
Ultimately he had a rising white count (into the 30s) as well as
a falling hematocrit. He was treated with RBCs and other blood
products as necessary in order to treat his coagulopathy and
bleeding-induced anemia.
ID: ID consultation was obtained due to the patient's resistant
pseudomonus found in his sputum. He was treated with various
antibiotics and was ultimately placed on vancomycin, doripenem,
and amikacin for his hospital acquired PNA with double-coverage
of the pseudomonas.
Medications on Admission:
Prilosec 20mg daily
prednisone 40mg daily
Percocet PRN pain
mercaptopurine 50 mg daily
labetalol 50mg once daily
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
CELIAC DISEASE, SEVERE TYPE 2
Multiorgan system failure secondary to sepsis
Pseudomonas pneumonia
enterocutaneous fistula
anastomotic breakdown
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"733.00",
"590.10",
"997.31",
"998.32",
"038.9",
"570",
"E870.4",
"288.60",
"510.9",
"569.81",
"427.1",
"576.8",
"401.9",
"427.31",
"286.9",
"998.0",
"997.4",
"579.0",
"E878.8",
"V55.1",
"789.59",
"998.2",
"E878.2",
"E932.0",
"482.1",
"518.81",
"285.1",
"578.9",
"511.9",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.61",
"45.62",
"99.15",
"87.59",
"38.91",
"97.05",
"54.91",
"51.01",
"38.97",
"44.13",
"45.61",
"43.19",
"97.02",
"46.20",
"46.10",
"33.24",
"96.72",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
16289, 16298
|
8818, 16094
|
275, 578
|
16505, 16515
|
3770, 8795
|
16571, 16689
|
2627, 2725
|
16257, 16266
|
16319, 16319
|
16120, 16234
|
16539, 16548
|
2740, 3751
|
227, 237
|
606, 2288
|
16338, 16484
|
2310, 2394
|
2410, 2611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,941
| 196,883
|
40391+58366
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-5-7**] Discharge Date: [**2185-5-15**]
Date of Birth: [**2115-11-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
Hip dissociation
Major Surgical or Invasive Procedure:
Left hip revision
Endotracheal intubation
History of Present Illness:
69 yo F with hx of left total hip replacement 8 years ago at
[**Hospital3 **] Hospital presents as transfer with left THR
dissociation on [**2185-5-7**] now s/p revision of left total hip
[**2185-5-10**]. She described walking
out of dinner yesterday evening when she felt a sudden
"numbness"
in her left hip, a feeling like her leg was no longer there.
Denies any presyncopal symptoms. She fell to ground, landing on
her knees but without injury or headstrike. Had immediate left
hip pain with movement and was unable to bear weight. Was taken
to [**Hospital3 **] Hospital where imaging was obtained and she was
transferred for further orthopaedic care. She had a hip
aspiration on [**5-8**] showing [**Numeric Identifier 88552**] RBC, 1000 WBC, 76 polys.
.
During the operation, EBL 1000 cc. She received 500 cc blood,
3500 crystalloid. She had 1500 UOP. She has 2 PIVs and an
arterial line. Neosynephrine at 0.5 at time of transfer. Pt was
on neosenphrine during entire case. When tried to wean off, pt
had low BP in mid 70s systolic but when on it SBPs in 100s. Pt
moving around w/out sedation but concern for possible fluid
overload and hypotension as she appeared a little more swollen
at the end of case than before. Also got opiods, dilaudid for
pain control. [**Hospital Ward Name **] surgical moonlighter will be contact.
.
On the floor, final reported blood loss was 1500cc, got 6L total
fluids, made good urine of 1600 and got back 500cc of own blood
from cell [**Doctor Last Name 10105**]. HCT had been checked and was stable but conern
that this may be not completely accurate. Currently on propofol
for sedation given still intubated but had been moving around
when sedation weaned.
.
Review of sytems:
pt intubated, not able to obtain
Past Medical History:
HTN
high cholesterol
hypothyroidism
appendectomy
tonsillectomy
ORIF right ankle
left total hip replacement at [**Hospital3 **] Hospital by Dr.
[**Last Name (STitle) 71113**] 8 years ago (currently followed by Dr. [**Last Name (STitle) 696**]
Social History:
Community ambulator, active. lives with husband. works
as teacher. former smoker, drinks [**1-2**] glasses of wine/night.
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: T:98.4 BP: 110/51 P: 78 R: 15 O2: 100%
General: intubated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, endotrach tube
in place
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally, vent sounds
CV: Limited exam b/c of breath and vent sounds. Regular rate and
rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. L
hip incision CDI with staples. +SILT, NVI distally.
+AT/PT/FHL/[**Last Name (un) 938**].
Pertinent Results:
[**2185-5-15**] 06:44AM BLOOD WBC-8.9 RBC-3.14* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.7 Plt Ct-316
[**2185-5-14**] 06:58AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.2* Hct-25.0*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.3 Plt Ct-259
[**2185-5-13**] 07:15AM BLOOD WBC-9.9 RBC-2.92* Hgb-8.6* Hct-26.4*
MCV-90 MCH-29.6 MCHC-32.7 RDW-13.3 Plt Ct-224
[**2185-5-12**] 04:47AM BLOOD WBC-10.6 RBC-2.97* Hgb-8.7* Hct-26.8*
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.4 Plt Ct-212
[**2185-5-11**] 02:08PM BLOOD WBC-11.0 RBC-3.14* Hgb-9.4* Hct-28.6*
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.2 Plt Ct-221
[**2185-5-11**] 01:50AM BLOOD WBC-16.9*# RBC-3.62* Hgb-10.8* Hct-32.9*
MCV-91 MCH-29.9 MCHC-32.9 RDW-13.1 Plt Ct-281
[**2185-5-15**] 06:44AM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
[**2185-5-14**] 06:58AM BLOOD Glucose-97 UreaN-9 Creat-0.5 Na-139 K-3.6
Cl-104 HCO3-27 AnGap-12
[**2185-5-13**] 07:15AM BLOOD Glucose-102* UreaN-7 Creat-0.5 Na-137
K-3.8 Cl-103 HCO3-27 AnGap-11
Brief Hospital Course:
69 yo F with hx of left total hip replacement 8 years ago at
[**Hospital3 **] Hospital presents as transfer with left THR
dissociation on [**2185-5-7**] now s/p revision of left total hip
[**2185-5-10**]. During the operation, EBL 1000 cc; received 500 cc
blood, 3500 crystalloid and had 1500 UOP. Pt had hypotension and
required Neosynephrine at 0.5 at time of transfer. Pt has 2
PIVs and an arterial line. Sent to ICU for management of
hypotension s/p surgery.
.
# Hypotension s/p hip replacement: patient had hypotension after
total hip replacement. Estimated blood loss in OR was 1500cc,
got 500cc blood back from cell [**Doctor Last Name 10105**] plus total of 6L IVF and
made 1600cc urine. Pt also sedated and got pain medications
which may have contributed to labile blood pressures. IV fluid
and blood transfusions, as well as phenylephrine, were given to
achieve goal MAP>65. Hematocrits were trended regualarly to
evaluate for blood loss.
- wean propofol --> switch to fentynal and midazolam
- titrate pain meds down as much as possible given could be
contributing to hypotension.
.
# Respiratory status/right lower lobe infiltrate on chest x-ray:
Because of labile pressures when tried to wean neosenphrine and
concern that pt may be fluid overload b/c noted to be swollen
compared to start of case, decision was made to keep intubated
and slowly wean off neosenprhine in ICU. Pt successfully
extubated and weaned off pressors on [**2185-5-11**]. On CXR, patient
had right lower lobe infiltrate with differential diagnosis of
atelectasis vs. pneumonia. Sputum and blood cultures were
obtained and .... Monitor exam, CXR.
.
# s/p right hip revision: patient had sudden dissocation of
prothesis in setting of no trauma. She is s/p left THR
dissociation on [**2185-5-7**] and now s/p revision of left total hip
[**2185-5-10**].
- monitor wound site for signs of bleeding or infection
- appropriate immobilzation for acute phase s/p hip replacement
- monitor coags, lytes, cbc
- sugery recs
- ancef
- enoxaparin per surgery
.
# Hypertension: home enalapril dose was held given hypotension
.
# Hypercholesteroloema: pt on lipitor at home
- hold for now in setting of acute hypotension and potential for
end organ damage; will restart once stablizes
- moniotor LFTs
.
# Hypothyroidism: patient is on levothyroxine at home, which was
continued during her hospitalization.
Postoperative course was remarkable for the following:
1. Transfer to ICU for hypotension (See above)
Otherwise, pain was initially controlled with a 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.
2. Transfusion 1 u PRBC on [**2185-5-14**]. HCT 28.3 on discharge,
symptoms resolved.
The patient's weight-bearing status is PARTIAL weight bearing on
the operative extremity with posterior precautions. Two crutches
or walker at all times x 6 weeks. Hip abduction brace at all
times when out of bed.
Ms. [**Known lastname 7749**] is discharged to rehab in stable condition.
Medications on Admission:
enalapril daily, lipitor daily, Vit D, levothyroxine daily
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 3 weeks.
Disp:*21 syringe* Refills:*0*
7. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing Lovenox, take as directed
with food.
Disp:*42 Tablet(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Left hip implant failure with breakage of trunnion of femoral
stem
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: Partial weight bearing on the operative extremity
until follow-up appointment. Posterior precautions. Hip
abduction brace on at all times when out of bed. No strenuous
exercise or heavy lifting until follow up appointment.
Physical Therapy:
PWB x 4 weeks
Hip abduction brace AAT when OOB
- 0-90 flexion
- 30 abduction
- No internal rotation
Mobilize
2 Crutches/Walker x 6 weeks
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice as tolerated
Staple removal POD 14 - replace with steristrips
TEDS x 6 weeks
Followup Instructions:
Please call [**Telephone/Fax (1) 1228**] to schedule/confirm your follow-up
appointment with Dr. [**Last Name (STitle) 5322**] in 4 weeks.
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
Completed by:[**2185-5-15**] Name: [**Known lastname 2534**],[**Known firstname 14053**] Unit No: [**Numeric Identifier 14054**]
Admission Date: [**2185-5-7**] Discharge Date: [**2185-5-15**]
Date of Birth: [**2115-11-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 942**]
Addendum:
Please note the proper admission diagnosis for this patient was
THR implant failure/broken femoral stem.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 945**]
Completed by:[**2185-5-20**]
|
[
"276.69",
"996.43",
"V43.64",
"458.29",
"518.81",
"E849.9",
"401.9",
"E878.1",
"272.0",
"244.9",
"518.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.72",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
13527, 13735
|
4279, 8002
|
313, 356
|
9161, 9161
|
3280, 4256
|
12732, 13504
|
2563, 2581
|
8112, 8969
|
9071, 9140
|
8028, 8089
|
9344, 11541
|
2596, 2596
|
12402, 12542
|
12564, 12709
|
257, 275
|
2106, 2141
|
11553, 12384
|
384, 2088
|
2610, 3261
|
9176, 9320
|
2163, 2407
|
2423, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,481
| 138,260
|
7318+55823
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-1-3**] Discharge Date: [**2111-1-14**]
Date of Birth: [**2042-8-14**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
right hand weakness, facial droop
Major Surgical or Invasive Procedure:
1. Percutanrous biopsy of lung pleura
2. Whole brain radiation therapy
3. Fine needle aspiration of abdominal wall mass
History of Present Illness:
68 yo woman recently s/p complicated hospital course [**2110-10-4**]
(see
below), also hx RCC s/p left nephrectomy in past, thyroid ca s/p
surgery and radiation, adrenal mass with no w/u yet, known pulm
nodules, known C7-T1 spine infiltrative process
(ca vs abscess) s/p lami with negative path for malignancy,
paraspinous abscess in recent past, among other medical problems
who presents with L facial droop, R hand weakness x 3 days. She
says that she had been doing well until 3 d pta when she noticed
over 30 min to 1 hr gradual weakening of right hand described as
"fingers closing up" which worsened more later in day. Speaking
with her daughter on the phone, the daughter thought she sounded
different and wasn't articulating her words. She was also
noticed to have a left facial droop that day (opposite side from
hand). She did not want to come to the ED because she was
afraid
she would be admitted to the hospital. PT came to visit on
third
day and recommended she come to ED. She had no improvement or
worsening of sx over past few days, and no ha/visual changes/
hearing/language/memory/
swallowing/dizziness/ltheaded/vertigo/unsteady gait (although
she
did have trouble holding onto her walker with the right hand)
and
no parasthesias/sensory loss/falls/weakness elsewhere. No
f/cp/palp/n/v/d/abd pain/sob/wheeze but chronic cough and
episodes hemoptysis. Other ROS + chills, depression related to
acute illness.
Pt had been hospitalized [**Date range (1) 27024**] after presenting with fever
after recently having been discharged from hospital for
paraspinous abscess s/p tx with Abx with vanco and levaquin.
Had
also c/o neck pain, found to have pseudomonal UTI but no other
source of fever; imaging showed fluid collection at L3-4 and
stable
cervical spine dz; cervical lesion through to be either
neoplastic
vs abscess. Tx'ed with vanco, zosyn. She persistently spiked,
extensive ID, rheum and malig w/u with the following results:
[**Doctor First Name **]
weakly positive; CRP elev 298; pleural-based nodules s/p VATS
neg
for malignancy or infection including AFB/fungal; BAL neg x some
[**Female First Name (un) **]; numerous neg bcx; stool neg c-diff; LP neg cytology and
other studies nl (prot 55, gluc 34, no cells); bone scan pos.
for
mult areas abnl uptake spine, humerus, tibia, sternoclav joint,
2nd rib suspicious for malig. Eventually underwent lami for
tissue dx epidural mass - was negative for malig, afb or fungus.
Hosp course also sig for pseudogout (crystals on tap); neck pain
with fluid collection at site of IND prev admission for
paraspinous abscess, improved by end of hosp on vanco;
tremor->MRI brain rec by neuro, found 2.5 cm meningioma R
parietal, no mets, no explanation for tremor x possible
metabolic
derangement; hemoptysis and chronic cough (vats neg for malig),
ARF thought some prerenal; anemia requiring several
transfusions;
yeast infection; elev TSH thought related to time of dosing per
endocrine. Improved and was sent to rehab. Stable on coumadin,
and dm and htn were under control at time. Improved at rehab
and
was sent home on [**Holiday **]; returned to rehab for anemia sx,
transfused and sent home the following wednesday. Did well over
next week, with no c/o until 3 days pta.
Past Medical History:
Per above; also sig for:
1. Papillary thyroid ca. Diagnosed by biopsy [**2102**], resected
[**2106**],
s/p radiation; on synthroid for replacement now
2. Renal cell ca, s/p left nephrectomy at [**Hospital1 112**], [**2103**], CRI
3. Adrenal mass, 2.8 cm, no w/u.
4. Diffuse pulmonary ground glass opacities, followed in
Pulmonary clinic by Dr. [**Last Name (STitle) 575**]. Also had numerous tiny
well-circumscribed nodules, of unclr etiology, but with one that
on last CT was enlarging (in LUL), was supposed to go for bronch
vs transthoracic bx but did not f/u.
5. Hx of positive PPD, (exposure to pt w/Tb when working as
nurse's aide), s/p rx w/INH.
6. DM x 30 years with peripheral neuropathy
7. HTN
8. PVD- Fem-ant/tib bypass on L in [**2099**] on coumadin since then
presumably for low flow state; no hx dvt's or pe's, no hx afib
10. CRI (ARF as inpt recently)
Social History:
Pt lives with her husband, has 6 children. Previous 40 pack
year smoking history, quit 10 years ago. No ETOH, no illict
drug use
Family History:
Children healthy, aunt with lung cancer, no other known fam hx
Physical Exam:
Physical Exam when seen initially in ED:
Vitals: T: 98.3 P: 76 BP: 140/80 to 193/56 at admission
RR: 18 SaO2: 95%
General: Awake, alert, and cooperative with exam in no acute
distress.
HEENT: Normocephalic, no scleral icterus noted, clear oropharynx
with moist mucus membranes
Neck: supple, with no TTP post neck
Pulmonary: Lungs clear anteriorly
Cardiac: regular rate and rhythm
Abdomen: soft, nontender, with normoactive bowel sounds
Extremities: Warm with no edema; feet slt cool
Skin: no rashes or lesions noted, but birthmark over right side
of face and forehead
Neurologic:
Mental status: The patient is awake, alert, and oriented x 3.
Able to relate history without difficulty. Language is fluent
with intact repetition and comprehension, and speech is normal
rate, tone and volume. Patient was able to register 3 objects
and recall [**3-27**] at 30 seconds and easily at 5 minutes. Could
recall phone number for pharmacy. There was no apraxia.
Cranial Nerves: Olfaction not tested. Pupils equal, round and
reactive to light bilaterally, and visual fields intact to
confrontation bilaterally with no hemineglect. No ptosis is
noted, and on fundoscopic exam discs were hard to visualize.
Extra-ocular muscles were intact without nystagmus. Sensation
was intact to light touch over face with no ext to DSS. Left
UMN
facial droop was noted; hearing was intact to finger-rub
bilaterally. Palate and uvula elevate at midline. There is 5/5
strength in trapezii and sternocleidomastoids bilaterally.
Tongue
protrudes in midline, with no fasciculations.
Motor: diffuse atrophy of limbs (arms and legs), nl tone
throughout. No tremor, asterixis or drift.
Delt Bic Tri WrE FFl FE IO IP Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 3 2 2 5 5- 5 5 4+ 4+
R 5 5- 5- 5- 5 5 5 5 4+ 5 5 4+ 4+
Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout upper extremity. Lower ext with decr
pp to ankle. No extinction to DSS. + agraphesthesia and
astereognosis of right hand, nl on left hand.
Coordination: Normal finger to nose on left; right could not
perform but touched face with hand, no tremor or dysmetria; nl
heel to shin bilat, with no dysmetria. Nl finger tapping on
left, could not perform on right; nl foot tapping.
Reflexes: 2+ biceps, triceps, brachioradialis, 1+ patellar and 0
ankle jerks bilaterally. The patient had mute toes on plantar
response bilaterally.
Gait: Could not assess due to pt's being taken for study.
PATIENT REEXAMINED AT 5:45PM FOR ACUTE CHANGE IN MS (last seen
at
5:30PM):
-pt now unresponsive to voice and sternal rub; finally awoke to
deep sternal rub and could raise hand on command, open eyes but
did not stay awake unless stimulated. MVMT of all four
extremities noted, toes still mute, reflexes unchanged. For
change in MS [**First Name (Titles) **] [**Last Name (Titles) 27025**] and intubated. BP in 200/80 range at
the time. INR reversed with Prolix.
Pertinent Results:
[**2111-1-3**] 03:20PM WBC-28.2* RBC-3.65* HGB-10.3* HCT-32.4*
MCV-89 MCH-28.1 MCHC-31.6 RDW-21.1*
[**2111-1-3**] 03:20PM NEUTS-67 BANDS-4 LYMPHS-2* MONOS-7 EOS-19*
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2111-1-3**] 03:20PM PLT COUNT-337
[**2111-1-3**] 03:20PM PT-18.2* PTT-28.2 INR(PT)-2.3
[**2111-1-3**] 03:20PM CK(CPK)-51
[**2111-1-3**] 03:20PM CK-MB-4 cTropnT-0.11*
[**2111-1-3**] 03:20PM GLUCOSE-307* UREA N-22* CREAT-1.3* SODIUM-133
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
[**2111-1-3**] 06:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2111-1-3**] 06:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2111-1-3**] 06:45PM PHENYTOIN-15.7
[**2111-1-3**] 09:25PM LACTATE-1.9
EKG:
Sinus rhythm. Poor R wave progression, cannot rule out old
anteroseptal
myocardial infarction. Loss of R waves in leads III and aVF,
consider old
inferior wall myocardial infarction. Compared to the previous
tracing
of [**2110-11-12**] loss of R waves in lead aVF is new. Otherwise, no
significant
diagnostic change.
MRI with contrast [**1-4**]
FINDINGS: Again seen are numerous intraparenchymal enhancing
masses with associated hemorrhage. These are compatible with the
clinical impression of metastatic disease. Note that a large
right frontal extra-axial lesion most likely represents a
meningioma. The extra-axial lesion appears approximately stable
since the MR [**First Name (Titles) **] [**2110-9-25**]. The intraparenchymal lesions are
new since that time, but appeared stable since the study of
[**2111-1-3**].
A preliminary report was issued that read "Multiple hemorrhagic
enhancing metastases are again seen, with variable amounts of
surrounding edema. The largest lesion is in the right cranial
vertex. The vasculature appears unremarkable."
CONCLUSION: Numerous hemorrhagic enhancing intraparenchymal
masses compatible with the clinical impression of metastatic
disease.
Extra-axial lesion at the right vertex likely representing a
meningioma.
1st CT [**1-3**]:
FINDINGS: Again seen is a calcified meningioma measuring
approximately 2.2 cm near the vertex in the right frontal
region. Since the prior examinations, there have been
development of numerous well-circumscribed rounded lesions of
increased attenuation seen scattered throughout both frontal and
temporal lobes. The largest two lesions are in the left frontal
lobe measuring approximately 10 x 12 mm and in the right
temporal lobe measuring 12 x 9 mm. Both these lesions have some
surrounding hypodensity consistent with edema. There is no
subdural or subarachnoid hemorrhage seen. There is no
hydrocephalus or shift of normally midline structures.
Soft tissues and osseous structures are normal. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Interval development of numerous hyperdense lesions within
both frontal and temporal lobes. The differential for this is
hemorrhagic metastases or traumatic contusion. The appearances
are suggestive of hemorrhagic metastasis.
2. Unchanged appearance of right calcified meningioma.
2nd CT brain [**1-3**]:
There has been no change in the appearance of innumerable
bilateral hemorrhagic lesions, likely hemorrhagic metastases.
The extent of surrounding vasogenic edema within the left
frontoparietal and right temporal lobes is also unchanged. There
is no new intracranial hemorrhage. The ventricles and sulci are
stable in appearance.
In the intervening time, the patient has been intubated.
CT TORSO:
FINDINGS: Images of the lower thorax again demonstrate nodular
thickening of the left pleura which is slightly increased since
the prior exam of [**2110-10-16**]. Interstitial thickening is present in
the left base which was also seen previously and is slightly
more prominent on the current exam. Again visualized is a left
subpulmonic fluid collection measuring 7.0 x 8.6 x 7.8 cm. It is
predominantly low density with iso and hyperdense material
present within it. No associated rib lesions are present. The
size of this collection has not significantly changed since an
MRI from [**2110-11-14**]. In the context of a non-contrast enhanced CT,
the liver, spleen, pancreas, and left adrenal gland are
unremarkable. Again noted is a 2.2 x 2.7 cm nodule in the right
adrenal gland which was seen on the recent MRI at which time it
likely represented an adenoma. The patient is status post left
nephrectomy. Cysts are again identified in the right kidney.
Again identified is prominence of the right collecting system
without hydronephrosis. There is no abdominal lymphadenopathy.
There is no evidence of intra-abdominal hemorrhage. A nodule is
present in the subcutaneous soft tissues of the anterior
abdominal wall which measures 1.4 cm in diameter. There is
atherosclerosis. There are no dilated bowel loops. The
gallbladder is present.
CT PELVIS FINDINGS: There is free fluid in the dependent
position of the pelvis. The urinary bladder is well distended
and contains gas likely related to the patient's Foley catheter.
A nodule is present in the right hemipelvis measuring 2.8 x 2.3
cm best seen on series 2, image 62. There are no dilated bowel
loops in the pelvis. Graft material is seen in the left external
iliac artery.
Bone windows demonstrate degenerative changes in the spine. No
blastic or lytic lesions are present.
IMPRESSION:
1. Stable appearance of a left subpulmonic fluid collection
representing either an abscess or hematoma. It has not changed
in size since the MR from [**2110-11-14**].
2. No dense material present within the abdomen on the current
examination to suggest hemorrhage.
2. Nodular thickening involving the left pleura and interstitial
thickening involving the left base likely representing
metastatic disease slightly worse since the previous exam. The
pericardium is slightly thickened on the current exam as well
but not significantly changed since the prior exam.
3. A soft tissue nodule in the right hemipelvis likely represent
an ovary. It was seen on a more remote exam from [**2108-2-3**].
4. Small amount of pelvic-free fluid.
Brief Hospital Course:
68 yo woman with dm, htn, past malignancies including RCC and
thyroid ca, and recent w/u with negative path for malignancy but
concerning bone scan, mult known pulm nodules, adrenal nodule,
who p/w right weak hand and left facial droop, multiple areas of
hemorrhage on ct with no substantial edema or effacement of the
grey-white jxn, no midline shift, vents open. Initial exam
showed left facial droop and right arm weakness; however,
several hours after being in the ED, (hours after being given 10
mg IV decadron and 1.5g IV dilantin) she became unresponsive.
She was intubated and a stat head CT was repeated after acute
change in MS, showing no change. Given her hx, and location of
hemorrhages, as well as the fact that they are multifocal, mets
were considered to be primary concern in this pt. Could have
recurrence of RCC, which can met to brain and bleed, versus new
lung cancer versus new malignancy of other source versus
recurrence of her thyroid cancer. Infection, autoimmune still
possibilities, but less likely given pattern of lesions, and
hemorrhagic component. Acute change in MS, given no change on
CT could have been sz.
She was admitted to Neuro ICU, attending Dr. [**Last Name (STitle) **]. BP was
monitored with goal 120-150. Neurosurg was consuted for workup
of ?brain mets. MRI showed lesions to be enhancing. WBC was
initially elevated with negative UA (except RBC's), CXR with no
change. She was placed on Dilantin 100 mg tid and Decadron 4 mg
IV q6hrs. She was managed on an insulin sliding scale, and
given protonix and pneumoboots for prophylaxis.
She was extubated within 24 hours with no recurrence of seizure
activity and return to her pre-mental status change state, with
some improvement of strength in the hand and facial droop. Dr.
[**Last Name (STitle) **] (PCP) and Dr. [**Last Name (STitle) 575**] (pulm) were involved with her care.
.
[**1-5**]: Onc thinks lung>brain ca, [**Last Name (un) **]. CEA and rad-onc consult,
bx pelvic lesion by surgery (not reachable per interv.rads); rad
onc aware. Pulm reluctant to re-bx lung b/c of mult neg bx'es
to date.
.
[**1-6**]: Got day [**1-29**] of whole brain XRT. Pelvic nodule is really
an ovary, not a mass, so can't be bx'ed. Pulm will touch base
with CT [**Doctor First Name **] ?look at lung bx option; tw neurosurg again- really
not good bx options, is stereotactic brain (ie, frontal lobe
lesion) feasible? CEA mildly elevated- unhelpful in
differentiating lung from renal cell.
.
[**1-7**]: Transferred to [**Hospital1 **]. AVSS. No complaints. Continued RUE
weakness ([**4-29**]). CT neck/chest today with increased pleural
thickening and nodularity.
.
[**1-8**]: AVSS w/ increased WBC to 32 likely secondary to
steroids. Foley replaced [**2-26**] PVR 400 and polyuria. FNA of
abdominal wall mass. Whole brain XRT QD continues.
.
[**1-9**]: AVSS with increased WBC to 34. No complaints.
Percutaneous biopsy of pleura performed without complication.
Touch prep positive cytology.
.
[**Date range (1) 27026**]: No XRT. Patient's NPH and metoprolol increased
for improved blood sugar and blood pressure control. Decadron
decreasaed to 4mg IV Q6 hours. [**1-11**] patient experienced [**9-3**]
chest pain relieved with nitorglycerin. No ECG changes. Cardiac
enzymes not sent.
.
[**1-12**]: AFVSS with SBP 170 transiently. Increased metoprolol to
37.5 TID. Patient NPO for possible open biopsy today. FSG 383.
NPH and humalog given as well as Mg 4 grams IV in 250cc D5W.
Pathology results: poorly differentiated malignancy.
.
[**1-13**]: AVSS with BP controlled. Patient "feeling great" and
would like to return home for the holidays. Social work
discussed with patient the general plan and Dr. [**Last Name (STitle) **] discussed
"next step" options with the family. PHysical therapy worked
with patient with very good response.
Medications on Admission:
1. Atorvastatin 20 mg qd
2. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY at 4pm to be taken 4 hrs separatedly with other
medications.
3. Gabapentin 300 mg TID
4. Candesartan 32 mg qd
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg [**Hospital1 **]
8. Senna 8.6 mg
9. Cepacol 2 mg Lozenge prn
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
12. Protonix 40 mg qd
13. Labetalol 150 mg PO BID
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
(30) units Subcutaneous daily at breakfast and (26) units
Subcutaneous at bedtime.
15. Insulin Regular Human Injection
16. Warfarin 2 mg PO HS
17. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
Allergies: IV CT contrast->rash
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*30 * Refills:*2*
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*30 * Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Phenytoin Sodium Extended 200 mg Capsule Sig: Two (2)
Capsule PO at bedtime.
Disp:*60 Capsule(s)* Refills:*2*
11. Decadron 4 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Physical Therapy
Bed Bar
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Metastatic non small cell carcinoma
2. Anemia
Discharge Condition:
Stable
Discharge Instructions:
1. Dressing changes to sacral decubitus ulcer per nursing
(duoderm or equivalent)
2. Regular diet/ pureed food as tolerated
3. Continue checking blood glucose QID (four times a day) while
on steroids.
4. Return to the Emergency Department for fevers, chills, chest
pain, shortness of breath, sensation changes, weakness, or other
concerns.
5. Do not restart coumadin
6. Continue insulin dosing as before admission
Followup Instructions:
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2111-2-16**]
3:00
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Date/Time:[**2111-3-9**] 3:00
VAS NON-INVAS LMOB VASCULAR LMOB (NHB) Date/Time:[**2111-6-29**] 10:00
[**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2111-1-23**]
1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2111-1-15**] 11:50
Name: [**Known lastname 4647**],[**Known firstname **] Unit No: [**Numeric Identifier 4648**]
Admission Date: [**2111-1-3**] Discharge Date: [**2111-1-14**]
Date of Birth: [**2042-8-14**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 4649**]
Addendum:
Patient failed due to void x 2 with retention of 400-600 cc
urine. Foley replaced. Patient without other complaints stable
for discharge with foley and leg bag. VNA can assist family with
training and maintenance.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2852**] MD [**MD Number(2) 2853**]
Completed by:[**2111-1-22**]
|
[
"285.22",
"431",
"564.00",
"198.5",
"197.2",
"162.9",
"V10.52",
"707.03",
"438.83",
"250.00",
"788.20",
"V10.87",
"198.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"92.29",
"96.71",
"38.93",
"34.24",
"99.07",
"83.21"
] |
icd9pcs
|
[
[
[]
]
] |
22308, 22523
|
14070, 17932
|
300, 422
|
20611, 20620
|
7901, 14047
|
21088, 22285
|
4767, 4831
|
19058, 20437
|
20539, 20590
|
17958, 19035
|
20644, 21065
|
4846, 5429
|
227, 262
|
450, 3709
|
5821, 7882
|
5444, 5805
|
3731, 4602
|
4618, 4751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,880
| 158,711
|
39211
|
Discharge summary
|
report
|
Admission Date: [**2158-5-17**] Discharge Date: [**2158-5-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Weakness, lethargy, fever
Major Surgical or Invasive Procedure:
[**2158-5-17**]:
1. Bilateral T1 laminotomy.
2. Laminectomy T2, T3, T4, T5.
3. Open resection interspinal abscess.
4. Deep bone biopsy.
5. Deep muscle biopsy.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: [**Age over 90 **]-year-old man with coronary
artery disease s/p CABG with aortic valve replacement 10 years
ago and recent NSTEMI [**2-/2158**] as well as hypertension, GERD,
prostate CA admitted from rehab to [**Hospital3 2783**] [**5-14**] with
weakness, lethargy, fever, diagnosed with possible
hospital-acquired left lower lobe pneumonia (hospitalized at [**Hospital1 **] since [**2158-2-10**]) and placed on
vancomycin and cefepime (possibly ceftazidime on [**5-14**]). Found to
have MSSA bacteremia by report, and OSH transthoracic echo
showed no vegetations on [**5-14**]. CT scan chest on [**5-16**] showed
bilateral pleural plaque formation, collapse of T3 vertebra with
paravertebral soft tissue densisty, suspicious for T2-3 diskitis
with adjacent osteomyelitis. CT abdomen on [**5-16**] was unremarkable.
On [**5-17**] vancomycin was discontinued and nafcillin 2g IV q4h was
started; also on gentamicin, rifampin at that time. MRI on [**5-17**]
showed large epidural abscess measuring 8 x 1.5 2 cm
with significant cord compression at T4 level with extensive
paravertebral phlegmon. Had lower extremity weakness and sensory
changes below the nipple line distally. He was transferred to [**Hospital1 **]
emergently for neurosurgical management.
Past Medical History:
CAD s/p NSTEMI [**2-/2158**] and CABG/AVR [**58**] years ago
CHF with mild systolic dysfunction, mild global hypokinesis of
posterior wall (EF 60%)
Hypertension
GERD
Gastritis
Hypercholesterolemia
Depression
Prostate CA
Polymyalgia rheumatica
H/o recent GI bleed
H/o delirium with narcotics
Hamstring muscle tear [**2-/2158**]
Social History:
Lived independently until [**2-19**], performed all own ADLs. Then
discharged to rehab. Denies smoking, drinks 1-2 drinks per day
(prefers wine in the am, [**Location (un) 21601**] or rum and coke in the pm).
Family History:
Non-contributory
Physical Exam:
Upon transfer to the floor from the SICU:
VS: 98.0 74 131/47 24 100%3L
Gen: NAD. Oriented to month and year, not date. Knows he is in
the hospital, not the city or hospital (he knows it's "not [**Hospital3 5870**]")
HEENT: NCAT. Sclera anicteric. MM slightly dry.
CV: RRR, III/VI systolic murmur at LUSB and LLSB, radiates to
carotids.
Chest: Resp were unlabored, no accessory muscle use. CTA
anteriorly. No wheezes or rhonchi heard.
Abd: Soft, NTND. New PEG tube dressing in place, with abdominal
binder in place as well. No HSM or tenderness.
Ext: No c/c/edema. Trace DP/PT
Pertinent Results:
Admission Labs:
[**2158-5-17**] 08:20PM WBC-6.0 RBC-3.05* HGB-8.7* HCT-27.1* MCV-89
MCH-28.6 MCHC-32.2 RDW-16.3*
[**2158-5-17**] 08:20PM PLT COUNT-432
[**2158-5-17**] 08:20PM PT-11.8 PTT-27.7 INR(PT)-1.0
[**2158-5-17**] 08:20PM GLUCOSE-114* UREA N-42* CREAT-2.0* SODIUM-135
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-30 ANION GAP-14
[**2158-5-17**] 08:20PM CALCIUM-8.8 PHOSPHATE-4.5 MAGNESIUM-2.1
[**2158-5-17**] 08:20PM CK-MB-NotDone cTropnT-0.06*
Discharge Labs:
[**2158-5-25**] 05:57AM BLOOD WBC-7.0 RBC-3.42* Hgb-9.5* Hct-30.4*
MCV-89 MCH-27.7 MCHC-31.3 RDW-16.6* Plt Ct-446*
[**2158-5-25**] 05:57AM BLOOD PT-15.2* PTT-34.9 INR(PT)-1.3*
[**2158-5-25**] 05:57AM BLOOD Glucose-103* UreaN-38* Creat-1.7* Na-141
K-3.6 Cl-107 HCO3-25 AnGap-13
[**2158-5-25**] 05:57AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
Studies:
ECG [**2158-5-17**]: Sinus rhythm. Modest ST-T wave changes with
prolonged QTc interval are non-specific but clinical correlation
is suggested for possible drug/electrolyte/metabolic effect. No
previous tracing available for comparison.
ECHO [**2158-5-18**]: No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. IMPRESSION: No vegetations seen.
Chest [**2158-5-18**]: CHEST, AP: A replaced right subclavian line
terminates in the high right atrium, near the cavoatrial
junction. Other monitoring and support devices are unchanged in
course and position. There is no pneumothorax. Moderate left and
small right pleural effusion are unchanged. Mild interstitial
edema and cardiomegaly persist. The aorta is calcified and
tortuous. Changes of median sternotomy and aortic valve
replacement are noted. IMPRESSION: Devices in standard
position. Mild volume overload.
Chest Xray [**2158-5-18**]: CHEST, AP: Endotracheal tube has been
removed. New right PICC ends in the right atrium, 3 cm beyond
the cavoatrial junction. Right dialysis catheter again
terminates at the cavoatrial junction. There is no pneumothorax.
Moderate layering left effusion persists. The cardiomediastinal
and hilar contours are normal, with changes of CABG and aortic
valve replacement. Lung volumes are low, with mild bibasilar
atelectasis. IMPRESSION: Right PICC 3 cm beyond cavoatrial
junction. Dr. [**Last Name (STitle) **] was notified on [**2158-5-25**] at 10:20 a.m.
Brief Hospital Course:
Mr. [**Known lastname 86804**] is a [**Age over 90 **] year old male with CAD s/p CABG with
bioprosthetic AVR [**58**] years prior and recent NSTEMI as well as
HTN, GERD, prostate CA and h/o GIB admitted with MSSA bacteremia
and epidural abscess with cord compression.
#. Epidural abscess s/p laminectomy: He was admitted on [**2158-5-17**]
and underwent emergent 1. Bilateral T1 laminotomy, 2.
Laminectomy T2, T3, T4, T5, 3. Open resection interspinal
abscess, 4. Deep bone biopsy, 5. Deep muscle biopsy by Dr. [**Last Name (STitle) 1007**]
after initial evaluation by medicine. Postoperatively he was
brought to the SICU and placed in a CTO brace to be worn at all
times when OOB. He is on strict logroll precautions when not in
his CTO brace. He was extubated on POD 1 without complication.
His blood cultures grew MSSA and the infectious disease team
recommended a 6 week course of nafcillin. He will need a weekly
CBC/diff, chem7, and LFTs. He will have a follow-up appointment
in 3 weeks with Dr. [**Last Name (STitle) 1007**] and repeat surgery in 6 weeks. He
also underwent TEE on [**5-18**] which showed no vegetations. His pain
was controlled with standing tylenol and oral oxycodone, with
occasional supplementation with IV morphine.
#. Delirium: He had delirium post-operatively that gradually
improved with pain control and reorientation. He was given
olanzapine twice daily as needed for agitation.
#. Nutrition: He had marked aspiration during his admission and
had a speech and swallow evaluation which he failed. He
ultimately had a PEG tube placed on [**5-24**] without complication.
Tube feeds were then initiated.
#. Acute on chronic diastolic CHF: He has a history of mild
systolic CHF. His diuretics were initially held and Lasix was
held on admission. He is also on Aldactone at as outpatient and
this should be added back as volume status tolerates. He was
continued on his home ACE-I and beta blocker.
#. CAD s/p NSTEMI: He had an NSTEMI in [**2-19**] and was started on
Plavix at that time. His Plavix was held perioperatively and
restarted on POD 7. He was continued on his outpatient beta
blocker and aspirin was also restarted post-operatively. His
Imdur was held and should be restarted as blood presure
tolerates.
#. Hypertension: His amlodipine and Imdur were held during this
admission and should be reinitiated as tolerated. His
lisinopril was given at a lower dose and should be uptitrated.
#. Anemia: He was moderately anemic perioperatively but his
hematocrit remained stable. He has had a recent GI bleed but
there was no evidence of GI bleeding during this admission.
#. Acute renal failure: His creatinine increased
post-operatively with a maximum of 2.9 on [**5-21**]. It was felt
that this was most likely prerenal azotemia in the perioperative
setting. His creatinine improved during admission.
#. Prostate cancer: He was given a lupron injection in the SICU
as he was due for prostate cancer treatment/suppression.
Medications on Admission:
Aldactone 12.5 mg daily
Caltrate 600 mg [**Hospital1 **]
Celexa 40 mg daily
Lactulose 30 mg daily prn
Colace 100 mg [**Hospital1 **]
Ecotrin 81 mg daily
Folic acid 1 mg daily
Imdur 60 mg daily
Lasix 40 mg daily
Vitamin b12 1000 mcg qhs
Vitamin d 50,000 units q friday
lisinopril 40 mg daily
Zocor 20 mg qhs
Zantac 150 mg [**Hospital1 **]
Prilosec 40 mg daily
Metoprolol xl 75 mg daily
Neurotonin 200 mg tid
Norvasc 10 mg daily
Plavix 75 mg daily
Thiamine 100 mg daily
Tylenol 975 mg [**Hospital1 **]
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once
a day as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Can uptitrate this medication to 40mg based on blood pressure.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Can uptitrate this medication to 37.5mg po bid
based on HR and BP.
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a
day.
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
16. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO DAILY (Daily)
as needed for constipation.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
18. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours): Until [**2158-7-1**].
19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for anxiety.
20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
21. Outpatient Lab Work
You should have labs drawn (CBC with diff, Chem7, LFTS, and
ESR/CRP) once per week and faxed to the infectious disease
nurses at [**Telephone/Fax (1) 1419**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnosis:
Epidural abscess s/p laminectomy
MSSA bacteremia
Acute renal failure
Secondary Diagnosis:
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Must wear thoracic-lumbar orthosis anytime out of
bed, otherwise should be on logroll precautions.
Discharge Instructions:
You were transferred to [**Hospital1 18**] due to an infection in your spine.
You are being treated with 6 weeks of antibiotics (nafcillin).
You underwent surgery (laminectomy) to drain your infection and
repair your spine.
Activity Instructions: You should where your cervical-thoracic
orthosis whenever out of bed; this is extremely important to
maintain your spine alignment.
Wound Care: Your wound should be covered with a dry sterile
dressing at all times
Changes to your medications:
Added Nafcillin until [**2158-7-1**]
Added subcutaneous heparin
Added Olanzapine
Added Senna
Stopped caltrate, B12, omeprazole, Zantac
Holding Imdur, amlodipine - can resume these medications as
tolerated
Changed dosing of lisinopril, metoprolol, and gabapentin
You should have labs drawn (CBC with diff, Chem7, LFTS, and
ESR/CRP) once per week and faxed to the infectious disease
nurses at [**Telephone/Fax (1) 1419**] while you are on nafcillin.
Followup Instructions:
You should see your orthopedic surgeon, Dr. [**Last Name (STitle) 1007**], 3 weeks after
surgery. They are working on a follow up appointment in
Orthopedics with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. You will be called at rehab
with an appointment. If you have not heard or have any questions
please call [**Telephone/Fax (1) 3736**].
- At the 3-week visit, they will check your incision, take
baseline X-rays and answer any questions.
- You will then have another appointment at 6 weeks from the day
of the operation and at that time release you to full activity.
You also need to follow up in the infectious disease clinic with
Dr. [**Last Name (STitle) 86805**] or Dr. [**Last Name (STitle) 4020**]. This clinic should call your
rehab to tell you about an appointment. If you do not hear from
them in [**2-11**] days, please call [**Telephone/Fax (1) 457**] to schedule an
appointment.
|
[
"790.7",
"730.08",
"324.1",
"272.0",
"293.0",
"722.72",
"285.1",
"428.33",
"530.81",
"185",
"V43.3",
"725",
"311",
"V45.81",
"428.0",
"584.5",
"412",
"041.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.21",
"03.09",
"96.6",
"88.72",
"77.49",
"43.11",
"03.4",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11481, 11581
|
5924, 8912
|
288, 448
|
11772, 11772
|
2991, 2991
|
13017, 13951
|
2360, 2378
|
9462, 11458
|
11602, 11602
|
8938, 9439
|
12050, 12432
|
3462, 5901
|
2393, 2972
|
12544, 12994
|
223, 250
|
12444, 12515
|
505, 1766
|
11712, 11751
|
3007, 3446
|
11621, 11691
|
11787, 12026
|
1788, 2116
|
2132, 2344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,514
| 132,252
|
1997
|
Discharge summary
|
report
|
Admission Date: [**2107-7-28**] Discharge Date: [**2107-8-4**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypertensive urgency, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 58M h/o HBV, HCV, COPD, CAD, PE s/p IVC filter and multiple
admissions for malignant hypertension found sitting on a park
bench confused, hypertensive with SBP 230s and bradycardic to
the 30s.
Pt reports being held at gunpoint and hit on the back of the
head with weapon.
.
In the ED, vital signs were T 96.1 HR 46 BP 222/110 RR 12 SpO2
98% on RA FSBG 126. Pt was started on nitro gtt for hypertention
and empirically treated with vanco and Ceftriaxone for
retrocardiac opacity on CT Chest. Received banana bag. Cardiac
enzymes negative x 2; tox screen positive for methadone and
benzos. Pt complained of b/L hand pain for which plastics was
consulted regarding ? of compartment syndrome in hands. However,
low level of suspicion.
.
In MICU, nitro gtt was d/c'd. Abx also were d/c'd as no
sx/suspicion for infection.
.
On my exam, patient complains of constant, persistent chest pain
([**6-2**]) since his assault that worsens with movement and deep
breathing. Pt also reports SOB, which is relieved while lying
flat. No diaphoresis or nausea. Also with bilateral hand pain
and swelling and occipital headache. Also complains of blurred
vision that began several days ago. Denies abdominal pain,
diarrhea, cough, numbness, weakness.
Past Medical History:
Hypertension- Uncontrolled. Normal P-MIBI [**6-28**], normal EF on
echo [**3-29**]. MRI of Kidneys were negative for RAS. TSH was normal.
Random AM cortisol normal.
COPD
GERD
h/o heroin abuse- now on methadone
h/o PE/DVT s/p IVC filter
Hepatitis B
Hepatitis C, undetectable HCV RNA [**3-29**]
Post traumatic stress disorder
Anxiety
Depression
Antisocial personality disorder-several psychiatric
hospitalizations
Microcytic Anemia
Vit B12 deficiency
Family History:
NC
Physical Exam:
T 96.2 HR 59 BP 122/80 RR 16 100% on RA
General: WDWN male in NAD, somewhat lethargic
HEENT: PERRL, EOMI, anicteric
Neck: supple, trachea midline, no LAD
Chest: diffuse pain on palpation of chest wall
Cardiac: RRR s1s2 normal, no m/r/g
Pulmonary: diffuse wheezes
Abdomen: soft, nontender, nondistended, +BS, no HSM
Extremities: warm, bilateral hand edema tender to palpation, <2
sec cap refill, 2+ radial pulses, no LE edema 2+ DP/PT pulses
Neuro: A&Ox3, CNII-XII intact
Pertinent Results:
[**2107-7-28**] 03:44PM BLOOD WBC-4.4 RBC-4.01* Hgb-11.0* Hct-33.3*
MCV-83 MCH-27.5 MCHC-33.1 RDW-16.1* Plt Ct-187
[**2107-8-4**] 05:50AM BLOOD WBC-4.2 RBC-3.99* Hgb-11.2* Hct-32.0*
MCV-80* MCH-28.0 MCHC-35.0 RDW-15.6* Plt Ct-161
[**2107-7-29**] 02:52AM BLOOD PT-12.2 PTT-31.9 INR(PT)-1.0
[**2107-7-28**] 03:44PM BLOOD Glucose-103 UreaN-16 Creat-1.2 Na-139
K-4.7 Cl-109* HCO3-23 AnGap-12
[**2107-8-4**] 05:50AM BLOOD Glucose-90 UreaN-22* Creat-1.2 Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
[**2107-7-28**] 03:44PM BLOOD ALT-11 AST-19 CK(CPK)-213* AlkPhos-124*
Amylase-62 TotBili-0.3
[**2107-8-3**] 05:45AM BLOOD ALT-13 AST-21 AlkPhos-95 TotBili-0.3
[**2107-7-28**] 03:44PM BLOOD CK-MB-9 cTropnT-<0.01
[**2107-7-29**] 02:52AM BLOOD CK-MB-7 cTropnT-<0.01
[**2107-8-2**] 05:40AM BLOOD TSH-4.9*
[**2107-7-28**] 03:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**8-3**] SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS.
There is a nonobstructive bowel gas pattern with no abnormally
dilated loops of bowel identified. A moderate amount of stool is
noted within the ascending and transverse colon. Trace amount of
air is noted distally within the region of the rectum. No
evidence of pneumatosis or pneumoperitoneum. There is stable
appearance to an IVC filter and mild levoscoliosis of the lumbar
spine.
IMPRESSION:
No signs of underlying obstruction. Moderate amount of stool
noted within the ascending and transverse colon. No
pneumoperitoneum.
[**8-3**] PA AND LATERAL CHEST: Patchy left lower lobe opacity is
again seen, probably unchanged from [**2107-7-28**], given
differences in technique between exams. This opacity was not
present in [**Month (only) **] or [**2106-7-24**], and most likely represents a focus
of pneumonia. There are no other consolidations, and no
congestive failure. Cardiac and mediastinal contours are
unchanged, with a mildly tortuous aorta. No pleural effusions or
pneumothorax. Osseous structures are unremarkable.
IMPRESSION: Left lower lobe patchy opacity is unchanged from six
days ago, and likely represents pneumonia.
Brief Hospital Course:
On presentation to the floor, the patient continued to complain
of chest and abdominal discomfort. He was found not be
experiencing myocardial ischemia as evidenced by lack of cardiac
enzymes and ECG changes. He continued to complain of nausea, and
diahrrea, and it was felt that the patient was receiving an
inadequate dose of his methadone. The patient reported thatthe
dose of his methadoen was in fact correct, however he was not
familiar with the dosage form being tablets of 40mg, as compared
to his usual tablets of 10mg. His systolic blood pressure was
gradually lowered over a span of 4 days from the 170's to the
130's, with the addition of nifedipine and lisinopril to the
clonidine he was already taking. He continued to complain of
light headedness while walking. Physical therapy worked with
the patient daily and did not report decreased blood pressure or
decreased oxygen saturation on ambulation. Psychiatry met with
the patient on several occasions, though he was resistant to
speaking with them. They eventually recommended he go to a pain
clinic, which could be handled as an outpatient. his TSH was
also found to be elevated and he was started on levothyroxine.
He was discharged on [**8-4**], afebrile, with stable vital signs and
systolic blood pressure in the 130's. He was given instructions
to follow up with his new primary care physician on [**8-24**],
and to return to the hospital if he experiences any further
chest pain.
Medications on Admission:
Medications (per recent d/c summary):
Tyenol prn
ASA 325 daily
Bisacodyl, colace, senna
Clonidine 0.2mg tid
Clonazepam 2mg tid
Labetalol 200mg [**Hospital1 **]
Lactulose prn
Methadone 135mg daily
Nifedipine CR 30mg daily
Combivent inh 1-2 puffs q6h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*qs * Refills:*0*
3. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
6. Methadone 5 mg Tablet Sig: Twenty Seven (27) Tablet PO DAILY
(Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Opiate withdrawal
Discharge Condition:
Good
Discharge Instructions:
Keep all of your follow-up appointments.
Take all of your medications as directed.
Call your doctor or go to the ER for any of the following: chest
pain, blurry vision, headache, lightheadedness, fevers/chills,
shortness of [**Month/Day (2) 1440**], nausea/vomiting or any other concerning
symptoms.
Followup Instructions:
Follow-up with primary careProvider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2107-8-24**] 1:30
You will need a repeat Chest X-Ray in 6 weeks.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"786.59",
"530.81",
"266.2",
"070.30",
"070.70",
"780.6",
"401.0",
"V12.51",
"301.7",
"V15.82",
"292.0",
"280.9",
"V60.0",
"729.5",
"518.0",
"496",
"304.00",
"427.89",
"300.4",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.65"
] |
icd9pcs
|
[
[
[]
]
] |
7488, 7494
|
4711, 6172
|
332, 339
|
7577, 7584
|
2608, 4688
|
7935, 8287
|
2097, 2101
|
6476, 7465
|
7515, 7556
|
6198, 6453
|
7608, 7912
|
2116, 2589
|
249, 294
|
368, 1608
|
1630, 2081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,948
| 115,326
|
47442
|
Discharge summary
|
report
|
Admission Date: [**2198-3-2**] Discharge Date: [**2198-3-3**]
Date of Birth: [**2145-3-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Blood transfusions
History of Present Illness:
52 F with metastatic cholangiocarcinoma to liver and lungs, dxed
[**2196**], with bright red blood in her stool x past month. On
[**2198-2-26**], she was going to but did not receive her second cycle
of carboplatin/Taxol with sorafenib. She received her first
cycle of [**Doctor Last Name **]/Taxol/sorafenib 3 weeks ago, which she appeared
to have tolerated well initially, but has had significant
weakness and SOB x weeks afterward. Her Hct was found to be 18,
she was transfused 2 URBC. Today in followup with Dr. [**First Name (STitle) **]
[**Name (STitle) **], her Hct was 18, and she noted that she has been having
small amounts of BRBPR in her stool, no melena, no hemoptysis.
Sorafenib was stopped.
Past Medical History:
Cholangiocarcinoma w/ liver mets dx [**2196**], s/p common
hepatic duct stent [**12-2**], s/p 2 cycles, last chemo [**1-17**]
(cis/gem)
GERD
Mastitis after first pregnancy
2 separate breast bx??????s (both neg)
Migraines
[**Doctor First Name **] Hx:
Appendectomy with L oopherectomy about 30 yrs ago
Diagnostic laproscopy for suspected endometriosis (neg)
Recent FNA of thyroid nodule (neg)
Social History:
Lives in [**Location 620**] with husband and daughter, one other daughter
at college. She is employed as a social worker. She [**Name2 (NI) 100360**] 1mile
2-3x per week, does not drink, smoked socially (tobacco and
marijuana) 30 years ago. Denies current drug use although she
states she had a dependency on pain-killers 30 years ago.
Family History:
Mother died of breast CA as did Grandmother and two maternal
great-aunts. One aunt died of pancreatic CA and another from
stomach CA. She denies other familial illnesses. She gets
regular mammogram and screening but does not want genetic
screening for BRCA.
Physical Exam:
VS: 99.1 / 122/80 / 12 / 92 / 99% RA
GEN: Pleasant thin female in no acute distress, in bed
HEENT: PERRL, no LAD, JVD flat, anicteric sclerae
LUNGS: CTA B
HEART: RRR, no m/r/g
ABD: Very mild epigastric tenderness to palpation, no rebound,
no guarding, soft, +BS, ND
EXTR: No c/c/e
NEURO: [**6-2**] motor, normal gait
SKIN: No rash
Pertinent Results:
Hct: 18.4 - 24.8 - 27 - 29.4
.
[**2198-3-2**] 10:40AM BLOOD WBC-8.2 RBC-2.17* Hgb-6.3* Hct-18.4*
MCV-85 MCH-29.0 MCHC-34.2 RDW-22.7* Plt Ct-127*
[**2198-3-2**] 07:16PM BLOOD WBC-5.4 RBC-3.04*# Hgb-8.8*# Hct-24.8*#
MCV-82 MCH-29.0 MCHC-35.5* RDW-20.0* Plt Ct-76*
[**2198-3-3**] 04:00AM BLOOD WBC-6.1 RBC-3.38* Hgb-9.8* Hct-27.0*
MCV-80* MCH-29.1 MCHC-36.3* RDW-19.1* Plt Ct-70*
[**2198-3-3**] 01:32PM BLOOD WBC-6.6 RBC-3.57* Hgb-10.1* Hct-29.4*
MCV-82 MCH-28.2 MCHC-34.3 RDW-19.6* Plt Ct-71*
[**2198-3-2**] 07:16PM BLOOD PT-22.3* PTT-22.3 INR(PT)-1.1
[**2198-3-2**] 07:16PM BLOOD Glucose-96 UreaN-18 Creat-0.5 Na-139
K-4.2 Cl-106 HCO3-25 AnGap-12
[**2198-3-2**] 07:16PM BLOOD CK-MB-1 cTropnT-<0.01
[**2198-3-2**] 07:16PM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.4*
Mg-2.1 Iron-238*
Brief Hospital Course:
52 F with metastatic cholangiocarcinoma to liver and lungs, dxed
[**2196**], with bright red blood in her stool x past month. Hospital
course by problem:
.
# BRBPR:
Appears to be mild and chronic over a month. [**Month (only) 116**] be associated
with sorafenib treatment, but this drug was only started [**2197-2-5**],
and she received only one treatment dose. She has received
Avastin in the past. The patient was given 3u of PRBCs with an
improvement in her hematocrit to 29 from 18. She was
hemodynamically stable and not experiencing melana or
hematochezia. She ambulated without significant presyncopal
symptoms. GI was consulted who recommended an EGD and
colonoscopy with 2-3 days following her initial evaluation. We
discharged the patient with instructions on how to communicate
with the GI team to set up her procedures.
.
# Metastatic cholangiocarcinoma:
Most recent treatment was [**2197-2-5**] of Cycle 1 of
[**Doctor Last Name **]/taxol/sorafenib. Cycle 2 was held on [**2-26**] for low Hct.
Most recent CT abd [**2198-1-31**]. Followed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. We
ordered a CT of the torso for the patient to get done as on
outpatient. We also continued her actigall.
.
# Chronic abdominal pain:
Well controlled on dilaudid 1-2mg q 3 hours prn.
.
# Depression:
We continued Celexa per home regimen.
Medications on Admission:
1. Ursodiol 300 mg QD
2. Lorazepam 0.5 mg Q8H
3. Citalopram Hydrobromide 40 QD
4. Ciprofloxacin 500 mg QD
5. Prochlorperazine 10 mg Q6H prn
6. Dilaudid 1-2 mg Q3H prn
7. Methylphenidate 5 [**Hospital1 **]
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet PO BID
9. Potassium Chloride 20 mEq Packet QD
10. Loperamide 2 mg prn
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO once a day.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for nausea.
5. Dilaudid 2 mg Tablet Sig: 0.5-1 Tablet PO every four (4)
hours as needed for pain.
6. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- BRBPR
- cholangiocarcinoma
- anemia
Secondary:
- Migraines
- s/p appy
Discharge Condition:
well
Discharge Instructions:
You were admitted with with bleeding out of your rectum. We
treated you with three units of blood and you were evaluated by
the GI physicians. Your hematocrit stabilized.
.
The GI physicians would like to perform an EGD and colonoscopy
on Tuesday, [**3-6**]. Dr. [**First Name4 (NamePattern1) 14992**] [**Last Name (NamePattern1) 9746**] will call you on
Sunday to discuss the prep. You may eat normally today. On
Sunday, please switch to a full liquid diet. Please avoid seeds
and high fiber foods in the meantime. On Monday night, please
have nothing to eat after midnight.
.
Please take your medications as instructed. Please contact your
doctor if you feel short of breath, chest pain, fever, chills,
weakness.
.
Please have a CT scan done on [**2198-3-5**]. You need to contact the
radiology department by [**Telephone/Fax (1) **] to confirm this
appointment.
Followup Instructions:
Please have a colonoscopy and EGD on Tuesday. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 100361**]
will call you to set this up.
.
Please call [**Telephone/Fax (1) **] to confirm your CT scan for [**2198-3-5**].
The time needs to be confirmed by phone. Please followup with
Dr. [**Last Name (STitle) **] within the next two weeks.
|
[
"287.5",
"285.9",
"311",
"346.00",
"197.0",
"155.1",
"569.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5535, 5541
|
3290, 4645
|
318, 338
|
5666, 5673
|
2487, 3267
|
6595, 6954
|
1858, 2120
|
5043, 5512
|
5562, 5645
|
4671, 5020
|
5697, 6572
|
2135, 2468
|
273, 280
|
366, 1074
|
1096, 1489
|
1505, 1842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,390
| 173,410
|
7833+55878
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-8-17**] Discharge Date: [**2184-8-23**]
Date of Birth: [**2130-3-27**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man
with a history of interstitial pulmonary fibrosis, UIP who
presents with fever and sudden shortness of breath. The
patient has shortness of breath at baseline, requiring home
oxygen of two to four liters. He is on chronic Prednisone
treatment, gamma interferon for his interstitial pulmonary
fibrosis. Sudden shortness of breath is thought to be
decompensation of his interstitial pulmonary fibrosis that
has been waxing and [**Doctor Last Name 688**] in severity. The patient was
started on Levaquin 500 mg daily to cover a missed pneumonia.
A chest x-ray shows an old right lower lobe nodule, thought
to be rounded atelectasis. The patient unlikely has
pulmonary embolus. The patient was stabilized in the
Emergency Room with oxygen saturation of 97% on four liters
of oxygen.
PAST MEDICAL HISTORY: 1. Interstitial pulmonary fibrosis.
2. T7 compression fracture. 3. No cardiac history.
MEDICATIONS ON ADMISSION: Prednisone 35 mg p.o.q.d., gamma
interferon 200 mcg q. Monday, Wednesday and Friday, Bactrim
500 mg i.v.t.i.d., Ambien 10 mg p.o.q.h.s.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 97.9, heart rate 74, respiratory rate
20, blood pressure 100/70 and oxygen saturation 97% on four
liters oxygen. The patient had bilateral dry crackles
two-thirds up the base. The patient was alert and oriented
times three.
LABORATORY DATA: Admission white blood cell count was 5.9,
hematocrit 33.5, platelet count 219,000, electrolytes within
normal limits, CK 43 and troponin-I less than 0.3. Blood
cultures were also negative. Chest x-ray showed right lower
lobe opacity consistent with a pneumonia superimposed upon a
chronic interstitial fibrosis, fullness in the right hilar
region
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2184-8-25**] 17:00
T: [**2184-9-1**] 18:56
JOB#: [**Job Number 28270**]
Name: [**Known lastname 4931**], [**Known firstname 126**] Unit No: [**Numeric Identifier 4932**]
Admission Date: [**2184-8-17**] Discharge Date: [**2184-8-23**]
Date of Birth: [**2130-3-27**] Sex: M
Service: MICU B
This is a continuation of the second half of Discharge
Summary.
COURSE IN HOSPITAL: For his respiratory status, he was
continued on prednisone 35 mg p.o. q. day as well as Gamma
Interferon. He was also covered with antibiotics including
Bactrim and Levaquin. The patient, on day two of
hospitalization, required up to 4 liters on nasal cannula,
sats supine 93%, erect 86%. At this time, Cardiovascular
causes of shortness of breath were ruled out for myocardial
infarction, no congestive heart failure and his pressures
were stable. The patient continued to desaturate over the
next few days requiring 10 liters of oxygen to stay above 90%
saturation and also developed fever and blood tinged sputum.
The patient got CTA with was negative for PE. The patient
was then started on Bactrim intravenous for coverage of PCP.
[**Name10 (NameIs) **] following day, on [**8-20**], the patient had a more difficult
day requiring nonrebreather, desating down to as low as 82%.
He was started on Solu-Medrol 40 intravenous q.6h. He
continued on Bactrim 500 mg intravenous q.8h. and started on
Oxacillin 2 grams intravenous q.6h. to cover broadly, covered
possible infection. The patient's code status was DNR/DNI.
However, the Medical Intensive Care Unit was made aware of
this patient and because of his terrible oxygenation he was
still intubated and transferred to MICU on [**8-21**]. The
patient's symptoms were thought to be progressive in nature
secondary to his idiopathic pulmonary fibrosis and not
improving. There was a discussion with the son who was the
health care proxy numerous times in conjunction with the
health care providing team as well as their primary pulmonary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4933**]. On [**8-23**], the decision
was made by the son as well as the family to proceed with
comfort measures only. Therefore, ventilation was withdrawn
slowly while increasing levels of morphine for patient
comfort. The patient expired after approximately 1-1/2 to 2
hours of ventilatory withdrawal. The patient was declared
dead at 4:08 p.m. on [**2184-8-23**].
CONDITION AT DISCHARGE: Dead.
DIAGNOSIS: Respiratory failure secondary to progressive
idiopathic pulmonary fibrosis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Dictator Info 4934**]
MEDQUIST36
D: [**2184-8-25**] 17:34
T: [**2184-8-31**] 10:48
JOB#: [**Job Number 4935**]
|
[
"515",
"255.4",
"486",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1123, 1314
|
1337, 4682
|
4697, 5053
|
162, 982
|
1005, 1096
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,977
| 100,538
|
54242
|
Discharge summary
|
report
|
Admission Date: [**2176-11-4**] Discharge Date: [**2176-11-8**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old
female status post myocardial infarction on [**11-2**] with
substernal chest pain and shortness of breath. On arrival to
the Emergency Room she had electrocardiogram changes with
increased CK. Diagnosis was coronary artery disease,
unstable angina. She was taken to the Operating Room for
coronary artery bypass graft times three by Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
peripheral vascular disease, hypothyroidism.
CATHETERIZATION REPORT: Left main was normal. Left anterior
descending coronary artery 90% stenosis. Left circumflex
20%. Obtuse marginal two 30% stenosis. Obtuse marginal
three 60% stenosis. Right coronary artery 80% stenosis.
MEDICATIONS AT HOME: Hyzaar 125, Synthroid .112 mcg po q
day, Pletal 100 mg po b.i.d., Lipitor 10 mg po q day.
HOSPITAL COURSE: The patient was taken to the Operating Room
for a coronary artery bypass graft times three, left internal
mammary coronary artery to left anterior descending coronary
artery, saphenous vein graft to posterior descending coronary
artery, and saphenous vein graft to obtuse marginal.
Postoperatively, the patient did well. Chest tube was
extubated promptly in the Intensive Care Unit. Chest tube
was taken out on postop day number one. The patient was
subsequently transferred to the floor on postop day number
one. Upon arriving on the floor the patient was able to work
with physical therapy to ambulate. Upon discharge the
patient was able to ambulate approximately 300 feet with
assistance. The patient will be discharged to rehab facility
on [**2176-11-9**].
DISCHARGE MEDICATIONS: Lopressor 50 mg po b.i.d., Synthroid
.112 mcg po q day, Lasix 20 mg po b.i.d. times ten days,
K-Ciel 20 milliequivalents po b.i.d. times ten days and ASA
81 mg po q day, Lipitor 10 mg po q.d., and iron sulfate 325
mg po t.i.d.
CONDITION ON DISCHARGE: Stable. She was in sinus rhythm.
Her pulse was at 95 and her blood pressure was at 126/67.
The patient was sating at 98% on 2 liters. Her hematocrit
was 25.3.
PHYSICAL EXAMINATION ON DISCHARGE: Lungs were clear to
auscultation. The heart was regular rate and rhythm.
Incision was clean and dry. No drainage. Sternum was
stable.
The patient is to discharged to a rehab facility on [**2176-11-9**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 33515**]
MEDQUIST36
D: [**2176-11-8**] 12:16
T: [**2176-11-8**] 13:02
JOB#: [**Job Number 111135**]
|
[
"429.9",
"V10.3",
"272.0",
"401.9",
"440.21",
"244.9",
"414.01",
"411.1",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"42.23",
"36.15",
"88.72",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1790, 2018
|
997, 1766
|
888, 979
|
2241, 2718
|
129, 526
|
549, 866
|
2043, 2226
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,572
| 145,608
|
13718
|
Discharge summary
|
report
|
Admission Date: [**2180-11-26**] Discharge Date: [**2180-12-14**]
Date of Birth: [**2114-12-8**] Sex: F
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
woman who presented to [**Hospital1 69**]
for difficulty speaking. She has past medical history of
a-fib, hypertension, status post MI, prior stroke and most
significantly, a 10 year history of inflammatory brain
disease which has not been convincingly diagnosed. She
presents with a two day course of progressive slurred speech
and difficulty speaking. She was apparently in her usual
state of health until two days prior to admission when her
husband noted that her speech was slurred. She called her
primary care physician and over the next day her speech
slurring continued and she became hoarse. She also had
trouble eating. She was on her way from [**State 760**] to
[**State 350**] and her husband noted she was unable to speak
at all. She seemed to be able to understand what was said to
her, but she could not utter any words. She was also unable
to eat or drink and food would simply sit in her mouth. She
has been followed very closely by Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] who has
seen her in the past for a long history of diffuse white
matter disease since [**2170**]. This has been carrying a
diagnosis of MS [**First Name (Titles) 23318**] [**Last Name (Titles) 41306**] disease [**Last Name (Titles) 23318**] unknown.
She was then sent to the emergency room for evaluation.
PHYSICAL EXAMINATION: On admission vital signs were normal,
temperature 98.9, blood pressure 208/65. Neck was supple.
CV regular rate and rhythm. Pulmonary was clear bilaterally.
Abdomen was soft, nontender. On neurologic exam, in general,
she was alert, but unable to answer questions. She seemed to
try to talk, but only occasional soft nonsense words were
able to be uttered. Comprehension for multiple step commands
was intact. She could not read, write or repeat. She was
mildly apraxic and made object substitutions. Her affect was
somewhat blunted. Cranial nerves pupils were post surgical.
Extraocular movements were full without nystagmus. Face was
symmetric. Sensation was intact. Corneals were intact.
Shoulder shrug was normal. Tongue did not protrude and was
able to only wiggle side-to-side. Strength exam had mild
left sided drift. Left deltoid was 4+/5. Hip flexors were
4+/5. The remainder of her strength exam was [**4-16**]+ bilateral
upper and lower extremities. Sensory exam was limited due to
language difficulty, however, she did withdraw to pain
bilaterally. Gait was narrow based and normal with some
slight left sided limp. Finger-nose-finger coordination was
intact. Reflexes were somewhat brisk in the upper
extremities, normal in the lower extremities.
HOSPITAL COURSE: She was admitted to the hospital for
further workup. She had an MRI from [**2180-4-12**] which showed
multiple white matter lesions in the entire brain and brain
stem. There was also a large right occipital lesion. MRI
showed multiple distal stenoses of vessels. Repeat MRI on
admission from [**2180-11-26**] with and without contrast showed a
left frontoparietal area of white matter edema with
enhancement that does not have the characteristic appearance
of an infarct and suspicious for neoplasm. We discussed
these findings at length with the entire neuroradiology,
neurosurgery and neurology teams and it was felt at this time
she should undergo a biopsy. Differential diagnosis at that
point included glioma [**Month/Day/Year 23318**] lymphoma [**Month/Day/Year 23318**] inflammatory
process. We discussed with the family that biopsy would
yield hopefully a definitive diagnosis for this patient. She
has been treated with steroid courses numerous times in the
past as she has had similar episodes of aphasia and similar
symptoms, in general, and all of these have been well served
with steroids. However, due to the fact that this lesion was
somewhat different in appearance on MRI, we needed to rule
out the possibility of malignancy.
Patient had an LP prior to biopsy. Opening pressure was 25,
white cells 4, red cells 0, polys 72, lymphs 16, monos 12,
protein 57, glucose 50. On [**11-28**] she had an episode of
facial twitching. Chin and mouth were twitching more on the
left side than the right. Ativan 1 mg was given and she
seemed to do better. She was loaded with fosphenytoin and
then started on Dilantin 100 mg p.o. t.i.d. An EEG was done
somewhat later in the hospital admission after she was more
stable. This EEG showed abnormal EEG due to the slow
background with additional bursts of generalized slowing
which suggested dysfunction of deep midline structures as can
be seen with moderate to midline encephalopathy. There was
also additional left temporal slowing with sharp and spike
and wave discharges over the left frontoparietal region and
this indicated focal cortical or subcortical dysfunction and
could be related to epileptogenesis. There were no
electrographic seizures noted during the trace. Thus, we
decided to continue her on Dilantin.
Patient had MR [**First Name (Titles) **] [**Last Name (Titles) 41307**] done on [**11-28**]. The
results of this exam were inconclusive. It was at this point
when we decided to go ahead with the biopsy. Biopsy was
performed on [**12-1**] without complications. She had some
difficulty with increased blood pressure and we needed to
increase metoprolol and ramipril. She was also started on
hydralazine at that time and her blood pressure continued to
come down well. After the biopsy was finished, we started an
IV steroid course of 1000 mg q.day of Solu-Medrol. This was
continued for five days and then she was tapered down with
p.o. steroids starting at 60. Throughout the time of the IV
steroids she continued to slowly improve with her speaking.
She was able to talk more. She was able to follow commands
more. She was much less apraxic. She was followed by speech
and swallow on a very close basis. After being fed by NG
tube for a week, she was cleared by speech to have a full
liquid diet with nectar thickening. She is to have speech
and swallow evaluations as an outpatient in rehab and she
needs a video swallow within one week to further assess her
swallowing and aspiration risk.
Two days prior to discharge she was doing well. However, she
had an episode in the morning where she was on the toilet and
it looked like she had a vasovagal syncope event. Blood
pressure at the time was 80/40 and she lost consciousness for
a few seconds. She went back to bed and was doing well, but
noticed that she was having bright red blood per rectum a few
milliliters. This persisted to approximately 50 cc of bright
red blood. At that time we checked stat blood work and
consulted GI. They decided to prep her for colonoscopy on
the next day and decided to watch her hematocrit very closely
q.12 hours. Her hematocrit always remained stable. She did
have some mild abdominal pain. However, the next morning she
received a colonoscopy by GI. This showed erythema,
congestion and exudate and friability in the sigmoid colon
compatible with ischemic colitis. We then ordered a stat CT
scan of the abdomen with contrast. This showed localized
wall thickening and adjacent fat stranding of the sigmoid
colon with the appearance of diverticulosis. The
inflammatory findings were most consistent with
diverticulitis. However, as direct visualization with
colonoscopy suggested ischemic colitis, CT appearance overall
was in keeping with that diagnosis as well. These findings
were discussed with GI and we continued her on q.12 hour
hematocrit checks which continued to be stable. Her most
recent hematocrit was 29.9 with MCV of 61. At that point we
sent off iron studies which are pending at this time.
We continued to maintain adequate hydration and are still
waiting for final biopsy results from the sigmoidoscopy. She
is to have a complete colonoscopy as an outpatient in six
months and will follow up with Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] in [**Hospital **] clinic
within this time, telephone number [**Telephone/Fax (1) 1954**]. We will
continue the steroid taper as an outpatient as directed
below. She will also need to follow up with Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **]
in neurology clinic in the next three to four weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
1. Left temporoparietal brain lesion.
2. Likely inflammatory brain disease, question multiple
sclerosis.
3. Status post craniotomy for biopsy.
4. Ischemic colitis.
5. Hypertension.
6. Seizure disorder secondary to #1.
DISCHARGE MEDICATIONS:
1. Tylenol 325 to 650 mg p.o. q.four to six hours p.r.n.
pain.
2. Albuterol one to two puffs q.six hours p.r.n. wheezing.
3. Dilantin 100 mg p.o. t.i.d.
4. Trazodone 50 mg p.o. q.h.s. p.r.n. sleep.
5. Lopressor 100 mg p.o. b.i.d., hold for SBP less than 110.
6. Ramipril 50 mg p.o. q.day, hold for SBP less than 110.
7. Hydralazine 20 mg p.o. q.six, hold for SBP less than 110.
8. Colace 100 mg p.o. b.i.d.
9. Simethicone 40 mg p.o. q.i.d. p.r.n. gas.
10. Lansoprazole oral solution 30 mg p.o. q.day.
Steroid taper: prednisone 40 mg times two days, 30 mg times
three days, 20 mg times two days, 10 mg times two days, 5 mg
times two days and stop.
Diet is full liquids nectar thick. Will need speech
evaluation at rehab as well as video swallow within a week.
She also needs physical therapy and occupational therapy as
needed. She needs to follow up with Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in
neurology clinic in the next three to four weeks. She needs
to see Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] within the next five to six months for
full colonoscopy.
The final biopsy report is pending at this time. However,
preliminary report shows acute inflammatory demyelination
with geographic areas of myelin containing macrophages with
partially preserved actins and intensely reactive astrocytes.
She also had extensive perivascular and intraparenchymal
infiltration by T-lymphocytes with scattered atypical forms,
mitoses and increased proliferation. The differential
diagnosis for this pattern of demyelination includes multiple
sclerosis/acute demyelinating encephalomyelitis as well as
treated B-cell lymphoma, atypical infection especially viral
infection, vasculitis and T-cell lymphoma. While multiple
sclerosis is most likely clinically, given this patient's
long history of inflammatory brain lesion, the other
etiologies cannot be excluded. These were the preliminary
results at this time.
[**Name6 (MD) 11982**] [**Last Name (NamePattern4) 11983**], M.D. [**MD Number(1) 11984**]
Dictated By:[**Last Name (NamePattern1) 30849**]
MEDQUIST36
D: [**2180-12-14**] 12:04
T: [**2180-12-14**] 12:00
JOB#: [**Job Number 41308**]
|
[
"401.9",
"557.9",
"340",
"780.2",
"427.31",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"03.31",
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
8575, 8800
|
8823, 11076
|
2865, 8490
|
1565, 2847
|
173, 1542
|
8515, 8554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,793
| 116,380
|
33214
|
Discharge summary
|
report
|
Admission Date: [**2135-2-1**] Discharge Date: [**2135-2-6**]
Date of Birth: [**2067-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Erythromycin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2135-2-1**] Aortic Valve Replacement w/ 23mm St. [**Male First Name (un) 923**] Epic Porcine
Tissue Valve
History of Present Illness:
67 y/o female with known aortic stenosis followed by echo's over
last several years. now she has been c/o progressively worsening
dyspnea on exertion. Aortic valve area has slowly worsened over
time with most recent showing [**Location (un) 109**] of 0.6.
Past Medical History:
Aortic Stenosis, Hypertension, Hypercholesterolemia,
Osteoarthritis, SLE, Peripheral Neuropathy w/ dropfoot, Spinal
cyst, Lumbar disc disease, Retinitis, Uveitis, Psoriasis,
Eczema, Melanoma s/p removal, s/p Hysterectomy, s/p
Appendectomy, s/p Multiple eye surgery, s/p Tonsillectomy
Social History:
Quit in [**2122**] after 1ppd x 30yrs. Denies ETOH use.
Family History:
NC
Physical Exam:
VS: 76 12 118/78 63" 187#
Gen: WDWN female wearing RLA brace and using cane
Skin: Healed scar on chest from melanoma removal
HEENT: EOMI, PERRL NCAT, OP benign
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR 3/6 SEM with radiation to carotids
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused 1+edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2-1**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). 3.
Right ventricular chamber size and free wall motion are normal.
4. There are simple atheroma in the aortic root. The ascending
aorta is mildly dilated. 5. The aortic valve is bicuspid. There
is moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Trace aortic regurgitation is seen. 6. Mild (1+) mitral
regurgitation is seen. POST-BYPASS: For the post-bypass study,
the patient was receiving vasoactive infusions including
phenylephrine and is being AV paced. 1. A well-seated
bioprosthetic valve is seen in the Aortic position with normal
leaflet motion and gradients. No aortic regurgitation is seen.
2. Biventricular function is preserved. 3. MR appeared to be
slightly worse with AV pacing. No [**Male First Name (un) **] physiology noted 4. A
slight hypoechoic area noted in the Ascending aorta with no
obvious dissection flaps noted. 5. Other findings are unchanged
[**2-3**] CXR: 1) No evidence of pneumothorax following tube removal.
2) Mid sternal lucency at proximal aspect of sternotomy, which
can occasionally be seen normally in the early postoperative
period. Correlation with physical exam findings and follow up
chest radiograph may be helpful to exclude early sternal
dehiscence. 3) Worsening left lower lobe atelectasis and new
small left pleural effusion.
[**2135-2-1**] 10:04AM BLOOD WBC-5.7 RBC-3.08*# Hgb-8.7*# Hct-26.6*#
MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 Plt Ct-240
[**2135-2-4**] 06:16AM BLOOD WBC-14.4* RBC-3.32* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.4 MCHC-32.1 RDW-14.1 Plt Ct-191
[**2135-2-1**] 10:04AM BLOOD PT-14.0* PTT-28.7 INR(PT)-1.2*
[**2135-2-1**] 11:13AM BLOOD UreaN-14 Creat-0.6 Cl-111* HCO3-23
[**2135-2-4**] 06:16AM BLOOD Glucose-120* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-99 HCO3-27 AnGap-13
[**2135-2-5**] 4:54 pm URINE Source: CVS.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
Mrs. [**Known lastname 77160**] was a same day admit after undergoing all
preoperative work-up as an outpatient. On day of admission she
was brought directly to the operating room where she underwent
an aortic valve replacement. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Later on op
day she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one she was started on beta
blockers and diuretics. She was gently diuresed towards he
pre-op weight. Later on this day she was transferred to the
telemetry floor for further care. On post-op day two her chest
tubes were removed. On post-op day three her epicardial pacing
wires were removed. She continued to improve quite well
post-operatively while working with physical therapy for
strength and mobility, which has declined since preoperatively.
On post-op day 5, she was discharged to rehab facility for
further physical therapy.
Medications on Admission:
Voltaren 75mg [**Hospital1 **], Prednisone 2mg [**Hospital1 **], Sular 10mg qd, Toprol XL
25mg [**Hospital1 **], Tricor 145mg qd, Sinemet 50/200 q6, Mirapex 25mg qhs,
Gluosamine, Levobunolol eye gtts, Alphagan eye gtts, Travatan
eye gtts, Premild eye gtts
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. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO QID (4 times a day).
6. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1)
Drop Ophthalmic once a day.
7. Alphagan P 0.15 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times
a day).
8. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
9. Travatan 0.004 % Drops Sig: One (1) Ophthalmic Daily ().
10. XIBROM 0.09 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a
day).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
13. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-8**] Sprays Nasal
5X/DAY (5 Times a Day) as needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 9188**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hypertension, Hypercholesterolemia, Osteoarthritis, SLE,
Peripheral Neuropathy w/ dropfoot, Spinal cyst, Lumbar disc
disease, Retinitis, Uveitis, Psoriasis, Eczema, Melanoma s/p
removal, s/p Hysterectomy, s/p Appendectomy, s/p Multiple eye
surgery, s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 77161**] in [**1-9**] weeks
Dr. [**Name (NI) 77162**] in [**12-8**] weeks
Completed by:[**2135-2-6**]
|
[
"710.0",
"355.8",
"696.1",
"272.0",
"736.79",
"599.0",
"493.20",
"V10.82",
"401.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6506, 6580
|
3592, 4606
|
320, 430
|
6940, 6946
|
1500, 3478
|
1112, 1116
|
4912, 6483
|
6601, 6919
|
4632, 4889
|
6970, 7434
|
7485, 7715
|
1131, 1481
|
261, 282
|
3513, 3569
|
458, 715
|
737, 1023
|
1039, 1096
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,672
| 147,841
|
16050
|
Discharge summary
|
report
|
Admission Date: [**2184-10-7**] Discharge Date: [**2184-10-16**]
Date of Birth: [**2128-11-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Vancomycin / Imipenem / Ciprofloxacin / Linezolid
/ Cefpodoxime
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic duct stricture
Major Surgical or Invasive Procedure:
[**2184-10-7**]: Puestow procedure
History of Present Illness:
The patient is a 55-years-old male with history of chronic
pancreatitis. He was noticed MRCP which demonstrated high grade
ductal stricture with CBD and intrahepatic ductal enlargment.
ERCP was unable to pass this stricture. The patient was
evaluated by Dr. [**Last Name (STitle) 468**] in his [**Hospital 45932**] clinic and
surgical approach was discussed. After all risks, benefits and
possible outcomes were discuss, the patient was scheduled for
elective Puestow procedure.
Past Medical History:
Type 2 diabetes
Chronic hepatitis C, last VL = 20 million
Prior hepatitis B infection
Hyperlipidemia
Hypertension
Pancreatitis (recurrent), initial episode [**2-19**] gallstones
Choledocholithiasis
s/p Cholecystecomy in [**2175**]
ARDS in setting of pancreatitis
Pseudocysts, aspirated twice
Chronic pancreatitis: atropthy, duct dilation
Mild COPD, not on any medication for this
Periumbilical hernia
History of colon polyps
VRE/MRSA
Social History:
Married, lives with wife. Owns a furniture company. Quit
tobacco 10 years ago with 40 pack year history. Prior alcohol
and heroin abuse quit [**2166**].
Family History:
Niece with pancreatic divisum. GF with gastric cancer.
Physical Exam:
Upon Discharge:
VSS
GEN: NAD
CV: RRR s1s2
RESP: CTAB
ABD: obese, soft, moderately distended, incisions c/d/i,
nontender, no masses on palpation
EXTR: wwp no c/c/e 2+ peripheral pulses
Pertinent Results:
[**2184-10-11**] 06:35AM BLOOD WBC-4.4 RBC-2.60*# Hgb-8.5*# Hct-25.0*#
MCV-96 MCH-32.8* MCHC-34.3 RDW-13.3 Plt Ct-182
[**2184-10-11**] 01:10PM BLOOD Hct-27.3*
[**2184-10-11**] 06:35AM BLOOD Glucose-128* UreaN-12 Creat-0.6 Na-134
K-3.9 Cl-101 HCO3-27 AnGap-10
[**2184-10-11**] 06:35AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8
[**2184-10-12**] 11:34AM ASCITES Amylase-12
Brief Hospital Course:
The patient with pancreatic duct stricture and chronic abdominal
pain was admitted to the HPB Surgical Service for elective
Puestow procedure. On [**2184-10-7**], the patient underwent
longitudinal pancreaticojejunostomy (Puestow procedure),
extensive lysis of adhesions and intraoperative ultrasound,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO, on IV fluids and
antibiotics, with a foley catheter, and epidural catheter with
Dilaudid PCA for pain control. The patient was hemodynamically
stable.
Neuro: The patient has a history of chronic pain and uses
opioids for last ten years. Post op pain was controlled with
Bupivacaine via epidural and Dilaudid PCA. His epidural was
replaced by APS on POD # 1 for better coverage. Chronic pain
service was consulted. The epidural was discontinued on POD # 3
and PCA was discontinued on POD # 4. The patient was
transitioned to oral pain medications with IV Dilaudid for
breakthrough pain. IV Dilaudid was weaned off on POD # 5, and
oral medication was titrated to achieve good pain control with
help of the CPS. Prior discharge patient was given an adequate
amount of long and short acting medication to control his pain.
The patient was explained, that HPB Surgery will prescribe his
medication only for post operative period, and if patient will
require long acting Oxycontin, he will have to see his PCP to
refill prescriptions.
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. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: 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. JP amylase was removed on
POD # 6 as amylase level and output were low.
GU: The foley catheter was discontinued at midnight of POD# 3.
The patient subsequently voided without problem.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was evaluated
daily knowing patient history of wound infection post prior
operations. Wound erythema was noticed on POD # 4 and was
watched carefully. The erythema subsided without any treatment,
no antibiotics were indicated.
Endocrine: The patient's blood sugar was monitored throughout
his stay; he was restarted on his home regiment prior discharge.
FS were within normal limits.
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.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic diet, ambulating, voiding without assistance, and pain
was relatively well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
amitriptyline 10mg (x3 qhs), gabapentin 300''', glyburide 5',
losartan 50', nifedipine 30', oxycodone 10 PRN, oxycontin 40'',
ibuprofen 200 PRN, humalog kwikpen SQ''', Lantus 6 units
Discharge Medications:
1. Amitriptyline 10 mg PO TID
2. Gabapentin 300 mg PO TID
3. GlyBURIDE 5 mg PO DAILY
4. Ibuprofen 400 mg PO Q6H:PRN pain
5. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Losartan Potassium 50 mg PO DAILY
7. NIFEdipine CR 30 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Oxycodone SR (OxyconTIN) 40 mg PO Q8H pain
10. OxycoDONE (Immediate Release) 20 mg PO Q3H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Chronic pancreatitis
2. Pancreatic duct stricture
3. Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for elective
Puestow procedure. You have done well in the post operative
period and are now safe to return home to complete your recovery
with the following instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-27**] 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:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2184-10-22**] at 2:00 PM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"576.2",
"070.54",
"V45.79",
"V26.52",
"401.9",
"V12.09",
"568.0",
"V12.72",
"577.1",
"276.7",
"496",
"272.4",
"577.8",
"338.29",
"V12.04",
"V15.82",
"250.00",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"52.96",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6278, 6284
|
2218, 5626
|
364, 401
|
6396, 6396
|
1831, 2195
|
7890, 8177
|
1556, 1612
|
5859, 6255
|
6305, 6375
|
5652, 5836
|
6547, 7360
|
7375, 7867
|
1627, 1627
|
299, 326
|
1643, 1812
|
429, 909
|
6411, 6523
|
931, 1366
|
1382, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,038
| 169,724
|
51565
|
Discharge summary
|
report
|
Admission Date: [**2179-12-22**] Discharge Date: [**2180-1-8**]
Date of Birth: [**2133-12-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
ARF, acidemia, Respiratory failure, hypotension
Major Surgical or Invasive Procedure:
Hemodialysis
Central line placement and removal
Tunnelled hemodialysis catheter placement
Peripherally inserted central catheter
Intubation and subsequent extubation
Endoscopy
Bronchial lavage
History of Present Illness:
46 yo m s/p CRT, hypertension, known to the MICU team after he
was recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum. He received
12 units of blood and his HCT finally stabilized 28-30 s/p
cauterization. Renal evaluated him and decided on HD for [**1-2**].
Wound cultures on the L subclavian tunnelled cath were sent for
concern of infected site. Dilt and BB were restarted.
Past Medical History:
Renal Transplant 16 yrs ago on immunosuppresants
-HTN poorly controlled
-Anemia on procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])
Social History:
lives with 2 children and mother
Family History:
unknown
Physical Exam:
VS: 97.3 103/37 81 11 93% AC 700x14 PEEP 5 FiO2 1.0
GEN: Intubated, sedated
HEENT: ETT in place, R-SVC in place, no cervical LAD, pinpoint
pupils, anicteric sclera
RESP: Course BS throughout L BS>R, no wheezing
CV: Reg Nml S1,S2 2/6 SEM throughout precordium
ABD: Soft ND/NT, +BS, black/coffee ground material from NGT
EXT: No peripheral edema, slight mottling of LE toes b/l
NEURO: hyporeflexia, sedated
Pertinent Results:
OSH
ABG-7.14/30.2/103/10.8
Tn-I:.05 (nml.01-.04)
131 92 160 Alb 2.9; Alk phos 140; LDH 1760; AST 22;
ALT 27
--------------<160 CK 2445
3.2 10 25.2
45.4>----<726
23.0
[**Hospital1 18**] ADMISSION LABS:
--See Below
.
[**2179-12-22**] 04:34PM BLOOD WBC-52.9*# RBC-2.96* Hgb-7.9*# Hct-25.0*
MCV-85 MCH-26.9* MCHC-31.8 RDW-16.9* Plt Ct-820*#
[**2179-12-22**] 04:34PM BLOOD Neuts-97* Bands-1 Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2179-12-22**] 04:34PM BLOOD Glucose-231* UreaN-197* Creat-22.0*#
Na-134 K-3.7 Cl-94* HCO3-8* AnGap-36*
[**2179-12-22**] 04:34PM BLOOD ALT-14 AST-26 LD(LDH)-717* AlkPhos-167*
Amylase-71 TotBili-0.4
[**2179-12-22**] 04:34PM BLOOD Lipase-109*
[**2179-12-22**] 04:34PM BLOOD CK-MB-13* cTropnT-0.12*
[**2179-12-22**] 04:34PM BLOOD Albumin-2.8* Calcium-4.1* Phos-17.3*#
Mg-2.4
[**2179-12-22**] 04:34PM BLOOD Osmolal-352*
[**2179-12-22**] 04:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-12-22**] 11:49PM BLOOD Type-ART Temp-36.2 Rates-14/5 Tidal V-700
PEEP-10 FiO2-100 pO2-120* pCO2-44 pH-7.00* calTCO2-12* Base
XS--20 AADO2-563 REQ O2-91 -ASSIST/CON Intubat-INTUBATED
.
Microbiology:
* Blood culture ([**12-22**]): Peptostreptococcus, coag negative staph
(2 different colonies)
* Blood cultures ([**12-27**], [**12-30**], [**12-31**], [**1-2**], [**1-3**], [**1-4**],
[**1-5**]): Negative
* Blood culture ([**1-6**]): No growth to date
* Catheter tip ([**12-30**], [**1-8**]): Negative
* Sputum ([**12-23**]): Coag positive staph (oxacillin sensitive)
* CMV antibody ([**12-23**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA .
87 AU/ML
* CMV viral load ([**12-23**]): negative
* EBV IgG positive, IgM negative ([**12-23**])
* BAL ([**12-23**]): GRAM STAIN (Final [**2179-12-23**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2179-12-26**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +.
10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL
MORPHOLOGIES.
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.
MORAXELLA CATARRHALIS. ~[**2173**]/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
LEGIONELLA CULTURE (Final [**2179-12-31**]): NO LEGIONELLA
ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2179-12-24**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2180-1-5**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2179-12-24**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
* Rapid Respiratory Viral Antigen Test (Final [**2179-12-24**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
* Urinary legionella antigen ([**12-24**]): Negative
* H. pylori ([**12-30**]): Negative
* Stool culture ([**12-28**], [**12-30**]): Negative for shigella,
salmonella, campylobacter
* Stool negative for C. diff X 3
* Left IJ HD cath site ([**1-1**]): 2+ PMNs, but culture negative to
date
* Cytology from BAL: Negative for malignant cells.
.
Radiology/studies:
* EKG ([**12-22**]): Poor quality tracing. Probable atrial
fibrillation with a rapid ventricular response. Since the
previous tracing of [**2175-9-12**] atrial fibrillation is new. QRS
voltage in the precordial leads may be increased. Clinical
correlation is suggested.
* EKG ([**12-24**]): Atrial fib with RVR then repeated with controlled
ventricular rate then repeated again with sinus rhythm
* EKG ([**12-25**]): Atrial flutter
* EKG ([**12-30**]): Sinus rhythm. Since the previous tracing of
[**2180-1-4**] T wave inversions in the anterolateral leads are seen
consistent with anterior ischemia or non-Q wave myocardial
infarction.
* Abdominal US ([**12-23**]): No cholelithiasis or son[**Name (NI) 493**] signs
of acute cholecystitis.
* ECHO ([**12-23**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is a mild resting left ventricular outflow tract
obstruction. A mid-cavitary gradient is identified. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated. The ascending aorta is
moderately 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. There is no mitral valve prolapse. There is mild
systolic anterior motion of the mitral valve leaflets. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric (posterior directed). The timing
of the mitral regurgitation is late systolic. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is a small posterior
pericardial effusion. There are no echocardiographic signs of
tamponade. Compared with the findings of the prior report
(images unavailable for review) of [**2176-1-25**], the left
ventricle is now hyperdynamic, with a resting left ventricular
outflow tract gradient.
* CT Chest without contrast ([**12-28**]): 1. Moderate amount of
pericardial effusion, which may have restrictive physiology. 2.
Bilateral pleural effusion, moderate. 3. Scattered areas of
ground glass, predominantly in the right lung which most likely
represent viral infection, aspiraation is less likely.
* ECHO ([**12-30**]): 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) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade. Compared with
the findings of the prior study (images reviewed) of [**12-23**]
[**2179**], the pericardial effusion may be slightly larger (but still
small); no evidence of cardiac tamponade.
* CT chest with contrast ([**1-2**]): 1. Moderate amount of
pericardial effusion, slightly increased, which may have
restrictive physiology. 2. Marked decrease in pleural effusion,
now smaller in size, and improvement in the scattered areas of
ground-glass most likely due to resolution or improvement in
viral infection. The aspiration etiology is less likely. 3.
Cholelythiasis with no cholecystitis.
* Lung scan ([**1-3**]): Normal lung scan. No evidence for PE.
* ECHO ([**1-4**]): The estimated right atrial pressure is
11-15mmHg. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is a small to moderate sized pericardial
effusion subtending the basal posterolateral wall and right
atrial free wall. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen. Compared with the findings of the prior study
(images reviewed) of [**2179-12-30**], the pericardial effusion
is somewhat further increased in size, but still with no
evidence of cardiac tamponade.
.
Labs at discharge:
WBC 9.9, Hgb 10.6, Hct 30.4, Plt 203
Brief Hospital Course:
46 yo m s/p CRT, htn, known to the MICU team after he was
recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum. He
received 12 units of blood and his HCT finally stabilized 28-30
s/p cauterization. Renal evaluated him and decided on HD for
[**1-2**]. Wound cultures on the L subclavian tunnelled cath were
sent for concern of infected site. Dilt and BB were restarted.
.
On the floor, he continued to spike fevers daily. The ID and
renal team's followed closely. Tacrolimus was weaned in setting
of graft failure. The right IJ was pulled. Multiple cultures
showed no subsequent growth. As of [**1-4**], the following
represents active issues:
.
A/P: 46 yo m w/ a h/o CRT and chronic graft rejection, admitted
with hypotension and PNA, stable s/p cauderization for ulcers
causing melana and hematocrit drop, now with persistent fevers
of unknown etiology.
.
#) ID - The patient had known coag neg staph bacteremia (2
distinct species) and Peptostreptococcus bacteremia with last
positive blood culture [**12-22**]. Of note, he had post-viral MSSA
PNA with respiratory failure that has resolved. CT Chest [**1-2**]
revealed ? worsening pericardial effusion (see below).
Pericarditis was considered but the patient did not have any EKG
changes consistent with this. Overall, his fever curve
decreased and at the time of discharge, he had not had a fever >
100.5 in over 24 hours.
- Zosyn was discontinued on [**1-4**] and vancomycin discontinued on
[**1-5**].
- The patient was discharged on Bactrim SS 1 TAB PO 3X WEEK for
Ppx while on steroids. He was instructed to return to the ER or
call his doctor should he have any temperature over 100.5. His
PICC line was removed prior to discharge as he was not going
home on any antibiotics; he does still have his tunnelled HD
catheter in place.
.
#) Pericardial Effusion - This was questionably worsening per CT
scans. However, the patient had 2 echos revealing pericardial
effusion without any echocardiographic signs of tamponade.
.
#) Melena - This was asymptomatic prior to presentation while
hospitalized. EGD showed multiple duodenal ulcers and a pyloric
channel ulcer (treated with BiCAP and epi on [**12-29**]). H. pylori
serology neg. His hematocrit remained stable post-procedure. He
was discharged on [**Hospital1 **] proton pump inhibitor.
.
#) Rash - The patient was noted to have a diffuse erythematous
rash, primarily on his back and trunk. He was evaluated by
Dermatology who felt that the rash could be consistent with a
drug rash. However, as the rash was not bothersome to the
patient in any way and seemed to be resolving (potentially since
discontinuing antibiotics), they did not recommend any specific
treatment. They specifically did not believe that his rash was
in any way related to his ongoing fevers. Please see their note
in OMR for further details.
.
#) Acute on chronic renal failure- Acute on chronic allograft
failure with initiation of hemodialysis while hospitalized. The
patient did have some recovery of his urine output following his
ICU stay. This could represent some graft recovery. However, the
patient is planned to continue hemodialysis as an outpatient
with his first appointment on Tuesday, [**1-11**]. He is to
continue his tacrolimus at 0.5 mg [**Hospital1 **] and prednisone at 10 mg
every other day for now.
- He was dialyzed on the morning of discharge without
complication.
.
#) Afib/flutter- The patient was restarted on diltiazem and BB
on [**12-31**]. He remained in sinus rhythm. His primary doctor could
consider changing to once daily dosing as an outpatient.
.
#) FEN - He tolerated a low sodium, 1 g phosphorus diet while
hospitalized.
.
#) Ppx - He was maintained on a [**Hospital1 **] PPI as above. He had
pneumoboots but was ambulatory prior to discharge.
.
#) Code full
.
#) Access- L PICC (removed prior to discharge), L SC tunneled HD
catheter intact at discharge.
Medications on Admission:
-Lisinopril 20mg qd
-Aronesp 40mg SQ QOWeek
-Fosamax 5mg qd
-MVI
-Cellcept 250mg [**Hospital1 **]
-Pravachol 10mg qhs
-Prednisone 10mg QOD
-Prograf 2mg [**Hospital1 **]
Discharge Medications:
1. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*20 Tablet(s)* Refills:*0*
3. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours) as needed.
Disp:*QS one month treatment* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*0*
7. 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:*0*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
Disp:*QS one month treatment* Refills:*0*
9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. nebulizer machine
Nebulizer machine for nebulizer treatments.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic renal failure
coagulase negative staphylococcal bacteremia, resolved
Community acquired pneumonia, resolved
Gastrointestinal bleeding, resolved
Duodenal ulcers status post thermal therapy/injection
Pericardial effusion
Secondary:
Status post cadaveric renal transplant
Hypertension
Anemia
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
Please take all medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following symptoms: fever > 101, chills, nausea or vomiting
with inability to keep down liquids or medications, vomiting
blood or blood in your stool, palpitations, dizziness or passing
out.
Please follow up with your already-scheduled dialysis
appointment next Tuesday. You will receive your erythropoietin
at dialysis.
Please call Dr. [**Last Name (STitle) **] should you have any problems in the interim.
Followup Instructions:
Please have your next outpatient dialysis on Tuesday, [**2180-1-11**], at
[**Location (un) 3320**].
Please make an appointment to see Dr. [**Last Name (STitle) **] within the next [**1-11**]
weeks. His office can be reached at [**Telephone/Fax (1) 250**].
Please keep these already scheduled appointments. Call the
office if there is a problem with the appointment date/time.
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-1-31**] 11:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-2-8**] 8:50
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2180-1-11**]
|
[
"584.9",
"532.40",
"423.9",
"693.0",
"482.41",
"427.31",
"785.52",
"996.81",
"E878.0",
"255.4",
"038.19",
"518.81",
"995.92",
"285.21",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"44.43",
"38.95",
"99.04",
"33.24",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20012, 20018
|
12225, 15201
|
364, 559
|
20369, 20419
|
4002, 4210
|
21006, 21837
|
3552, 3561
|
18674, 19989
|
20039, 20348
|
18480, 18651
|
20443, 20983
|
3576, 3983
|
277, 326
|
15216, 18454
|
12163, 12202
|
587, 3306
|
4226, 12144
|
3328, 3486
|
3502, 3536
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.