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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
5,691
| 104,316
|
51435
|
Discharge summary
|
report
|
Admission Date: [**2165-5-22**] Discharge Date: [**2165-6-5**]
Date of Birth: [**2087-6-7**] Sex: F
Service: MEDICINE
Allergies:
Rapamune / Ativan
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC line [**2165-6-3**]
History of Present Illness:
77 y.o. female with PMHx of PCKD and PCLD (s/p bil native
nephrectomy and liver dissection) and s/p cadaveric renal
transplant in [**2155**] with past history of multiple abd surgeries
including rectopexy for irreducible rectal prolapse on [**2165-3-27**]
presented to the ED with increasing shortness of breath. Patient
reports becoming acutely short of breath on the night prior to
admission. On the following day, she was hypertensive to 199/90
with a mild headache and noted a temperature of 99. She also
noted profound weakness and thus came into the ER for further
evaluation. She denies any chest pain, palpitations, fevers,
recent sick contacts or travel.
In the ED, vitals were T 99.5, P 76, BP 183/75, RR 25, O2: 77%
on RA, 96% [**Date Range 597**]. O2 sats began to trend down on [**Last Name (LF) 597**], [**First Name3 (LF) **] she was
eventually switched to CPAP. Given the hypoxia, a CXR was
ordered which showed bibasilar PNA and CHF. BNP was elevated to
53,163. Patient was also noted to have a distended abdomen,
concerning for SBO. KUB showed no ileus or obstruction. Surgery
was consulted and felt that there were no acute surgical issues
and that a CT scan of the abdomen could be performed if there
were increasing concern for obstruction. Given the CXR findings,
patient was started on Levofloxacin. She was additionally given
a dose of Flagyl for concern of an intrabdominal process. She
was then admitted to the ICU for PNA/CHF.
Past Medical History:
1. s/p cadaveric renal transplant in [**2155**] for polycystic
kidney disease, status post bilateral nephrectomy ([**2148**], [**2152**])
2. Polycystic liver disease- s/p liver resection- left Hepatic
Trisegmentectomy and Right Lobe Cyst Reduction ('[**57**]).
3. Recurrent partial small bowel obstruction
4. s/p cholecystectomy
5. s/p appendectomy
6. s/p excision of parathyroid adenoma '[**58**] [**Doctor Last Name **]
7. Hypertension
8. Breast cancer, s/p L radical mastectomy ([**2151**])
9. History of right elbow and humeral fracture
10. History of incarcerated hernias although per history
"reduced" nonsurgically in the past
11. spinal stenosis
12. Irreducible Rectal Prolapse, s/p abdominal rectopexy
([**2165-3-27**])- [**Doctor Last Name **]
Social History:
Lives with husband who recently fractured his hip, has two
children who live locally. Denies tobacco, EtOH, drugs.
Family History:
Polycystic kidney disease.
Physical Exam:
PE: BP 173/64, 16, HR 75, 97 on 4L
Gen: Awake, alert, breathing comfortably on nasal cannula, NAD
Heart: S1, S2 nl, II/VI SEM, II/VI SEM noted.
Lungs: Bilateral lower lobe crackles diminished breath sounds,
RUL crackles
Abd: Multiple surgical incisions, abdomen is firm, distended,
NT,
decreased BS
Rectal: Guaiac negative per ICU
Ext: Warm, well perfused, no C/C/E.
Neuro: CN II-XII grossly intact.
Skin: Multiple ecchymotic lesions
Pertinent Results:
[**5-22**]: Portable Abdomen:
FINDINGS: A single portable AP view of the abdomen is obtained
which excludes the upper abdomen. Multiple surgical clips are
again noted in the mid abdomen which are unchanged from prior
study. There has been interval removal of the skin staples. The
bowel gas pattern is nonspecific, though demonstrates no
definite evidence of ileus or obstruction. The abdominal aorta
is calcified and appears tortuous. Visualized osseous structures
are unremarkable.
[**5-22**]: Abdominal US:
FINDINGS: Limited four quadrant views of the abdomen demonstrate
large amount of simple-appearing ascites in all four quadrants,
including the right perihepatic space.
[**5-22**]: Chest x-ray
FINDINGS: Two bedside frontal views labeled "upright at 12:50,
1:00 p.m." with lordotic positioning, are compared with most
recent study dated [**2165-4-15**]. There is dense retrocardiac opacity
with air bronchograms and obscuration of that hemidiaphragm,
likely representing combination of consolidation and effusion,
new. There is also further patchy opacity at the right lung
base; this process is likely pneumonic. There is cardiomegaly
with pulmonary vascular congestion and blurring and small
bilateral pleural effusions. Noted are numerous surgical clips
in the upper abdomen, particularly on the right and a right
shoulder arthroplasty.
[**5-23**]: Chest x-ray
IMPRESSION:
1. Increasing right lung consolidation suggesting worsening
infection.
2. Increasing left basilar opacity possibly representing a
combination of atelectasis and effusion, although infection
cannot be excluded.
[**5-23**]: Abdominal US
IMPRESSION:
1. Patent hepatic vessels with normal directional flow.
2. Numerous cysts throughout the liver.
3. Dilated extrahepatic common bile duct measuring 16 mm in
greatest dimension.
[**5-23**]: ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2165-3-26**],
left ventricular diastolic function has worsened. The amounts of
mitral regurgitation, tricuspid regurgitation, and estimated
pumonary artery systolic pressure have increased.
[**5-27**]: CT Torso
FINDINGS: There is severe scoliosis of the thoracic spine.
Consecutive asymmetry of the rib cage. Multicystic liver
disease. In the thorax, the right-sided pleural effusion has a
diameter of 5.2 mm at its largest size. Considerably smaller
left-sided pleural effusion. The most remarkable finding in the
lung parenchyma is a right-sided extensive perihilar opacity
with air bronchograms and central consolidations. This opacity
has a subtle ground- glass halo and several satellite lesions.
At the apex and the base of the right lung, linear areas of
atelectasis are seen. _Areas of hypoventilation at the lung
bases. Calcification of the mediastinal vessels, no
pneumothorax.
Brief Hospital Course:
77 year old female with extensive PMH who was admitted with PNA
and pulmonary edema, requiring non-invasive ventilation. She
was initially in the intensive care unit until her breathing
status improved.
In the ICU, the patient was diuresed with IV Lasix and received
antibiotics for her PNA. Initially, she was on BiPAP but
improved throughout her course of stay until she was saturating
comfortably on room air. On admission the patient had a surgical
eval for abdominal distention which resolved w/o intervention,
her imaging was negative for SBO. She was transferred to the
floor for further management.
On exam, the patient had dyspnea and fever felt most likely
secondary to a factor of both CHF and PNA noted on CXR. The
patient was treated with levofloxacin for a likely community
acquired pneumonia. She was also treated initially with IV
Lasix as her xray seemed consistent with a degree of heart
failure.
The patient has a history of multiple SBOs in the setting of
numerous abdominal surgeries. She denied any vomiting, though
she did have some mild nausea at the beginning of her
hospitalization. Her last BM was the day before admission and
she denies passing flatus since. She says that her current
abdominal distention is not comparable to previous SBOs. Of
note, she was started on iron supplements approximately one week
ago and has noted constipation with this. The patient was
treated with an aggressive bowel regimen.
For her chronic polycystic kidney disease s/p transplant, the
patient was treated with her usual dose of prednisone and a
slightly decreased dose of CellCept given her neutropenia. Her
polycystic liver disease was stable. She did have a RUQ US
which showed dilation of her common bile duct. LFTs and exam
remained stable throughout her hospital course and she was
discharged to follow this finding up with her PCP.
The patient has a history of hypertension for which she was
taking atenolol and diltiazem as an outpatient. Her blood
pressure was markedly elevated upon arrival. Per her history,
the patient has had problems with hypertensive urgency in the
past. She was initially treated with metoprolol and diltiazem
with PRN hydralazine. Doxazosin was introduced once the patient
was called out to the floor, however, the patient experienced
relative hypotension likely causing a bump in her creatinine.
The doxazosin was discontinued with a slow improvement in her
creatinine. Her outpatient Lasix was held and she was advised
to discuss restarting this medication with her primary care
doctor.
The patient was continued on her outpatient Epogen regimen for
her anemia. She received one unit of packed red blood cells as
well as six infusions of IV Ferrlecit.
The patient was continued on her outpatient regimens for her
spinal stenosis, depression, anxiety and insomnia with the
following medications Neurontin, Tramadol, Zoloft, Klonopin and
Ambien.
# Communication: [**Doctor First Name 717**] (daughter) [**Telephone/Fax (1) 106650**]; [**Name (NI) **] (son)
[**Telephone/Fax (1) 106651**]
.
# Code: FULL (confirmed with patient and daughter)
Medications on Admission:
Ambien 5 mg QHS
Atenolol 75 mg QD (occasionally 150 mg for severe HTN)
Cartia XT 240 mg PO QD
Lasix 20 mg PO QD
Zoloft 50 mg PO QD
Prednisone 6 mg PO QD
Cellcept [**Pager number **] mg PO BID
Tramadol (dose unknown)
Neurontin (dose unknown, but taken TID)
Klonopin 1 mg PO QD
Senna
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
6. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO daily () as needed for prn
constipation.
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please take a total of 6 mg daily.
12. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day:
please take 6 mg daily.
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Outpatient Lab Work
Please have your CBC, Chemistries, and renal function tests
(Creatinine, BUN), drawn this Friday, [**2165-6-7**]. These results
need to be called into Dr.[**Name (NI) 9377**] office at ([**Telephone/Fax (1) 6117**]
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary -
Pneumonia, complicated by a parapneumonic effusion
Acute on chronic renal failure
Secondary -
Polycystic Kidney Disease s/p transplant
Polycystic Liver Disease
Hypertension
Anemia
Spinal stenosis
Discharge Condition:
Stable, O2 sats above 95% on room air
Discharge Instructions:
You were admitted for a pneumonia which required treatment with
antibiotics and oxygen. You were also started on new medication
for your blood pressure, doxazosin, which was stopped while you
were in the hospital due to elevated kidney function tests.
Your lasix has been stopped and should not be started until you
see Dr. [**Last Name (STitle) **].
You need to have your labs checked again this Friday, including
your renal function tests (lab slip included). These should be
called into Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 6117**].
Please continue all medications as instructed. You have an
appointment with Dr. [**Last Name (STitle) **] on [**6-11**] for follow-up. While you
were in the hospital, an ultrasound demonstrated dilitation of
your common bile duct. You did not have any lab abnormalities
or symptoms associated with this finding. Please follow up this
result with your primary care physician at your appointment.
If you experience any symptoms of fevers, difficulty breathing,
shortness of breath, chest pain, or any other concerning
symptoms, please seek medical attention immediately.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-6-11**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-7-2**] 1:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"403.90",
"751.62",
"285.9",
"486",
"584.9",
"585.9",
"428.30",
"V42.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11815, 11886
|
6852, 9965
|
284, 311
|
12137, 12177
|
3222, 6829
|
13357, 13749
|
2724, 2752
|
10298, 11792
|
11907, 12116
|
9991, 10275
|
12201, 13334
|
2767, 3203
|
237, 246
|
339, 1797
|
1819, 2575
|
2591, 2708
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,142
| 186,635
|
33982
|
Discharge summary
|
report
|
Admission Date: [**2129-4-10**] Discharge Date: [**2129-5-4**]
Date of Birth: [**2079-2-16**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Aspirin / Codeine / Nsaids
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2129-4-15**]: ORIF right femur periprosthetic fracture
[**2129-4-26**]: I&D of right hip hematoma
History of Present Illness:
Mr. [**Known lastname 28893**] is a 50 year old man who suffered a right acetabular
fracture and underwent operative repair on [**2128-5-3**] after being
involved in a motor vehicle crash. He went on to develop
post-traumatic arthritis and underwent a right total hip
replacement on [**2129-1-4**]. He was intoxicated and suffered a fall
on [**2129-4-9**]. He was found by his wife on [**2129-4-10**] in the morning
and taken to a local hospital. He was found to have a right
femur periprosthetic fracture and was then transferred to the
[**Hospital1 18**] for further evaluation.
Past Medical History:
PMH: asthma, C2-C7 fx, DJD, h/o alcoholism, peripheral
neuropathy, depression, benign pancreatic tumor, IBS
.
PSH: s/p appy, s/p Whipple, s/p anterior fusion C4-6 & posterior
fusion C3-7, R acetabular fracture ORIF [**2128-5-3**], R total hip
replacement [**2129-1-4**]
Social History:
Married, lives with wife
Does office work
+ ETOH Abuse
+ Tobacco
Family History:
Noncontributory
Physical Exam:
Upon admission
VITAL SIGNS: 100.2 97.3 97 132/82 20 97% RA
GENERAL: Appears to be in mild distress from pain, pleasant,
asking for pain medication
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus.
PERRLA/EOMI. MM dry. OP clear. Neck Supple, No LAD, No
thyromegaly. Vertical scar present posteriorly with firm nodule
at base of neck.
CARDIAC: RRR. Normal S1, S2. No M,R,G.
LUNGS: CTA b/l
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: + edema on R thigh, +ttp over fracture site, trace
RLE edema with 2+ pedal pulses b/l.
SKIN: No rashes
NEURO: A&Ox3. Appropriate. + tremor of upper extremities,
preserved sensation throughout. 4+/5 strength in hands, [**5-3**] in
prox. UE, LLE [**5-3**] and unable to lift R leg [**1-31**] pain/fracture.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2129-5-3**] 06:35AM BLOOD WBC-6.2 RBC-3.54* Hgb-9.8* Hct-29.6*
MCV-84 MCH-27.8 MCHC-33.1 RDW-16.0* Plt Ct-259
[**2129-5-2**] 07:10AM BLOOD WBC-5.6 RBC-3.53* Hgb-9.5* Hct-29.6*
MCV-84 MCH-27.0 MCHC-32.2 RDW-16.2* Plt Ct-264
[**2129-5-1**] 06:25AM BLOOD WBC-7.3 RBC-3.91* Hgb-10.8* Hct-33.1*
MCV-85 MCH-27.6 MCHC-32.6 RDW-16.4* Plt Ct-343
[**2129-4-30**] 06:10AM BLOOD Hct-27.6*
[**2129-4-28**] 06:25AM BLOOD Hct-27.3*
[**2129-4-27**] 07:20AM BLOOD WBC-7.7# RBC-3.35* Hgb-9.5* Hct-28.1*
MCV-84 MCH-28.2 MCHC-33.6 RDW-16.8* Plt Ct-358
[**2129-4-26**] 01:28PM BLOOD Hct-32.7*
[**2129-4-25**] 07:15AM BLOOD WBC-4.6 RBC-3.58* Hgb-10.1* Hct-30.6*
MCV-86 MCH-28.2 MCHC-32.9 RDW-17.0* Plt Ct-341
[**2129-4-24**] 05:50AM BLOOD WBC-4.4 RBC-3.43* Hgb-9.4* Hct-29.2*
MCV-85 MCH-27.4 MCHC-32.3 RDW-17.0* Plt Ct-352
[**2129-4-23**] 03:40PM BLOOD WBC-4.8 RBC-3.18* Hgb-8.9* Hct-26.9*
MCV-85 MCH-28.1 MCHC-33.2 RDW-16.9* Plt Ct-292
[**2129-4-22**] 07:00AM BLOOD WBC-4.4 RBC-3.64* Hgb-9.9* Hct-30.9*
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.8* Plt Ct-215
[**2129-4-20**] 07:35AM BLOOD WBC-4.5 RBC-3.46* Hgb-9.3* Hct-28.7*
MCV-83 MCH-27.0 MCHC-32.5 RDW-17.0* Plt Ct-156
[**2129-4-18**] 06:30AM BLOOD WBC-7.4 RBC-3.45* Hgb-9.7* Hct-28.5*
MCV-83 MCH-28.2 MCHC-34.2 RDW-16.9* Plt Ct-105*
[**2129-4-17**] 06:25AM BLOOD WBC-11.7*# RBC-3.74* Hgb-10.1* Hct-30.2*
MCV-81* MCH-27.1 MCHC-33.6 RDW-16.6* Plt Ct-127*
[**2129-4-16**] 03:12AM BLOOD WBC-7.0 RBC-4.22* Hgb-11.5* Hct-34.1*
MCV-81* MCH-27.3 MCHC-33.8 RDW-16.7* Plt Ct-104*
[**2129-4-15**] 09:17PM BLOOD WBC-5.1 RBC-4.10* Hgb-11.3* Hct-32.8*
MCV-80* MCH-27.6 MCHC-34.5 RDW-16.4* Plt Ct-92*
[**2129-4-15**] 05:55AM BLOOD WBC-4.2 RBC-3.69* Hgb-9.9* Hct-30.4*
MCV-82 MCH-26.9* MCHC-32.7 RDW-17.4* Plt Ct-122*
[**2129-4-14**] 06:20AM BLOOD WBC-4.2 RBC-3.56* Hgb-9.3* Hct-28.6*
MCV-80* MCH-26.1* MCHC-32.4 RDW-16.6* Plt Ct-105*
[**2129-4-13**] 06:15AM BLOOD WBC-5.5 RBC-3.68* Hgb-9.8* Hct-30.0*
MCV-82 MCH-26.6* MCHC-32.7 RDW-17.0* Plt Ct-107*
[**2129-4-12**] 06:30AM BLOOD WBC-6.6 RBC-3.71* Hgb-9.8* Hct-30.3*
MCV-82 MCH-26.5* MCHC-32.4 RDW-16.8* Plt Ct-92*
[**2129-4-11**] 11:45AM BLOOD WBC-8.8 RBC-4.06* Hgb-10.7* Hct-32.5*
MCV-80* MCH-26.3* MCHC-32.9 RDW-16.4* Plt Ct-112*
[**2129-4-11**] 06:35AM BLOOD WBC-11.9* RBC-4.28* Hgb-11.1* Hct-33.6*
MCV-79* MCH-26.0* MCHC-33.1 RDW-16.3* Plt Ct-141*
[**2129-4-10**] 08:55PM BLOOD WBC-14.4*# RBC-4.86# Hgb-12.8*#
Hct-37.8*# MCV-78* MCH-26.4*# MCHC-33.9 RDW-16.9* Plt Ct-208#
[**2129-4-20**] 07:35AM BLOOD PT-14.2* PTT-29.2 INR(PT)-1.2*
[**2129-5-3**] 06:35AM BLOOD Glucose-110* UreaN-2* Creat-0.7 Na-132*
K-4.4 Cl-98 HCO3-27 AnGap-11
[**2129-5-2**] 07:10AM BLOOD Glucose-109* UreaN-3* Creat-0.7 Na-129*
K-3.7 Cl-97 HCO3-28 AnGap-8
[**2129-5-1**] 06:25AM BLOOD Glucose-113* UreaN-4* Creat-0.7 Na-129*
K-4.3 Cl-93* HCO3-27 AnGap-13
[**2129-4-30**] 05:15PM BLOOD Glucose-111* UreaN-4* Creat-0.7 Na-122*
K-4.2 Cl-89* HCO3-26 AnGap-11
[**2129-4-30**] 06:10AM BLOOD Glucose-105 UreaN-3* Creat-0.6 Na-122*
K-4.0 Cl-87* HCO3-27 AnGap-12
[**2129-4-27**] 07:20AM BLOOD Glucose-98 UreaN-4* Creat-0.6 Na-131*
K-4.4 Cl-98 HCO3-26 AnGap-11
[**2129-4-25**] 07:15AM BLOOD Glucose-116* UreaN-3* Creat-0.6 Na-134
K-3.5 Cl-98 HCO3-26 AnGap-14
[**2129-4-23**] 03:40PM BLOOD Glucose-113* UreaN-3* Creat-0.6 Na-132*
K-3.6 Cl-97 HCO3-27 AnGap-12
[**2129-4-22**] 07:00AM BLOOD Glucose-100 UreaN-2* Creat-0.6 Na-132*
K-3.7 Cl-99 HCO3-25 AnGap-12
[**2129-4-20**] 07:35AM BLOOD Glucose-100 UreaN-3* Creat-0.6 Na-128*
K-3.3 Cl-96 HCO3-25 AnGap-10
[**2129-4-16**] 03:12AM BLOOD Glucose-111* UreaN-5* Creat-0.5 Na-131*
K-4.2 Cl-99 HCO3-26 AnGap-10
[**2129-4-30**] 09:35AM BLOOD ALT-11 AST-32 LD(LDH)-225 AlkPhos-243*
TotBili-0.7
[**2129-4-10**] 08:55PM BLOOD ALT-30 AST-58* AlkPhos-148* TotBili-0.7
[**2129-5-3**] 06:41PM BLOOD Vanco-7.2*
[**2129-5-1**] 05:30PM BLOOD Vanco-10.1
[**2129-4-10**] 08:55PM BLOOD ASA-NEG Ethanol-163* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2129-4-15**] 05:55AM BLOOD Osmolal-267*
[**2129-4-30**] 09:35AM BLOOD CRP-47.7*
Brief Hospital Course:
Mr. [**Known lastname 28893**] presented to the [**Hospital1 18**] on [**2129-4-10**] via transfer from a
local hospital after suffering a fall at home resulting in a
right femur periprosthetic fracture. He was evaluated by the
orthopaedic and medical services. Due to his alcohol withdrawal
he was admitted to the medical service for pre-operative
clearance. On [**2129-4-15**] he was taken to the operating room and
underwent an ORIF of his right femur periprosthetic fracture.
He was transfused 4 units of packed red blood cells due to acute
blood loss anemia. He was transferred from the operating room,
intubated to the intensive care unit for pain control and
extubation. On [**2129-4-16**] he was transferred from the intensive
care unit to the floor for further care. Chronic pain service
was consulted to help with his pain control. On [**2129-4-17**] his
surgical drains were removed. On [**2129-4-19**] he was started on IV
Ancef due to cellulitis around his wound. On [**2129-4-26**] he
returned to the operating room and underwent an I&D of his right
hip hematoma. Unfortunately his wound culture was positive for
pseudomonas and cornybacterium. Infectious disease was
consulted for help with antibiotic management. He was placed on
vancomycin and Zosyn for coverage. On [**2129-5-3**] a PICC line was
placed for long term antibiotics. On [**2129-5-4**] his vancomycin was
increased to 1250 mg Q12hrs due to a low trough. During his
hospital stay he was started on salt replacement and fluid
restrictions as his sodium levels were decreased. He will need
further monitoring of this. Through out his stay he was seen by
social work due to his alcohol abuse and physical therapy to
help with his strength and mobility. The rest of his hospital
stay was uneventful with his lab data and vital signs within
normal limits and his pain controlled. He is being discharged
today in stable condition.
Medications on Admission:
Folic acid 1mg daily
Lisinopril 5mg
Geodon 50mg qhs
Vitamin B1
Colace prn
Senna prn
Tylenol 1000mg po Q6
Lorazepam 1 mg [**Hospital1 **]
Fentanyl Patch 75 mcg/hr TP Q72H
Oxcarbazepine 600 mg PO BID
Temazepam 30 mg PO HS:PRN
Lasix 20mg daily
Lisinopril 5mg daily
Discharge Medications:
1. Outpatient Lab Work
Please draw weekly
CBC, BUN, Cr, LFT's, and Vancomycin trough
Please fax results to infectious disease attention Dr. [**Last Name (STitle) 438**]
[**Telephone/Fax (1) 432**]
**Trough should be done prior to [**5-6**] am dose
2. PICC Care
Per protocol
3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
1250mg Intravenous Q 12H (Every 12 Hours) for 6 weeks: Start
date [**2129-4-26**]
End date [**2129-6-7**].
4. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) 4.5gm Intravenous Q8H (every 8 hours) for 6 weeks: Start
date [**2129-4-26**]
End date [**2129-6-7**].
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime): Hold for sedation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
17. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO TID (3 times
a day).
18. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
19. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
20. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) 125mcg patch
Transdermal Q48 HOURS () as needed for pain.
21. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous Q24H (every 24 hours) for 2 weeks.
22. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day).
23. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8641**] Healthcare, NH
Discharge Diagnosis:
s/p fall
Right periprosthetic femur fracture
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be touchdown weight bearing on your right leg
Continue your lovenox injections as instructed
Please take all medications as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription refil
requests. There will be no prescription refils on Saturdays,
Sundays, or holidays. Please plan accordingly.
Physical Therapy:
Activity: As tolerated
Right lower extremity: Touchdown weight bearing
Treatment Frequency:
Staples out 14 days after surgery
Dry dressing daily
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics next
Thursday, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up with Dr. [**Last Name (STitle) 438**] in infectious disease in 4
weeks, prior to stopping antibiotics. Please call [**Telephone/Fax (1) 457**]
to schedule that appointment.
Appointments already scheduled prior to admission
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2129-9-16**] 1:30
Completed by:[**2129-5-4**]
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1,972
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20838+20839
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Discharge summary
|
report+report
|
Admission Date: [**2128-5-16**] Discharge Date: [**2128-5-21**]
Date of Birth: [**2062-12-18**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
Vietnamese nonsmoker with a past medical history significant
for hypertension and a remote history of tuberculosis treated
ten years ago who presented to an outside hospital with a
chief complaint of shortness of breath. The patient was in
his usual state of health until one week prior to admission
when he developed an acute and chronic exacerbation of his
baseline shortness of breath. The patient woke from sleep
with increased shortness of breath unable to walk. Patient
was taken by EMS to an outside hospital where his room air
saturation was 89 percent. At that time a CBC was obtained
which revealed a white blood cell count of 12,000 with a left
shift including 78 percent polys and 12 percent bands.
Patient was treated for an asthma exacerbation with Solu-
Medrol nebs. His shortness of breath persisted and he was
given a trial of BiPAP. The patient continued to have
respiratory distress and an arterial blood gas was obtained
which revealed a pH of 7.19, a pCO2 of 59 and a pAO2 of 52.
The patient was then intubated and started on propofol drip
and required increased sedation due to agitation while on
ventilator. On [**2128-5-11**] he was started on tube feeds and
increased abdominal distention was noted. A chest x-ray and
KUB showed bilateral upper lobe scarring and fibrosis. No
dilated loops of small bowel or free air. The patient
continued to have some difficulty oxygenating and was noted
to have increased sputum secretions requiring frequent
suctioning. The patient's sputum grew out methicillin
sensitive staph aureus and he was started on cefazolin.
While ventilated the patient's peak pressure was elevated in
the 40s and his plateau pressure was elevated in the 20s.
Bronchoscopy was then performed showing compression of the
right main stem bronchus and malposition of the endotracheal
tube against the lateral wall of the trachea. A subsequent
chest CT was performed which revealed bullous emphysematous
changes with equal scarring, external compression of the
right main stem bronchus. A CTA was not performed secondary
to poor renal function. With regards to the patient's mental
status he remained unresponsive while hospitalized. On
physical examination the patient had anisocoria with the left
pupil than the right. A head CT was obtained which showed no
bleed or mass effect. Neurologic consult was also obtained.
Propofol was discontinued and the patient was loaded on
phosphofenatoin. The patient's mental status improved
minimally while off sedation.
REVIEW OF SYSTEMS: Was negative for fever, chills, cough,
weight loss or change in appetite. The patient also denied
abdominal or pleuritic chest pain.
PAST MEDICAL HISTORY: [**10/2127**] echocardiogram revealing an
ejection fraction of 64 percent. Mild 1+ mitral
regurgitation. [**10/2127**] Thallium stress test revealing no
reversible defect. Tuberculosis diagnosed and treated 10
years ago in [**Country 3992**]. Bilateral lower extremity
paresthesias. Renal insufficiency with baseline creatinine
of 1.7. Hypertension. Asthma diagnosed three years ago.
History of deep venous thrombosis and hyperlipidemia.
ALLERGIES: No known drug allergies.
LABORATORY STUDIES: CBC: WBC 26.3, hematocrit 36.2,
platelets 251. PT 12.7, PTT 29.2, INR 1.1. Chem-7: Sodium
154, potassium 3.2, chloride 109, bicarb 34, BUN 60,
creatinine 2.2, glucose 144, calcium 8.3, phos 2.7, magnesium
2.7. Arterial blood gas: pH 7.38, pCO2 55, pAO2 107,
lactate 1.6. Electrocardiogram: Sinus rhythm at a heart
rate of 115, normal axis. Borderline left ventricular
hypertrophy. No acute ST or T wave changes. No significant
change from prior electrocardiogram. Head CT: No
significant atrophy, no bleed or mass effect.
PHYSICAL EXAMINATION: Temperature 100.7, heart rate 118,
blood pressure 143/84, saturation 96 percent on assist
control, ventolung 500, respiratory rate 16, FIO2 of 40
percent, PEEP of 5. General: Patient was intubated,
appearing comfortable. Head, eyes, ears, nose and throat:
Pupils minimally reactive. Anisocoria noted with left pupil
greater than right pupil. Dry mucous membranes. No
lymphadenopathy. Unable to assess jugular venous distension.
Cardiovascular: Regular rate and rhythm, faint S1 and S2,
unable to appreciate any murmurs, rubs or gallops. Lungs:
Coarse breath sounds throughout with deceased breath sounds
at right base. Abdomen: Positive bowel sounds, minimally
distended. Extremities: 2+ dorsalis pedis and posterior
tibial pulses bilaterally. No lower extremity edema. No
rashes noted. Neurologic: Pupils were reactive to light.
Patient withdrew to pain.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit team at which time he was fairly stable
on the ventilator. Chest CT with contrast was obtained which
revealed narrowing of the right main stem bronchus without
evidence of associated mass lesion. The right pulmonary
artery appears to compress the airway at this level. The
differential diagnosis includes bronchomalacia, mass effect
from pulmonary artery in the setting of pulmonary arterial
hypertension, involving of the bronchus with tuberculosis.
Intraluminal irregularities of uncertain etiology were also
noted. The patient also had severe [**Hospital1 **]-apical bullous disease
and fibrosis which is consistent with stated history of prior
tuberculosis. Patient underwent bronchoscopy and brushings
were sent for cytology. The results of these brushings are
pending at time of dictation. The patient then underwent
rigid bronchoscopy the following day and a stent was placed
to his right main stem bronchus. Multiple biopsies were
obtained at the site of progression. Results of these
biopsies are pending at time of dictation. The patient was
then extubated without difficulty. Following extubation the
patient likely had an episode of aspiration while taking P.O.
medications. This required suctioning. The patient was
briefly placed on BiPAP. The following day he did well and
was weaned off BiPAP without any difficulties. He was seen
by Speech and Swallow for evaluate for aspiration and he did
relatively well with thin liquids. The Speech and Swallow
consult recommended puree diet. She felt comfortable with
the patient taking oral P.O. medications again.
Cardiovascular: During the patient's hospitalization he was
persistently hypertensive. He was started on a diltiazem
drip as he was tolerating POs. He was then transitioned to
Lopressor and hydralazine. At time of discharge his regimen
was changed again to nifedipine and Lopressor.
Infectious Disease: The patient spiked a fever during his
hospitalization. Blood cultures were obtained on [**2128-5-16**]
and [**2128-5-18**] both of which were negative to date at time of
dictation. The patient completed a course of cefazolin and
this medication was discontinued. However, persistent white
blood cell elevation and a sputum culture growing very rare
gram negative rods prompted the team to re-initiate
antibiotic therapy. In addition, the patient had sparse gram
positive cocci on sputum culture. Thus he was started on
Vancomycin and Zosyn.
Fluid, electrolytes and nutrition: The patient was
hypernatremic at time of presentation. He remained
hypernatremic on hospital day one. This responded to
intravenous fluids and was likely secondary to dehydration.
His sodium was 144 at time of discharge.
Access: The patient had a right internal jugular at time of
presentation. This was discontinued and a peripheral
intravenous was established.
Gastrointestinal: The patient was transiently started on
tube feeds. However, these were discontinued in the setting
of extubation. The patient did not have a bowel movement
during his hospital stay although he was on Senna and Colace.
A KUB was obtained which was unremarkable.
Neurologic: The patient was maintained on gabapentin during
his hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital 1281**] Hospital.
DISCHARGE DIAGNOSIS:
1. Right main bronchus stenosis of unknown etiology.
2. Severe emphysema.
3. Likely pneumonia.
4. Chronic renal insufficiency.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram q 24 hours.
2. Metoprolol 50 mg t.i.d.
3. Zosyn 2.25 mg intravenous q six hours.
4. Metronidazole 500 mg intravenous q 8 hours.
5. Atorvastatin 20 mg P.O. q d.
6. Albuterol.
7. Ipratropium.
8. Gabapentin 100 mg P.O. t.i.d.
9. Heparin subcutaneous 500,000 units subcutaneously q 12
hours.
10. Senna 1 tablet P.O. B.I.D p.r.n.
11. Senna 1 tablet P.O. q.d.
12. Docusate 100 mg P.O. B.I.D
13. Tylenol p.r.n.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761
Dictated By:[**Doctor Last Name 2020**]
MEDQUIST36
D: [**2128-5-21**] 12:22:57
T: [**2128-5-21**] 13:21:44
Job#: [**Job Number 19678**]
Admission Date: [**2128-5-16**] Discharge Date: [**2128-5-31**]
Date of Birth: [**2062-12-18**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 65-year-old Vietnamese
male with a history of hypertension, history of TB treated 10
years ago, who is transferred from the ICU status post stent to
right mainstem bronchus and preliminary path showing non-
small cell lung cancer. The patient presented to [**Hospital 1281**]
Hospital on [**2128-5-10**] for an increasing shortness of breath
plus wheezing. Shortness of breath has been chronic for
approximately 2 years, but worsened on night of [**2128-5-9**].
The patient awoke from sleep feeling short of breath, unable
to catch breath to walk. No fevers, chills or sweats. No
cough. Nonsmoker. No weight loss or change in appetite. No
abdominal pain. No pleuritic pain. Taken by EMS at outside
hospital, and the patient was intubated for respiratory
stress. Chest x-ray showed bilateral upper lobe scarring,
thrombosis and continued difficulty with oxygenation. The
patient was noted to have increased sputum secretion with
frequent plugging. Sputum grew methicillin-sensitive
Staphylococcus aureus. Initially treated with one dose of
vancomycin and then switched to cefazolin. CT of the chest
performed, which showed bullous emphysematous changes with
apical scarring. External compression of right mainstem
bronchus with question of node versus tumor. Small left
upper lobe pneumothorax. The patient's mental status became
unresponsive. Outside hospital head CT showed no bleeding or
mass effect. Neurologic consult concerned for anoxic
encephalopathy, but mental status improved off sedation. The
patient was transferred and Interventional Pulmonary at [**Hospital1 1444**] placed stents in the right
mainstem bronchus and the patient was extubated. The
patient's mental status continued to improve in the MICU and
preliminary lung biopsy from the right mainstem bronchus
showed non-small cell lung cancer. The patient was
transferred to the medical floor.
PAST MEDICAL HISTORY: History of TB diagnosed 10 years ago
and treated.
Bilateral lower extremity paresthesias.
Chronic renal insufficiency, creatinine 1.7.
Hypertension.
Asthma diagnosed approximately 3 years ago.
DVTs.
Palpitations.
Hyperlipidemia.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Vietnamese speaking only. The patient has
involved family members. Nonsmoker. [**Name2 (NI) **] alcohol. No herbal
meds. Occasionally drinks some tea. Recently moved to
[**Location (un) 86**] from [**State 4565**].
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 85,
blood pressure 135/65, respirations 25, O2 95 percent on 2 L,
in no apparent distress, lying in bed. GENERAL: He does
have some abdominal grunting and labored breathing. HEENT:
Moist mucous membranes. Oropharynx is clear. HEART:
Regular rate without murmur. CHEST: Diffuse wheezes
bilaterally. ABDOMEN: Soft, nontender, and nondistended.
Positive bowel sounds. EXTREMITIES: No clubbing, cyanosis
or edema. [**Male First Name (un) **] hose in place.
LABORATORY DATA: CT of chest; emphysema with blebs, volume
loss in the right upper lobe. Apex, extensive scarring
apical, small left hemothorax, question chronic compression
of right mainstem bronchus, tracheal deviation on the right,
unable to assess lymphadenopathy secondary to non-contrast
CT. No adrenal masses. Atrophic kidneys. CT of the head,
no significant atrophy. No bleed. No mass effect.
HOSPITAL COURSE: Non-small cell lung cancer. The patient
has no medical insurance. The patient is now applying for
Mass Health. The patient will be seen by Dr. [**Last Name (STitle) **] in the
Thoracic Clinic. The Interdisciplinary Team felt that there
was no role for surgery, but maybe endobronchoscopy light
therapy may be an option at a future date. The patient will
follow up this Thursday, [**2128-6-3**], with Dr. [**Last Name (STitle) **] in the
Thoracic Clinic to initiate beginning of chemotherapy. The
patient will follow up with Interventional Pulmonary in 6
weeks. The patient also has no metastasis so far by MRI of
the brain or CT of the abdomen. A bone scan will be
performed on [**2128-6-3**].
Altered mental status. This dramatically improved as the
patient came out of the unit and was rehydrated for his
hypernatremia. Discharged to home.
DISCHARGE STATUS: The patient is able to ambulate without
difficulties, requiring no oxygen.
DISPOSITION: Discharged to home.
DISCHARGE MEDICATIONS:
1. Tylenol as needed.
2. Albuterol 1 to 2 puffs q.6h. as needed.
3. Atorvastatin 20 mg q.d.
4. Docusate sodium 100 mg b.i.d.
5. Gabapentin 100 mg t.i.d. The patient takes this for
neuropathy in the lower extremities. The patient was
taking this prior to admission.
6. Ipratropium bromide 2 puffs q.i.d.
7. Metoprolol 75 mg t.i.d.
8. Nifedipine sustained release 60 mg q.d.
9. Senna 1 tablet q.d.
FOLLOWUP: The patient is to follow up on [**2128-6-3**] at 10:30
a.m. with Dr. [**Last Name (STitle) **] in the Thoracic Clinic. The patient will
follow up with Interventional Pulmonary. They will contact the
patient with a translator for an appointment in 6 weeks for
endobronchial therapy. The patient will follow up with a bone
scan on [**2128-6-3**] at 10 a.m. in the Radiology Department.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**]
Dictated By:[**Last Name (NamePattern1) 14382**]
MEDQUIST36
D: [**2128-5-31**] 12:51:14
T: [**2128-6-1**] 09:42:43
Job#: [**Job Number 55507**]
|
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2,628
| 105,769
|
7220+7221+55817
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2125-12-11**] Discharge Date:
Date of Birth: [**2097-9-9**] Sex: M
Service: [**Last Name (un) 26755**] ICU
REASON FOR ADMISSION: Hypoxic respiratory distress.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26756**] is a 28-year-old
gentlemen with a history of type 1 diabetes and hypertension
who presented on [**2125-12-21**] to the [**Hospital1 **] Emergency Department with a three day history of
total body myalgias, a one day history of fever to 102
associated with rigors, and a productive cough without
hemoptysis times three days alongside worsening dyspnea at
rest and exertional dyspnea. The patient denied chest pain
or pleurisy at the time of admission. He had had no recent
nasal congestion, headache, swollen glands, but he did report
a sick contact seen over the [**Holiday 1451**] weekend one week
prior to admission. There was no recent travel. No pets at
home. No chronic steroid use or history of opportunistic
infections or insect bites.
When the patient presented to the Emergency Department, he
was diagnosed with a right lower lobe pneumonia and started
on levofloxacin and volume resuscitated with two liters of
normal saline. His initial oxygen saturation was 95% on room
air at the time of arrival to the Emergency Department. By
the time of arrival to the floor, 18 hours later, his oxygen
saturation was 94% on four liters nasal cannula with a normal
respiratory rate.
Upon arrival to the floor, he had the acute onset of hypoxia
with tachypnea with an oxygen saturation of 91% on 100%
nonrebreather and respiratory rate into the 40s. An arterial
blood gas at the time was 742, 33 and 62. A chest x-ray
showed blossomed left upper lobe infiltrated in addition to
the right lower lobe and the patient's clinical status
resolved quickly with chest physical therapy. It was felt
that he had developed a mucus plus. The patient was
clinically stable until [**2125-12-23**] when he developed a
similar episode of acute onset hypoxemic respiratory distress
which was nonresponsive to chest physical therapy. He was
intubated semiurgently and brought to the Intensive Care Unit
for further evaluation and management.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes times 25 years followed at the
[**Last Name (un) **].
2. Diabetic retinopathy status post laser photocoagulation.
3. Hypertension.
MEDICATIONS ON ADMISSION:
1. Insulin Humalog 12 units q.a.m., 12 units q.p.m. and NPH
32 units q.a.m. and 24 units q.p.m.
2. Zestril, dose unknown.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, no intravenous drug use, mild
alcohol consumption. Patient is sexually active with a
longtime female partner at times unprotected. He lives with
multiple roommates. He is physically very active.
FAMILY HISTORY: Father with diabetes otherwise unremarkable.
ADMISSION PHYSICAL EXAMINATION: Physical examination at time
of admission to Intensive Care Unit: Temperature 100.2.
Heart rate 129. Blood pressure 128/72. Respiratory rate 43.
Oxygen saturation 94% on six liters nasal cannula. General:
A young white male in moderate respiratory distress. Head,
eyes, ears, nose and throat: Pupils equal, round and
reactive to light. Extraocular movements intact. Sclerae
are anicteric. Oropharynx clear. No nystagmus. Mucous
membranes were dry. Neck: Jugular veins were flat. No
thyromegaly, no thyroid tenderness to palpation. Chest:
Inspiratory crackles halfway up on the right. Patient
talking in full sentences, using expiratory muscles, no
wheezes were auscultated. Cardiac: Tachycardic, no murmurs,
rubs or gallops. Abdomen: Soft, nontender, no
hepatosplenomegaly, normal active bowel sounds. Extremities:
Trace bilateral lower extremity edema. No clubbing, no
cyanosis, no intertriginal rash. Neurological: Alert and
oriented times two. Cranial nerves II through XII are
intact. Strength 5/5 in all four extremities.
LABORATORIES: White blood cell count 9.9, hematocrit 40.6,
platelets 216,000. SMA-7: Sodium 134, potassium 3.8,
chloride 98, bicarbonate 23, BUN 15, creatinine 1.0, glucose
246. Arterial blood gas 742, 30, 80 on six liters nasal
cannula oxygen. Chest x-ray: Bilateral diffuse infiltrates
with sparing of the apices and bases. No effusions. Normal
cardiac silhouette. Urinalysis: 1.07 large blood, 8 red
blood cells, 2 white blood cells, greater than 1000 glucose,
trace ketones. Electrocardiogram: Sinus tachycardia at 130,
axis is 100 degrees, normal intervals, T wave inversions in
II, III and aVF. Q waves in II, III and aVF.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for management of hypoxic respiratory
distress. The following will outline his Medical Intensive
Care Unit course from [**2125-12-13**] to [**2125-12-29**]
by systems:
1. Neurological: The patient had no acute neurological
issues. He had an escalating sedation requirement
additionally managed on Ativan and Fentanyl drips. Ativan
was switched over to midazolam on [**2125-12-29**] for
prophylaxis against crystal induced acute renal failure.
2. Respiratory: The patient was originally admitted to the
[**Hospital6 733**] Service with atypical community
acquired pneumonia. He was initially started on levofloxacin
after being admitted to the unit and intubated Ceftriaxone
was added on [**2125-12-13**]. Bronchoscopy was done which
was unremarkable except for friable mucosa. BAL studies were
negative for PCP. [**Name10 (NameIs) 26757**] caused her acid fast bacilli
smear viral and >.....<virilized and culture. The patient
appeared to have developed adult respiratory distress
syndrome and was management with a long protective strategy.
He was aggressively volume resusitated to a wedge of 29 which
corrected to 24 with discounting of a PEEP of 20. He was
ruled out for PE by CT angio and a normal echocardiogram on
[**2125-12-13**].
In addition to atypical community acquired pneumonia, adult
respiratory distress syndrome and volume overload, it
appeared that the patient had developed a vent associated
pneumonia as evidenced by a new retrocardiac opacity and
increased purulence secretions; vancomycin was added on
[**2125-12-24**]. Ceftazidime was subsequently added on
[**2125-12-26**] for persistent fevers to cover gram
negative pathogens. At the time of this dictation, the
patient is on assist controlled ventilation with PEEP of 14
and FIO2 of 50%.
3. Cardiac: In pursuit of the patient's concerning
electrocardiogram, there were no prior electrocardiograms for
comparison and the clinical suspicion was high for RV strain
in the setting of multiple PEs. However, an echocardiogram
showed a normal ejection fraction, normal RV size and
function and a normal left ventricular ejection fraction and
normal left ventricular size. There were no significant
valvular abnormalities and no vegetations on transfer
>.....<ultrasound. For the first five days of the [**Hospital 228**]
hospital course, he was noted to be on a high cardiac output
low SVR state. During that, he never developed hypotension
or oliguria. He was eventually volume resusitated to a wedge
pressure of 29.
4. Renal: The patient came to the unit originally in renal
failure with a creatinine of 2 over a baseline of 1.0. After
aggressive volume recessitation, his creatinine returned to
[**Location 213**]. FeNA obtained was consistent with previous azotemia.
Since [**2125-12-25**], the patient has been on a Lasix drip
to achieve diuresis to help resolve respiratory failure,
which he has tolerated well from a renal and hemodynamic
standpoint.
5. Gastrointestinal: The patient has had stabilely elevated
liver biochemistries including an alkaline phosphatase of
roughly 400 and T bilirubin that had risen from .2 to 1.1. A
gallbladder ultrasound obtained on [**2125-12-26**] showed
mild gallbladder distention with a normal gallbladder wall
thickness and question of pericholecystic fluid. Subsequent
HIDA scan to evaluate for a calculus cholecystitis showed
equivocal results. The results of a repeat ultrasound of the
gallbladder on [**2125-12-29**] are pending. The patient is
currently being ruled out for C. difficile and is negative
times one.
6. Infectious Disease: The patient was initially managed on
levofloxacin for community acquired pneumonia started on
[**2125-12-31**]. Ceftriaxone was added to that on [**2126-1-2**]. Levofloxacin was added to that on [**2125-12-24**]
for suspicion of vent associated pneumonia. Ceftriaxone was
replaced by ceftazidime on [**2125-12-26**] to cover for
possible gram negative pulmonary pathogens. The patient has
had persistent fevers since [**2125-12-26**]. [**Doctor First Name **], ANCA and
HIV antibody were all negative obtained during this
hospitalization. Urine legionella antigen is negative. PCP
immunofluorescent on BAL is negative. His right internal
jugular and right arterial line were both changed to a left
subclavian and a left-sided radial arterial line on [**2125-12-28**] with tip sent. Gallbladder evaluation for a
calculus cholecystitis was underway. The patient was being
ruled out for C. difficile. Drug fever may be the culprit
here with likely pathogens including ceftazidime and Lasix.
The patient does have eosinophilia with an absolute
eosinophils count of 800 on [**2125-12-28**] and a truncal
rash has developed from [**2125-12-28**] to [**2125-12-29**]. At the current time, ceftazidime is on, but may be
discontinued with patient observation should the rest of his
Infectious Disease work-up be negative. The patient has had
no positive culture date including multiple blood cultures,
sputum cultures and BAL cultures.
7. Endocrine: The patient had a high dose ACTH stimulation
test which was normal. The patient's diabetes has been
managed with an insulin drip.
8. Nutrition: The patient is currently on hyperalimentation
with tube feds being titrated up as tolerated.
9. Prophylaxis: Patient on subcutaneous heparin and proton
pump inhibitor along with tube feds.
10. Access: Left subclavian placed on [**2125-12-28**].
Left radial arterial line placed on [**2125-12-28**].
DIAGNOSES AT THE TIME OF THIS DISCHARGE SUMMARY:
1. Atypical community acquired pneumonia.
2. Adult respiratory distress syndrome.
3. Vent associated pneumonia.
4. Volume overload.
5. Persistent fevers.
6. Right axis deviation of unclear etiology and duration.
7. Status post peripheral compartment syndrome from tense
peripheral edema.
8. Diabetes mellitus.
9. Possible drug fever.
10. Possible a calculus cholecystitis.
MEDICATIONS AT TIME OF DISCHARGE:
1. Vancomycin 1 gram q. 12 hours.
2. Levofloxacin 500 mg q. 24 hours.
3. Ceftazidime 2 grams q. 8 hours.
4. Insulin drip.
5. Midazolam drip.
6. Fentanyl drip.
7. Lasix drip.
8. Insulin drip.
9. Protonix.
10. Subcutaneous heparin.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2125-12-29**] 17:21
T: [**2125-12-28**] 22:52
JOB#: [**Job Number 26758**]
Admission Date: [**2125-12-21**] Discharge Date: [**2126-2-13**]
Date of Birth: [**2097-9-9**] Sex: M
Service:
Time covering [**2125-12-29**] to [**2126-1-19**].
1. From a respiratory standpoint the patient was continued
on empiric Vancomycin and Levaquin. On [**12-31**] he failed
a trial of pressor support secondary to apnea which was
thought secondary to sedation. Therefore he was changed to
AC. The positive end-expiratory pressure was decreased. On
[**1-1**], he had a diagnostic thoracentesis performed
under ultrasound monitoring. The parameters were
transudative with a pleural fluid pH of 7.41, total protein
2.3 with a ratio to serum of 39%, glucose 154, LDH 150 to
serum of 265, ratio 57%, gram stain had 2+ polymorphonuclear
leukocytes and no microorganisms. Ventilator wean was
continued and on [**1-3**], pressor support was weaned
down. On [**1-3**], he had a respiratory rate of 37,
however, secondary to his mental status it was felt unsafe to
extubate him at that time. Through the night of [**1-3**]
to [**1-4**] he had increasing secretions and decreasing
oxygen saturations requiring increased support and instead
the morning of [**1-4**] was requiring AC settings again.
The concern was for ventilator-associated pneumonia and Zosyn
and Vancomycin were added to the patient's antibiotics. On
[**1-5**], he had continued secretions and his sputum on
that day was positive for Methicillin-resistant
Staphylococcus aureus. At that time discussions about
tracheostomy were initiated. Interventional Pulmonology saw
the patient on [**1-7**] and the tracheostomy was planned
for the next day, however, on [**1-10**], the patient
extubated without the need for tracheostomy. He had
aggressive sectioning and was able to remain extubated.
However, the day prior to his extubation on [**1-9**],
during a right subclavian line placement there was a
complication of a pneumothorax and the chest tube was placed.
The pneumothorax resolved and the chest tube was removed on
[**1-11**]. The patient's respiratory status continued to
improve and with frequent suctioning he was slowly weaned
from the face mask to nasal cannula 2 liters. However, on
late day [**1-14**] and through the night the patient
developed increasing respiratory rate and was tried on BiPAP
and felt panicked. He started to tire and was reintubated
the morning of [**1-15**]. It was thought that the patient
had another possible aspiration event. He was sedated with
Propofol at that time. He was started on pressor support and
over the next couple of days was noted to be very tachypneic
the night of [**1-16**], with a high ventilation. He was
switched back to AC with an increased sedation. Given his
continued fevers another chest computerized tomography scan
was done. This was without contrast, given his kidney
function. It showed bibasilar consolidation with a moderate
right pleural effusion. On the following day it was decided
to do a contrast computerized tomography scan which he had on
the morning of [**1-18**], showing the bibasilar
consolidation, right pleural effusion, regions of goundglass
opacity and perihilar regions consistent with mild pulmonary
edema, no pericardial effusion. On [**1-17**], a bronchoscopy
was performed without difficulty. Airways were inspected to
the segmental level. Last night he had diffuse airway
erythema with thick tan secretions noted in the left lower
lobe which were collected and in the right middle lobe
greater than right lobe and anomalous right upper lobe
bronchi noted with two bronchi off the right main stem. On
[**1-18**], after the computerized tomography scan was
completed, ultrasound came and marked the pleural effusion
for which another diagnostic thoracentesis was performed.
This fluid was now exudative with pH of 7.31, white cells
2,200, 54 polys, 11 lymphocytes, 21 monocytes, 4 mesophils,
247,250 red blood cells, total protein 3.8, glucose 76, LDH
453 with a serum LDH of 208. Gram stain had 1+ PMNs and no
microorganisms. The patient was tried several times on
[**1-19**] on AC but he was uncomfortable on this setting and
was switched back to CPAP pressor support for which he is
more comfortable. He continued to have secretions that were
suctioned. Currently the patient is unstable. Ventilator
settings, CPAP pressor support with positive end-expiratory
pressure and pressor support being weaned down slightly, he
is having venous blood gases followed closely along with
chem-7. His arterial access for venous blood gases is very
difficult because the right radial fills a reverse [**Doctor Last Name 6237**]
test, the left radial has a lot of scar tissue from previous
arterial lines. He is on heparin, so femoral arterial blood
gases are a higher risk as well as he intermittently has less
warmth in his right foot and the dorsalis pedis becomes only
dopplerable during these episodes, making his capillary
system questionable for perfusion and concerning. However,
arterial blood gases have been drawn when indicated.
2. Infectious disease - The patient continued to have fevers
and it was felt this was not a hepatobiliary source of
infection. He had increased eosinophils and rash and his
Ceftazidime was stopped. He was tested numerous times for
Clostridium difficile which was negative. He had numerous
pancultures of sputum, urine and blood, all of which remained
negative thus far although multiple are pending. There was a
question of whether any of this could be related and so drugs
that were not necessary were stopped such as Reglan. He did
have several sputums positive for yeast and
Methicillin-resistant Staphylococcus aureus and the only
other culture that was positive was arterial line tip
positive for Staphylococcus coagulase negative and viral
studies for Ebstein-[**Doctor Last Name **] virus positive, although numerous
studies are pending at this time. On [**12-30**], Podiatry
was consulted given his foot infection which they felt was
tinea and recommended Betadine and dressing changes. He had
dark discoloration and some cracks between the left fourth
and fifth toes. On [**1-1**], thoracentesis was performed
which was transudative Ebstein-[**Doctor Last Name **] virus, PCA and IgG and a
very positive EPV, and an IgG antibody positive, Ebstein-[**Doctor Last Name **]
virus, VCA, IgM antibody positive, cytomegalovirus negative,
HCV 1 and 2 negative, HCV, RMA negative, adenovirus negative.
On [**1-2**] he had a computerized tomography scan of his
chest, sinuses, abdomen and pelvis because of the results of
this which showed pelvis and abdomen with no free fluids, no
abnormalities other than bibasilar small pleural effusions,
scattered mediastinal axillary lymph nodes. The T-sinus
showed near total opacification of the frontal air cells,
maxillary, ethmoid and sphenoid sinuses are with significant
opacification of the maxillary air cells bilaterally which
could be secondary to the patient's tube but could not be
distinguished from acute sinusitis. Otorhinolaryngology was
consulted. They felt that there was likely some sinusitis
but unlikely that this was the source of fevers and that no
intervention was indicated other than antibiotics and
Aspirin. On [**1-3**], Plastics was consulted to look at
the foot as a possible source. They felt again that it was
an unlikely source of infection and recommended Lamisil. On
[**1-4**], when he had the desaturations, concerns for
ventilator associated pneumonia and Zosyn was added to the
Vancomycin. He also had increasing diarrhea on that day and
concern for Clostridium difficile given his long antibiotic
course, the Flagyl was started empirically, however, it was
stopped when Clostridium difficile was negative. He had
sputums that were positive for Methicillin-resistant
Staphylococcus aureus and yeast. On [**1-8**], Podiatry
was reconsulted to look at the foot as a possible source of
fevers and infection. However, again they felt it was low
suspicion for ostial myelitis. On [**1-11**], his white
blood count went from 13.9 to 25.1. He was clinically stable
and then his white count trended down. He continued to have
fevers although a lower curve. On [**1-14**], Zosyn was
planned to be stopped the next day. The patient remained
clinically stable despite lowgrade fevers and elevated white
count. Plan was to culture the patient and no further
intervention at that time. On [**2126-1-15**] Infectious
Disease was consulted who recommended repeating culturing,
stopping Zosyn, continuing Vancomycin and retesting
Methicillin-resistant Staphylococcus aureus for
sensitivities. The patient continued spiking high fevers.
Infectious Disease continued to follow the patient. On
[**1-16**], his amylase and lipase were elevated and it was
thought abdominal could be a possible source. Ultrasound was
obtained which showed stable sludge in the gallbladder but no
wall thickening or free fluid. Pancreas seemed normal, so
computerized tomography scan without contrast was obtained
and then was repeated with contrast as the noncontrast
computerized tomography scan was unrevealing for a source,
abscess and only had bibasilar lung consolidations and small
axillary mediastinal retroperitoneal inguinal lymph nodes.
On [**1-16**], the patient was febrile all day and was
writhing. Imipenem and Ampicillin were started for broad
coverage in this diabetic who had been on total parenteral
nutrition. The patient had continued to rigor and spike
temperatures. On [**1-17**], he had computerized tomography
scan of sinus, chest, abdomen and pelvis as above, and
bronchoscopy as above. Otorhinolaryngology was reconsulted
on that day and they did a maxillary sinus fungal biopsy and
aspirate. Because of the sinus computerized tomography scan
that showed persistent significant opacification of the
paranasal sinuses, complete opacification of the sphenoid
with near complete ethmoid opacification, right greater than
left, decrease in the amount of opacification in the
maxillary sinus which had air fluid levels now and so there
was a concern for invasive fungal infection. On [**1-18**],
the left internal jugular was placed and right internal
jugular was removed and tip sent for culture. Lumbar
puncture was attempted but was unsuccessful and this was
abandoned as it was felt that it was very unlikely that the
patient developed nisochromial meningitis and so Flagyl was
also added. The patient's white count was noted to be
trending down and his fever curve was noted to be lower. At
the time of this dictation, multiple cultures are pending as
well as viral studies. Tomorrow, cytomegalovirus antigenemia
should be sent. Pathology of sinus biopsy and aspirate will
need to be followed as well as multiple cultures, data and
studies.
3. Gastrointestinal - On [**12-30**],
Gastroenterology/Hepatology was consulted for increased liver
function tests, smooth left lower antibody was weakly
positive, however, HCV viral load, negative, HSV negative,
cytomegalovirus negative, Ebstein-[**Doctor Last Name **] virus as above. [**Doctor First Name **]
negative, ANCA negative and gastrointestinal thought the
source was likely not his hepatobiliary tract and while his
liver function tests remained elevated, they trended down and
it was felt that most likely this was secondary to either
medications or total parenteral nutrition. On the night of
[**1-8**], the patient was noted to have coffee ground
emesis which was possibly trace positive. This happened
again on [**1-10**] and esophagogastroduodenoscopy was
performed on [**1-10**] and showed small local erythema and
erosions in the mucosa of the stomach with mild gastritis
versus nasogastric tube trauma, localized erythema at the
gastroesophageal junction. The patient was changed from q.
day proton pump inhibitors to b.i.d. proton pump inhibitors
and no more gastrointestinal bleeding was noted. The patient
was noted to have very high residuals with even small amounts
of tube feeds and minimal to no bowel sounds for much of this
time. Therefore, tube feeds were abandoned and the patient
was continued only on total parenteral nutrition for
nutrition. The nasogastric tube was placed to intermittent
low suction. It was felt that most likely this was a
combination of opiate effect and diabetic gastroparesis.
Reglan was restarted but then was stopped in the light of
fevers and possible source of the fevers being Reglan.
4. Endocrine - The patient was maintained on an insulin
drip. He was a brittle Type 1 diabetic requiring close
monitoring q. 1 hour fingersticks at this time. The
Cortrosyn stimulation test was performed on [**2126-1-18**],
looking for possible Addison's and the results are pending at
this time.
5. Acid base - During most of this hospitalization the
patient was noted to be alkalotic particularly after his
diuresis. This resolved somewhat after the discontinuation
of Lasix. Arterial blood gases was followed and when
arterial line was discontinued arterial blood gases were
followed only as needed and venous blood gases were followed.
On [**1-15**] or [**1-16**], the patient's bicarbonate was
noted to fall. It was unclear reason for this fall, it was
shown to be a metabolic acidosis, non-gap, however,
etiologies of this were not elicited. He had a positive
urine anion gap showing that his kidneys were not
compensating appropriately but the primary etiology was not
found. He was not having diarrhea during this time. He had
a negative lactate on multiple occasions, negative ketones
despite it was mostly non-gap acidosis. Acetate was
increased in his total parenteral nutrition and he several
times went on a bicarbonate drip to help correct this.
Arterial blood gases and venous blood gases were followed as
well as chem-7 to look at bicarbonate and anion gap. This
was slowly resolving with supplementation at the time of this
dictation, but the etiology still was not clearly defined.
6. Anemia - On [**1-3**], hematocrit was stabilized in the
mid 20s. Reticulocyte count was noted to be 2.2 Numerous
times the patient had hemolysis laboratory studies sent which
were negative. He did have a gastrointestinal bleed and
received some blood transfusions intermittently when the
hematocrit dipped low. On [**12-30**], iron ratio revealed
an iron of 24, TIBC of 156, ferritin 693, TRS of 128. On
[**1-19**], the hematocrit was noted to fall from 27.3 to 23.
It was felt this most likely secondary to procedures the
patient has had before. He was transfused 2 units of packed
red blood cells, however, he did not have enough red blood
cells bump and his hematocrit was only 26. Therefore chest
x-ray was obtained as he has recently had a thoracentesis and
central line placed. This did not show a large effusion that
would have been consistent with a hemothorax. Hemolysis
laboratory studies were sent, they were negative.
Nasogastric was occult blood negative. He was having stool.
It was unclear where the blood loss was from and hematocrits
were followed, and at this time are being followed and if
stable will not be worked up further. However, if they fall
any more an abdominal computerized tomography scan would be
considered to look for bleed.
7. Clot - On [**1-9**], the patient was found to have a
left upper extremity clot by ultrasound. This was felt to be
most likely related to a central line that he had. After his
esophagogastroduodenoscopy was cleared for signs of active
bleeding he was started on heparin. The heparin was more
consistently on, however, for procedures it was shut off.
8. Fluids, electrolytes and nutrition - The patient was
allowed to run positive when he was very febrile and
tachypneic given it was felt that his insensible losses were
probably high, although at this point he is likely a little
bit positive. At the time of this dictation, gentle diuresis
will be started again if the patient tolerates. The patient
was continued on total parenteral nutrition and Nutrition
followed and helped adjust total parenteral nutrition daily.
The patient was noted to be hyponatremic and this was thought
secondary to syndrome of inappropriate antidiuretic hormone
as his urine sodium was noted to be 35. Most likely this was
secondary to his pulmonary process. Normal saline was tried
to be the base fluid for all of the medications that he
received and total parenteral nutrition was adjusted. It was
noted that his calcium and ionized calcium started to rise,
unclear etiology of this and it is being closely followed.
However, over the last few days it was noted that his
phosphate has also started to rise. On [**1-20**], given his
ionized calcium rose to 1.51, total calcium rose to 10.2 and
phosphorus 6.6, Amphojel was started and Renal was consulted
to help with his electrolyte abnormalities as well as renal
issues.
9. Renal - The patient had bump in creatinine up to 1.6
earlier in [**Month (only) 1096**] likely felt secondary to diuresis and
this slowly resolved, although it was felt the patient may
have underlying diabetic nephropathy given his eye disease
and that he may not have much renal reserve. On [**1-4**]
to [**1-15**], creatinine rose from .6 to 1.1 for unknown
reasons. Prior to his contrast computerized tomography scan
Mucomyst was given. Creatinine was noted to bump slightly as
high as 1.4 and is being followed closely. Urine output was
followed closely and remained good. Renal will be consulted.
10. Foot - Left foot, #4 and #5 toe, had dark and dry skin
and cracks which Podiatry and Plastics saw and felt was
likely athlete's foot.
11. Neurology - The patient is currently sedated with
Fentanyl and Propofol after his reintubation. If needed, we
would consider adding Versed at that time, however, will need
to be assessed if he needs further sedation.
12. Cardiovascular - The patient has had persistent sinus
tachycardia, had thyroid workup for hypothyroidism which was
negative. For the last several weeks the patient's blood
pressure has remained stable.
13. Prophylaxis - The patient was maintained on intravenous
heparin and b.i.d. Protonix.
14. Lines - The patient had a left internal jugular placed on
[**1-18**], Foley catheter and endotracheal tube.
Communication was with family.
15. The patient was a full code.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 4572**]
MEDQUIST36
D: [**2126-1-20**] 17:12
T: [**2126-1-20**] 19:05
JOB#: [**Job Number 26759**]
Name: [**Known lastname 4617**], [**Known firstname 4618**] Unit No: [**Numeric Identifier 4619**]
Admission Date: Discharge Date: [**2126-2-13**]
Date of Birth: [**2097-9-9**] Sex: M
Service:
ADDENDUM: This is an interval history from [**2126-1-21**] until
[**2126-2-12**].
1.) From a respiratory standpoint, the patient was able to be
slowly weaned from the ventilator. He had a tracheostomy
attempted at the bedside, which was unsuccessful. On [**1-22**], he was taken to the operating room and had a tracheostomy
placed by cardiothoracic surgery. He has slowly been weaned
from the ventilator and is tolerating a tracheostomy mask for
up to 42 hours at a time. Currently, he does well with
frequent reassurance, bronchodilator treatments and very
minimal amounts of suctioning. He has requested to be placed
on the ventilator at night and is placed on pressure support
ventilation with eight of pressure support, five of PEEP and
40% FI02. His last arterial blood gas, dated [**2-10**] on a
tracheostomy collar was 7.46/48/85. His chest x-ray remained
unchanged during the remainder of his hospital course with
bilateral opacities consistent with post adult respiratory
distress syndrome changes and a right sided pleural effusion
that was unchanged.
A Passey mirror valve was placed by speech and swallow and
the patient tolerates this for most of the day well. He has
a strong cough. He is able to handle his own secretions. He
requires prn bronchodilators and pulmonary toilette.
His last sputum culture was positive for Methicillin
resistant Staphylococcus aureus with greater than 25 PMN's.
He was started on Vancomycin times one week on [**2126-2-10**]. He had no new infiltrates on his chest x-ray but had
large amounts of copious sputum at the time that antibiotics
were started.
2.) Infectious disease. The patient continued to have
multiple studies performed to identify the source of his
spiking fevers. He was having fevers to 103 degrees F. for
several weeks. Sinus biopsy was performed by ENT on [**1-19**], which was negative for evidence of a fungal infection.
He had been on Ambazone empirically and this was discontinued
when the results of that biopsy became available. He had
serology sent for Histoplasma, Bartonella and chlamydia
pneumoniae with IGG positive, indicating evidence of a past
exposure but remaining serologies were negative. He had a
negative CMV antigenemia.
On [**1-21**], he underwent a bronchoscopy that was negative
for viral washings and cultures.
He underwent a lumbar puncture that showed evidence of
Xanthochromia. At that time, Acyclovir was started
empirically. HSV PCR was sent and was negative and Acyclovir
was discontinued. His Cerebrospinal fluid cultures were
negative.
The patient became afebrile after a central line change,
although it was unclear as to the exact etiology of the
defervescence. He was taken off all antibiotics on [**2-4**]. He remained afebrile with a trend in the white count
that was improving.
On [**2-8**], he had a sputum that was positive for
Methicillin resistant Staphylococcus aureus in the setting of
more copious sputum production, in addition to a central line
tip that was also positive for Methicillin resistant
Staphylococcus aureus. He was started on Vancomycin. The
central line tip was from [**2126-2-8**]. He was to complete a one
week course for those infections.
On [**2-8**], a urine culture was also positive for
Enterobacter, sensitive to Bactrim, Meropenem and Cefepime.
However, his Foley was changed and a repeat urinalysis and
culture on the following day was negative and a third repeat
on [**2-11**] remained no growth to date. He was not treated
with antibiotics for this urinary tract infection.
All other blood cultures remained no growth to date. He had
Clostridium difficile sent times two on [**2-2**] and
[**2-5**] which were negative. His pleural fluid from
[**1-24**] showed no growth.
On review of his records, the patient was treated with the
following antibiotics during this past month: Ambazone from
[**1-16**] to [**1-24**]; intravenous Flagyl from [**1-18**] to
[**1-30**]; Imipenem [**1-20**] to [**1-19**] and Nasalilid
[**1-18**] to [**2-4**]. These were all empiric treatments
as no cultures grew other than the sputum with Methicillin
resistant Staphylococcus aureus and the central line tip with
Methicillin resistant Staphylococcus aureus as well.
3.) Cardiovascular: The patient was started on Lisinopril 5
mg p.o. q. day, given his history of diabetes and
hypertension, as well as Lopressor 100 mg p.o. twice a day.
He has had a persistent sinus tachycardia but adequate blood
pressure control. His sinus tachycardia is felt secondary to
his low grade fevers and agitation at times as well as
anxiety.
His electrocardiogram remained unchanged.
4.) Gastrointestinal. A percutaneous endoscopic gastrostomy
tube was placed by thoracic surgery in the operating room
during his tracheostomy procedure on [**2126-2-11**]. It
was noted several days later on a subsequent abdominal CT
scan that the percutaneous endoscopic gastrostomy tube
traversed the left lobe of the liver. There were no
immediate complications to this and the patient was seen by
the general surgery service. It was decided that the
percutaneous endoscopic gastrostomy tube would remain in
place for four to six weeks, to allow a healing tract to form
through the liver and then be removed only by Dr. [**Last Name (STitle) **] in
surgery department. The patient will have an outpatient
appointment scheduled for this prior to discharge.
A gastrojejunostomy tube was placed on [**2-1**] by
interventional radiology for tube feedings, as it was felt
that the above mentioned gastrostomy tube was not safe for
use for feeding. It was, however, used for medications and
there were no complications. The patient was started on tube
feeds and did well. He had intermittent episodes of nausea
and vomiting. He had a KUB that was negative for
obstruction. His tube feeds were held temporarily. His
bowel regimen increased and he was treated with anti-emetic
medications and this resolved. Reglan was started. He had
no further fevers and his nausea and vomiting have resolved
at this time.
His liver function tests were within normal limits when last
evaluated. He has had no complaints of abdominal pain. He
remains on a Proton pump inhibitor for the history of coffee
ground emesis which has been stable and not recurred.
5.) Psychiatry. The patient suffered from continuous
agitation and anxiety. He was evaluated by the psychiatry
service and it was felt that he should be treated with Haldol
as needed, as well as Ativan, if it does not cause confusion.
When the patient was able to speak, he admitted to some
hallucinations and delirium. This has since resolved. The
patient was started on Zoloft 50 mg p.o. q. day during the
course of his hospitalization, given his evidence of
depressed mood. He has had no suicidal ideations. It was
felt that he may be suffering from a form of post traumatic
stress disorder. It is felt at this time that he may benefit
from further psychiatric evaluation after discharge. He will
remain on the SSRI.
He was on very large doses of sedation during the hospital
stay including narcotics. He had problems with withdraw when
his narcotics were tapered too quickly. After weaning 15%
per day over the past several weeks, he has been able to be
converted to a Fentanyl patch which is at 50 mcg
transdermally q. 72 hours to be continued to be tapered. His
next patch will be 25 mcg to be changed on [**2-13**]. He is
managed currently with prn Ativan, Ambien q. H.s. for sleep
and Haldol as needed.
6.) Hematology. The patient was anticoagulated on [**1-10**] for a left upper extremity deep vein thrombosis with
heparin. He had no evidence of further bleeding. His
platelets remained stable. Lovenox was started on [**2-11**]
at 80 mg subcutaneous twice a day and a repeat ultrasound of
his left upper extremity was performed on [**2-7**] for
persistent left upper extremity edema. The studies revealed
a persistent mural thrombus with normal flow and
compressibility. It was felt that the patient would benefit
from further anticoagulation to complete three months and
then a repeat left upper extremity should be performed at
that time.
7.) Neurology. He was noted to have diffuse weakness and
hyper reflexia as well as clonus. Neurology service was
consulted. During episodes of agitation, the patient was
also noted to have staring spells with eye deviation and
facial twitching.
An EEG was performed on [**1-29**] that showed no evidence of
seizures but mild slowing. This was in the setting of heavy
sedation. During the end of his hospital stay, his strength
has continued to improve daily. He has had no further
clonus. His hyper reflexia has improved.
A Magnetic resonance scan was recommended by the neurology
service but, at this time, given his improved symptoms, this
was deferred. He had a head CT recently that was normal.
8.) Renal. His creatinine remained stable with good urinary
output. He had problems with hyperphosphatemia which
resolved after discontinuation of Propofol. He had periods
of hypercalcemia that were of unclear etiology, felt
secondary perhaps to immobility. This has, however, resolved
spontaneously. He continued to have adequate urine output.
He failed a voiding trial times three. He has had continued
bladder training on a regular basis, which continues at this
time.
9.) Endocrine. Cortisol stimulation test was performed on
[**1-18**] with an inappropriate response, consistent with
mild or partial adrenal insufficiency. Hydrocortisone was
started at 50 mg intravenous q. six hours and was tapered
slowly over the next two weeks. All steroids were
discontinued at that time. A repeat Cortisol stimulation
test was performed on [**2-8**] which showed an appropriate
response and no further steroids were indicated.
The patient remained on an insulin drip for most of his
hospitalization and, at this time, requires daily insulin.
His daily insulin requirement is 50 to 60 units at his
current tube feeds which are at his goal of 85 cc an hour.
The [**Last Name (un) 4620**] Diabetes Service was consulted as he is followed
there as an outpatient. They recommended that we start
insulin at 25 units q. day which was started on [**2-11**].
He will be started on a Humilog sliding scale and insulin
drip discontinued.
Thyroid studies were sent during his hospitalization times
two which were both normal.
10.) Dermatology. The patient was noted to have macerations
and tinea pedis on his feet bilaterally. The podiatry
service saw the patient several times during the
hospitalization and recommended that no lotions or cream be
used between his toes, he have lamb's wool, dry gauze and
diluted Betadine or saline moistened gauze used on his feet.
If prolonged bed rest, multi-podice boots/splints should be
applied. His nails have been trimmed. He continues on
Miconazole powder for his tinea pedis and his skin is healing
well.
11.) ENT. The patient complained of hearing loss in his left
ear and later in his right ear. Initial audiology consult
felt this was consistent with inner ear fluid. At this time,
his hearing has resolved and a formal audiogram was to be
performed today and results are pending.
12.) Nutrition. The patient failed a video swallowing study
on [**2-1**] and had a repeat test on [**2-11**] on
which he did very well with minimal aspiration. It was
recommended at this time that he remain on aspiration
precautions and he can tolerate thin liquids, soft solids and
have his medications crushed and continue weaning his tube
feeds after discharge. He will continue to have his J tube
in place until it is no longer necessary to continue his
nutritional needs. At that time, he can be discontinued.
13.) Access. At this time, the patient has a right PICC line
that was placed on [**2-6**]. Tracheostomy was placed on
[**1-22**]. Percutaneous endoscopic gastrostomy tube was
placed on [**1-22**]. This is to be removed four to six
weeks after its insertion by the general surgery service, by
Dr. [**Last Name (STitle) **]. He has a J tube placed on [**2-1**] as well as
a Foley catheter at this time.
DISCHARGE MEDICATIONS:
Reglan 10 mg intravenous q. six hours.
Prevacid 30 mg per G tube twice a day.
Miconazole 2% powder to feet three times a day.
Fentanyl patch 50 mg transdermally q. 72 hours until [**2-13**], to be tapered to 25 mcg and again tapered every 72
hours.
Surgilene 15 mg q. day.
Lovenox 80 mg subcutaneous twice a day.
Lisinopril 5 mg per gastric tube q. day.
Vancomycin one gram intravenous q. 12 hours until [**2126-1-18**].
Lopressor 100 mg p.o. twice a day.
Largine insulin 25 units subcutaneous q. day.
Haldol 2.5 to 5 mg intravenous q. four hours prn agitation.
Lorazepam 2 to 4 mg intravenous q. four hours prn agitation.
Dulcolax 10 mg p.r. q h.s. prn.
Acetaminophen 650 mg q. four to six hours prn.
Albuterol inhalers q. four to six hours as needed.
Nystatin oral suspension 5 mls p.o. three times a day prn.
Ambien 10 mg p.o. q h.s. prn insomnia.
Humilog insulin sliding scale to be checked prior to meals,
fingerstick 100 to 150 four units subcutaneous; 151 to 200
five units subcutaneous; 201 to 250 six units subcutaneous;
251 to 300 eight units subcutaneous; 301 to 350 ten units;
351 to 400 12 units and greater than 400, call medical
doctor. This will be required to be adjusted as his p.o.
intake improves and his tube feeds are weaned.
FOLLOW-UP: The patient will need a follow-up left upper
extremity ultrasound in two months after discharge and
continue on anticoagulation until his clot has resolved.
Follow-up appointment to be scheduled with Dr. [**Last Name (STitle) **] for
removal of percutaneous endoscopic gastrostomy tube. His
percutaneous endoscopic gastrostomy tube is not to be
removed, under any circumstances, except by general surgery
at [**Hospital1 536**] given its location
through his liver and risk of bleeding with its removal.
The patient will have a follow-up with [**Hospital 4620**] Clinic
scheduled and will need follow-up with his primary care
physician.
DISCHARGE CONDITION: Stable.
He will be transferred to rehabilitation to continue vent
weaning, physical therapy, physical and occupational therapy.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Last Name (NamePattern1) 4621**]
MEDQUIST36
D: [**2126-2-11**] 11:20
T: [**2126-2-12**] 04:35
JOB#: [**Job Number 4622**]
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31,989
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8439
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Discharge summary
|
report
|
Admission Date: [**2158-12-18**] Discharge Date: [**2159-1-9**]
Date of Birth: [**2091-7-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Intraortic balloon pump
Pacemaker placement and ICD placement
Right IJ line
History of Present Illness:
67M h/o HTN, seizure disorder, inferior NSTEMI ([**2150**]) with
unsucessful PTCA of RCA (TIMI I flow), thoracic AAA repair
complicated by cardiac arrest/femoral artery repair ([**2150**]), who
presents to [**Location (un) **] @ 1407 [**2158-12-18**] after increasing chest pain /
shortness of breath x several days. He reports no chest pain
until about 9 days ago when he had one of the worst seizures he
has had in a long time. After that he reports that it felt as
though he had a pressure on his chest. He continued to do push
up and other exercising, but could not do as many given the
pain. He took garlic which helped relieve his pain until today
when it became unbearable. His pain was [**5-15**] on arrival to the
OSH. VS=98.0 78 24 103/78 88%RA. Trop 5.59 at OSH, noted to
have 1.5mm anterior STE in v2-v4, CXR concerning for widened
medisteinum. Rythym was initially regular, then noted to be in
"heart block" on nursing flow with BP 80/58 at 1700 after
receiving nitro, ativan 1mg, asa, lopressor 25mg po @ 1600,
lasix 20mg x 1. Per report given 600cc IVF bolus without
benefit. Pt transfered to [**Hospital1 18**] for cath.
.
Upon arrival to [**Hospital1 18**], pt found to have proximal LAD occlusion,
with incomplete revascularization after POBA, and was started on
IABP [**1-6**] hypotension. A foley was placed tramatically and he
developed hematuria.
.
.
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, 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
currently, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- CAD - s/p MI ([**2151-1-13**]) - discrete 100% lesion of the distal
RCA and normal left main. LAD and left circumflex had mild
irregularities. RCA was occluded distally, and a large
filling defect consistent with thrombus was present. Mild
left to right collaterals observed. Intervention with
percutaneous transluminal coronary angioplasty and angio-jet,
thrombectomy of the distal RCA was unsuccessful. large aortic
aneursym noted.
- resection of aortic arch aneurysm ([**2151-2-1**]) - c/b right
common
femoral artery repair.
- HTN
- h/o seizures x 40y - tonic-clonic, evaluated by neurology
[**4-10**], felt [**1-6**] ?traumatic brain injury, failed Dilantin and
phenobarbital in past, on lamictal prophylaxis.
- h/o right occipatal bleed - observed x24hr by neurosurg [**1-10**]
- OSA
- s/p transurethral prostatectomy
Social History:
Social history is significant for the absence of current or past
tobacco use. There is no history of alcohol abuse.
Family History:
There is a family history of premature coronary artery disease
in his parents.
Physical Exam:
VS: T 98, BP 100/82, HR 94, RR 21, O2 93% on L NC%; On IABP 1:1
with PAP 62/35 and mean PAP 48.
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. No JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Difficult to hear over IABP
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: +BS, Obese, soft, NTND, no tenderness.
Ext: No c/c/e. Sheath in place from cath
Pulses:
Right: Carotid 2+ without bruit; dopplerable DP
Left: Carotid 2+ without bruit; dopplerable DP
Pertinent Results:
EKG demonstrated sinus rhythm, nl axis, nl intervals, STE in
V1-5. STD in III and aVF.
[**2158-12-19**] 01:00AM BLOOD WBC-9.6 RBC-3.81* Hgb-12.3* Hct-36.4*
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.5 Plt Ct-310#
[**2158-12-19**] 01:00AM BLOOD PT-16.7* PTT-35.4* INR(PT)-1.5*
[**2158-12-19**] 01:00AM BLOOD Glucose-112* UreaN-26* Creat-0.9 Na-137
K-4.4 Cl-108 HCO3-20* AnGap-13
[**2158-12-19**] 01:00AM BLOOD ALT-46* AST-36 CK(CPK)-268* AlkPhos-46
TotBili-0.4
[**2158-12-19**] 05:00AM BLOOD ALT-46* AST-39 CK(CPK)-269* AlkPhos-47
TotBili-0.5
[**2158-12-20**] 04:25AM BLOOD CK(CPK)-176*
[**2158-12-19**] 01:00AM BLOOD CK-MB-6 cTropnT-2.81*
[**2158-12-19**] 05:00AM BLOOD CK-MB-6 cTropnT-2.36*
[**2158-12-20**] 04:25AM BLOOD CK-MB-4 cTropnT-2.06*
[**2158-12-19**] 05:00AM BLOOD %HbA1c-5.8
[**2158-12-19**] 05:00AM BLOOD Triglyc-74 HDL-23 CHOL/HD-6.4 LDLcalc-110
[**2158-12-18**] 07:52PM BLOOD Glucose-96 Lactate-0.9 K-4.5
.
Cath [**12-18**]:
COMMENTS: 1. Selective coronary angiography in this right
dominant
patient revealed two vessel CAD. The LMCA had a distal taper.
The LAD
had moderate proximal calcification and a ostial occlusion with
faint
filling by collaterals. The large LCX was without critical
lesions.
The RCA was occluded mid-segment with distal vessel filling via
left to
right collaterals. The RCA was felt to be chronically occluded.
2. Resting hemodynamics revealed elevation of PCWP with mean
wedge of
31mmHG. The cardiac index was low at 1.9. We did not obtain RA
or RV
pressures but the PA pressure was elevated at 48/28. The
hemodynamics
were consistent with cardiogenic shock.
3. Placement of IABP via RFA for cardiogenic shock.
4. Balloon angioplasty of origin and proximal LAD with 3mm
balloon
resulting in TIMI 2 flow.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Anterior MI of greater than 24 hour duration
3. Cardiogenic shock with placement of IABP
4. Successful POBA of ostial LAD.
.
CXR [**12-19**]:
IMPRESSION: Tip of the aortic balloon pump 2.2 cm from the
aortic arch. Although it appears somewhat lateral, this is
likely due to the patient positioning. Recommend close attention
to patient positioning on any subsequent followup exams.
.
TTE [**12-19**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with akinesis of the anterior wall, septum and apex,
as well as basal and mid-inferolateral wall (c/w multivessel
coronary disease). There is moderate hypokinesis of the
remaining segments (LVEF = 15-20%). There is a large left
ventricular thrombus, layering along the distal anterior and
lateral walls and apex. The clot is mural and not mobile. Right
ventricular chamber size is normal. with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is mild mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe regional and
global left ventricular systolic dysfunction, c/w multivessel
CAD. Large left ventricular mural thrombus.
Compared with the report of prior study (images not available
for review) of [**2151-1-14**], anterior/anteroseptal wall motion
abnormalities are new, and left ventircular function has
deteriorated. Left ventricular thrombus is new.
.
.
Brief Hospital Course:
The patient is a 67-year-old man with a past medical history
significant for hypertension, seizure disorder, inferior NSTEMI
in [**2150**] with unsuccessful PTCA of the RCA (TIMI I flow), who
presents with a late LAD STEMI s/p cardiac catheterization with
unsuccessful PTCA complicated by cardiogenic shock, now
resolved.
.
# STEMI: On cardiac catheterization, the patient was found to
have a large anterior MI, where the LAD had moderate proximal
calcification and an ostial occlusion with faint filling by
collaterals. PTCA was unsuccessful and complicated by
cardiogenic shock for which an IABP was placed. CT surgery was
consulted and felt the patient is not a candidate for CABG.
Patient was vasopressor dependent post-MI and was gradually
weaned off IABP, Milrinone and Levophed. Because of his large
infarction, he will require cardiac rehabilitation at the time
of discharge. He will also require close follow up of digoxin
levels within 1 week from discharge.
.
# Pump: After MI, a TTE was obtained and revealed EF of 15-20%
with a dilated left ventricle with severe regional and global
left ventricular systolic dysfunction, and a large left
ventricular mural thrombus. He is anticoagulated, currently on
coumadin daily, and his INR will need to be monitored by his
outpatient cardiologist. He is scheduled for a low level stress
test at [**Hospital3 7569**] on [**2159-1-15**] at 10:15 AM in prepartion
for cardiac rehabilitation.
.
# Bradycardia / Asystole: Post MI, the patient experienced 2
episodes of asystole associated with increased vagal tone.
Patient underwent successful placement of permanent pacemarker
with ICD function secondary to his severely depressed ejection
fraction. In the post-implantation period, the patient developed
a hematoma at the subcutaneous site of pacemaker implantation,
which was monitored closely and resolved spontaneously. He was
closely monitored on telemetry and did not experience any
further events; he is not pacemaker dependent but is
episodically paced. He will follow-up in device clinic.
.
# Anxiety: The patient has baseline anxiety and was well
controlled with anxiolytics as needed.
.
# Hypertension: The patient is known to have chronic
hypertension as an outpatient. Post-MI, however, the patient
experienced profound hypotension requiring vasopressor and IABP
support as above. Although normotensive at the time of
discharge, the patient did not tolerate ACE-inhibitor therapy
because of his hypotension. It is recommended that he re-start
and ACE-inhibitor as an outpatient, as his blood pressure
tolerates.
.
# Fevers: During the immediate post-MI period, the patient
experienced fevers and was empirically treated with broad
spectrum antibiotics without any identified infectious source.
He did not have any further febrile episodes and likely
experienced the fevers because of his MI.
.
# Hematuria: The patient experienced painless hematuria after a
difficult Foley catheter placement and while on anticoagulation.
The hematuria resolved spontaneusly and the patient's hematocrit
remained stable during the hospitalization. If this recurs, the
patient should have outpatient evaluation.
.
# Seizure disorder: Neurology was consulted while the patient
was hospitalized, and the patient was started on Keppra and
Lamictal with good response. He did not experience any seizure
episodes while hospitalized. He will require close follow-up of
his Keppra levels within 1 week of discharge, and further
management will be deferred to the patient's outpatient
neurologist and/or PCP.
.
# FEN: Patient tolerated a cardiac diet without difficulty.
.
# Prophylaxis: lovenox, PPI
.
# Code: Patient remained FULL CODE during hospitalization.
.
# Communication: wife - [**First Name8 (NamePattern2) **] [**Known lastname 29741**] - [**Telephone/Fax (1) 29742**].
.
.
Medications on Admission:
CURRENT MEDICATIONS:
lamictal 150mg po bid
.
.
MEDS ON TRANSFER:
ativan 1mg po
asa 81 mg po x 1
sl ntg 0.4 x 1
lopressor 25mg @ 4PM
lasix 20mg iv @ 4PM
lovenox 80mg SC @ 420PM
plavix 600mg x 1
morphine 2mg iv x1
aggrastat bolus + gtt started at 415PM
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) for 7 days: Take as directed.
Disp:*7 Tablet(s)* Refills:*0*
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily) for 7
days.
Disp:*7 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM and
QPM for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO QAM and QPM for
7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please check PT, PTT, INR. Please fax results to Dr.[**Name (NI) 27809**]
office fax [**Telephone/Fax (3) 29743**]. Also fax copy to Dr. [**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) 29744**]
office [**Telephone/Fax (1) 29745**]
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual Take up to 3 times 5 monutes apart as needed for
chest pain as needed for chest pain.
Disp:*30 tablets* Refills:*0*
11. Outpatient Lab Work
Please check Chem 7 on [**2159-1-11**]. Please fax results to Dr. [**Last Name (STitle) 11493**]
fax [**Telephone/Fax (3) 29743**]. Also send fax copy to Dr. [**Telephone/Fax (1) 29745**]
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Primary
1. STEMI s/p PCI
2. Cardiogenic shock s/p intraaortic balloon pump
3. LV thrombus
4. Bradycardia
5. CHF
6. Hematuria
7. UTI
Secondary
1. Anemia
2. Epilepsy
3. Hypertension
4. OSA
Discharge Condition:
HD stable, afebrile
Discharge Instructions:
You were admitted to the hospital for a heart attack. You also
had a blood clot in your heart. During your hospitalization a
pacemaker and defibrillator was placed.
Please take all of your medications as directed. You are now
taking coumadin. You need to have you INR checked and your dose
will be adjusted accordingly.
Please keep all of your follow-up appointments.
If you develop chest pain, shortness of breath, dizziness,
palpitations, fevers, pain at your pacemaker site or any other
concerning symptoms, you should call your doctor or come to the
emergency room.
You should check your weight daily, if you gain more than 3 lbs
you should call your doctor. Please maintain a low salt diet.
Followup Instructions:
You have an appointment with your cardiologist Dr. [**Last Name (STitle) 11493**]
[**Telephone/Fax (1) 11767**] on Wednesday, [**1-24**] at 2:20 pm. At that time
you should discuss starting on an ACE inhibitor, which was
started while you were in the hospital because your blood
pressure was too low.
You have a follow up appointment with your primary doctor, Dr.
[**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) **] [**2159-1-25**] at 2 pm. At that time you should discuss
having your urine checked as you had some blood in your urine
during your hospitalization.
You have a follow up appointment for your pacemaker in the
device clinic [**Telephone/Fax (1) 59**] on Date/Time:[**2159-1-16**] 10:30
Stress test (low level): [**Hospital 29746**] clinic ([**Telephone/Fax (1) 29747**]
[**2159-1-15**] at 10:00 am. This is necessary to arrange for the
cardiac rehabilitation you require.
|
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icd9cm
|
[
[
[]
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[
"97.44",
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icd9pcs
|
[
[
[]
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13686, 13741
|
7793, 11619
|
320, 421
|
13972, 13994
|
4158, 5910
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14747, 15658
|
3368, 3448
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11920, 13663
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13762, 13951
|
11645, 11645
|
5927, 7770
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14018, 14724
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3463, 4139
|
275, 282
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11666, 11692
|
449, 2364
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2386, 3219
|
3235, 3352
|
11710, 11897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,905
| 118,074
|
42719
|
Discharge summary
|
report
|
Admission Date: [**2136-1-31**] Discharge Date: [**2136-2-7**]
Date of Birth: [**2056-7-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Replacement of ascending and hemiarch aorta with a 30-mm
Gelweave Dacron graft. [**2136-1-31**]
History of Present Illness:
Mrs. [**Known lastname 5749**] reports several days of abdominal bloating, increased
gas and developed abdominal pain, back pain and vomiting. She
went to an outside hospital thinking she had a flair of her
Crohn's disease. A CTA was done which showed a Type A aortic
disection. She was transferred to [**Hospital1 18**] for surgical repair of
her dissection.
Past Medical History:
hypertension
hypothyroid
Crohn's disease
Bell's palsey-R facial droop
s/p colostomy and reversal for Crohn's
s/p open cholecystectomy
s/p C-Section
s/p hysterectomy
Social History:
She reports smoking one pack per day.
Family History:
unable to obtain due to emergent nature of dissection
Physical Exam:
Pulse:122 Resp:18 O2 sat:96%
B/P Right:109/68 on esmolol and nipride Left:
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade _unable to assess
Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Edema [] _none____
Varicosities: None [x]
Neuro: Grossly intact-except R facial droop []
Pulses:
Femoral Right:2+ Left:2+
DP Right:Tr Left:Tr
PT [**Name (NI) 167**]:Tr Left:Tr
Radial Right: 2+ Left:2+
Pertinent Results:
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 92325**] (Complete) Done
[**2136-1-31**] at 5:45:19 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2056-7-16**]
Age (years): 79 F Hgt (in): 62
BP (mm Hg): / Wgt (lb): 143
HR (bpm): BSA (m2): 1.66 m2
Indication: Emergent aortic dissection
ICD-9 Codes: 441.00, 441.2
Test Information
Date/Time: [**2136-1-31**] at 05:45 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) 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 #: 2012AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: *4.2 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Mildly dilated aortic arch. Mildly dilated descending aorta.
Complex (>4mm) atheroma in the descending horacic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Small to moderate pericardial effusion. Stranding
is visualized within the pericardial space c/w organization. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: The patient was under general anesthesia
throughout the procedure. No TEE related complications. The
patient appears to be in sinus rhythm. Results were personally
post-bypass data
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. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. An
echodense mass 0.5 cm x 0.5 cm is seen outside the left atrial
appendage floating the pericardial effusion (suggestive of
strands?). No mass seenn in the left atrial appendage. This was
confirmed before sync cardioversion for the afib after
induction.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 40 %). Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %). LV function seem to be [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
after initial stabilization of hemjodynamics.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are complex (>4mm) atheroma in the descending thoracic aorta.
An echodense mobile density is seen in the ascending aorta from
the ST junction at the Right coronary cusp going across and
extending into the distal ascending aorta with hematoma
suggestive of aortic dissection. In the visualized portion of
aortic arch and descending thoracic aorta, this dissection is
not seen.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is a small to moderate sized pericardial effusion.
Stranding is visualized within the pericardial space c/w
organization. There are no echocardiographic signs of tamponade.
POST-BYPASS:
Normal RV systolic function.
LVEF 45% (Mild global LV systolic dysfunction).
Intact thoracic aorta with the intact graft visualized.
Minimal MR [**First Name (Titles) **] [**Last Name (Titles) **].
[**2136-2-6**] 04:35AM BLOOD WBC-9.3 RBC-4.30 Hgb-10.7* Hct-32.9*
MCV-77* MCH-24.8* MCHC-32.4 RDW-18.0* Plt Ct-301
[**2136-2-6**] 04:35AM BLOOD Na-137 K-4.6 Cl-99
[**2136-2-5**] 04:32AM BLOOD Glucose-86 UreaN-24* Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-32 AnGap-9
[**2136-1-31**] 02:15AM BLOOD WBC-12.4* RBC-4.51 Hgb-10.9* Hct-32.6*
MCV-72* MCH-24.1* MCHC-33.3 RDW-14.9 Plt Ct-335
[**2136-1-31**] 02:15AM BLOOD Glucose-133* UreaN-27* Creat-1.1 Na-130*
K-4.5 Cl-97 HCO3-22 AnGap-16
[**2136-1-31**] 02:15AM BLOOD ALT-11 AST-12 CK(CPK)-85 AlkPhos-113*
Amylase-29 TotBili-0.3
Brief Hospital Course:
On [**2136-1-31**] Ms. [**Known lastname 5749**] was brought emergently to the Operating Room
and underwent repair of her Type A aortic dissection. This
procedure was performed by Dr. [**Last Name (STitle) **]. Please see the operative
note for details. She tolerated the procedure well, weaned from
bypass on Neo Synephrine and Propofol and was transferred in
critical but stable condition to the surgical intensive care
unit. She was given Amiodarone for post-operative atrial
fibrillation, which quickly resolved.
By post-operative day one she was extubated and tolerated
beta-blockade. Her chest tubes were removed. On the following
day she was transferred to the surgical step down floor.
Amiodarone was discontinued secondary to her history of thyroid
dysfunction and she remained in a sinus rhythm. Her epicardial
wires were removed on POD 3. Mesalamine was resumed and no ASA.
Physical Therapy worked with her and she was diuresed towards
her preoperative weight.
She was transferred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 6981**] on [**2-6**] for
further recovery prior to returning home.
Medications on Admission:
colace 100mg daily
levothyroxine 50mcg daily
lisinopril 10mg daily
mesalamine 800mg three times a day
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 6
days: until at pre-op weight.
11. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 7 days: please
check K+ .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 31356**] Healthcare Center - [**Location (un) 730**]
Discharge Diagnosis:
Type A Aortic Dissection
emergency repair of Type A dissection
hypertension
Crohn's disease
hypothyroidism
Bell's Palsy
s/p colon resection for Crohn's
s/p cholecystectomy
s/p hysterectomy
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
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]on [**2136-3-8**] at 1:00pm in the
[**Hospital **] Medical office building [**Doctor First Name **]. [**Hospital Unit Name **]
Cardiology- please have your primary care physician recommend
one
Please call to schedule appointments with:
Primary Care Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24642**] ([**Telephone/Fax (1) 9674**]) in [**2-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2136-2-7**]
|
[
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icd9cm
|
[
[
[]
]
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icd9pcs
|
[
[
[]
]
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|
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|
321, 419
|
10068, 10247
|
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|
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1072, 1127
|
8578, 9721
|
9856, 10047
|
8451, 8555
|
10271, 11148
|
1142, 1754
|
267, 283
|
447, 812
|
834, 1001
|
1017, 1056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,442
| 121,242
|
52220
|
Discharge summary
|
report
|
Admission Date: [**2133-12-29**] Discharge Date: [**2134-1-6**]
Date of Birth: [**2052-1-4**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
Central line placement and removal.
PICC line placement [**2134-1-4**]
Echocardiogram
History of Present Illness:
Mrs. [**Known lastname **] is an 81 yo F with PMH DM2 on metformin, asthma,
recent admission [**Date range (1) 108031**] for CAP/asthma exacerbation and new
onset afib sent home on coumadin and diltiazem who presented to
the emergency department complaining of dizziness. Her HR was
noted to be 50 upon presentation. She was diaphoretic and
complaining of n/v. She reported that she took one extra ER
diltiazem today out of confusion. She was just started on this
medication. She denies f/c, abd pain, diarrhea/constipation,
chest pain, headache, confusion. She reports worse SOB,
orthopnea. She denies any other changes other than coumadin,
diltiazem.
.
In the ED, VS were 106/42, HR 50, AF. She received 4mg calcium
gluconate, 2mg atropine as well as zofran, reglan, and compazine
for n/v. She was put on an insulin drip and peripheral dopa for
chronotropy. Her lactate was noted to be over 10. She was given
vanc and cefepime. Her gas was 7.24/34/90 and she had new renal
failure at 2.1 (bl 1.1). Renal saw her in the ED as did tox.
Before transfer to the MICU, her HR had improved to 85, BP
114/32, and she was satting 100% on 3L. She received 3L NS.
.
Of note she was recently admitted from [**12-19**] -[**12-27**] for CAP and
asthma exacerbation. She failed outpatient tx with azithromycin
and was changed to levaquin, for which she finished a 6 day
course on [**2133-12-24**].
.
On the floor her only complaint is SOB. Her HR is in the 80s.
Her SBP is in the 110s, though her MAP is < 60.
Past Medical History:
1. Asthma
2. T2DM
3. HTN
4. Hyperlipidemia
5. Depression
6. Osteoarthritis
.
PSHx:
1. Hip replacement
2. Cataract surgery
3. Appendectomy
4. Hernia repair
Social History:
Lives alone but gets help for meals. Husband has been in [**Hospital1 1501**] for
2 yrs and she frequently visits and feels caregiver [**Last Name (Titles) 8373**]. She
has three sons. She denies smoking (remote history), alcohol or
drug use
Family History:
Father died at age 57 of CHF
MOther died at age 49 of cerebral bleed
Sister is eight yrs younger and has no known med problems
Physical Exam:
vitals: 93F HR 86 RR31 92% on 6L
gen: moderately tachypneic, o/w comfortable, resting,
cooperative
heent: ncat, mmd, surgical pupils
neck: no elevated JVP
pulm: slight expiratory wheeze, o/w ctab
cv: hrrr, no m/r/g
abd: s/nt/nd/nabs, no hsm
extr: 2+ pulses, warm, no c/c/e
neuro: aox4, cn 2-12 intact grossly
Pertinent Results:
labs on admission:
WBC 16.5 N 83.6, L 14.4, M 1.7 no bands
HCT 27.6
Plt 592
INR 3.1
PT 30.4
PTT 29.2
ALT 61
AST 82
AP 72
Lip 43
Tbili 0.5
Na 134
K 5.6
Cl 94
bicarb 13
BUN 48
Cr 2.1
Glu 251
Trop 0.02
CK 33
MB Not done
gas: 7.24/34/90
15
lactate 10.3 --> 7.3
UA neg for infection
.
Blood Culture, Routine (Final [**2134-1-5**]):
THIS IS A CORRECTED REPORT [**2134-1-2**] AT 3:25PM.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2134-1-2**] AT 3:25PM.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). FINAL
SENSITIVITIES.
ERYTHROMYCIN > 4 MCG/ML.
Sensitivity testing performed by Sensititre.
PREVIOUSLY REPORTED AS.
SENSITIVE TO ERYTHROMYCIN Penicillin AND VANCOMYCIN
([**2134-1-2**] AT
1:29PM).
SENT TO [**Hospital1 4534**] LABS FOR SPECIATION PER DR. [**First Name (STitle) **]
[**2134-1-4**]..
Refer to sendout system for results.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS)
|
ERYTHROMYCIN---------- R
PENICILLIN G---------- 8 R
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2133-12-31**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO PAT KINS ON [**12-31**] AT 0824.
.
Cdifficile toxin - NEGATIVE X 3 separate specimens.
.
studies:
CXR [**2133-12-29**]:
FINDINGS: There has been minimal improved aeration of the right
lung base with persistent opacity noted. There is a more linear
opacity noted in the lateral aspects of the right mid lung near
an area of remote chronic healed rib fractures which may
represent scarring. The previously noted mild volume overload
has somewhat subsided to near resolution. There is mild
tortuosity of the thoracic aorta. The cardiac silhouette is
within normal limits for size accounting for patient and
technical factors. The right costophrenic angle is again
blunted, possibly due to a small pleural effusion. No left
effusion is seen. There is no underlying pneumothorax.
IMPRESSION: Relative to the most recent prior exam, there is an
improved aeration of the right lung base with persistent
opacity, possibly reflecting a resolving pneumonia with a small
parapneumonic effusion.
.
Renal u/s [**2133-12-31**]: IMPRESSION: No evidence of hydronephrosis in
either the right or left kidney
.
ECG: Sinus rhythm. Compared to the previous tracing of [**2133-12-30**]
there is no significant change.
.
ECHO [**2134-1-5**]:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-11**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2132-4-11**],
mitral regurgitation appears slightly more prominent
Brief Hospital Course:
Mrs. [**Known lastname **] is an 81 yo F with PMH of asthma, DM2, HTN, recent
admission for PNA treated with levaquin x6 days, presenting with
bradycardia, hypotension, lactic acidosis and acute renal
failure.
.
1) Bradycardia: Based on her report of taking extra long acting
diltiazem, her bradycardia and hypotension likely [**3-14**] diltiazem
overdose. In addition, she was in acute renal failure on
admission which also likely contributed to CCB toxicity. She
was evaluated by toxicology consult in the ED who agreed with
this assessment. She was started on insuling gtt for CCB
toxicity and started on dopamine gtt for hemodynamic support.
She was admitted to the ICU and her heart rate and blood
pressure improved by the morning after admission and her insulin
and dopamine were able to be weaned off in less than 24 hours.
All nodal agents were held for the first 24 hours after which
she was titrated up on metoprolol (to 100mg PO BID) and
diltiazem 240 mg SR (her home dose) for HR control.
2)Lactic acidosis: She had a lactic acidosis on admission which
resolved with IVF most likely [**3-14**] to metformin in the setting of
acute on chronic renal failure. Her metformin was discontinued
and will not be restarted on discharge given the lactic
acidosis.
3)Hypotension/BP control: She was initially on dopamine gtt due
to hypotension thought most likely due to both Diltiazem
toxicity and sepsis given that she also had an elevated WBC
count and was hypothermic on admission. She was covered broadly
on admission to the ICU to cover for partially treated
nosocomial pneumonia with vancomycin and zosyn, beginning on
[**2133-12-29**]. Hypotension resolved the morning after admission once
her HR recoverd and she was weaned off the dopamine gtt with no
further hypotensive episodes. She later became hypertensive and
her medications were re-started. Final regimen included
Diltiazem SR 240mg Daily, Metoprolol 100mg PO BID, and
Nifedipine CR 30mg Daily. Of note, her home regimen was
Diltiazem SR 240mg Daily, Atenolol 100mg and Nifedipine 60mg
daily. She can be changed over to her home regimen at rehab.
Infections will be discussed below.
4) Infectious disease: As noted in HPI, she was undergoing
treatment for Community acquired pneumonia (R lung base) as an
outpatient. In the hospital, she had significant leukocytosis
which increased from 16 to 32 on the second day of admission as
well as [**5-15**] blood cultures from admission positive for
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). CXR showed persistent
RLL opacity, which may represent unresolved or recurrent
pneumonia. As noted above, due to her hypotension and concern
for sepsis, she was started on broad spectrum antibiotics
(Vanco/Zosyn) from Day 1. Later Flagyl was added for concern
for Cdifficile, but discontinued when 3 stools returned negative
for Cdiff toxin. She improved from a respiratory standpoint
(weaned off oxygen, cough improved), and remained afebrile. ID
was consulted for assistance in management of the Diphtheroids
in the blood and ? Diphtheria pneumonia. She was placed on
droplet precautions for ? Diptheria pneumonia, and the patient
transitioned to oral Penicillin only on hospital day #6.
However, later same day (hospital day #6), the sensitivities on
the Corynebacterium returned indicating the bacteria was
RESISTENT to penicillin and sensitive only to Vancomycin.
Therefore vancomycin was restarted at a renally adjusted dose.
A trough was checked on [**2134-1-6**] and was low at 12.7. Her
Vancomycin was increased to 750mg IV q12H. She will need to
complete a total of 14 days, from [**Date range (2) 108032**]. She should
have a trough drawn after her third dose, on [**2134-1-8**] before the
morning dose. A nasopharyngeal swab for diptheria culture and
blood sent for diptheria antibody testing, but these are still
pending at time of discharge. A PICC line was placed on [**1-4**]
for administration of antibiotics. A trans-thoracic echo was
done on [**2134-1-5**] and was negative for vegetation. Surveillance
blood cultures could be checked in the outpatient setting after
she is off antibiotics.
5) Resp distress: This was noted in the ICU, and resolved by the
time she was transferred to the medical floor. It was felt
likely due to a combination of known COPD, pneumonia, as well as
volume overload after she received large amounts of IVFs for
resuscitation. She was given IV lasix, standing nebulizers, and
antibiotics as above. Oxygen was weaned off. Her requirement
for nebulizers resolved. Antibiotics were continued as above to
complete a 14 day course.
6) Renal failure: This was felt likely [**3-14**] to ischemic ATN while
bradycardic and hypotensive. Resolved with fluid resuscitation
and treatment of infection.
7) Paroxysmal afib: This was diagnosed at her prior admission.
Echo was done [**1-5**] and unremarkable (see results). She
initially had her rate-controlling agents held as she was
bradycardic. Later these were restarted, and titrated up to
current doses (Home dose Diltiazem SR 240mg, along with
Metoprolol 100mg [**Hospital1 **] -[she takes Atenolol 100mg at home]). She
was continued on coumadin and will be dishcarged on 5mg daily.
An INR should be repeated in [**3-15**] days.
8) DM: She was an insulin drip and d10 in the ICU for treatment
of CCB toxicity per toxicology service. Metformin was held
throughout hospital stay b/c of lactic acidosis. She was placed
on Glipizide 5mg [**Hospital1 **] after being called out to floor, which was
uptitrated to 10mg [**Hospital1 **] due to elevated blood sugars. She was
also covered with an insulin sliding scale. Final diabetic
regimen deferred to outpatient setting.
9) Anemia - Her Hct decreaed in the ICU, as low as 23. It then
stabilized and improved to 25 and remained stable x several
days. Iron studies revealed iron 25, ferritin 206, calTIBC 302
TRF 232, Vit-B12 1088, Folate 15.1, most consistent with anemia
of acute inflammation. She did have guaiac positive brown
stools but no sign of acute GI bleeding. She will need an
outpatient colonoscopy.
10) FEN: cardiac/diabetic reg diet, replete lytes prn
11) PPx: She was on stress ulcer prophylaxis while in ICU
(ranitidine), but this was discontinued on the medical floor.
She was maintained on SC heparin and a bowel regimen.
12) CODE: FULL
Medications on Admission:
Meds (per D/C summary [**12-27**]):
1. Fluticasone-Salmeterol 250-50 [**Hospital1 **]
2. Citalopram 10 mg DAILY
3. Nifedipine 60 mg Sustained Release DAILY
4. Atenolol 100 mg DAILY
5. Ferrous Sulfate 325 mg qday for 2 months.
6. Glipizide 5 mg [**Hospital1 **]
7. Warfarin 5 mg
8. Metformin 1000mg [**Hospital1 **]
9. Aspirin 81 mg
10. Atorvastatin 20 mg
11. Calcium Carbonate 1000 mg [**Hospital1 **]
12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) prn
13. Diltiazem HCl 240 mg Sustained Release qday
14. Vitamin D-3 400 unit [**Hospital1 **] .
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
13. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Check INR in [**3-15**] days.
15. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
18. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
19. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Vancomycin 750 mg IV Q 12H Duration: 7 Hours
Dose 1: [**2133-12-29**], end on [**2134-1-13**] to complete a 14 day course
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab of [**Location (un) 1121**]
Discharge Diagnosis:
1. Acute renal failure
2. Septic shock
3. Pneumonia
4. Bradycardia, likely [**3-14**] medication effect
5. Anemia, likely [**3-14**] acute inflammation
6. Acute metabolic acidosis, likely due to lactic acidosis.
Discharge Condition:
Afebrile, on room air. Heart rate and blood pressure
controlled.
Discharge Instructions:
You were admitted with low blood pressure, slow heart rate, and
infection (pneumonia and bacteria in your blood). You were in
the intensive care unit and also had renal failure, likely due
to your blood pressure and poor perfusion of the kidney.
Fortunately, the blood pressure, heart rate, and kidney failure
have all resolved. Your pneumonia was treated and you will
continue antibiotics for the blood infection up to [**2134-1-13**].
Your medications were changed as follows:
1. Stop atenolol. Take Metoprolol 100mg twice a day instead.
Your doctor at rehab or your primary care doctor may elect to
switch you back to atenolol at a later date
2. Your dose of nifedipine is less, currently at 30mg daily (you
were taking 60 mg daily at home). Again, this may be changed
back to your home dose by your rehab physician
3. Continue your warfarin at 5mg daily. Please have your INR
checked in 3 days
4. You will be on Vancomycin until [**2134-1-13**], 750mg IV q12 hours.
You will need to have a trough checked at rehab after 3 doses.
5. You should STOP metformin due to a complication called Lactic
Acidosis. Do not take this again until you speak to your
outpatient doctor
6. Your glipizide dose was increased to 10mg [**Hospital1 **]. You also are
given insulin coverage for now, but may not need this as an
outpatient.
.
You will need an outpatient colonoscopy b/c you had low blood
count without evidence of overt bleeding. Your stool had
microscopic amount of blood in it.
.
You had an echocardiogram to rule out infection on your heart
valve, and this was negative. Your primary care doctor may
order surveillance blood cultures after you complete your
antibiotics.
.
Call your doctor if you have fever, chills, feel dizzy, have
chest pain, or any other symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2134-1-26**] 10:15
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2134-2-1**] 11:15
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2135-7-22**] 11:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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[
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[
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12,702
| 134,372
|
20953
|
Discharge summary
|
report
|
Admission Date: [**2113-6-9**] Discharge Date: [**2113-6-15**]
Service: NSU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old male with
a history of AAA aneurysm and CVA in [**2107**] with residual right
facial droop presents to [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **]
from transferred from [**Hospital3 **] status post a fall and
head trauma earlier today. Patient was amnesic to the event.
Wife and son reported patient stepping out of an elevator,
when suddenly he fell straight over backwards. No loss of
consciousness, slight confusion immediately afterwards. The
patient's only complaint was a slight headache. He was taken
to [**Hospital6 4620**] later that afternoon. No
neurologic deficits were noted at that time.
A head CT revealed a 1.3 cm x 4 cm contusion within the right
frontal lobe and a 1.0 x 1.0 cm contusion in the right
temporal lobe with small subdural subarachnoid hemorrhage in
the right frontal lobe.
On admission, the patient denied headache, chest pain,
shortness of breath, vision changes, or weakness, or
paresthesias.
PAST MEDICAL HISTORY:
1. Chronic renal insufficiency.
2. CVA back in [**2107**].
3. AAA.
4. Hypertension.
5. Psoriasis.
6. Arthritis.
7. Bell's palsy.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient was awake, alert, and
oriented times three in no acute distress. Cardiac:
Regular, rate, and rhythm. Lungs are clear bilaterally.
Abdomen is soft and nondistended. Neurologic exam: He is
alert, awake, oriented x3. Short and long-term memory was
intact. Hearing was intact to finger rub. Visual fields
were intact to confrontation. EOMIs were full. Facial
sensation was normal. Face was symmetric. Shoulder shrugs
intact bilaterally. His motor strength was 5 on his right
side of his upper and lower extremities and 4 plus on his
left side.
Patient was admitted to the unit, loaded with Dilantin over
two hours, and then received 100 mg t.i.d. He had some hip
films for complaints of hip pain. All his medications were
placed in normal saline, and his C spine was cleared. His
admission laboratories showed a white count of 10.5, his
hematocrit was 35.4. Sodium 138, potassium 4.1. Chest x-ray
showed a mildly enlarged heart.
On his first admission day, his temperature was 97. Blood
pressure 141-165/60-70. He was on some Nipride to control
his blood pressure less than 140. His white count was 8.3.
His hematocrit was 30. Sodium was 140, 3.6 for potassium,
109 for his chloride, 21 for his bicarb, 22 for BUN and 1.5
for creatinine. He is awake, but slightly dysarthric. His
pupils were 3 to 2.5 bilaterally. His EOMs were full.
A MRI/MRA was done on the 15th that same day, which was
negative for aneurysm. He was given 1 unit of FFP to bring
down his INR to 1.3.
Later on the [**11-10**], the patient underwent a repeat head
CT, which again showed a small amount of blood within the
occipital horns. Stable subarachnoid hemorrhage
interdigitating between the sulci and the parietal lobe. No
evidence of hydrocephalus or shift of normal midline
structures. The overall contusion in the right frontal lobe
was unchanged.
On [**6-12**], the patient was awake, alert, and oriented times
two. He was unsure of the place. Followed commands. Had a
left facial droop, which is baseline. He had no drift. His
I's and O's were within normal limits. His hematocrit was
30.2. His INR had continued to be 1.4. He received FFP to
get it below 1.3.
On [**6-12**] he was transferred to the floor, where a PT, OT, and
bedside swallow exam was completed. He obtained a video
swallow test, which showed occasional aspiration of thin
liquid, but frequent penetration of thin liquids just above
the vocal cords. Penetration was successfully reduced when
he took smaller sips of thin liquids. They recommended that
his medications be with nectar-thick liquids, a diet of
solids, then thin liquids before eating, he should take small
sips.
He had a Physical Therapy evaluation, which initially found
him to be quite unsteady, however, he on the 19th, he did
much better with Physical Therapy, and he was found to be
safe to go home with home physical therapy and 24-hour care,
which his family stated would be available at all times.
Also on the 19th, he underwent a hip x-ray, which showed no
evidence of fracture or dislocation at this point.
On [**2113-6-15**], he had a Dilantin level checked, which was 11.3
and his LFTs were within normal limits. His family was told
to have his Dilantin level checked again in one week at his
primary care doctor. He should continue on Dilantin for one
month after his injury.
The patient was discharged neurologically intact. He is
ambulating in the hallways with assistance and tolerating a
regular diet.
DISCHARGE INSTRUCTIONS: He should come back if he develops a
fever, a headache, or difficulty with ambulating. He should
have home physical therapy.
DISCHARGE MEDICATIONS:
1. Amlodipine besylate 5 mg two tablets p.o. q.d.
2. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. as needed.
3. Dilantin 100 mg tablets take one twice a day, first dose
in
the morning and second in the afternoon, and then Dilantin
100 mg at bedtime.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**]
Dictated By:[**Last Name (NamePattern1) 23079**]
MEDQUIST36
D: [**2113-6-15**] 13:40:43
T: [**2113-6-16**] 09:40:39
Job#: [**Job Number 55698**]
|
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"E888.9",
"696.1",
"593.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4984, 5496
|
4834, 4961
|
1318, 1497
|
117, 1104
|
1515, 4809
|
1126, 1295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,084
| 183,744
|
40288
|
Discharge summary
|
report
|
Admission Date: [**2113-10-24**] Discharge Date: [**2113-11-6**]
Service: NEUROSURGERY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
"worst headache of my life" and frequent sleeping spells
Major Surgical or Invasive Procedure:
[**2113-10-25**] Angiogram with coiling for anterior communicating
artery saccular aneurysm
History of Present Illness:
This is an 86 year old Male who reported he experienced the
"worst headache of his life" about a week ago. He reports the
headache was not accompanied by nausea or vomiting and he notes
no significant visual changes. The headache was
short lasting in duration. He denies continuous headache, but
reported
he would get experience head pressure with coughing or Valsalva.
He presents to the ER, the date of admission, because his wife
had concerns when he was found sleeping during different times
of the day. He has had frequent sleeping spells and would 'doze
off' quickly, but was always easily aroused.
Past Medical History:
Hypertension, BPH, peripheral edema, s/p hernia repair
Social History:
Lives with wife. Is currently retired. Non-smoker but was once a
smoker 50+ years ago. Reports one hard liquor beverage per week,
one glass of wine daily.
Family History:
Denies any familial history of aneurysms or stroke.
Physical Exam:
PHYSICAL EXAM (upon admission):
O: T: 97.8 BP: 161/85 HR: 70 R 16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: intact to current president. Able to name multiple
objects.
Language: Speech is hesitant (per pt this is baseline) but no
word finding difficulty on exam. Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact, left [**Last Name (un) **]-labial
flattening
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-12**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
On Discharge:
A&Ox3
PERRL 3-2mm bilaterally
EOMs: intact
Face symmetrical, tongue midline
Motor: [**4-12**] throughtout
Pertinent Results:
CT HEAD W/O CONSTRAST [**2113-10-24**]:
Essentially unchanged, predominantly bifrontal SAH.
CT ANGIOGRAM [**2113-10-24**]:
14 (CC) x 8 (TRV) x 8 (AP) mm, lobulated, saccular aneurysm
originating
from the anterior communicating artery. Final read pending.
MRI/MRA [**2113-10-30**]:
IMPRESSION:
1. 6 x 6 mm region with tiny foci of flow related enhancement at
the base
of the coil pack of the anterior communicating artery aneurysm
representing residual patency. Correlate with conventional
angiogram as necessary.
2. Tiny infarcts in the left cerebellar and occipital lobes.
3. Diminutive caliber of medial A1 segments and mid left A2
segments ,
suspicious for mild vasospasm.
4. Frontal subarachnoid and intraventricular hemorrhage, similar
to prior.
CTA HEAD W&W/O C & RECONS [**2113-11-3**]
1. Evolving subarachnoid hemorrhage in the bifrontal lobes.
2. Coiling in the anterior communicating artery without evidence
of new focus of hemorrhage or acute major vascular territorial
infarction. CTA
demonstrates no evidence of vasospasm in the anterior and
posterior
circulation.
Brief Hospital Course:
Mr. [**Known lastname 88398**] is an 86 year old male who noted the "worst headache
of his life" one week prior to admission, found by wife to be
somnolent, thus brought to the ED after transfer from OSH (CT
head showing subarachnoid hemorrhaging) with CTA evidence of a
predominantly bifrontal SAH, 14 x 8 x 8 mm lobulated saccular
aneurysm originating from the anterior communicating artery. The
patient had a non-focal neurologic exam on admission. On [**10-25**]
he underwent angiography with coiling of the large saccular
anterior communicating artery aneurysm. He stayed in the ICU for
close monitoriing and hydration. On [**10-28**], his exam was stable
and patient was transferred to step down. His foley was removed
on [**10-30**] and patient awaiting repeat angiogram.
He had a repeat angiogram on [**11-1**] for stenting and re-coiling
that was uneventful.
[**11-3**] patient was more confused and very hesitant speech, he was
sent for a CTA to rule out vasospasm which was negative. On
[**11-4**] he had a repeat chest x-ray to rule retrocardiac opacity
which was negative. His examination remains intact and he will
be discharged home with PT.
Medications on Admission:
Lasix 40mg daily, KCL 20 mEq daily, Cardura 8mg daily
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 8 days.
Disp:*96 Capsule(s)* Refills:*0*
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
Disp:*1 tube* Refills:*0*
10. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four
(4) hours for 2 days.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Saccular anterior communicating artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
* SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
Completed by:[**2113-11-6**]
|
[
"285.9",
"401.9",
"600.00",
"430",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.40",
"00.45",
"39.75",
"00.65"
] |
icd9pcs
|
[
[
[]
]
] |
6074, 6157
|
3798, 4958
|
290, 383
|
6249, 6249
|
2691, 3775
|
8414, 8579
|
1284, 1337
|
5062, 6051
|
6178, 6228
|
4984, 5039
|
6400, 7471
|
7497, 8391
|
1352, 1536
|
2564, 2672
|
194, 252
|
411, 1018
|
1851, 2550
|
6264, 6376
|
1040, 1096
|
1112, 1268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,733
| 119,009
|
12159
|
Discharge summary
|
report
|
Admission Date: [**2184-7-20**] Discharge Date: [**2184-7-28**]
Date of Birth: [**2107-8-16**] Sex: M
Service: OMED
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
SOB with cough x 2 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76yo M with h/o nonsmall cell lung cancer, metastatic to chest
wall, spinal cord, and brain p/w 2d h/o SOB, cough productive of
yellow sputum. Pt. is s/p a recent right frontal craniotomy and
resection of metastatic tumor ([**5-19**]). He is currently on
taxotere chemotherapy, most recent dose on [**7-15**] which is cycle 6
for him and continued whole brain XRT for his brain mets. Was
recently admitted to OMED service on [**6-20**] for 6days with exact
similar presentation of cough and shortness of breath and had
just completed his steroid taper for brain mets when symptoms
recurred. There does not seem to be increasing exertional
dyspnea or a h/o orthopnea. Pt also notes some chest pressure
at rest which he has experienced before -- he took oxycodone
which relieved the sx. Pt says his sx improved yesterday PM and
today AM without any intervention. Pt denies fever/chills,
orthopnea/PND, current chest pain/pressure, n/v/d.
IN ED hypoxic to 87% on RA--> 90-95% on face mask b/c known
COPD. Started on levo/flagyl and solumedrol, CXR confirmed LLL
opacity- seen on previous study one month ago with simlar
presentation. Also tachycardic to 123 and with low grade temps
on admission to ED.
Past Medical History:
1.)NSCLC as above
2.)COPD
3.)Hearing loss
4.)PUD
Social History:
Pt smoke 1.5ppd x 65 years, quit two years ago. He's a retired
painter living with his wife and has three kids. Used to drink
[**2-26**] drinks/day, now just occasional etoh use.
Family History:
Non-contributory
Physical Exam:
t 100.0, bp 140/70, hr 120, rr 36, spo2 90% 4L NC
Gen: Elderly male, +temporal wasting, in respiratory distress,
taking rapid shallow breaths
HEENT: perrl, eomi, slight scleral icterus, op clear with dry mm
NECK: no JVD, no lad
PULM: tachypneic with use of accessory muscles, no paradoxical
breathing, lung sounds are diffusely diminished, wheezes and
diffuse ronchi
COR: tachycardic S1/S2, no murmurs
ABD: firm, nontender, nondistended, nabs
EXT: no CCE
NEURO: cn II-XII intact, motor [**4-28**] prox and distal in all extrm,
sensation intact
Pertinent Results:
[**2184-7-20**] 01:20PM BLOOD WBC-5.7# RBC-3.72* Hgb-11.8* Hct-36.3*
MCV-98 MCH-31.6 MCHC-32.4 RDW-17.2* Plt Ct-217
[**2184-7-24**] 06:25AM BLOOD WBC-11.2* RBC-3.58* Hgb-11.1* Hct-34.7*
MCV-97 MCH-31.2 MCHC-32.1 RDW-17.1* Plt Ct-308
[**2184-7-22**] 08:28AM BLOOD Neuts-77* Bands-6* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2*
[**2184-7-24**] 06:25AM BLOOD Plt Ct-308
[**2184-7-24**] 06:25AM BLOOD Glucose-94 UreaN-25* Creat-0.6 Na-135
K-4.4 Cl-96 HCO3-25 AnGap-18
[**2184-7-21**] 07:10AM BLOOD LD(LDH)-165 CK(CPK)-20*
[**2184-7-24**] 06:25AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
Brief Hospital Course:
Pt was admitted to OMED from the ED. Pt was started on bactrim
in addition to his ceftriaxone and azithromycin, as it was felt
that his recent steroid taper might have predisposed him to PCP
[**Name Initial (PRE) 1064**]. Albuterol/ipratropium nebs were started for COPD
relief, however steroids were initially held given possible
immunosuppressed state (recent steroids, possible PCP). On the
day following admission, in the AM pt looked better less
respiratory distress and tachypnea. However, as the day
progressed, Mr. [**Known lastname **] became increasingly dyspneic and
experienced desaturations into the mid-low 80's, and the patient
was admitted to the ICU where his nebs were continued, steroids
added on (inhaled and systemic, the latter for a 2-week course),
and antibiotics changed to ceftriaxone, metronidazole, and
vancomycin given possible postobstructive pneumonia with sputum
cx growing out coag + staphylococci. Pt stabilized in the ICU
and was called out to the floor where he remained tachypneic but
appeared less symptomatic, with main complaint being copious
sputum production that was difficult to clear. The results came
back from the sputum cx, showing pcn-resistance, so vancomycin
was continued. Final culture results revealed MRSA and no PCP;
vancomycin was continued, and pt was placed on MRSA precautions.
For sputum, started aggressive chest PT, guaifenisen, and
mucomyst. Pt continued to require 5L O2 by nasal cannula, but
appeared clinically improved from a respiratory standpoint.
Aggressive chest PT was pursued, which also helped, per report
of pt. A PICC was placed in anticipation of pt's dispo to a
pulmonary rehabilitation facility to finish vancomycin course.
Medications on Admission:
oxycontin 10mg po hs prn
percocet prn
FeSO4 tab 325mg po qam
Discharge Disposition:
Extended Care
Facility:
Courtyard - [**Location (un) 1468**]
Discharge Diagnosis:
pneumonia (methicillin resistant Staph aureus)
chronic obstructive pulmonary disease
non-small cell lung cancer
Discharge Condition:
currently on O2 5L nasal cannulatolerating po diet well,
ambulating
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] with fevers, increasing shortness of
breath, or chest pain.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**]
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-8-2**] 10:15
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2184-8-2**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-8-2**] 1:00
Completed by:[**2184-7-28**]
|
[
"162.8",
"198.3",
"492.8",
"482.41",
"428.0",
"V09.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4854, 4917
|
3028, 4743
|
289, 295
|
5073, 5142
|
2414, 3005
|
5292, 5860
|
1817, 1835
|
4938, 5052
|
4769, 4831
|
5166, 5269
|
1850, 2395
|
226, 251
|
323, 1531
|
1553, 1603
|
1619, 1801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,782
| 197,553
|
40952
|
Discharge summary
|
report
|
Admission Date: [**2101-4-22**] Discharge Date: [**2101-5-22**]
Date of Birth: [**2065-6-5**] Sex: M
Service: MEDICINE
Allergies:
Chlorhexidine
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Acute leukemia.
Major Surgical or Invasive Procedure:
Central venous line placement
Bone marrow biopsies x3
History of Present Illness:
35 year old male transferred from [**Hospital **] Hospital with malaise
for 2 months, which had worsened resulting in fatigue when
walking from his bedroom to his bathroom in the last 1-2 weeks.
He states that his fatigue started when he got an upper
respiratory tract infection two months before admission, for
which he was prescribed two regimens of antibiotics, first
azithromycin and then amoxicillin. His symptoms somewhat
improved after this. One month ago, he noted that he could not
get through his free weight workouts like he had previously due
to fatigue. Over the past two weeks, he reports dyspnea on
exertion, associated with fatigue after ambulating from his bed
to the bathroom, with no associated chest pain or palpitations.
He also endorses lightheadedness for the last 2 weeks, as well
as intermittent fevers to as high as 101 F and night sweats. He
was seen by his PCP one week ago, for which he was prescribed
levofloxacin for a probable respiratory infection. Patient
reports a 60 lb voluntary weight loss since [**Month (only) 404**], with 8-10
lb unintentional weight loss over the last week. He reports
several recent falls in the last few days after going to the
bathroom and rising from a sitting position, including one
resulting in a head strike where he briefly lost consciousness.
There was no history of tongue biting or incontinence after
these falls. He has had diffuse headaches for the last few
days, but reports no headache over the course of the day of
admission.
.
Patient presented to his PCP [**Last Name (NamePattern4) **] [**2101-4-21**], upon which labs were
drawn. He was noted to have WBC of 150K, Hct 17.5. He was
called on [**2101-4-22**] and asked to report to [**Hospital **] Hospital due to
concerns for acute leukemia. Further studies showed that he had
PT 19.5, PTT 42, K 2.0, Cr 2.8. He received 40 mEq IV KCl as
well as total 1 liter NS IVF in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. A head CT was
done and was reported as negative and CXR did not show any acute
pathology. Fecal occult blood test was done which was positive.
Patient was transfered to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] ED, initial vitals were as follows: T 96.0 P 91
BP 96/40 R 18 Sat 100% 2L NC. He was noted to be comfortable,
but tachycardic in the 100s. He was given 2L NS. One unit of
pRBCs was ordered but not started. He was administered 300 mg
of allopurinol. 40 mEq PO and IV KCl and 4 gram IV magnesium
sulfate were given. Vitals in ED prior to transfer were as
follows: BP 85/29 HR 106 RR 22 O2sat95% RA.
.
On the floor, patient reports no headache or current shortness
of breath. He has no current sweats or chills. His last time
urinating was while in the ED, where he reports urinating about
24 ounces. He has no complaints of dysuria, but does note that
he his urinating less over the last few days.
.
Review of systems:
(+) Diffuse headache for last few days, with exception of today,
patient reports decreased urination
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. No vision loss, focal weakness or
numbness, or confusion.
.
Past Medical History:
Hepatosteatosis
Inguinal hernia
s/p concussion in [**2089**]
s/p periodontal surgery 4-5 days before admission
Social History:
Works for [**Company 7546**], with exposure to many chemicals and some
solvents. He was previously in the Marines from [**2084**]-[**2089**]. No
smoking history, social alcohol drinker. Patient endorses past
casual use of cocaine, marijuana and Ecstasy. His mother lives
in the area. Patient is getting engaged in couple weeks, and
fiance is in [**Location (un) 19061**], where he has had plans to move to.
Family History:
Breast cancer history on mother's side, including mother (dx
~60s), aunt. Ovarian cancer in patient's maternal aunt. There
is history of throat cancer and brain cancer in the patient's
father, who was a smoker. No family history of leukemia or
lymphoma.
Physical Exam:
On admission:
Vitals: T: 98.9 BP: 99/47 P: 108 R: 25 O2: 93%RA
General: Alert, oriented x 3, patient appears comfortable,
pleasant and cooperative, no acute distress
HEENT: contusion present in left occipital area, sclera
anicteric, PERRL, EOMI, no conjunctival hemorrhage, MMM,
oropharynx clear, + gingival hyperplasia
Neck: supple, JVP not elevated, enlarged 2 cm lymph node in left
submandibular area, no cervical or supraclavicular LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, PMI not displaced
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
noted ecchymosis in RLQ
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; ecchymosis present at right antecubital area, no
petechiae or purpura on upper or lower extremities, no
peripheral lesions
Neuro: CNs II-XII intact, sensation intact to LT, 5/5 strength
in all muscle groups, all extremities, [**Doctor First Name **] intact, 2+ reflexes
in all extremities
At discharge:
Pertinent Results:
ADMISSION LABS
--------------
[**2101-4-22**] 03:22PM BLOOD WBC-119.9* RBC-1.65* Hgb-5.8* Hct-15.7*
MCV-95 MCH-35.0* MCHC-36.7* RDW-15.8* Plt Ct-94*
[**2101-4-22**] 03:22PM BLOOD Neuts-2* Bands-0 Lymphs-11* Monos-83*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 Other-2*
[**2101-4-22**] 03:22PM BLOOD PT-22.1* PTT-36.4* INR(PT)-2.0*
[**2101-4-22**] 03:48PM BLOOD Fibrino-609*
[**2101-4-22**] 03:48PM BLOOD Gran Ct-2800
[**2101-4-22**] 03:22PM BLOOD Glucose-116* UreaN-40* Creat-2.7* Na-134
K-2.3* Cl-95* HCO3-27 AnGap-14
[**2101-4-22**] 03:48PM BLOOD ALT-72* AST-68* LD(LDH)-622* AlkPhos-84
TotBili-0.5
[**2101-4-22**] 03:48PM BLOOD Albumin-3.1* Calcium-6.7* Phos-4.3
Mg-1.1* UricAcd-15.2*
[**2101-4-22**] 09:32PM BLOOD freeCa-0.86*
DISCHARGE LABS
--------------
MICROBIOLOGY: all results are negative to date.
------------
[**2101-5-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2101-5-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2101-5-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2101-5-10**] URINE URINE CULTURE-FINAL
[**2101-5-10**] URINE Chlamydia trachomatis, Nucleic Acid Probe, with
Amplification-FINAL
[**2101-5-10**] URINE URINE CULTURE-FINAL
[**2101-5-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-5**] URINE URINE CULTURE-FINAL
[**2101-5-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-5-1**] STOOL OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL
[**2101-5-1**] URINE URINE CULTURE-FINAL
[**2101-5-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-29**] URINE URINE CULTURE-FINAL
[**2101-4-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-26**] URINE URINE CULTURE-FINAL
[**2101-4-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2101-4-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-4-22**] URINE URINE CULTURE-FINAL
[**2101-4-22**] MRSA SCREEN MRSA SCREEN-FINAL
[**2101-4-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
IMAGING
-------
[**2101-4-22**] BM biopsy: MARKEDLY HYPERCELLULAR BONE MARROW EXTENSIVELY
INVOLVED BY ACUTE MYELOID LEUKEMIA WITH MONOCYTIC
DIFFERENTIATION. MICROSCOPIC DESCRIPTION Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are markedly
decreased in number, normochromic and exhibit mild
anisopoikilocytosis. Occasional target cells and spherocytes are
seen. The white blood cell count appears markedly increased and
comprised of almost entirely of neoplastic promonocytes an
occasional mature monocyte. Platelet count appears decreased,
occasional large forms are seen. Differential count shows 5%
neutrophils, 0% bands, 1% lymphocytes, 11% monocytes, 0%
eosinophils, 0% basophils, 83% blasts and promonocytes.
Occasional myelocyte and metamyelocyte seen on scan. Aspirate
Smear:
The aspirate material is adequate for evaluation. It consists of
several hypercellular spicules. The M:E ratio is 8.5:1.
Erythroid precursors are markedly decreased in number with
overall normoblastic maturation. Myeloid precursors appear
markedly increased in number and show left-shifted maturation.
Occasional erythroid precursor with irregular nuclear contours
and asymmetrical nuclear budding is seen. Megakaryocytes are
present in normal numbers; loosely clustered and abnormal forms
are seen including some hypolobated forms. Differential (500
cells) shows: 58% Blasts and promonocytes, 2% Promyelocytes, 6%
Myelocytes, 3% Metamyelocytes, 8% Bands/Neutrophils, <1% Plasma
cells, 13% Lymphocytes, 9% Erythroid.
[**2101-4-22**] TTE: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is no pericardial effusion.
[**2101-4-22**] Chest X-ray: The cardiac silhouette and mediastinum is
grossly normal. Lungs demonstrate some atelectasis at the right
base. There is no focal consolidation or pneumothoraces.
[**2101-4-23**] Renal ultrasound: No hydronephrosis. Large kidneys
bilaterally with no focal masses.
[**2101-4-23**] Left wrist X-ray: There are no signs of acute fractures
or dislocations. There is normal osseous mineralization. There
are no bony erosions. An IV catheter is seen in the dorsal soft
tissues next to the fifth metacarpal.
[**2101-4-26**] CT chest: Diffuse predominantly peribronchial
parenchymal opacities suggesting recent infection. Moderate
reactive bronchial wall thickening and pleural effusions. The
airways are patent. Moderate mediastinal and axillary
lymphadenopathy.
[**2101-4-27**] LENI's: No evidence of DVT in either lower extremity.
[**2101-5-1**] CXR: The heart is not enlarged. There is no CHF, focal
infiltrate, or effusion. No pneumothorax is detected. A
right-sided PICC line is present. The tip is poorly visualized,
but most likely lies in the region of the cavoatrial junction.
No pneumothorax detected. Subtle changes described in the report
of a [**2101-4-26**] CT scan are not appreciated on today's
radiograph, question due to interval resolution versus
limitations of radiographs versus CT.
[**2101-5-6**] BM cytogenetics: KARYOTYPE:
47,XY,+15,[**Doctor First Name 15**](15)(Q15Q24)[5]/46,XY[11]
INTERPRETATION: Five of 16 metaphases contained an additional
copy of
chromosome 15 (TRISOMY 15) and an interstitial deletion of the
long arm of chromosome 15.
[**2101-5-6**] BM biopsy: BONE MARROW WITH FINDINGS CONSISTENT WITH
CHEMOTHERAPEUTIC MYELOABLATION. MORPHOLOGIC FEATURES OF
INVOLVEMENT BY ACUTE MYELOID LEUKEMIA ARE NOT SEEN. Peripheral
Blood Smear:
The smear is adequate for evaluation. Erythrocytes appear
decreased in number and exhibit mild anisopoikilocytosis.. Rare
dacrocytes and red cell fragments seen. The white blood cell
count appears markedly decreased. Rare large granular
lymphocytes seen on scan. Platelet count appears markedly
decreased. Differential count shows 2% neutrophils, 76%
lymphocytes, 19% monocytes, 1% basophils, 2% plasma cells.
Aspirate Smear: The aspirate material is adequate for
evaluation. It consists of few cellular spicules. The majority
of the cellularity is comprised of stromal cells, lymphocytes
and reactive plasma cells. Scattered clusters of
hemosiderin-laden macrophages are seen. Maturing myeloid
elements are rare. Erythroid elements and megakaryocytes are
nearly absent. Based on a 300 cell Differential: <1% Blasts,
1% Promyelocytes, 2% Myelocytes, 3% Metamyelocytes, 1%
Bands/Neutrophils, 48% Plasma cells, 40% Lymphocytes, <1%
Erythroid, 5% monocytes.
[**2101-5-7**] CT chest: No acute intrathoracic process.
[**2101-5-8**] CT sinus: Mild bilateral maxillary sinus mucosal
thickening but no bone destruction or remodeling.
[**2101-5-9**] CT abd/pelvis: 1. Decreased attenuation in the
peripheral zone of the prostate in the appropriate clinical
setting could reflect prostatitis. Clinical correlation with
examination is advised. The well circumscribed hypodensity is
likely a prostatic cyst, but an abscess cannot be excluded. 2.
Linear opacity in the proximal appendix could reflect an
intraluminal foreign body such as a bone, the distal appendix is
not distended and there is no associated inflammatory change.
There are, however, two large lymph nodes in the ileocolic
region of uncertain significance.
Brief Hospital Course:
35 year old male with no past medical history with multiple
month history of malaise and shortness of breath, presents with
laboratory studies suggestive of acute leukemia, found to have
AML. He completed 7+3 with...
# Acute leukemia: Aggressive presentation found to be monocytic
leukemia as expected given signs of gingival hyperplasia.
Patient also presented with acute kidney injury and elevated
uric acid. Leukopheresis was not performed given no signs of
leukostasis. Bone marrow biopsy was completed on admission and
showed ... Hydroxyurea was started on admission, and then
discontinued once 7+3 chemotherapy was begun the following day.
Transthoracic echocardiogram was completed on admission prior to
chemotherapy dosing. Electrolytes, CBC, fibrinogen, uric acid,
and LDH were checked initially every four hours, but then every
six hours to evaluate for both tumor lysis and DIC. He
completed 7+3 with the only complication of mucositis. He had
persistent daily febrile neutropenia. CT sinus, chest, abdomen,
and pelvis were done to evaluate but did not identify a source.
There is a question of prostatis on imaging but without any
clinical symptoms and with all urine cultures incl chlamydia
being negative, but regardless was started on meropenem. There
is also a question of a bone in his appendix, but upon review
with rads, this could be an appendicolith which may cause
appendicitis when his white count recovers. He noted new pain
at angle of the left jaw. CT neck ordered to evaluate and
negative for mastoiditis. ENT was curbsided and wo evidence of
mastoiditis pt was not candidate for surgical intervention or
drainage. He was treated with Afrin x 3 days with resolution of
the pain attributed to congestion and otitis. Abx continued as
well.
Repeat bone marrow biopsy done on day 14 revealed persistent
cytogenetic abnormalities. Bone marrow biopsy done on day 20
revealed no leukemic cells and pt was discussed at transplant
meeting w decision to postpone additional chemo or SCT at this
time w plans for observation. Micafungin (started for febrile
neutropenia) was dc'd [**5-20**] and vanco/[**Last Name (un) 2830**] was dc'd on [**5-21**].
He started levofloxacin for otitis media coverage after
discontinuing broad spectrum abx.
.
# Thrombocytosis: Uptrend observed and splenomegaly appreciated
on exam [**5-21**] w pt c/o mild abd discomfort w sitting. He was
started on 81mg asa when plts reached 1million. CT abd showed no
acute process.
.
# Acute kidney injury: Likely secondary to leukemic infiltration
and excess lysozyme release. Renal ultrasound was perfomed and
showed enlarged kidney. Aggressive IV fluid administration was
undertaken. Patient was started on allopurinol and was given
one dose of rasburicase prior to chemotherapy administration to
for tumor lysis prophylaxis. Tumor lysis labs were obtained at
first every four hours, then every six hours. Patient was also
started on calcium carbonate to bind phosphrous. His kidney
function returned to baseline after the first week of admission.
.
# DIC: Patient presented with signs of DIC on admission, with
elevated PT, PTT, INR and fibrinogen. DIC labs were initially
obtained every four hours, then every six. Patient required two
units of FFP prior to central line placement. Active type and
screen was maintained. His INR has been elevated so he has
received 3 courses of vitamin K 5mg PO x3 days.
.
# Normocytic anemia: MCV was 96 on admission, likely in setting
of excess blast cells. Transfusions were given to maintain
hematocrit greater than 21. CBC was trended multiple times per
day.
.
# Dyspnea on exertion: Patient presented with dyspnea, likely
related to anemia and acute leukemia. There was no history of
lung disease, and symptom was not associated with chest pain or
palpitations. A baseline chest X-ray was obtained and showed no
abnormality. Nebulizers were given PRN for symptoms of dyspnea
during admission.
.
# Lightheadedness/syncope: Patient sustained numerous falls
before admission, likely related to anemia and volume depletion.
A transthoracic echocardiogram was performed before
chemotherapy administration which showed no gross abnormalities
of heart function. ECG showed no abnormalities.
.
# Otitis: no evidence of mastoiditis on CT. ENT curbsided and
recommended treatment with afrin. Pt had resolution of jaw pain,
pt had continued congestion and "muffled hearing" that will
likely resolve slowly in next few weeks.
.
Medications on Admission:
Meclizine
Multivitamin
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*120 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
4. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Acute myelogenous leukemia
Secondary Diagnosis: Prostatitis
Tertiary Diagnosis: Otitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted with dehydration and recurrent falls, found to
have acute myelogenous leukemia. You completed induction
chemotherapy with 7+3. You had persistent fevers during the
course of your neutropenia was likely a cause of prostatitis and
treated with antibiotics. Repeat bone marrow biopsy done on day
14 showed a persistence of abnormal cells. Bone marrow biopsy
done on day 20 revealed lack of leukemia and we plan to observe
you for now without additional chemotherapy at this time.
You had jaw pain and muffled hearing consistent with otitis
media. A catscan was negative for bone involvement and you were
treated with Afrin.
Your platelets rose very quickly to a high level and you were
started on a baby aspirin. [**Name2 (NI) **] had a cat scan of your abdomen
which was negative.
The following changes were made to your medication regimen:
STARTED aspirin
STARTED acyclovir
STARTED calcium supplement
STARTED levofloxacin for ear infection
Followup Instructions:
The following appointments were made for you:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2101-5-25**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2101-5-25**] at 1 PM
With: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
|
[
"288.03",
"584.9",
"276.8",
"382.9",
"205.00",
"286.6",
"528.01",
"238.71",
"285.9",
"784.92",
"780.61",
"276.50",
"E933.1",
"601.9",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"41.31",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18994, 19000
|
13912, 18391
|
289, 345
|
19152, 19152
|
5771, 13889
|
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|
4341, 4599
|
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|
19021, 19021
|
18417, 18442
|
19303, 20348
|
4614, 4614
|
5752, 5752
|
3327, 3762
|
234, 251
|
373, 3308
|
19089, 19131
|
19040, 19068
|
4628, 5737
|
19167, 19279
|
3784, 3896
|
3912, 4325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,740
| 154,162
|
46265
|
Discharge summary
|
report
|
Admission Date: [**2196-3-29**] Discharge Date: [**2196-4-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal pain, shortness of breath.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 88 M with CAD s/p IMI and stenting, Afib,
admitted with progressive SOB. In ED, noted to be in AF with RVR
at rate of 130s. Was rate controlled on 15 mg IV dilt. Pt then
received 120 PO dilt. Given concern for PE, D-dimer sent and
returned at 516. CTA not performed given renal insufficiency,
and pt given 60 mg SQ lovenox for empiric treatment of PE . On
initial floor eval by primary team, noted to be tachypneic, with
basilar crackles, HR ~100. Given IV lasix. Then as pt was
straining to have BM, became bradycardic and hypotensive. Stools
guaiac negative. ABG 7.25/47/79 with lactate 6.1. On further
exam, was also noted to have lower abdominal pain.
.
Per daughter, pt functional at baseline. Lives alone, no
assistance with ADLs. Walks up to a mile to market without
exertional symptoms. Daughter takes [**Name2 (NI) **] weekly. Had been
regular up until this past Saturday when she noted it to be
irregular. Pt had otherwise been in USOH until this weekend when
had worsening SOB.
Past Medical History:
- Atrial fibrillation s/p cardioversion [**2190**]
- Hx upper GI bleed
- MI s/p stent [**2187**]
- HTN
- Hypercholesterolemia
- BPH
Social History:
Moved from [**Country 5881**] 50 years ago; he is widowed, lives alone and
is independent in all ADLs. He quit smoking 35 years ago, and
smoked 1ppd for "many years." Occasional alcohol use. Has 2
children. Daughter lives in [**Location 86**] and is active in his care. He
used to work at a raincoat factory.
Family History:
Many family members with CAD.
Physical Exam:
VS - 96.0, BP 94/79, HR 48, RR 28, O2 sat 96% 2L NC, wt 78 kg
Gen - somewhat uncomfortable, but NAD, speaking in full
sentences
HEENT - NCAT, PERRL, OP clr, MMM, no LAD
CV - [**Location 64063**] [**Last Name (LF) 64063**], [**First Name3 (LF) **], no mur
Lungs - dependent R-sided crackles (pt laying on R side)
Abdomen - NABS, distended, tender in lower abdomen with
voluntary guarding, no rebound tenderness, no CVA tenderness
Back - no back tenderness
Ext - 1+ bilat edema, WWP, distal pulses 2+
Neuro - A&Ox3
Skin - Pink, warm, no rashes
Pertinent Results:
Radiographic studies:
HIDA scan on [**2196-3-31**]:
Serial images over the abdomen show normal uptake of tracer into
the hepatic parenchyma. At 15 minutes, the gallbladder is
visualized with tracer. No activity is seen in the small bowel
to 90 minutes. The findings suggest sphincter of Oddi
contraction, possibly secondary to narcotic administration (as
tracer is not seen in the small bowel).
IMPRESSION: Evidence of sphincter of Oddi medication effect. No
evidence of cystic duct obstruction or cholecystitis.
Right upper quadrant ultrasound on [**2196-3-30**]:
IMPRESSION:
1. No evidence of focal hepatic mass, ascites or biliary ductal
dilatation.
2. Significant gallbladder wall edema concerning for acute
acalculous cholecystitis. If clinically indicated, a HIDA scan
could be considered for further confirmation.
Abdominal plain film on [**2196-3-30**]:
IMPRESSION: No evidence of free air under the hemidiaphragms.
No evidence of obstruction.
CXR on [**2196-3-29**]:
CHEST, ONE VIEW: Comparison with [**2191-12-17**], there is no
appreciable change. There is persistent cardiomegaly, but no
pleural effusion, new consolidation, or pneumothorax. There is
no pulmonary edema.
IMPRESSION: Cardiomegaly without acute cardiopulmonary process.
[**2196-4-1**] 02:35AM BLOOD WBC-13.1* RBC-4.26* Hgb-12.9* Hct-39.7*
MCV-93 MCH-30.3 MCHC-32.5 RDW-14.8 Plt Ct-222
[**2196-3-31**] 04:02AM BLOOD ALT-38 AST-44* LD(LDH)-350* CK(CPK)-277*
AlkPhos-70 Amylase-55 TotBili-0.9
[**2196-4-1**] 02:35AM BLOOD Calcium-10.6* Phos-2.7 Mg-2.5
[**2196-3-30**] 09:52AM BLOOD Type-ART pO2-90 pCO2-25* pH-7.56*
calTCO2-23 Base XS-1
Brief Hospital Course:
88 year-old male with hypertension, coronary artery disease,
history of myocardial infarction, atrial fibrillation, who
presented initially with shortness of breath, found to be in
atrial fibrillation with rapid ventricular response and then
with abdominal pain and metabolic acidosis.
.
# Abdominal pain: Localized to right-upper quadrant. Ultrasound
was concerning for acalculus cholecystitis but HIDA scan
negative for cystic duct obstruction or cholecystitis.
Therefore, abdominal pain is likely secondary to mesenteric
ishcemia (given initial lactate 6.1 on admission, history of
atrial fibrillation and not anticoagulated.) No evidence for
ascending cholangitis on imaging and LFTs near normal. CTA of
abdomen deferred due to [**3-4**] renal failure. GI, ERCP, and surgery
were consulted initially but family decided they do not want
surgery or any invasive measures. NO further intervention for
mesenteric ischemia. Initially antibiotics were started but
these were discontinued once patinet was made comfort measures
only. Morphine infusion was initiated. Patient receiving
lorazepam and haloperidol as needed for comfort. No longer
checking labs.
.
# delirium: Patient had new mental status changes likely
secondary to abdominal pathology. Geriatrics was consulted for
management of delirium. Delerium improved with better pain
control, haloperidol and lorazepam. Can consider sublingual
olanzapine if needed.
.
# Atrial fibrillation: Likely secondary to abdominal
pathology/infection. Started metoprolol initially for rate
control.
.
# Shortness of breath: Likely secondary to rapid AF with
resultant CHF. No infiltrate on CXR. Slight troponin elevation
with normal CKs, probably due to rapid heart rate and renal
failure. No AMI.
.
# Hypercalcemia: Chronically elevated PTH, patient started on
bisphosphonate initially.
.
# Coronary artery disease, s/p MI with stent: as above, low
suspicion for myocardial ischemmia as primary problem. [**Name (NI) **]
maintained on aspirin and statin.
.
# Renal insufficiency: Known chronic renal insufficiency with
baseline cr 1.3-1.5. 1.7 on admit and now 2.2 x 2 days. Due to
volume depletion but also poor forward flow given CHF/atrial
fibrillation. Treated with fluids and rate control with
metoprolol
.
# DM: Patient maintained on insulin sliding scale.
.
# Access: Peripheral IV
.
# FEN: NPO, NG tube pulled out.
.
# Prophylaxis: Initially on heparin subcutaneous which should
be discontinued. Bowel regimen for comfot.
.
# Code: CMO
.
# Communication: With daughter, [**Name (NI) **]. c: [**Telephone/Fax (1) 98355**],
h: [**Telephone/Fax (1) 98356**]. Patient is Greek speaking mainly but does speak
a little bit of english.
Medications on Admission:
ASA daily
Previously on amio, but stopped several months ago
Discharge Disposition:
Expired
Discharge Diagnosis:
Mesenteric ischemia
Atrial fibrillation
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2196-4-3**]
|
[
"V45.82",
"414.01",
"557.0",
"428.0",
"276.50",
"276.2",
"584.9",
"272.0",
"585.9",
"600.00",
"403.90",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6909, 6918
|
4101, 6797
|
299, 305
|
7001, 7010
|
2452, 4078
|
7062, 7095
|
1843, 1874
|
6939, 6980
|
6823, 6886
|
7034, 7039
|
1889, 2433
|
222, 261
|
334, 1344
|
1366, 1500
|
1516, 1827
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,742
| 134,089
|
46836
|
Discharge summary
|
report
|
Admission Date: [**2151-10-28**] Discharge Date: [**2151-11-9**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
woman who fell down on a flight of stairs with no loss of
consciousness, with severe neck pain, no headache, and
baseline dementia. Husband now reports increased confusion.
PAST MEDICAL HISTORY: Hypertension, atrial fibrillation,
Paget's disease, and dementia.
PHYSICAL EXAMINATION: Blood pressure was 170/80, heart rate
103, and saturation 94 percent. The patient was confused and
screaming. Pupils were 3 mm and 2 mm bilaterally. Cranial
nerves appeared grossly intact; unable to assess specific
muscle tone. Breasts were equal. Deep tendon reflexes 1
plus in the upper and lower extremities. Toes were down
running; no clonus.
HOSPITAL COURSE: CT showed a large right frontal parietal
subdural hematoma with the extension into the anterior
hemispheric fissure with midline shift. The patient was
admitted to the ICU for close neurologic observation. She
was given FFP, vitamin K, and factor 7; loaded with Dilantin;
taken emergently to the OR for an emergent evacuation of the
subdural hematoma. She had a postoperative head CT that
showed interhemispheric hemorrhage plus herniation and new
pneumocephalus. On [**2151-10-29**], the patient had a repeat head
CT that showed decreased pneumocephalus and less mass effect.
The patient continued to require FFP for INR greater than
1.4; neurologically continued to be intubated and sedated.
She did not follow commands, has random purposeful movement
of all extremities, more so in the arms than left leg.
Withdraws all extremities to pain, has a positive cough,
gagged corneas, and blank reflex. Pupils are equal, round
and reactive to light.
On [**2151-10-30**], the patient was extubated. She had a head CT
that remained stable. On [**2151-10-30**], she was hyponatremic
requiring fluid restriction. Renal was consulted for acute
renal failure. Three percent saline was stopped. The
patient was transferred to the step-down unit on [**2151-10-31**].
Neurologically, she remained in waxing and [**Doctor Last Name 688**] mental
status; sometimes answering questions. C-collar remained in
place. She was placed on swish and swallow study; she
remained in atrial fibrillation. She was on Lopressor.
Chest x-ray showed worsening pneumonia. She was started on
levofloxacin for raising white count and chest x-ray was
consistent with infiltrates. She was evaluated by swish and
swallow who felt the patient was aspirating and was at high
risk for continued aspiration. The patient had her TL spine
cleared. She was discontinued off her nimodipine. Renal
felt her acute renal failure was contrast related. Head CT
was stable. She was at her baseline neurologic function
being confused and agitated at times, moving all extremities.
She continued to have waxing and [**Doctor Last Name 688**] mental status.
On [**2151-11-2**], she was lethargic, rarely opening her eyes to
name, oriented to person only; able to state her husband's
name and town she lived in. Answering simple questions at
time and consistently following some simple commands. On
[**2151-11-4**], the patient had decreased saturation, and was
transferred back to the ICU. At that time, there was a
discussion here with the family and the patient was made a
DNR/DNI. Cardiology was consulted for atrial flutter who
recommended titrating the Metoprolol and hold anticoagulation
at this point. She had a head CT on [**2151-11-1**] that had no
change. Chest x-ray on [**2151-11-5**] showed bilateral pulmonary
edema. Renal continued to follow the patient and recommended
giving Lasix. The patient was still being followed by
Cardiology for chronic atrial fibrillation and flutter.
Neurologically, she was nonverbal, localizing 30 percent on
the left, trace movement on the right upper extremity
withdrawal, trace movement of bilateral lower extremities.
On [**2151-11-6**], the patient had an MRI of her brain, which
showed water shade at subacute infarctions involving both
posterior parietal lobes and the left frontal lobe.
Neurology was consulted. The patient's blood pressure was
controlled and they have recommended a blood transfusion for
a low hematocrit. The patient was transferred to the step-
down unit again on [**2151-11-5**]. Stroke service continued to
follow the patient and continued to recommend blood
transfusion, treating infections, and TEE to help assess
cardiac pump status. Neurologically, the patient was
unresponsive verbally, unable to assess orientation. Her
pupils were 3 mm and reactive. Right upper extremity flaccid
and left upper extremity moved on the bed; nonpurposeful
movement of the lower extremities to painful stimulation.
On [**2151-11-8**], discussion was held with the family regarding
the patient's severe deterioration of neurologic status.
Both the husband and son were spoken to. The husband agreed
to make the patient comfort measures only and then an hour
later resented that order. The patient remained decreased
neurologically with decreasing saturation and decreasing
blood pressure. The patient expired on [**2151-11-9**] at 11:28
a.m.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2151-12-9**] 12:08:33
T: [**2151-12-10**] 07:07:38
Job#: [**Job Number 99396**]
|
[
"253.6",
"401.9",
"294.10",
"852.21",
"428.0",
"584.9",
"V58.61",
"731.0",
"272.0",
"331.0",
"434.91",
"427.31",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"01.31",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
809, 5456
|
437, 791
|
119, 324
|
347, 414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,804
| 107,868
|
45628
|
Discharge summary
|
report
|
Admission Date: [**2168-11-13**] Discharge Date: [**2168-11-18**]
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained from son and from [**Name (NI) **] notes and signout as pt.
somnolent and on BIPAP on arrival to ICU. In brief, Mr. [**Known lastname 5749**] is
an 89 year old [**Hospital 100**] Rehab resident with history of coronary
artery disease, congestive heart failure, OSA, multiple previous
pneumonias/bronchitis presents with 1 day of shortness of breath
and non-productive cough at [**Hospital 100**] rehab, and started on
ciprofloxacin (per ED resident) 1d prior to admission. This AM,
he became increasingly tachypneic and hypoxic to 80s on baseline
oxygen, given abx. and lasix 40mg IM.
Recent admission in may with similar presentation, given abx.,
nebs, lasix, and improved without need for intubation or NIPPV.
Per son, also recently treated for PNA 1 month ago. Today, also
became more lethargic, so decision made to send patient to [**Hospital1 18**]
ER. At baseline, most vigorous activity involves transfers to
powerized wheelchair, but is cognitively clear.
.
In [**Name (NI) **], pt. 99.6, HR 93, 128/68, 35 91% on NRB, somnolent on NRB
with initial gas of 7.23/106/133/47 on NRB. Repeat gas
7.30/90/62/46 on 30%FiO2 on BIPAP. CXR showed increased
inflitrates bilaterally, so given 1 dose of vancomycin. Given
poor gas, ED had discussion of possible temporary intubation
(pt. has signed DNR/DNI) with pt. who refused, but was thought
to be too somnolent to have capacity.
.
I spoke with son and both of his most recent PCPs Drs. [**Last Name (STitle) 14936**]
and [**Name5 (PTitle) **] about his code status, and pt. was clear that he did
not want prolonged or permanent time on ventilator but had not
had discussion re: temporary intubation for reversible causes,
and both PCPs felt that it was appropriate for that decision to
be made by his son who was HCP. When I spoke to his son, he
reiterated above, but agreed that a trial intubation would be
what his father would want.
Past Medical History:
DDD Pacemaker placed [**7-8**] for second degree AV block
Coronary Artery Disease
Congestive Heart Failure. Echo: LVEF>55% [**2168-5-25**]
Obstructive Sleep Apnea
Hypertension
gout
Lichen Simplex Chronicus, on zyrtec
Incisional hernia
chronic skin ulcers
iron-deficiency anemia
h/o DVT
s/p prostatectomy
s/p appy
Ventral hernia
Obesity
H/o DVT, on coumadin completed 6m course [**2166**]
Hypothyroidism
Chronic bilateral bronchiectasis and bronchomalecia
CRF with BL Cr in 1.1-1.4
Social History:
Lives at [**Hospital 100**] Rehab, denies ever smoking
Family History:
NC
Physical Exam:
Vitals: T 96 axillary HR 74, BP 118/60 RR 15 O2 sat 93% on CPAP
Fio2 35% on 15/8.
Gen: somnolent, arousable to voice for a few seconds before
falling back asleep, A&Ox2, answers intermittently coherent
HEENT: PERRL, EOMI, OP exam deferred as on BIPAP
CV: RRR, nl S1/S2
Chest: Coarse rhonchi diffusely, decreased BS throughout, worst
at apices, no wheezes
Abd: Soft, NDNT, ventral hernia
Ext: No edema
Neuro: moving all 4 ext. against gravity. EOMI, + cough, Hearing
intact.
Pertinent Results:
Admit labs:
[**2168-11-13**] 12:28PM LACTATE-0.8 K+-4.7
[**2168-11-13**] 12:28PM TYPE-ART PO2-133* PCO2-106* PH-7.23* TOTAL
CO2-47* BASE XS-12 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2168-11-13**] 12:40PM PT-30.6* PTT-35.0 INR(PT)-3.2*
[**2168-11-13**] 12:40PM PLT COUNT-280
[**2168-11-13**] 12:40PM NEUTS-74.8* LYMPHS-18.5 MONOS-4.6 EOS-1.8
BASOS-0.3
[**2168-11-13**] 12:40PM WBC-6.1 RBC-4.46* HGB-13.2* HCT-43.6 MCV-98
MCH-29.5 MCHC-30.1* RDW-15.8*
[**2168-11-13**] 12:40PM DIGOXIN-0.9
[**2168-11-13**] 12:40PM CALCIUM-9.5 PHOSPHATE-4.1# MAGNESIUM-2.4
[**2168-11-13**] 12:40PM CK-MB-NotDone
[**2168-11-13**] 12:40PM cTropnT-0.03*
[**2168-11-13**] 12:40PM CK(CPK)-39
[**2168-11-13**] 12:40PM estGFR-Using this
[**2168-11-13**] 12:40PM GLUCOSE-123* UREA N-22* CREAT-1.5* SODIUM-143
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-46* ANION GAP-5*
[**2168-11-13**] 12:46PM LACTATE-1.2 K+-4.9
[**2168-11-13**] 12:46PM COMMENTS-GREEN TOP
[**2168-11-13**] 01:20PM TYPE-ART O2-31 PO2-62* PCO2-90* PH-7.30*
TOTAL CO2-46* BASE XS-13 INTUBATED-NOT INTUBA
[**2168-11-13**] 02:22PM TYPE-ART TEMP-37.6 RATES-/14 PEEP-8 O2-33
PO2-64* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 INTUBATED-NOT
INTUBA COMMENTS-CPAP
[**2168-11-13**] 05:20PM TYPE-ART TEMP-36.7 PO2-65* PCO2-64* PH-7.44
TOTAL CO2-45* BASE XS-15
[**2168-11-13**] 07:46PM PT-33.3* PTT-35.2* INR(PT)-3.6*
[**2168-11-13**] 07:46PM PLT COUNT-274
[**2168-11-13**] 07:46PM WBC-6.0 RBC-4.10* HGB-12.3* HCT-40.1 MCV-98
MCH-30.0 MCHC-30.6* RDW-15.9*
[**2168-11-13**] 07:46PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.2
[**2168-11-13**] 07:46PM GLUCOSE-119* UREA N-26* CREAT-1.4* SODIUM-143
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-44* ANION GAP-7*
[**2168-11-13**] 09:44PM O2 SAT-92
[**2168-11-13**] 09:44PM LACTATE-2.0
[**2168-11-13**] 09:44PM TYPE-[**Last Name (un) **] PO2-65* PCO2-76* PH-7.35 TOTAL
CO2-44* BASE XS-11
CHEST (PORTABLE AP) [**2168-11-13**] 12:27 PM
IMPRESSION: Persistent, patchy, right-sided multifocal airspace
process unchanged in appearance compared to [**2168-5-24**] and [**2165-8-23**]
probably related to chronic findings secondary to
bronchiectasis. Question new left perihilar opacities. Probable
small pleural effusions. Clinically correlate.
.
CHEST (PORTABLE AP) [**2168-11-17**] 10:45 AM
FINDINGS: In comparison with the study of [**11-16**], there is little
change. Again, there are bilateral lower lobe and right middle
lobe opacifications consistent with pneumonia. Pacemaker device
remains in place.
.
MICROBIOLOGY: Blood Cx ([**11-13**]): NGTD x2
.
Discharge labs:
[**2168-11-18**] 03:43AM BLOOD WBC-5.9 RBC-4.07* Hgb-12.0* Hct-39.0*
MCV-96 MCH-29.4 MCHC-30.7* RDW-16.5* Plt Ct-340
[**2168-11-17**] 06:05AM BLOOD Neuts-62.6 Lymphs-22.8 Monos-5.9 Eos-8.3*
Baso-0.3
[**2168-11-18**] 03:43AM BLOOD PT-19.3* PTT-28.0 INR(PT)-1.8*
[**2168-11-18**] 03:43AM BLOOD Glucose-101 UreaN-40* Creat-1.5* Na-140
K-4.3 Cl-100 HCO3-37* AnGap-7*
[**2168-11-18**] 03:43AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.5
[**2168-11-17**] 10:55AM BLOOD pO2-67* pCO2-65* pH-7.37 calTCO2-39* Base
XS-8
Brief Hospital Course:
He was admitted to the MICU [**Location (un) **] team, where he was treated on
BiPAP with good success, along with vancomycin and cefepime from
presumed nosocomial pneumonia.
.
He was transferred to the floor on evening of [**2168-11-16**], but was
noted to be hypoxic with oxygen saturation of 85% on 4L. He had
been stable overnight while on BiPAP, however he had increased
respiratory rate and was hypoxic on 50% face [**Last Name (LF) **], [**First Name3 (LF) **] he
transferred back to MICU due to need for more frequent BiPAP and
for closer monitoring.
.
# Hypercarbic respiratory distress/PNA: As previously related,
at baseline patient requires 2 L NC O2 prn and is unable to do
most physical activity, including walking. He presented with
with worsening chronic respiratory acidosis with likely
additional metabolic alkalosis, this was felt to be secondary to
a nosocomial pneumonia in conjunction with his baseline lung
disease and sleep apnea. He continues to have stable blood
gases, however was noted to be more somnolent. The
differential, as previously discussed, included PNA, CHF
exacerbation, bronchiectasis/bronchomalacia causing worsening
ventillation. Admission CXR showed question new left perihilar
opacities and probable small pleural effusions. WBC 6.1 on
admission. Blood cx on admission with NGTD x2.
Vancomycin/cefepime (7 days total) to cover nosocomial,
post-obstructive PNA, and possible aspiration PNA as well, given
allergy to penicillins and levofloxacin. Has tolerated
cephalosporins well in past. Antibiotics were started on [**11-13**],
so will complete course on [**11-19**]. Patient was put on BIPAP at
night and as needed during day for somnolence, FaceT and Venturi
otherwise. He received Chest PT and incentive spirometry as
possible. Aimed for o2 sats 88-92 given likely a co2 retainer.
Given Lasix [**11-15**] with good UOP, and will continue diuresis as
tolerated as patient may have element of failure which is
worsening his respiratory status. He was also given albuterol
ATC, but stopped Atrovent as it may have made his secretions
thicker. Given Guaifenesin ATC to thin secretions.
.
# Afib: Patient started on coumadin in [**5-9**] per Dr. [**Last Name (STitle) **]. INR
3.2 on admission, so Coumadin was initially held. Coumadin was
re-started on [**11-6**] at 5mg. On discharge his INR was 1.8, so
coumadin was increased to his original home dose of 7.5mg qhs.
Coumadin to be titrated per rehab facility. Continued digoxin
at admission dosing.
.
# CHF: Patient has preserved EF, not currently on ACE-I, BB, or
statin. Does not appear grossly overloaded on exam. Lasix to
mantain negative fluid balance (started [**11-15**]). Continued
digoxin at home dosing.
.
# Gout: Continued allopurinol at 100mg qdaily, dosed per renal
function, though on 250qdaily at prior to admit.
.
# Hypothyroidism: continued levothyroxine 75mg po
.
# Allergies: Continued fexofenadine.
.
# [**Hospital 97291**] health care maintenance: Continued ASA for
cardiac health. Continued Vitamin D/Calcium for bone health.
.
# FEN: Speech and swallow evaluation completed, recommendations
were for PO diet of nectar thick liquids and regular consistency
solids, assistance with meals, and pills whole with purees.
.
# Code: DNR/DNI: Confirmed with pt., that given unlikelihood of
being able to wean off ventilator if intubated, he is DNR/DNI.
Medications on Admission:
- Allopurinol 250 mg qdaily
- Calcium Carbonate 650bid
- Vit D 1000U daily
- Digoxin .0625 mg QMOWEDFRI
- Digoxin 0.125 mg QSUNTUESTHURSSAT
- Fexofenadine 60 mg [**Hospital1 **]
- Furosemide 20mg po daily
- Synthroid 75 mcg qd
- senna 1 tab qd
- tylenol 650 mg q4 hours prn
- guaifenesin/dextromethorphan prn
- hydrocortisone 1% cream to buttock area
- coumadin, doses not clear
- albuterol/atrovent 2 puffs q8h
- Fluticasone (2) Inhalation [**Hospital1 **]
- albuterol nebs q4h
- atrovent nebs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for wheezing.
12. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY16
(Once Daily at 16).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QSU, TU, TH,
SA ().
14. Digoxin 125 mcg Tablet Sig: [**1-5**] tab Tablet PO QMO, WE, FR
().
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 1 days: last day
[**11-19**].
17. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q24H
(every 24 hours) for 1 days: last day [**11-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Health care associated-Pneumonia
Bronchomalacia
____________________
Secondary:
Atrial Fibrillation
CHF
Gout
Hypothyroid
Discharge Condition:
good, satting well on BIPAP, tolerating pos, unable to walk
Discharge Instructions:
Please seek medical attention ahould you develop chest pain,
increased shortness of breath, fever, or any other concerning
symptoms. You have been diagnosed with pneumonia which
increases respiratory secretions and bronchomalacia, which makes
it more difficult to clear these secretions resulting in your
shortness of breath.
You will have one more day of vancomycin and cefepime
antibiotics. You should continue on your BIPAP at night and
during the day whenever you are sleeping or short of breath.
We have decreased your allopurinol dose to account for your
impaired renal function.
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] as previously scheduled
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
[]
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|
6410, 9793
|
254, 260
|
12077, 12139
|
3302, 5869
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|
10339, 11814
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11924, 12056
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12163, 12754
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5886, 6387
|
2807, 3283
|
195, 216
|
289, 2194
|
2216, 2699
|
2715, 2772
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,811
| 179,323
|
54845
|
Discharge summary
|
report
|
Admission Date: [**2166-10-9**] Discharge Date: [**2166-10-17**]
Date of Birth: [**2092-2-6**] Sex: M
Service: SURGERY
Allergies:
ciprofloxacin / latex
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Adenocarcinoma of the head of pancreas
Major Surgical or Invasive Procedure:
Whipple procedure with SMV reconstruction
History of Present Illness:
Born in [**2091**], Mr. [**Known lastname **] is a strong and healthy gentleman who
suffered a recent episode of acute pancreatitis in [**Month (only) **] of this
summer of [**2166**]. He was identified as having a pancreatic head
mass on CT imaging amidst the pancreatitis. This has been
followed up further with subsequent MRI and MRCP imaging in
[**Month (only) 205**].
He lost some weight, suffered through some anorexia that is
slowly improving, and was ultimately discharged from the
hospital
and has continued to improve. He is moving his bowels, making
good urine, and has no diarrhea. He has never developed
obstructive jaundice. The only recent symptom otherwise was
just
a general feeling of dizziness about three to four months ago.
He has no real prior surgical history. There was a question of
coronary artery disease, but he did well according to his result
with the stress test three to four years ago. I asked him to
determine from you if he has had any sort of carotid imaging in
light of the dizziness feeling and question of a vision loss
that
occurred three to four months ago. He had prostate cancer for
which he received external beam radiation therapy and he has
known Barrett's esophagus.
He also underwent an endoscopic ultrasound by Dr. [**Last Name (STitle) **]. This
clearly sees the pancreatic head lesion, which does not involve
any of the vasculature. Quite surprisingly, in my judgment, the
cytology report is negative for malignancy.
He has no other symptoms of chest pains or palpitations; no
pneumonia, shortness of breath, and he has not got diabetes.
Other than the recent weight loss around this acute illness, he
has been well. There is no family history of pancreatic cancer.
He is not anticoagulated, but does take aspirin 325 mg a day.
Past Medical History:
Barrett's esophagus
RETINAL VASCULAR OCCLUSION - BRANCH
CANCER, PROSTATE s/p radiation beam therapy in [**2159**]
CORONARY ARTERY DISEASE
HEADACHE - MIGRAINE
HYPERCHOLESTEROLEMIA
PRESBYOPIA
HEARING LOSS, SENSORINEURAL
GLAUCOMA
Social History:
Retired. Software developer (worked on the first computer system
at the [**Hospital1 **]), then product development consultant. Now composes
computer music. Two children from previous marriage. Lives with
wife. [**Name (NI) **]: [**Name2 (NI) **] cigars in 20s. EtOH/illicits: never.
Family History:
No first degree relatives with cancer.
Physical Exam:
Pre-Op Exam
On physical exam, he is well appearing, not jaundiced, and quite
intelligent. He understands the uncertainties of his case. His
neck is supple with midline trachea and no jugular venous
distention. His chest is clear. His cardiac rate and rhythm is
normal. His abdomen is entirely benign today with no masses or
tenderness. His extremities show no peripheral edema and full
range of motion with a normal gait and grossly normal neurologic
and vascular exams.
Discharge Exam
98.2 97.6 67 122/62 18 99%RA
Gen: NAD, A&Ox3
CV: RRR
Pulm: CTAB
Abd: Soft, non-distended, non-tender, well healing incision
dressed with steri-strips; dressed prior JP site
Pertinent Results:
[**2166-10-13**] 11:00AM BLOOD WBC-8.5 RBC-4.32* Hgb-11.6* Hct-35.9*
MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-218
[**2166-10-11**] 02:00AM BLOOD WBC-15.5* RBC-4.15* Hgb-11.3* Hct-34.1*
MCV-82 MCH-27.2 MCHC-33.1 RDW-14.7 Plt Ct-175
[**2166-10-10**] 03:25AM BLOOD WBC-21.9* RBC-4.40* Hgb-11.7* Hct-36.1*
MCV-82 MCH-26.6* MCHC-32.4 RDW-14.8 Plt Ct-192
[**2166-10-9**] 06:08PM BLOOD WBC-24.5*# RBC-4.50* Hgb-12.1* Hct-37.2*
MCV-83 MCH-26.9* MCHC-32.5 RDW-14.6 Plt Ct-191
[**2166-10-13**] 11:00AM BLOOD Plt Ct-218
[**2166-10-11**] 02:00AM BLOOD Plt Ct-175
[**2166-10-10**] 03:25AM BLOOD Plt Ct-192
[**2166-10-10**] 03:25AM BLOOD PT-14.2* INR(PT)-1.3*
[**2166-10-9**] 06:08PM BLOOD Plt Ct-191
[**2166-10-9**] 06:08PM BLOOD PT-14.1* INR(PT)-1.3*
[**2166-10-13**] 11:00AM BLOOD
[**2166-10-11**] 02:00AM BLOOD
[**2166-10-10**] 03:25AM BLOOD
[**2166-10-9**] 06:08PM BLOOD
[**2166-10-13**] 11:00AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-30 AnGap-9
[**2166-10-11**] 02:00AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-139
K-4.2 Cl-105 HCO3-29 AnGap-9
[**2166-10-10**] 03:25AM BLOOD Glucose-148* UreaN-15 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-24 AnGap-13
[**2166-10-9**] 06:08PM BLOOD Glucose-147* UreaN-16 Creat-0.8 Na-137
K-4.5 Cl-106 HCO3-20* AnGap-16
[**2166-10-13**] 11:00AM BLOOD ALT-62* AST-52* AlkPhos-44 TotBili-0.3
[**2166-10-11**] 02:00AM BLOOD ALT-63* AST-48* AlkPhos-32* TotBili-0.5
[**2166-10-10**] 03:25AM BLOOD ALT-97* AST-72* AlkPhos-33* TotBili-0.5
[**2166-10-9**] 06:08PM BLOOD ALT-136* AST-104* AlkPhos-35* TotBili-0.7
[**2166-10-13**] 11:00AM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.4*
Mg-2.0
[**2166-10-11**] 02:00AM BLOOD Calcium-8.0* Phos-1.7* Mg-2.1
[**2166-10-10**] 03:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3
[**2166-10-9**] 06:08PM BLOOD Calcium-7.9* Phos-4.3# Mg-1.7
[**2166-10-9**] 06:39PM BLOOD Type-ART pO2-86 pCO2-41 pH-7.32*
calTCO2-22 Base XS--4
[**2166-10-9**] 04:30PM BLOOD Type-ART Temp-36.8 Rates-10/ Tidal V-560
FiO2-100 pO2-120* pCO2-46* pH-7.32* calTCO2-25 Base XS--2
AADO2-549 REQ O2-91 Intubat-INTUBATED Vent-CONTROLLED
[**2166-10-9**] 02:09PM BLOOD Type-ART pO2-160* pCO2-44 pH-7.33*
calTCO2-24 Base XS--2
[**2166-10-9**] 12:40PM BLOOD Type-ART pO2-194* pCO2-42 pH-7.39
calTCO2-26 Base XS-0
[**2166-10-9**] 04:30PM BLOOD Glucose-155* Lactate-4.0* Na-136 K-4.6
Cl-106
[**2166-10-9**] 02:09PM BLOOD Lactate-2.6*
[**2166-10-9**] 12:40PM BLOOD Glucose-130* Lactate-1.7 Na-137 K-4.5
Cl-107
[**2166-10-9**] 04:30PM BLOOD Hgb-13.8* calcHCT-41
[**2166-10-9**] 02:09PM BLOOD Hgb-13.8* calcHCT-41
[**2166-10-9**] 12:40PM BLOOD Hgb-13.8* calcHCT-41
[**2166-10-9**] 04:30PM BLOOD freeCa-1.06*
[**2166-10-9**] 12:40PM BLOOD freeCa-1.11*
[**2166-10-17**] 11:01AM BLOOD CA [**73**]-9 -PND
Brief Hospital Course:
The patient was admitted to the Hepatopancreaticobiliary Surgery
on [**2166-10-9**] for treatment of a presumed pancreatic adenocarcinoma
with suspected invasion of superior mesenteric vein. On [**2166-10-9**],
the patient underwent pylorus preserving pancreaticoduodenectomy
with en bloc resection of superior mesenteric vein, superior
mesenteric vein primary venorrhaphy (end-to-end), and CyberKnife
fiducial placements, which went well without complication
(reader referred to the Operative Note for details). Of note, a
Left subclavian line was placed with a post-placement CXR that
showed a Large left sided Pneumothorax. A pigtail catheter chest
tube was placed and eventually, the lung fully expanded. The
chest tube was then removed with post-removal CXR showing
continued expansion of the lung.
After a brief, uneventful stay in the PACU, the patient was
transfered to the ICU for increased monitoring given his
vascular repair. After being stabilized in the unit for a couple
days, the patient arrived on the floor NPO on IV fluids, with a
foley catheter and a JP drain in place, and an epidural for pain
control. The patient was hemodynamically stable.
The [**Hospital 228**] hospital course was uneventful except for the need
for a chest tube placement (see above) and followed the Whipple
Clinical Pathway without deviation. Post-operative pain was
initially well controlled with an epidural, which was converted
to oral pain medication when tolerating clear liquids. The NG
tube was discontinued on POD#3, and the foley catheter
discontinued at midnight of POD#4. The patient subsequently
voided without problem. The patient was started on sips of
clears on POD#4, which was progressively advanced as tolerated
to a regular diet by POD#7. JP amylase was sent in the evening
of POD#6; the JP was discontinued on POD#7 as the output and
amylase level were low.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge on [**2166-10-17**], 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. Staples were removed, and steri-strips
placed. The patient was discharged home without services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. atorvastatin 20mg daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE [**Hospital1 **]
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**2-10**] tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
6. Senna 1 TAB PO BID
7. Ranitidine 150 mg PO HS
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
9. Metoclopramide 10 mg PO Q6H
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth daily Disp
#*56 Tablet Refills:*0
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
adenocarcinoma of the head of the pancreas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a Whipple procedure for adenocarcinoma of the head of
your pancreas with reconstruction of your superior mesentery
vein.
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 [**6-19**] 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:
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 2835**]
Date/Time:[**2166-10-27**] 9:30am
|
[
"157.0",
"V10.46",
"367.4",
"272.0",
"196.2",
"300.00",
"512.1",
"V15.82",
"414.01",
"389.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.37",
"52.7",
"34.04",
"03.90",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
10446, 10465
|
6255, 8991
|
319, 362
|
10552, 10552
|
3507, 6232
|
12953, 13084
|
2755, 2795
|
9533, 10423
|
10486, 10531
|
9017, 9510
|
10703, 11814
|
12440, 12930
|
2810, 3488
|
11846, 12425
|
241, 281
|
390, 2187
|
10567, 10679
|
2209, 2437
|
2453, 2739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,422
| 167,640
|
15650+15651+56679
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2198-1-2**] Discharge Date: [**2198-1-5**]
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
with symptomatic critical aortic stenosis. Short of breath,
without angina or syncope. Catheterization shows LVEDP of
25, gradient 45, mean [**Location (un) 109**] 0.62, PA 73/27, with CI of 1.87.
PHYSICAL EXAMINATION: General examination normal. Healed
right carotid endarterectomy. Chest clear. S1, S2, III/VI
systolic ejection murmur with radiation to carotids.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2198-1-2**], where an aortic valve replacement (21 mm
[**Last Name (un) 3843**]-[**Doctor Last Name **]) was performed. The pericardium was left
open, and ventricular and atrial wires were placed, as well
as two mediastinal tubes. The patient was transferred to the
Cardiothoracic Surgery Intensive Care Unit, where her
postoperative course was uneventful.
She remained in normal sinus rhythm and was transferred to
the Surgical floor on postoperative day two. The patient, on
postoperative day two, reverted to atrial fibrillation. The
patient was known to revert to occasional atrial fibrillation
rhythm. The patient was started on Lopressor 25 mg twice a
day, and her Digoxin regimen was restarted for rate control.
The patient continued to do well in terms of controlling her
rate of atrial fibrillation, but her rhythm remained
unchanged. She was normotensive throughout her postoperative
course, and the patient was discharged on her preoperative
regimen of rate control medication.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg (Tuesday, Thursday, Saturday, Sunday),
0.25 mg (Monday, Wednesday and Friday)
2. Captopril 25 mg by mouth three times a day
3. Amitriptyline 10 mg by mouth once daily
4. Aspirin 325 mg by mouth once daily
5. Zantac 150 mg by mouth twice a day
6. Colace 100 mg by mouth twice a day
7. Lasix and potassium chloride 20 mg twice a day for seven
days
8. Lopressor 25 mg by mouth twice a day
FO[**Last Name (STitle) **]P PLANS: The patient is to follow up with Dr. [**Last Name (Prefixes) 411**] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 17480**]
MEDQUIST36
D: [**2198-1-4**] 22:24
T: [**2198-1-5**] 00:27
JOB#: [**Job Number 45183**]
Admission Date: [**2198-1-2**] Discharge Date: [**2198-1-9**]
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is an 84 year old with
symptomatic critical aortic stenosis. The patient is short
of breath without angina or syncope. Catheterization shows
normal
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2198-1-9**] 09:25
T: [**2198-1-9**] 09:27
JOB#: [**Job Number 45184**]
Name: [**Known lastname 497**], [**Known firstname 3441**] Unit No: [**Numeric Identifier 8316**]
Admission Date: [**2198-1-2**] Discharge Date: [**2198-1-9**]
Date of Birth: [**2112-12-31**] Sex: F
Service:
ADDENDUM: The patient was kept for three days secondary to
mental status changes that were inconsistent with her
baseline state of health. The patient was consistently
confused from [**1-5**] and a urinalysis,
electrocardiogram, and urine culture at that time were all
negative for any changes. The patient remained in atrial
fibrillation which was not new for her. There were no
neurological deficits.
Psychiatry was consulted and recommendations were made to
give the patient prn Risperdal and this was based on a
diagnosis of delirium.
On [**2198-1-7**] in the evening, the patient spiked a
temperature of 101, and was subsequently pancultured.
Urinalysis was found to have white count of greater than
1,000, and the patient was started on ciprofloxacin 500 [**Hospital1 **].
The patient subsequently returned to her baseline mental
status and was able to converse and was engagable as per her
family. The patient was also restarted on her previous
Coumadin regimen and the INR will be followed by her primary
care physician.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg po bid.
2. Folic acid 1 mg po q day.
3. Vitamin B12 50 mcg po q day.
4. Coumadin 3.75 4x a week; Tuesdays, Thursdays, Saturday,
Sunday, Coumadin 7.5 mg po Monday, Wednesday, Friday.
5. Digoxin 0.25 mg po Monday, Wednesday, Friday. Digoxin
0.125 mg po Tuesdays, Thursdays, Saturday, and Sunday.
6. Metoprolol 25 mg po bid.
7. Amitriptyline 10 mg po q hs.
8. Captopril 25 mg po tid.
9. Colace 100 mg po bid.
[**Last Name (STitle) 1383**] DR.[**Last Name (Prefixes) **],[**First Name3 (LF) **] 02-351
Dictated By:[**Last Name (NamePattern1) 8317**]
MEDQUIST36
D: [**2198-1-9**] 09:36
T: [**2198-1-9**] 09:38
JOB#: [**Job Number 8318**]
|
[
"293.0",
"424.1",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
4352, 5038
|
556, 1613
|
388, 538
|
1628, 1674
|
2624, 4329
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,463
| 119,399
|
27037
|
Discharge summary
|
report
|
Admission Date: [**2168-12-18**] Discharge Date: [**2168-12-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
Resuscitation
History of Present Illness:
88yo man with PMH significant for HTN and prostate cancer
presents with approximately one year of "dizziness." He notes
this began approx 1 yr ago after a gallbladder operation at
[**Hospital3 **]. Since then, he has had an extensive workup,
including MRI/MRAs x 2, which has shown that he has had a stroke
in the past. He does not know of any other findings. He comes to
the hospital today because it has been progressive over the last
year and his daughter finally brought him to the hospital. He
reports increasing difficulty walking, though he lives by
himself, and is still able to get around his house while holding
on to objects in his home. He describes his dizziness as a
"heaviness" in his head that occurs mostly upon standing up,
though it can occur when lying in bed with change in position.
He always has this feeling when standing. He reports associated
nausea, no vomiting. Denies vertigo (any sense of spinning).
Denies loss of consciousness. He also reports two episodes that
he describes as "seizures." These also occurred upon standing,
and he described them as a feeling that "somebody takes your
head and shakes it up and goes crazy." They last for
approximately five minutes and are associated with weakness.
Once he fell on the bed, once he sat down on a bench and they
resolved. Neither were associated with bowel or bladder
incontinence or loss of consciousness. It is unclear if they
were associated with confusion after the episode, but the
patient was able to get home from the park. ROS is significant
for hearing loss in his right ear x years. Denies vomiting,
headache, cough, URI sx, palpitations.
Past Medical History:
arthritis
asthma
s/p cholecystecomy [**12-16**]
s/p CVA
prostate cancer
back surgery for ruptured disc
infection in back
fractured leg and ankle
Social History:
lives alone, operating engineer
quit smoking [**2123**], denies EtOH, drugs
Family History:
noncontributory
Physical Exam:
VS: afebrile, HR 72, BP 183/85, RR 14, SaO2 100%/RA, not
orthostatic
Genl: pleasant elderly man alert in bed
HEENT: NCAT, conjunctiva clear, fundi clear, MMM, OP clear;
tympanic membrane clear on R, nonvisualized on left secondary to
pts significant pain with exam
Neck: no LAD
CV: RRR, nl S1, S2, no S3, S4, no m/r/g
Lungs: CTA bilaterally, no wheezes, rales, rhonchi
Abd: soft, nontender, nondistended, BS+, no hepatosplenomegaly,
no rebound/guarding
Ext: warm and dry, L>R (atrophy on R), R foot s/p injury, thenar
atrophy, PP 2+ in LLE, 1+ in RLE
Neuro: CNII-XII intact w/ occasional counterclockwise torsional
nystagmus on right gaze, no vertical nystagmus, and hearing
decreased in R ear, fairly preserved in L. Strength preserved in
BUE in all muscle groups except 4+ grip in L, 4 grip in R.
Strength preserved in BLE except decreased plantarflexion of R
foot. Atrophy as above. Sensation intact except in R foot,
vibration decreased in B feet. Reflexes 2+ except 1+ in
achilles, none on soles, 3+ w/ spreading with R patellar, 2+ in
L patellar. FNF intact. [**Doctor First Name **] decreased on R, pt right handed.
Gait wide-based per neuro R2 and MSIII.
Pertinent Results:
Admission labs:
CBC: WBC-14.5* RBC-3.78* Hgb-11.6* Hct-34.4* Plt Ct-248
Diff: Neuts-43* Bands-0 Lymphs-55* Monos-2 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0 (on [**12-20**], Lymphs were 70%)
Smear: Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL
Coags: PT-12.9 PTT-20.6* INR(PT)-1.1
Chem 10: Glucose-140* UreaN-32* Creat-1.6* Na-142 K-4.4 Cl-106
HCO3-23
Calcium-8.7 Phos-2.9 Mg-2.0
Fe studies: Iron-69 calTIBC-263 VitB12-384 Folate-19.5
Ferritn-81 TRF-202
Other:
LD(LDH)-172
TSH-1.1
Testost-764
PSA-1496*
Admission EKG:
Normal sinus rhythm, rate 93. No diagnostic abnormality. No
previous tracing available for comparison.
Admission CXR:
1. No evidence of consolidation.
2. Bilateral symmetric increased interstitial opacities with
bilateral septal lines. Statistically this is most likely due to
interstitial pulmonary edema. Nevertheless the heart is of
normal size and there are no pleural effusions. If this findings
persist after diuresis, other causes of interstitial lung
disease should be considered and high resolution CT of the chest
should be performed.
L knee xray: Advanced medial osteoarthritis of the left knee and
small joint effusion.
BLE u/s: There is extensive acute intraluminal occlusive
thrombus involving the deep veins of the left side extending
from the below-knee tibial veins to the level of and involving
the common femoral vein. Within the posterior aspect of the knee
there is also identified a 3.6 x 2.5 cystic structure which
contains intraluminal echogenic material, which has the
morphology of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst. This is non-vascular and is not
thought to represent a vascular lesion.The intracystic echogenic
material probably represents fibrinous debris and/or clot. The
deep veins of the right groin appear compressible with normal
augmentation and respiratory variation. A small amount of
circumferential thickening on the right side may represent
recanalization from the previous DVT.The remainder of the right
leg is not examined.
CONCLUSION:
1. Extensive deep venous thrombosis on left side.
2. Complicated [**Hospital Ward Name 4675**] cyst, left popliteal fossa.
3. Possible chronic nonocclusive recanalized thrombosis of right
SFV.
Renal u/s: The right kidney measures 10.3 cm. The left kidney
measures 10.3 cm. There is no hydronephrosis or stones. The
bladder is normal in appearance, without any evidences of wall
thickening. The prostate appears enlarged.
Brief Hospital Course:
This is an 88 yo man with HTN, prostate ca w/ poss mets to bone,
previous CVA, here for dizziness after extensive outpt workup
with unknown findings. He was found to have an extensive DVT on
his second hospital day, [**12-19**], and was receiving
anticoagulation and further evaluation for dizziness when on the
night of [**12-20**] he went into PEA arrest, was recusitated by the
code team, and transferred to MICU. There goals of care were
made to be comfort measures only, and all other care was
withdrawn.
Hospital course is reviewed below by problem:
1. PEA arrest: This was thought to be most likely secondary to a
PE, given his known extensive DVT. He was resuscitated on four
pressors, and weaned to two in the MICU. However, he remained
unresponsive with questionable hope for improvement. His family
decided that he would not want to remain in the state in which
he was, and they requested that the goals of care be comfort
measures only. All other treatment was withdrawn.
2. Dizziness: Differential diagnosis included central,
peripheral, and cardiogenic etiologies. Suspected peripheral
causes included BPPV or vestibular neuritis possibly from
vertebrobasilar insufficiency. Pt had intermittent rotational
nystagmus.
Central etiologies were also considered and included: a) mets to
the brain from metastatic prostate cancer; b) spinal involvement
from prostate cancer; c) new brain infarcts from additional,
perhaps "silent" CVAs; d) processes affecting the vestibular
nerve, such as schwannomas, although pt did not report tinnitus
or other findings characteristic for acoustic neuromas. MRI/MRAs
of the head and spine were ordered and both oncology and
neurology were following.
Cardiogenic causes for pt's dizziness seemed less likely. Pt was
on telemetry but had no telemetry events despite continued
episodes of dizziness. He also had normal EKG findings, no
cardiac/pulmonary symptoms, and no hx of palpitations,
arrhythmias, or heart disease.
Additionally, the pt had other causes contributing to gait
instability and increased fall risk. He had impaired function in
righ foot, significant right sided leg atrophy, and impairment
of dynamic motion from chronic back pain. The patient had been
living alone and future falls were concerning. He had PT/SW
consults scheduled. He was started on calcium and vitamin D.
For adjunctive treatments related to his dizziness, pt was
receiving ASA 81 and compazine PRN. He was able to ambulate with
assistance.
In the MICU, he was made CMO and all other care was withdrawn.
3. DVT: on [**12-19**], the pt had sudden onset of left knee pain and
swelling while walking with his physical therapist. The knee was
warm and erythematous with anterior and posterior/popliteal
swelling and within an hour the erythema had extended up to his
mid-thigh and his left foot was reported to have cyanotic
changes. He was sent to U/S and found to have an extensive DVT
in his left leg involving tibial and femoral veins, as well as a
complicated [**Hospital Ward Name 4675**] cyst, and possible chronic nonocclusive
thrombosis of the right SFV. He had a significant risk factor,
hypercoagulability from his prostate cancer. He had been on
subcutaneous heparin injections, but was started on IV heparin
and coumadin when his DVT was discovered. In the MICU, he was
made CMO and all other care was withdrawn.
4. Increased interstitial opacities on CXR - Though these were
concerning for CHF or PNA, he was asymptomatic. No antibiotics
or diuretics were started. He was made CMO and no other care was
given.
5. Renal insufficiency - He was noted to have a creatinine of
1.5 at [**Hospital1 **]. Urine electrolytes revealed a FENa of 0.65%,
BUN/CR ~ 20, suggesting a prerenal process. He was hydrated. A
renal ultrasound to assess for postobstructive process showed no
hydronephrosis.
6. HTN - Well controlled on 25mg metoprolol [**Hospital1 **], withdrawn when
pt was made CMO.
7. Prostate cancer - Oncology was consulted. Casodex was
started. Other recommendations were made just prior to the
patient going into cardiac arrest.
8. Asthma - Continued albuterol during the hospitalization until
CMO.
9. Leukocytosis - The patient was noted to have a leukocytosis
with lymphocytic predominance. Given the number of lymphocytes,
CLL was a possibility.
Medications on Admission:
toprol
albuterol
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulseless electrical activity arrest
Presumed pulmonary embolus
Deep venous thrombosis in left lower extremity
Dizziness, unspecified
Prostate cancer
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"585.9",
"V10.46",
"780.4",
"453.8",
"518.81",
"493.20",
"401.9",
"781.2",
"198.5",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.71",
"99.10",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10411, 10420
|
6009, 10316
|
273, 288
|
10613, 10622
|
3442, 3442
|
10674, 10680
|
2226, 2243
|
10383, 10388
|
10441, 10592
|
10342, 10360
|
10646, 10651
|
2258, 3423
|
224, 235
|
316, 1948
|
3458, 5986
|
1970, 2117
|
2133, 2210
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,109
| 179,978
|
1460
|
Discharge summary
|
report
|
Admission Date: [**2197-5-26**] Discharge Date: [**2197-5-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
[**Age over 90 **] year old female with recent admission from [**Date range (1) 8677**] for
upper GI bleed secondary to duodenal ulcer, discharged to [**Hospital 100**]
Rehab. She was found at rehab incontinent of large amounts of
melena and BRBPR with clots. On last admission, EGD revealed
duodenal ulcer s/p epinephrine injection, clipping, and thermal
therapy. EGD x 2 given re bleed. HR at rehab was 105, systolic
BP 90s. Patient was lightheaded and developed bright red blood
per rectum and clots.
.
On arrival to ED patient was having active BRBPR, BP as low as
77/37, HR 110. HCT 22.3 She was transfused 2 units of RBCs, and
cross matched 4 units. 1 unit of FFP ordered. 1 liter NS given
with return of SBP to 100. GI was notified and recommended ICU
admission.
.
In the ICU patient alert, and interacts though with noted
conjunctival palor. Denies CP, shortness of breath, or abdominal
pain. Endorses some weakness that began earlier today, but has
since resolved. No nausea, says she vomited x1 on the way to the
hospital. Though no blood in her emesis. States visiting nurse
noticed blood in her stool and was concerned given hx therefore
sent her to the ED. Patient unable to relate details of earlier
today. Intubated for procedure, complicated by hypotension and
respiratory distress. Question of reintubation, and thus on
BiPAP. Having active melena. No more interventions per GI
other than surgery. Melana now improved. Got lasix and prn
morphine. Comfortable. Currently DNR/DNI without esclation.
Past Medical History:
Anemia, Acute blood loss
duodenal ulcer with bleed [**2196-4-26**]
Chronic renal insufficiency -baseline Cr 1.9
chronic CHF
HTN
A-fib
Hypothyoidism
MDS Hct ~30s, plts ~100, worsening leukocytosis
Pulmonary fibrosis on home 02 (2L)
s/p Right Hip Replacement
s/p Right Knee Replacement
s/p Appendectomy
Social History:
- Home: lives in senior housing in [**Location (un) **], has nurse in
facility who visits her regularly and administers weekly
procrit. She has two sons, [**Name (NI) **] lives in [**Name (NI) 1439**], other son in
[**Name (NI) 701**]. Widowed since [**2157**]. Walks with walker.
- Tobacco: Smoked 1 PPD x 40 yrs, quit in [**2147**].
- EtOH: No EtOH.
- Occupation: She worked many years ago as a clothing buyer.
Family History:
nc
Physical Exam:
Physical Exam on transfer:
Vitals: T: 98.3 BP:118/54 P: 108 R:22 O2: 91% on 2L
General: Pale appearing, sitting up eating dinner, NAD
HEENT: Sclera anicteric, dry mucus membraines, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: tachypneic, no nasal flaring, crackels [**1-27**] way up lung
fields bilaterally
CV: Irregularly irregular, nl s1/s2, II/VI systolic murmur heard
best at left lower sternal border, no rubs, gallops
Abdomen: + BS throughout, soft, non-tender, non-distended, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses. No clubbing or cyanosis. 2+
pitting edema of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. Chronic venous stasis changes
Pertinent Results:
[**2197-5-25**] 11:00PM PT-16.1* PTT-30.4 INR(PT)-1.4*
[**2197-5-25**] 11:00PM PLT SMR-LOW PLT COUNT-145*#
[**2197-5-25**] 11:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
[**2197-5-25**] 11:00PM NEUTS-70 BANDS-1 LYMPHS-9* MONOS-16* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-2* NUC RBCS-1*
[**2197-5-25**] 11:00PM WBC-29.2* RBC-2.34*# HGB-7.3*# HCT-22.3*
MCV-95 MCH-31.2 MCHC-32.9 RDW-16.6*
[**2197-5-25**] 11:00PM GLUCOSE-130* UREA N-47* CREAT-1.6* SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
[**2197-5-26**] 01:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
.
Upper endoscopy: Ulcer in the at the junction of first part of
and second part of the duodenum (endoclip, injection). Erosion
in the fundus compatible with likely an NG trauma Otherwise
normal EGD to second part of the duodenum. Recommendations: [**Hospital1 **]
PPI if recurrent bleeding pls get a surgical consult. [**Month (only) 116**] need
IR embolization by IR if recurrent bleeding. AVOID NSAIDs.
.
EKG [**2197-5-27**]- Atrial fibrillation with a moderate to rapid
ventricular response. Diffuse non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2197-5-25**] the
heart rate is marginally faster. QRS voltage in the limb leads
is slightly larger. Clinical correlation is suggested.
.
blood culture [**2197-5-26**] - pending
.
Urine culture [**2197-5-26**]- URINE CULTURE (Final [**2197-5-30**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
CIPROFLOXACIN Susceptibility testing requested by
[**First Name8 (NamePattern2) 8678**] [**Doctor Last Name 8679**]
([**Numeric Identifier 8680**]).
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
CIPROFLOXACIN--------- 1 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
[**Age over 90 **] yo F with known duodenal ulcer s/p EGD injection, endoclip,
and thermal therapy one week prior to admission, presented with
BRBPR and melena.
.
# GI bleed: Hct 22 on admission secondary to duodenal ulcer,
that has previously since been clipped and injected. Patient
presented to ED with active BRBPR and hyptension, given 2 units
pRBCs and 1 liter NS. In ICU additional unit pRBC given and
continued to be hypotension. NG lavage with bright red blood.
Patient was electively intubated for upper endoscopy which
demonstrated ulcer at the junction of first part of and second
part of the duodenum which was then endoclipped and injection.
GI recommended if further bleeding would need surgical/IR
intervention. Patient and family did not want further aggressive
intubation. On transfer to the floor patient is tachycardic and
tachypneic. GI stated that the plan was that if patient
continued to bleed that she would need surgery, however patient
and family have declined this intervention so that plan is to
pursue non-aggressive care. ON transfer patient advanced to
full diet and tolerated it well. Hematocrit on the floor
remained stable. Patient was maintained on IV PPi [**Hospital1 **] with
active type and screen and two large bore IVs.
.
# Chronic renal insufficiency: Baseline Cr 1.9, however Cr on
admission 1.6 which improved to 1.5. UA suggestive of UTI with
urine culture with gram + bacteria, urine culture with
enterococcus that is sensitive to ciprofloxacin. Patient was
treated with ciprofloxacin and this is to be continued on
discharge (confirmed with microbiology lab that enterococcus
that was isolated is indeed sensitive to ciprofloxacin).
Nephrotoxins were avoided.
.
# Leukocytosis: WBC 29.2 on admission which trended down to 21
which is patient's baseline. Patient has known MDS, and
persistent leukocytosis. On last admission, WBC between 19 and
28. Patient had infectious work-up initially because hypotensive
in the ICU. Patient had one blood culture drawn which is still
no growth to date on day of discharge. UA demonstrates [**7-5**]
WBCs, trace LE. Culture with gram + bacteria, enteroccos. No
Evidence on chest x-ray of infiltrate. Patient has been
afebrile with no other localizing symptoms. UTI treated with
ciprofloxacin as above.
.
# Hypertension: Patient has a history of HTN, on metoprolol as
outpatient. Patient was previously hypotensive in the ICU so
beta blocker was held in teh setting of GI bleed, once
stabilized was discharged back on outpatient beta blocker dose
which was converted to long acting.
.
# Chronic diastolic CHF: Echo on last admission shows preserved
EF of 60%. Patient appears to have evidence of volume overload
on exam with significant bilateral lower extremity edema and
crackles in bilateral lung fields after transfer out of the MICU
likely secondary to volume resuscitation and diastolic heart
failure. Patient was diuresed with 20 IV Lasix x2 and put out
over 1 liter of urine to each of these. A decision was made to
discharge patient on low dose oral lasix.
.
# Atrial fibrillation: Patient not anticoagulated secondary to
active GI bleed and previous history of GI bleed. Initially held
outpatient metoprolol, restarted once hemodynamically stable.
Beta blocker converted to long acting, HR on discharge low 100s.
.
# h/o MDS: Baseline HCT in 30s, currently 29, platelets in low
100s, with persistent leukocytosis. Patient with baseline
thrombocytopenia, did not recieve any platelet products.
.
# h/o pulmonary fibrosis: Uses 2L oxygen at baseline which was
continued on admission. Patient with difficult extubation after
endoscopy, however did well on 2L NC afterwards. Patient with
some evidenec of fluid overload on exam after transfer out of
the MICU was diuresed appropriately with 20 IV lasix x2 with
some mild subjective improvement in shortness of breath. Patient
was started in ipratropium nebs standing which also appeared to
help with shortness of breath. WOuld continue additional O2 to
maintain sats > 92%.
.
# Hypothyroidism: Patient was continued on synthroid per
outpatient regimen
.
# FEN: encourage PO intake, replete electrolytes PRN, 2 liter
fluid restriction
.
# Prophylaxis: pneumoboots
.
# Access: 2 large bore PIVs
.
# Code: DNR/DNI, no escalation of care (confirmed with Patient
and health care proxy)
.
# Communication: Patient and family
In Emergency [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 8676**] ( home) [**First Name8 (NamePattern2) **] [**Known lastname **] best
number: ([**Telephone/Fax (1) 8681**]
Medications on Admission:
1. Simethicone 80 mg Tablet, Chewable Sig: [**1-27**] Tablet, Chewables
PO QID (4 times a day) as needed.
2. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
q Wednesday.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day). Tablet(s)
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for dyspnea, pain: please hold for sedation or
RR < 12.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
please hold for BP < 100, HR < 55.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia: please hold for sedation or RR < 12.
9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary: upper GI bleed
.
Secondary:
Anemia, Acute blood loss
duodenal ulcer with bleed [**2196-4-26**]
Chronic renal insufficiency -baseline Cr 1.9
chronic CHF
HTN
A-fib
Hypothyoidism
MDS Hct ~30s, plts ~100, worsening leukocytosis
Pulmonary fibrosis on home 02 (2L)
s/p Right Hip Replacement
s/p Right Knee Replacement
s/p Appendectomy
Discharge Condition:
afebrile, vital signs stable, awake, alert, oriented x3, NAD
Discharge Instructions:
You were admitted to the hospital with an upper GI bleed.
Initially you were in the ICU and were somewhat unstable,
however your bleeding stopped and your hemodynamics improved.
You underwent endoscopy which required intubation and extubation
was difficult. You were transferred to the floor. A family
meeting was held and decision to pursue non-aggressive care was
decided upon - as GI felt that if you were to bleed again you
would require surgery and this option was declined by you and
your family. You are being transferred back to [**Hospital 100**] Rehab at
this time with the plan that if you were to rebleed you would
not be rehospitalized.
.
Medication changes:
1) You were started on low dose oral lasix to prevent fluid
accumulation in your lungs
2) Your beta blocker was changed to long acting
3) You were started on a proton pump inhibitor twice a day given
your GI bleeding
4) You were started on an antibiotic given a urinary tract
infection for which you should complete the outpatient course
.
You should take your medications as prescribed. In addition, we
would reccomend that on transfer to rehab you have a palliative
care consult.
.
Given you diastolic heart failure you should have daily weights
every morning and if you are noted to have > 3 pound weight gain
your dose of lasix should be increased. You should ddhere to 2
gm low salt heart healthy diet with a loose fluid restriction to
less than 2 liters per day. It has been a pleasure taking care
of you at [**Hospital1 **].
Followup Instructions:
You can follow up with your primary care doctor Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8682**] after discharge from [**Hospital 100**] Rehab. She can be reached
at ([**Telephone/Fax (1) 8683**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2197-5-31**]
|
[
"515",
"427.31",
"244.9",
"041.04",
"532.40",
"287.5",
"V46.2",
"428.0",
"428.32",
"286.9",
"599.0",
"238.75",
"403.90",
"285.1",
"584.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43",
"96.04",
"93.90",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11878, 11943
|
5670, 10243
|
267, 284
|
12325, 12388
|
3376, 5647
|
13941, 14288
|
2606, 2610
|
10830, 11855
|
11964, 12304
|
10269, 10807
|
12412, 13065
|
2625, 3357
|
13085, 13918
|
222, 229
|
312, 1835
|
1857, 2159
|
2175, 2590
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,520
| 199,872
|
32040
|
Discharge summary
|
report
|
Admission Date: [**2132-3-12**] Discharge Date: [**2132-6-12**]
Date of Birth: [**2061-5-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Colocutaneous fistula
Major Surgical or Invasive Procedure:
[**2132-3-18**] - Exploratory laparotomy, lysis of adhesions (4-1/2
hours), closure of 2 enterotomies, and transverse colostomy
feeding jejunostomy.
[**2132-4-17**] - [**Last Name (un) **] gastrostomy, change in the J-tube and
revision of colostomy.
[**2132-6-2**] - "colonoscopy" through stoma and EGD
History of Present Illness:
Mrs. [**Known lastname 75027**] is a pleasant 70 year old woman who has had an
enterocutaneous fistula ever since undergoing open repair of a
ruptured AAA in [**5-28**] at an outside hospital. Since then the
fistula has been treated with ostomy appliance and TPN. She was
discharged from [**Hospital1 18**] to [**Hospital **] rehab facility in [**11-28**]. At
rehab she gradually became stronger and her appetite increased
to
where she is now able to tolerate soft mechanical diet in
addition to her TPN. She is able to walk 250-400 feet as well.
While at rehab she had a Klebsiella UTI which was successfully
treated, and also received 4 doses of Ferrlicit for iron
deficiency anemia. Her albumin remained low throughout her time
at rehab. She reports only occasional abdominal pain/nausea
unrelated to eating, and says that her weight has been
increasing steadily. She does not have bowel movements and is
incontinent of urine. Patient was admitted for colocutaneous
fistula takedown.
Past Medical History:
*open [**Last Name (un) **] gastrostomy tube x 2 [**11-28**], [**10-28**]
*Ruptured AAA; s/p endovascular abdominal aortic aneurysm repair
[**2131-6-2**]
*[**2109**]: colon cancer; s/p right hemicolectomy; treated with s/p
radiation treatment (has bowel damage from XRT).
*[**2127**]: Postoperative radiation resulted in bowel damage;
developed small bowel obstruction underwent exploratory lap with
loa, complicated by developement EC fistula that closed with
after 1 year of treatment with TPN/enteral feedings.
*Incarcerated hernia
*Coronary artery disease s/p PCI (MI in '[**07**])
*Chronic obstructive pulmonary disease
*Chronic renal failure
*Hypertension
*Hypercholesterolemia
*Choleithiasis (asymptomatic)
*Urinary tract infection (Kleb, VRE)
*Chronic diarrhea
*Small bowel obstructions
*Weight loss (since [**2127**]) from 200lbs to 80lbs per patient
report
*Malnutrition/ failure to thrive
*History of C. Diff
*Hearing loss - wears right hearing aid
Social History:
Pt comes from Rehab facility, prior to which she has been
hospitalized since [**2131-5-22**] at various facilities. Prior to
[**May 2131**] she smoked 1 ppd for 55 years, and was drinking several
drinks per night for 12 years as well. She denies any
recreational drug use. Prior to [**5-28**] she was independent and
living on her own.
Family History:
Significant for father who died of MI at age 79; grandmother
with ? eye cancer
Physical Exam:
Weight: 49.4 kg
Height: 64inches
VS: 97.4 52 128/62 18 100% on RA
GEN: NAD, thin, well appearing elderly woman
HEENT: PERRLA, EOMI, anicteric, conjunctivae clear, oropharynx
pink/moist, upper dentures
NECK: Supple, no LAD, JVD or bruits
Chest: CTA B/L, adequate air intake
Heart: S1S2 RRR no M/G/R
Abd: Soft, mildy tender to palpation lateral to fistula on R,
hyperactive BS, fistula with [**Location (un) 2452**] output, ostomy appliance
intact without leak
Ext: no C/C/E
Neuro: Grossly intact, 4/5 strength x4, no focal deficits, AAO
x3
On discharge:
Weight:
Height: 64 inches
VS: 99.3 90 160/80 18 95RA FS 129
Gen: NAD, thin
CV: Irregularly irregular with normal rate
Lungs: CTABL decrease breath sounds bilateral bases
Abdomen: +BS, soft, nontender G and J tube in place without
surrounding erythema. Ostomy functioning with thin stool that
has particulate matter
Extremeties: thin but no edema or lesions\
Coccyx: Stage IV pressure ulcer 3.5x2.5x1 cm with granular
tissue upper [**1-24**] of wound bed. There is 3cm of undermining from
[**2-26**] oclock. There is moderate amount of straw coloered drainage
that is not malodorous. No signs of infection.
Neuro: no focal deficits
Pertinent Results:
Admission Labs
--------------
[**2132-3-12**] 05:34PM GLUCOSE-86 UREA N-55* CREAT-1.1 SODIUM-137
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2132-3-12**] 05:34PM ALBUMIN-2.6* CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-2.0 IRON-21*
[**2132-3-12**] 05:34PM calTIBC-163* FERRITIN-815* TRF-125*
[**2132-3-12**] 05:34PM TRIGLYCER-98
[**2132-3-12**] 05:34PM WBC-9.0 RBC-3.75*# HGB-10.4*# HCT-32.1*#
MCV-86# MCH-27.7# MCHC-32.4 RDW-16.1*
[**2132-3-12**] 05:34PM PLT COUNT-235
[**2132-3-12**] 05:34PM PT-14.4* PTT-34.2 INR(PT)-1.3*
.
Radiology
---------
[**2132-3-12**] 8:41 PM ~ CHEST (PRE-OP PA & LAT)
IMPRESSION: No acute pulmonary process. Resolved pulmonary edema
and left pleural effusion.
[**2132-3-26**] CT abd
IMPRESSION:
1) The right kidney hydronephrosis has resolved. There is mild
prominence of the upper right ureter. Relatively large right
parapelvic cyst is visualized.
2) Pneumatosis partially resolved.
3) Unchanged small quantity of free intraperitoneal air and
fluid related to the patient's recent surgery.
4) No distended loop of small bowel or large bowel is
visualized.
5) Interval development of bilateral patchy opacities of both
lung bases is most likely suggestive of aspiration.
6) Findings of chronic pancreatitis.
7) Unchanged left adrenal nodule.
8) Unchanged abdominal aortic aneurysm status post repair.
[**2132-4-3**] CT abd
IMPRESSION:
1. No definite evidence of obstruction, fistula, or leak. Near
complete resolution of pneumatosis.
2. Tiny focus of extraluminal air in the right lower quadrant,
may represent post-surgical change, verus residuum of
pneumatosis, versus air in small diverticulum.
3. Area of nodular tissue thickening, and enhancement in the
lower abdomen adjacent to open wound, involving fascia, and
adjacent bowel loops. No definite fistulous connection is seen.
4. Unchanged appearance of 3.2-cm saccular abdominal aortic
aneurysm.
5. Increased small left pleural effusion.
6. Unchanged appearance of findings consistent with chronic
pancreatitis.
7. Unchanged small left adrenal nodule.
[**2132-5-31**] CXR
No free intraperitoneal air is identified. Heart size is normal,
and lungs are grossly clear.
[**2132-5-31**] AXR
Tubular structure overlies the left upper abdomen and probably
represents the gastrostomy tube. Mildly distended loops of small
and large bowel are present in the mid abdominal region.
.
Date---Fe---TIBC--[**Last Name (un) **]---TRF---Alb---TG
[**3-12**]---21---163---815----125---2.6---98
[**3-17**]---34---152---872----117---2.7---53
[**3-24**]----15---90---1151----69----2.9
[**3-31**]---18---82---1082----63----1.9--103
[**4-7**]---32---103---969----79----2.4--118
[**4-14**]---24---[**Telephone/Fax (1) 75028**]----80----2.4--124---22---5.7----79
[**4-21**]---30---87---1603----67----2.3---69
[**4-28**] ---15---81-->[**2124**]----62----2.1--117
[**5-5**]---26---[**Telephone/Fax (1) 75029**]---2.1
[**5-11**]---34---[**Telephone/Fax (1) 75030**]---2.4--123
[**5-19**]---25---[**Telephone/Fax (1) 75031**]----90 ---1.9--
[**5-25**]----32---[**Telephone/Fax (1) 75032**]----93----2.0--107
[**6-1**]---13---[**Telephone/Fax (1) 75033**]----86----2.1--78
[**6-8**]---31---[**Telephone/Fax (1) 75034**]---2.2--365
.
[**2132-3-26**] ECG
Sinus tachycardia and occasional atrial ectopy. Tall peaked P
waves with
rightward P wave axis consistent with right atrial enlargement.
Compared to the previous tracing of [**2132-3-21**] no diagnostic
interim change.
.
[**2132-6-10**]
NA 137 Cl 103 BUN 55 Glc 86 AGap=13
K 5.1 BUN 26 Cr 1.1
Ca: 9.6 Mg: 2.0 P: 3.7
WBC 9.0 HCT 32.1 Platelets 235
PT: 14.4 PTT: 34.2 INR: 1.3
Micro:
[**3-15**] UCx: pseud, R Cipro
[**2-/2053**] Sp Cx: MRSA, yeast, mod GNRs
[**3-24**] BCx: P, UCx:NG
[**3-25**] bile cx: 4+ GPC pairs, chains, 4+ GNRs, 3+ budding yeast;
cx: enterococcus, klebsiella pneumo (s-zosyn, amikacin), coryn
dipth, yeast (sparse)
[**3-25**] Cdiff toxin B: neg
[**3-25**] sputum: 4+GNR, 2+GPC; klebsiella pn (S-amikacin, [**Last Name (un) 2830**],
zosyn)
[**3-25**] BCx: NG, UCx: NG
[**4-7**] UCx: yeast >100K
[**4-9**] BCx: enterococcus faecium, resistent to vanc, amp, levo
[**4-10**], [**4-12**], [**4-13**] BCx: NG
[**4-15**] UCx: yeast >100K
[**4-16**] blood cx: NG
[**4-21**] UCx: Klebsiella-[**Last Name (un) 2830**] [**Last Name (un) 36**]
[**4-27**] Ucx: Klebsiella-[**Last Name (un) 2830**] [**Last Name (un) 36**]
[**4-27**] BCx: NG
[**5-15**] Ucx: Pseudomonas + Klebsiella (amikacin and [**Last Name (un) 2830**] [**Last Name (un) 36**])
[**5-31**] Bcx: negative x 2
[**5-31**] sacral decubitus ulcer wound swab - Pseudomonas rare growth
[**5-31**] Ucx: Klebsiella [**Last Name (un) 36**] only to Amik, [**Last Name (un) **], Zosyn
Brief Hospital Course:
Patient was admitted and preopped and consented for fistula
takedown, colostomy creation and J tube placement. She
tolerated the procedure reasonably well. She was transferred to
the unit and was there until HD 69. During her ICU course she
had afib with RVR and was placed on diltiazem drip. She an
episode of possible aspiration and was treated with
hydrocortisone lavage. She recovered well from this and
eventually tube feeds through J tube were restarted. On [**4-17**]
she had an G tube placed for increased NGT output. Her tube
feeds were gradually increased and G tube was to gravity putting
out thick bilious fluid. She was treated with prokinetics with
minimal decrease in G tube output.
On HD 83 a pediatric cscope was used to look up her stoma.
There was no obvious obstruction but she did have a 5cm
stricture at the colostomy site. Her EGD was unremarkable.
Post cscope she had significant increase in her ostomy output
with subsequent decrease of the Gtube output. Her tubefeeds
were increased and her G tube was clamped for increasing time
intervals. She tolerated these well and was eventually able to
tolerate 2.5 to 3 hour clamps every 4 hours. Ostomy output
became more particulate throughout postoperative period.
Her pain was initially controlled with IV pain medications but
was transitioned to fentanyl patch at 75mcg. This was weaned
off over the last 3 weeks of her hospitalization and at
discharge was on no narcotic pain medications.
Her afib was intermittent and she was monitored on telemetry.
She was rate controlled with scheduled po diltiazem and with prn
metoprolol. On [**6-10**] she had aflutter with RVR. Cardiac enzymes
were negative and EKG showed no ST changes. She was
asymptomatic and had onset while OOB. She was rate controlled
with IV lopressor and HR stayed around 80 bpm thereafter.
She had some respiratory distress early in her hospitalization
due to aspiration and was treated with hydrocortisone lavage.
Her respiratory status improved and on discharge has been off
any supplemental 02 for weeks.
She developed multiple UTI's and was treated intermittently with
IV abx for these infections. Her most recent UTI was Klebsiella
sensitive only to meropenem and amikacin - she was treate with
10 day course of meropenem.
Her nutritional status was closely monitored and on discharge
she was tolerating regular diet, TPN, and 1/2 strength tube
feeds. Please see nutrition labs in lab section.
Physical therapy was [**Month/Year (2) 4221**] and were able to get her OOB and
walking with assistance for the last 3-4 weeks of
hospitalization. She was able to ambulate with assistance for
~20 feet. She will need continued work with PT and this will be
one of her primary goals of rehab.
Wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] on her coccygeal ulcer and was
performing aquacel dressing changes to coccyx and moist to dry
dressing changes [**Hospital1 **] to abdominal wound. Please see their note
for wound care recommendations. She was on a kinair bed and q2
rolling.
Medications on Admission:
Medications from [**Hospital3 7**]:
Imodium 2 mg PO TID
Reglan 5 mg IV Q8P nausea
Zofran 4mg IV Q8P nausea
Protonix 40mg PO daily
Paxil 30 mg PO QHS
Lopressor 75 mg PO BID
Wellbutrin 37.5 mg PO''
Fragmin 5000 units SQ daily
Ativan 0.5 mg PO BIDP anxiety.
Discharge Medications:
1. Lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane
[**Hospital1 **] (2 times a day) as needed for sore throat.
2. Potassium Iodide 1 gram/mL Solution Sig: 0.6 ML PO TID (3
times a day).
3. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Mineral Oil Oil Sig: Fifteen (15) ML PO TID (3 times a
day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
8. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Papain Powder Sig: Ten (10) ML Miscellaneous PRN (as
needed) as needed for clogged J tube.
10. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP >150.
11. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
13. Metoclopramide 5 mg/mL Solution Sig: Three (3) ml Injection
Q6H (every 6 hours).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: [**1-23**] ml
Injection Q8H (every 8 hours) as needed for nausea.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Colocutaneous fistula
Delayed gastric emptying
Multiple urinary tract infections
Atrial Fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Call or come back in if you experience fevers, chills,
increasing abdominal pain, nausea, vomiting, chest pain,
shortness of breath or any other concerns.
Take medications as prescribed. Continue with the TPN and tube
feeds. You may have a regular diet. Your G tube should be left
open to gravity for now - it may be clamped progressively as
tolerated starting at 1 hour clamps every 2 hours and advancing
as tolerated.
You may get OOB with assist and should work with PT multiple
times per day.
Wound care as directed by wound care nurse instructions.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 957**] in 2 weeks. Please call
([**Telephone/Fax (1) 376**] to set up an appointment.
|
[
"401.9",
"593.4",
"569.89",
"E879.8",
"579.3",
"V15.3",
"569.81",
"999.31",
"569.69",
"707.03",
"591",
"997.4",
"507.0",
"112.0",
"560.81",
"599.0",
"427.31",
"998.2",
"557.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"97.03",
"38.93",
"46.39",
"45.22",
"96.56",
"43.19",
"00.14",
"46.79",
"45.13",
"54.59",
"46.43",
"46.10",
"99.15",
"46.76"
] |
icd9pcs
|
[
[
[]
]
] |
13828, 13907
|
9051, 12127
|
337, 642
|
14052, 14061
|
4331, 9028
|
14668, 14810
|
3022, 3103
|
12433, 13805
|
13928, 14031
|
12153, 12410
|
14085, 14645
|
3118, 3662
|
3676, 4312
|
275, 299
|
670, 1666
|
1688, 2649
|
2665, 3006
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,429
| 118,768
|
31112
|
Discharge summary
|
report
|
Admission Date: [**2122-7-13**] Discharge Date: [**2122-7-19**]
Date of Birth: [**2045-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion/Chest discomfort
Major Surgical or Invasive Procedure:
[**2122-7-13**]
1. Bentall procedure with a 25-mm [**Company 1543**] freestyle graft with
coronary button reimplantation, model #995, serial #[**Serial Number 73440**].
2. Replacement of ascending aorta and hemiarch with a 26-mm
Dacron tube graft with deep hypothermic circulatory arrest. The
graft is a Gelweave graft, catalog #[**Numeric Identifier 73441**], lot #[**Serial Number 73442**],
serial #[**Serial Number 73443**].
3. Coronary artery bypass grafting x1 with a reverse saphenous
vein graft from the neo-ascending aorta to the left anterior
descending coronary artery.
4. Epiaortic duplex scanning.
History of Present Illness:
77 year old female with history of aortic stenosis followed by
serial echocardiograms. Her most recent echocardiogram in [**Month (only) 958**]
showed a significant worsening of her aortic stenosis as
compared to her last echocardiogram in 6/[**2120**]. She complains of
exertional shortness of breath and chest discomfort and has now
been referred for surgical evaluation.
Past Medical History:
-Aortic stenosis
-Hypertension
-Hypercholesterolemia
-Uterine fibroid s/p hysteroscopic myomectomy on [**2118-8-18**]
-Plantar fasciitis
-Mild scoliosis
-Meniscus tear
Social History:
Lives with: Husband
Occupation: Retired
Tobacco: Denies
ETOH: Denies
Family History:
Father died at 53 from complications of CVA brother died at 72
w/DM and Parkinson's.
Physical Exam:
Pulse: 74 Resp: 16 O2 sat: 98
B/P Right: 133/89 Left: 143/93
Height: 5'4" Weight: 178 lbs
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [X] Murmur 2/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: None
Varicosities: None, superficial spider veins
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2122-7-13**] Intra-op TEE: PRE-CPB: The left atrium is moderately
dilated. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. Shortly after aortic cannulation, a mobile density is
seen in the ascending aorta consistent with an intimal
flap/aortic dissection.The dissection flap is seen extending to
the distal arch. No dissection is seen in the descending
thoracic aorta. There is no flow seen the in false lumen which
then quickly becomes echogenic, likely representing clot
formation in the false lumen. The aortic valve is bicuspid with
a horizontal commisure. The aortic valve leaflets are severely
thickened/deformed. Significant aortic stenosis is presen. No
aortic regurgitation is seen. After ascending aortic dissection
is noted, there is still no AI seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
POST-CPB: After initial separation from bypass, the LV EF
appeared normal without wall motion abnormalities. However,
after a few minutes, the anterior and anteroseptal walls became
hypokinetic, then akinetic, associated with precipitous
hemodynamic decline. (CPB was reinstituted and LAD was bypassed
with venous graft) After second separation from bypass, the LV
EF appears normal, estimated EF=60%. No wall motion
abnormalities are noted. There is a bioprosthetic valve in the
aortic position. The valve appears well-seated with normal
leaflet mobility. There is trace central AI. The peak gradient
across the aortic valve is 6mmHg, the mean gradient is 3mmHg
with CO of 3.5 The ascending aorta is brightly echogenic,
consistent with ascending tube graft. Residual dissection flap
can be seen at the distal arch. This does not extend to the
descending thoracic aorta. The TR has increased to moderate.
[**2122-7-19**] 06:20AM BLOOD WBC-9.9 RBC-3.80* Hgb-11.4* Hct-32.6*
MCV-86 MCH-30.1 MCHC-35.1* RDW-13.8 Plt Ct-227
[**2122-7-19**] 06:20AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
Brief Hospital Course:
The patient was a same-day admit for elective aortic valve
replacement. Intra-operatively she was noted to have an
iatrogenic Type A aortic dissection following cannulation. The
dissection flap was not associated with the arterial cannulation
site. She underwent a Bentall procedure including a 25mm Porcine
valve/root graft, 26mm Gelweave Dacron graft to the ascending
aorta and reimplantation of coronary buttons under hypothermic
circulatory arrest and coronary bypass graft with saphenous vein
graft to LAD. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. She received
cefazolin for perioperative antibiotics. That evening she
remained on propofol and phenylephrine. On post operative day
one she was weaned off sedation, awoke, and was extubated
without complications. Additionally she was weaned off
phenylephrine and started on beta blockers and diuretics. She
continued to progress slowly, remaining in the intensive care
unit for monitoring and was taken off narcotic pain medication
due to somnolence, and was treated with Tylenol and Ultram with
good effect. Her chest tubes and wires were removed per
protocol. On post operative day three she was ready for transfer
to the floor. Physical therapy worked with her on strength and
mobility. She was placed on Bactrim for an asymptomatic urinary
tract infection. By post-operative day six she was ready for
discharge to [**Hospital 100**] Rehab [**Location (un) 550**]. All follow-up appointments were
advised.
Medications on Admission:
Zocor 80mg daily
Hydrochlorothiazide 25mg Daily
Atenolol 100mg daily
Aspirin 81mg daily
Multivitamin daily
Calcium Carbonate daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. simvastatin 40 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. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
7. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Aortic stenosis s/p Bentall procedure
Intraoperative iatrogenic type A aortic dissection with coronary
involvement s/p CABG x1
Past medical history:
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with
Sternal Incision - healing well, no erythema or drainage
Leg: open GSV harvest right calf healing well no erythema or
drainage
1+ Edema
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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] on [**8-18**] at 1:45pm, please obtain
echocardiogram and chest CT in the morning before you arrive for
you appointment.
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**8-12**] at 10:30am
Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28549**] [**Telephone/Fax (1) 28551**] in [**4-21**] 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:[**2122-7-19**]
|
[
"V13.01",
"E878.2",
"V17.49",
"997.1",
"V18.0",
"401.9",
"411.1",
"414.12",
"997.79",
"441.01",
"599.0",
"424.1",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"36.11",
"35.21",
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7422, 7507
|
4846, 6429
|
346, 957
|
7727, 7946
|
2472, 4823
|
8817, 9509
|
1653, 1739
|
6610, 7399
|
7528, 7655
|
6455, 6587
|
7970, 8794
|
1754, 2453
|
270, 308
|
985, 1360
|
7677, 7706
|
1567, 1637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,661
| 198,842
|
52271
|
Discharge summary
|
report
|
Admission Date: [**2145-9-25**] Discharge Date: [**2145-9-29**]
Date of Birth: [**2073-10-12**] Sex: M
Service: MEDICINE
Allergies:
Tetanus Toxoid,Adsorbed
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
The patient is a 72 year old male with ESRD on HD, diastolic HF,
poorly controlled hypertension, and psoriasis who was BIBA from
home with increasing SOB throughout the day. He had a regularly
scheduled dialysis session on Friday, the day before admission
with about [**2133**] ml fluid removed. During the week, he had noted
increasing orthopnea and coughing when laying flat. He also had
some mild URI symptoms for 2-3 days with nasal congestion and
nonproductive cough but no fevers. The morning of admission, he
forgot to take his BP meds, and became increasingly SOB
throughout day. He is poorly compliant with his diet and ate
pizza with a friend for dinner. His SOB acutely worsened after
dinner, and he used his Lifeline upon arrival home. He was
brought in by EMS. His SPO2 had been in the low 90s on NRB but
improved to mid-90s on CPAP.
.
In the ED, he was afebrile, HR 130s, BP 200/110s, RR 30s, O2 sat
92% on CPAP. Labs were notable for WBC 20.7, bicarb 30,
electrolytes otherwise consistent with ESRD, and Troponin 0.19.
His EKG showed sinus tachycardia with LBBB unchanged from prior.
CXR showed pulmonary edema, bilateral pleural effusions, and
opacities likely representing atelectasis, though infection
could not be excluded. He was started on a Nitro drip and given
Lasix 80 mg IV x1, Ceftriaxone 1000 mg IV, Azithromycin, and
Labetolol 10mg IV x1. Renal service was consulted for emergent
dialysis. He was admitted to MICU [**Location (un) **].
.
On arrival to the MICU, initial vitals were HR 92, BP 156/77, O2
sat 98% on Bi-Pap. He stated that his breathing was comfortable
on BiPap. He denies subjective fevers/chills, chest pain,
pleuritic pain, nausea/vomiting, abdominal pain, diarrhea,
constipation, melena, or BRBPR. He was taken for emergent
dialysis with about [**2133**] ml fluid removed. After dialysis, he
felt much better with decreased SOB and improvement in his SpO2.
He was weaned off CPAP to face mask oxygen. He was given
Vancomycin, Cefepime, and Levofloxacin for possible HCAP, but
antibiotics were stopped earlier today given his lack of fevers
or sputum production and inconclusive CXR. His Troponin was
trended after admission, and rose from 0.19 on arrival to the
ED, 0.38 several hours later at midnight, and 0.53 at noon
today. He denied chest pain and EKG was unchanged, though
difficult to assess for ischemia given his baseline LBBB.
Dialysis is planned for tomorrow on his usual MWF schedule with
additional fluid removal.
.
When seen prior to floor transfer, he reported feeling much
better, and was sitting comfortably in a chair on 5L NC without
respiratory distress. He denied any current medical complaints.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied current cough, improved shortness of breath. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel habits. No black or bloody stool. Recent decrease in urine
output, denies any urinary discomfort. Chronic joint pain from
arthritis. Review of systems was otherwise negative.
Past Medical History:
- Hypertension - sees Dr. [**Last Name (STitle) 2204**]. Prior to [**8-4**], was last seen
in [**2138**].
- Chronic Renal Failure: thought to be from hypertension. MR [**First Name8 (NamePattern2) **] [**Location (un) 108084**]-vasculature in [**2133**] showed <50% stenosis of right renal
artery (not thought to be significant/flow limiting). Crt in
[**2138**] was 1.7. Next level is from [**8-4**], when pt found to have crt
of 5 and rising. Worsening renal function thought to be from
uncontrolled HTN. Dr. [**Last Name (STitle) **] is pt's nephrologist.
- Hyperlipidemia: Tot Chol 226, Tg 465, LDL 119, HDL 29. Not on
statin
- h/o elevated PSA: last value 3.3 on [**2141-8-16**], up from 2.1 in
[**2134**]
Social History:
Lives alone. Divorced. Following his divorce, pt lost health
insurance & did not see a physician [**Name Initial (PRE) 767**] [**2138**] to [**2141-7-29**]. Pt
quit smoking tobacco >30yr ago. Does not drink ETOH or use
recreational drugs.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had HTN & renal artery stenosis.
Physical Exam:
VS: T 99.9, BP 150/58, HR 72, RR 17, SpO2 95% on 5L NC
Gen: Elderly male in NAD. Speaking in full sentences. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP elevated. No cervical
lymphadenopathy.
CV: RRR with occasional premature beats. Normal S1, S2. Soft
systolic murmur [**1-3**] at axilla.
Chest: Respiration unlabored. Decreased breath sounds
bilaterally with coarse crackles. Dullness at bases. No
egophony. No wheezes.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. LE edema 2+ bilaterally. Fingers
with DIP nodules. Distal pulses intact radial 2+, DP 2+.
Skin: Scattered plaques with silvery scale consistent with
psoriasis.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.
Pertinent Results:
CBC
[**2145-9-25**] 08:45PM BLOOD WBC-20.7* RBC-4.29* Hgb-12.8* Hct-40.7
MCV-95 MCH-29.8 MCHC-31.4 RDW-15.6* Plt Ct-206
[**2145-9-26**] 01:07AM BLOOD WBC-14.0* RBC-3.66* Hgb-11.1* Hct-35.2*
MCV-96 MCH-30.4 MCHC-31.6 RDW-16.1* Plt Ct-164
[**2145-9-27**] 08:19AM BLOOD WBC-8.8 RBC-3.78* Hgb-11.3* Hct-35.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-15.8* Plt Ct-170
CHEM--7
[**2145-9-25**] 08:45PM BLOOD UreaN-43* Creat-8.3* Na-145 K-4.4 Cl-94*
HCO3-30 AnGap-25*
Cardiac enzymes:
[**2145-9-25**] 08:45PM BLOOD cTropnT-0.19*
[**2145-9-26**] 12:13AM BLOOD CK-MB-7 cTropnT-0.38*
[**2145-9-26**] 04:56AM BLOOD CK-MB-9 cTropnT-0.41*
[**2145-9-26**] 12:53PM BLOOD CK-MB-6 cTropnT-0.53*
[**2145-9-27**] 06:33AM BLOOD CK-MB-2 cTropnT-0.45*
.
Discharge Labs
IMAGING:
Portable CXR [**2145-9-25**]:
FINDINGS: There are moderate sized bilateral pleural effusions.
Bibasilar
opacification likely represents effusion and compressive
atelectasis, but
underlying consolidation cannot be excluded. Evaluation of the
cardiac
silhouette cannot be performed in the setting of these
opacities. No
pneumothorax is seen on this single view. Calcification of
aortic knob is
noted.
IMPRESSION: Bilateral pleural effusions and opacities likely
representing
efffusions and atelectasis, but underlying consolidation cannot
be excluded.
[**2145-9-29**] 06:21AM BLOOD WBC-7.6 RBC-3.69* Hgb-11.1* Hct-34.1*
MCV-92 MCH-30.0 MCHC-32.4 RDW-15.9* Plt Ct-215
[**2145-9-28**] 08:50AM BLOOD WBC-9.0 RBC-4.05* Hgb-12.2* Hct-39.0*
MCV-96 MCH-30.1 MCHC-31.2 RDW-16.0* Plt Ct-222
[**2145-9-27**] 08:19AM BLOOD WBC-8.8 RBC-3.78* Hgb-11.3* Hct-35.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-15.8* Plt Ct-170
[**2145-9-29**] 06:21AM BLOOD Neuts-74.5* Lymphs-12.7* Monos-4.1
Eos-7.6* Baso-1.0
[**2145-9-27**] 08:19AM BLOOD Neuts-79.4* Lymphs-10.5* Monos-4.3
Eos-4.8* Baso-1.0
[**2145-9-29**] 06:21AM BLOOD Plt Ct-215
[**2145-9-29**] 06:21AM BLOOD Glucose-93 UreaN-64* Creat-10.2*# Na-141
K-4.5 Cl-99 HCO3-26 AnGap-21*
[**2145-9-29**] 06:21AM BLOOD ALT-10 AST-17 LD(LDH)-167 CK(CPK)-35*
AlkPhos-64 Amylase-92 TotBili-0.3
[**2145-9-27**] 08:19AM BLOOD ALT-12 AST-18 LD(LDH)-172 CK(CPK)-37*
AlkPhos-61 Amylase-139* TotBili-0.4
[**2145-9-29**] 06:21AM BLOOD Lipase-51
[**2145-9-29**] 06:21AM BLOOD CK-MB-2 cTropnT-0.80*
[**2145-9-29**] 06:21AM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.4* Mg-2.4
[**2145-9-28**] 08:50AM BLOOD Calcium-9.9 Phos-5.4* Mg-2.4
[**2145-9-25**] 08:46PM BLOOD Glucose-235* Lactate-1.4 K-4.3
Brief Hospital Course:
MICU Course
72M with h/o ESRD on HD, diastolic HF admitted to MICU for
hypoxia [**12-30**] pulmonary edema.
# Hypoxia: Likely [**12-30**] flash pulmonary edema (seen on CXR) in
setting of hypertension, ESRD and known chronic diastolic
dysfunction. Also possible that he has concurrent pna given
recent cough and leukocytosis. Cardiac event unlikely given
unchanged EKG, trop mildly elevated but likely [**12-30**] renal
failure. He was given lasix 200mg IV x1 with little response. He
had emergent HD with 1.5L fluid removal. His O2 requirement
significantly improved after HD, and on HD#2 he was maintaining
O2 sats >90% on NC. He was also started on antibiotic coverage
for ?HCAP given he is on dialysis (vanc/zosyn/levo), however
these were discontinued as he improved significantly with HD.
Sputum cx and legionella Ag were pending at time of transfer to
the floor.
# Hypertensive crisis: BP elevated to 200s/100s with flash
pulmonary edema, likely due to not taking home BP meds on day of
admission. His BP improved in the ED with IV labetolol, and he
was restarted on his home meds on HD#2.
# ESRD: Patient dialyzed on day PTA, on MWF dialysis schedule.
The renal service was consulted and he was emergently dialyzed
overnight for fluid removal. He then resumed his normal HD
schedule. He was continued on his home dialyvite, sensipar, and
calcium acetate.
# Leukocytosis: WBC on admission was 20, initially concerning
for possible HCAP. However it rapidly improved to wnl,
suggesting most likely reactive. He remained afebrile without
localizing sx of infection, and his antibiotics were
discontinued on HD#2. Blood and urine cx were negative.
# CAD: Troponins were elelevated on admission (troponin 0.19,
CK-MB 2), thought likely [**12-30**] renal failure. His enzymes were
trended and remained stable. He was continued on his home ASA
81mg qod and simvastatin 10mg PO daily.
[**Hospital1 **] Floor Course
The patient is a 72 year old male with ESRD on HD, diastolic
Heart failure, and hypertension admitted to the MICU for hypoxia
due to flash pulmonary edema in the setting of dietary
noncompliance and missed BP meds.
.
# Hypoxia: His hypoxemia was most likely due to flash pulmonary
edema (seen on CXR) in the setting of hypertension, ESRD, and
known chronic diastolic dysfunction. There was also initial
concern for pneumonia given his leukocytosis, cough, and recent
URI symptoms, however he has been afebrile with no clear
consolidation on CXR. He was initially covered for a hospital
acquired pneumonia, but antibiotics were stopped earlier today
before callout. A cardiac event was possible given his rising
Troponin, though he denied chest pain. Demand ischemia was smore
likely. His EKG was unchanged from baseline, though difficult to
evaluate for ischemia given his baseline LBBB. His dyspnea and
SpO2 improved significantly after emergent dialysis with 2L
fluid removal.Persantine MIBI stress test did not show any new
ischemic changes.
.
# Hypertension: His BP was elevated to 200s/100s on ED arrival
with flash pulmonary edema, likely due to not taking home BP
meds in the morning. He was placed on a Nitro drip initially,
but quickly weaned off. His BP was controlled with Labetolol IV
and fluid removal in dialysis. Home meds were restarted on the
floor which included Lisinopril, Amlodipine, Doxazosin. His
Metoprolol Tartrate was increased to 150mg [**Hospital1 **].His BP remained
160-170/80-90's. Renal recommended to consider minoxidil 5 mg po
daily if BP remains high in the future.
.
# ESRD: He is typically on a MWF schedule, with an emergent
session Saturday shortly after arrival.Substiture Nephrocaps 1
tab PO daily and Continued Sensipar 30 mg PO daily,Calcium
acetate 667 mg PO TID.
.
# Leukocytosis: Unclear whether reactive vs infectious. He is
currently afebrile but notes recent cough. There was initial
concern for pneumonia given his leukocytosis, cough, and recent
URI symptoms, however he has been afebrile with no clear
consolidation on CXR. He was initially covered for HCAP, but
antibiotics were stopped earlier before MICU callout. Urine
Legionella antigen was negative and sputum could not be
obtained.
.
# CAD: He was seen to have one vessel CAD with RCA involvement
on cardiac cath [**2143-8-20**]. His Troponin was elevated to 0.19 on ED
arrival, 0.38 several hours later at midnight, and 0.53 at noon
today. A cardiac event was possible given his rising Troponin,
but he denied chest pain. His CK and CK-MB were flat. Demand
ischemia due to his hypertension and hypoxia at presentation was
more likely. His EKG was unchanged from baseline, though
difficult to evaluate for ischemia given his baseline
LBBB.Continued home Aspirin 81 mg PO every other day Simvastatin
10 mg PO daily. p MIbi stress testing was negative for cardiac
ischemia.
.
# Insomnia:
-- Continued home Trazodone 50 mg PO QHS
.
Full code during this admission
.
Outpatient f/u
1) Titration of BP medications
2) continued workup for renal transplant
3) Conitnue Dialysis
Medications on Admission:
Aspirin 81 mg PO every other day
Simvastatin 10 mg PO daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Metoprolol tartrate 100 mg PO BID
Doxazosin 2 mg PO BID
Dialyvite 800 0.8 mg 1 tab PO daily
Sensipar 30mg PO daily
Calcium acetate 667 mg PO TID
Trazodone 50 mg PO QHS
Hydrocodone-acetaminophen 5/500 1-2 tabs Q4-6H PRN pain
Allopurinol 100 mg PO daily
Docusate 100 mg PO daily
Senna 8.6mg PO BID PRN constipation
Bisacodyl 10 mg PO daily PRN constipation
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every other day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. DIALYVITE 800 0.8 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every 4-6 hours as needed for pain.
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pulmonary edema
Secondary: Chronic Kidney Disease, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 47774**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath at home. You were treated with emergency dialysis and
oxygen in the intensive care unit, and your symptoms improved.
You were treated for high blood pressure. We also evaluated you
with a persantine stress test, which was not concerning for
ischemic heart disease.
You continued on dialysis while you were a patient here.
We made the following changes to your home medications:
INCREASED Metoprolol to 150 mg twice daily.
INCREASED Lisinopril to 40 mg daily.
Please continue taking your other medications as usual.
Please followup with your doctors, see below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 2204**]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
.
Department: TRANSPLANT CENTER
When: TUESDAY [**2145-11-2**] at 9:20 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2145-11-25**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
|
[
"780.52",
"V45.11",
"403.91",
"428.0",
"585.6",
"272.4",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14871, 14877
|
8000, 13012
|
293, 308
|
14994, 14994
|
5534, 5986
|
15878, 17000
|
4531, 4653
|
13530, 14848
|
14898, 14973
|
13038, 13507
|
15145, 15651
|
4668, 5515
|
15669, 15855
|
3021, 3522
|
6003, 7977
|
246, 255
|
336, 3002
|
15009, 15121
|
3544, 4258
|
4274, 4515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,701
| 193,745
|
18812+18813
|
Discharge summary
|
report+report
|
Admission Date: [**2126-9-12**] Discharge Date: [**2126-9-26**]
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Father [**Name (NI) 51510**] is an 85 year
old male with a past medical history significant for
hypertension, asymptomatic left bundle branch block, prostate
carcinoma with radiation treatment eight years ago, skin
cancer for which his nose has been resected, arthritis, no
tobacco, no ETOH.
The patient was admitted on [**2126-9-12**], after a syncopal
episode at home left him unresponsive for ten minutes. He
was found to have ST elevations inferiorly and a subsequent
troponin bump. Cardiac Surgery was consulted on [**9-12**]. We
saw the patient and accepted him into our service.
On [**2126-9-13**], he went for a cardiac catheterization (see
catheterization report), which in summary showed left main
and left anterior descending disease with a preserved
ejection fraction of 50%. On [**9-13**], he went into atrial
fibrillation with the rate elevating to the 120s. After
Lopressor, the rate came down to the 80s to 90s. He
converted to sinus rhythm with one dose of Amiodarone on
[**9-14**].
On [**9-16**], he was seen by GI secondary to melena in his stool.
He had been on heparin for his cardiac disease. An
esophagogastroduodenoscopy was done (see EGD report).
On [**9-17**], he went to the Operating Room (see OR report), for
which in summary he had a three vessel coronary artery bypass
graft: Left internal mammary artery to the left anterior
descending, saphenous vein graft to the diagonal and
saphenous vein graft to the obtuse marginal. CPB time was 98
minutes, cross clamp time was 80 minutes. Upon conclusion of
the surgery, he was transferred to the CSRU; he was weaned
and extubated the first day postoperatively. His chest tubes
were discontinued on [**2126-9-19**] and his vasopressor
medications were weaned off on [**9-20**].
Postoperatively, he was also found to be in atrial
fibrillation and treatment with Lopressor and Amiodarone
resumed. He awoke and he once again converted to sinus
rhythm on [**9-24**].
The patient was transferred to the Floor on [**9-21**] to continue
rehabilitation. On [**9-24**], his white blood cell count
elevated to 14.6. He was pan cultured and found to have E.
coli in his urine and he was started on Levaquin for seven
days p.o. He is now stable and ready to be discharged for
further rehabilitation.
Current vital signs were temperature of 97.9 F.; blood
pressure 124/63; pulse of 67; respiratory rate of 18. He is
[**Age over 90 **]% on room air. His weight on [**9-24**] was 76.3 kilos;
admitting weight was 74.1 kilo.
ALLERGIES: No known drug allergies.
DISCHARGE MEDICATIONS:
1. Warfarin: Titrate for an INR of 2.0.
2. Atorvastatin 10 mg p.o. q. day.
3. Amiodarone 400 mg p.o. q. day.
4. Aspirin 81 mg p.o. q. day.
5. Pantoprazole 40 mg p.o. q. day.
6. Colace 100 mg p.o. twice a day.
7. Atenolol 75 mg p.o. q. day.
8. Levaquin 250 mg p.o. times six days.
9. Acetaminophen 650 mg p.o. q. four hours p.r.n.
LABORATORY: Recent laboratory work on [**9-25**] was white blood
cell count of 11.8, hemoglobin and hematocrit of 10 and 31.2.
Platelet count of 403. Sodium of 137, potassium of 4.4,
chloride 102, bicarbonate of 28, BUN and creatinine of 21 and
1.4. PT and INR was 19.8 and 2.6.
PHYSICAL EXAMINATION: Neurologically, he is alert and
oriented times three. Cranial nerves II through XII intact.
Cardiovascular: He is in sinus rhythm, S1 and S2 are audible
with a systolic murmur; trace pedal edema. Sternal incision
with Steri-strips, no drainage noted. Incisional wounds on
the left leg times two with Steri-Strips; no drainage noted.
Positive dorsalis pedal and posterior tibial pulses
bilaterally. Respiratory: He is clear to auscultation.
Dyspnea on exertion per patient. No cough noted. GI:
Abdomen soft and nontender, no distress. Genitourinary:
Voiding q. shift.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation.
CONDITION AT DISCHARGE: Stable condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Syncope.
3. Non-ST elevated myocardial infarction.
4. Atrial fibrillation.
5. Gastrointestinal bleed.
6. Esophagogastroduodenoscopy.
7. Coronary artery bypass graft times three vessels.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**Last Name (STitle) 1537**] in three to
four weeks.
2. The patient is to follow-up with Dr. [**Last Name (STitle) 20222**] and
[**Doctor Last Name **] upon discharge from the rehabilitation facility.
Dr. [**Last Name (STitle) 20222**] is at [**Telephone/Fax (1) 20223**], and should be notified upon
discharge from rehabilitation to assume Coumadin monitoring
for an INR goal of 2.0.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor Last Name 51511**]
MEDQUIST36
D: [**2126-9-25**] 17:05
T: [**2126-9-25**] 18:48
JOB#: [**Job Number 51512**]
Admission Date: [**2126-9-12**] Discharge Date: [**2126-9-26**]
Service: Cardiothoracic Surgery
ADDENDUM: Note to rehabilitation. Please dose Coumadin 0.5
mg in the p.m. of [**2126-9-26**] and recheck INR on
[**2126-9-27**] and dose Coumadin levels for a target INR
of 1.8 to 2.2.
MEDICATIONS ON DISCHARGE: (Medications on discharge
included)
1. Colace 100 mg by mouth twice per day.
2. Aspirin 81 mg by mouth once per day.
3. Protonix 40 mg by mouth once per day.
4. Amiodarone 400 mg by mouth twice per day.
5. Lipitor 10 mg by mouth once per day.
6. Albuterol inhaler 2 puffs inhaled as needed.
7. Atenolol 75 mg by mouth once per day.
8. Levofloxacin 250-mg tablets one by mouth once per day
(for five days).
9. Warfarin 0.5 mg by mouth once per day for one day; then
dose for a target INR of 1.8 to 2.2.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 6297**]
MEDQUIST36
D: [**2126-9-26**] 09:41
T: [**2126-9-26**] 10:19
JOB#: [**Job Number 51513**]
|
[
"780.2",
"410.71",
"414.01",
"535.50",
"401.9",
"427.31",
"578.1",
"599.0",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.72",
"88.53",
"36.15",
"36.12",
"39.61",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
4079, 4304
|
2717, 3341
|
5352, 6133
|
4328, 5325
|
3364, 4023
|
4039, 4058
|
147, 2694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,785
| 189,410
|
50478
|
Discharge summary
|
report
|
Admission Date: [**2170-3-3**] Discharge Date: [**2170-4-4**]
Service: SURGERY
Allergies:
Clonidine / Aquaphor / Codeine
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
82F presenting through th ED with 2-3 week history of increasing
abdominal pain and bloating.
Major Surgical or Invasive Procedure:
lysis of adhesions
tracheostomy
open g-tube
History of Present Illness:
82F presented to ED with 2 week of history of bloating. CT scan
consistent with partial small bowel obstructoin, aprox. 1 year
followng partial colectomy (carcinoma).
Past Medical History:
CAD
CHF
HTN
hypothyroid
chronic back pain
DVT
L. hip replacement
TAH
partial colectomy (carcinomoa)
s/pp open CCY
Social History:
DAUGHTER ACTIVELY INVOLVED... HAS BEEN AT HOSPITAL SINCE
[**2-28**]...HAS NOT
LEFT HOSPITAL... SOCIAL WORKER ENCOURAGED HER TO LEAVE..DAUGHTER
ANGRY WITH
THIS.
Physical Exam:
AFVSS
patient described as a somehat frail appearing older woman,
A&Ox2
PERRL, CN II-XII intact. Contusion noted over right eye
lungs clear, reduced breath sounds at bases
abdomen distended, diffusely tender, tympanetic, no bowel
sounds, no peritoneal signs
no evidence of herniation
rectal exam guiac (-)
Pertinent Results:
PTT 49..HEPARIN DRIP UP TO 800 U/HR AT 12 NOON.
INR UP TO 1.4 COUMADIN 10 MG LAST EVE...TO GET 5 MG TONIGHT.
[**2170-3-2**] 07:18PM BLOOD ALT-13 AST-18 CK(CPK)-93 AlkPhos-77
Amylase-37 TotBili-0.5
[**2170-3-2**] 07:18PM BLOOD ALT-13 AST-18 CK(CPK)-93 AlkPhos-77
Amylase-37 TotBili-0.5
[**2170-3-2**] 07:18PM BLOOD Glucose-132* UreaN-22* Creat-1.0 Na-134
K-4.4 Cl-91* HCO3-36* AnGap-11
[**2170-3-2**] 07:18PM BLOOD WBC-14.4*# RBC-5.30 Hgb-14.3 Hct-44.7
MCV-84# MCH-27.0# MCHC-32.0 RDW-16.9* Plt Ct-304
[**2170-3-3**] 05:30PM BLOOD PT-19.7* PTT-35.4* INR(PT)-2.5
[**2170-3-2**] 07:18PM BLOOD Glucose-132* UreaN-22* Creat-1.0 Na-134
K-4.4 Cl-91* HCO3-36* AnGap-11
Brief Hospital Course:
After presentation to the ED, patient had a CT scan. This
showed several very dilated loops of small bowel, a high grade
obstruiction, and a completely decompressed colon. After
agressive resuscitation, including NG suction and crytalloid,
she was taken to the operating room on [**2170-3-9**] for lysis of
adhesions.
Post-operative course was complicated by acute on chronic CO2
retention, poor oxygenation, and hypotension. On POD 10,
patient was transferred to the floor. On POD 12 patient became
hypercarbic (has baseline CO2 retention), with increasing
respiratory distress. While preparing to electively intubate,
patient had a PEA arrest. Intubation was completed, and the
patient was quickly resuscitated.
Post-intubation status was gaurded. Patient continued to have
a. fib. She was lowly diuresed on a natrecor drip, but required
a swan-ganz [**Last Name (un) **] and drip for worsening CHF. 5 days later,
patient had a repeat arrest, again requiring CPR, but was
succesfully resuscitated. On [**3-24**], she was cardioverted for
stable a. fib, but ultimately reverted back to a. fib. On [**3-28**]
she uder went operative trachesotomy and placement of g-tube,
all without event. Hospital course thereafter was uneventful,
responding well to PT, and tolerated TFs well.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q2H (every 2 hours) as needed. puffs
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-4**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: per insulin
sliding scale units Injection ASDIR (AS DIRECTED).
7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Glutamine 10 g Packet Sig: 0.5 Packet PO TID (3 times a day).
10. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO
DAILY (Daily).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) ML
Mucous membrane PRN (as needed).
15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
18. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) capsule PO
DAILY (Daily).
19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) container
container PO BID (2 times a day).
21. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
22. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
25. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once): titrate to INR of [**3-8**].
26. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
27. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN
(as needed) as needed for Mg < 2.0.
28. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1)
Intravenous PRN (as needed) as needed for ioCa < 1.14.
29. Morphine Sulfate 8 mg/mL Syringe Sig: Two (2) mg Injection
Q2H (every 2 hours) as needed for pain.
30. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed).
31. Hydralazine HCl 20 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours) as needed for SBP>160.
32. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: titrate to PTT 60-80 Intravenous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
S/P PROLONGED ICU COURSE
s/p llysis of adhesions
Partial small bowel obstruction
Respiratory arrest
failed video swallow
sever COPD
pulmonary hypertension
a. fib
hypothyroid
CAD
CHF
HTN
chronic back pain
DVT
L. hip replacement
colectomy for cancer
s/p cholecystectomy
Discharge Condition:
GOOD.
Discharge Instructions:
[**Name8 (MD) **] MD'S.
Physical therapy pas directed.
Will need trach downsized in next 2-3 weeks.
Currently on a Heparin drip, will need to get coumadin
therapeutic ([**3-8**]) for a. fib, before stopping drip.
Followup Instructions:
Follow-up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (surgery), as needed
Completed by:[**2170-4-4**]
|
[
"414.01",
"V45.3",
"427.31",
"584.9",
"560.81",
"V43.64",
"518.5",
"V10.05",
"427.5",
"244.9",
"560.1",
"276.0",
"707.03",
"V12.51",
"416.8",
"496",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.62",
"99.60",
"00.17",
"54.59",
"99.04",
"96.6",
"00.13",
"99.15",
"43.19",
"89.64",
"31.1",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6157, 6227
|
1924, 3219
|
338, 384
|
6539, 6546
|
1237, 1901
|
6807, 6939
|
3242, 6134
|
6248, 6518
|
6570, 6784
|
910, 1218
|
205, 300
|
412, 581
|
603, 718
|
734, 895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,490
| 124,523
|
33641
|
Discharge summary
|
report
|
Admission Date: [**2103-2-16**] Discharge Date: [**2103-2-21**]
Date of Birth: [**2063-6-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Status post fall from height
Status post multiple stab wounds
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 39 year old male who was transferred from [**Hospital3 1280**]
hospital for multiple stab wounds to the head and chest and for
back injury after a fall from height. Reportedly the patient was
hiding in a closet, waiting to attack his father as he returned
home and sustained his injuries when the father was defending
himself. He was transferred to [**Hospital1 18**] for further care.
Past Medical History:
h/o CVA in [**2101**]
h/o alcoholism
recent h/o erratic behavior, manic episodes and rambling
h/o torn myelin sheath requiring extensive rehabilitation care
Social History:
born and raised in [**State 350**]
- sister x1, brothers x4
- completed high school
- mostly self-employed, ex-carpenter, currently on disability
- served in armed forces(Desert Storm)
- s/p divorces x2, most recently '[**01**]
-has 4 children (20M, 16M, 7M, 10F) from 3 past relationships
- h/o arrests ([**2081**], [**2088**] for bad check and driving w/o license
Family History:
Noncontributory
Physical Exam:
Upon admission:
Intubated, sedated. Puplis equal, round, reactive. Medial
canthus stable with lateral pull of lower lid. No nasal septal
hematoma or perforation. Bilateral conjuctival hemmorage.
CV:RRR
P:CTAB
Abd:s/nt +BS
Pertinent Results:
[**2103-2-16**] 12:30AM BLOOD WBC-6.1 RBC-3.70* Hgb-11.8* Hct-32.2*
MCV-87 MCH-32.0 MCHC-36.7* RDW-13.7 Plt Ct-135*
[**2103-2-16**] 05:57AM BLOOD Neuts-79.7* Lymphs-15.3* Monos-3.8
Eos-0.9 Baso-0.2
[**2103-2-16**] 05:57AM BLOOD Plt Ct-109*
[**2103-2-16**] 05:57AM BLOOD PT-14.3* PTT-29.3 INR(PT)-1.2*
[**2103-2-16**] 05:57AM BLOOD Glucose-104 UreaN-12 Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-28 AnGap-10
[**2103-2-16**] 12:30AM BLOOD Amylase-44
[**2103-2-16**] 05:57AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
[**2103-2-16**] 12:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-2-16**] 03:43AM BLOOD Type-ART pO2-212* pCO2-39 pH-7.42
calTCO2-26 Base XS-1
[**2103-2-16**] 12:30AM BLOOD Glucose-105 Lactate-0.9 Na-139 K-3.7
Cl-106 calHCO3-23
CT C-SPINE W/O CONTRAST
Reason: ? FX
[**Hospital 93**] MEDICAL CONDITION:
39M trauma patient s/p fall from [**Location (un) **]
REASON FOR THIS EXAMINATION:
r/o c-spine injury
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: 39-year-old male status post fall from
[**Location (un) 1773**], rule out C-spine injury.
COMPARISON: None.
NON-CONTRAST CT C-SPINE: There is no acute fracture or
malalignment. The imaged soft tissues are unremarkable. Although
CT is unable to give intrathecal detail compared to MRI, the
visualized intrathecal sac appears unremarkable. The patient has
an endotracheal and an endogastric tube with their tips below
the imaging plane.
IMPRESSION: No acute fracture or malalignment.
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: fx? pulmonary assessment (PTX vs hemothorax)?
Field of view: 40
[**Hospital 93**] MEDICAL CONDITION:
26 year old man with fall from second story with initially neg
CT chest/abd other than spinous process fxs, now with left lower
lobe effusion vs hemothorax vs contusion on CXR (supine port).
Please also scan through sacrum for full bony evaluation.
REASON FOR THIS EXAMINATION:
fx? pulmonary assessment (PTX vs hemothorax)?
CONTRAINDICATIONS for IV CONTRAST: just got contrast at OSH
STUDY: CT torso.
INDICATION: 26-year-old male status post two-story fall. Assess
for fracture.
COMPARISONS: Outside hospital CT scan of the torso.
TECHNIQUE: Non-contrast MDCT axial images were acquired from the
thoracic inlet to the pubic symphysis. Coronal and sagittal
reformatted images were then obtained.
CT OF THE CHEST WITHOUT IV CONTRAST: The heart and great vessels
are unremarkable without evidence of acute aortic injury. There
are no pathologically enlarged mediastinal, hilar, or axillary
lymph nodes. Endotracheal tube is noted in good position. A
small area of focal consolidation is noted in the posterior
aspect of the right upper lobe. There are bibasilar dependent
areas of consolidation as well. Otherwise, the lungs are clear.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The spleen is
significantly enlarged, measuring 18 cm in the coronal plane.
Please note, lack of intravenous contrast administration
somewhat limits detailed evaluation of intraabdominal organs. A
few hyperdense foci within the gallbladder are consistent in
appearance with gallstones. The liver, adrenal glands, and
abdominal portions of the large and small bowel appear within
normal limits. A few curvilinear calcifications are noted within
the body of the pancreas. The kidneys are noted to be
unremarkable and are excreting contrast from previous CT
evaluation. Nasogastric tube terminates within the stomach.
There is no free fluid or free air within the abdomen. There is
expansion of the left quadratus lumborum muscle indicative of
underlying hematoma. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are noted. Mild stranding is noted
in the posterior subcutaneous tissues.
CT OF THE PELVIS WITHOUT IV CONTRAST: A foley balloon is present
within a collapsed bladder. The rectum, sigmoid colon, prostate,
and intrapelvic loops of small bowel appear unremarkable. There
is no free fluid within the pelvis. No pathologically enlarged
inguinal or pelvic lymph nodes are noted.
OSSEOUS STRUCTURES: There is a minimally displaced fracture
involving the left transverse process of the T12 vertebral body.
There are widely displaced fractures involving the transverse
processes of the L1 through L5 vertebral bodies. Minimally
displaced fractures involving the left posterior eleventh and
twelfth ribs are also noted. There is a minimally displaced
fracture involving the spinous process of the L3 vertebral body.
There are numerous anterior buckle-type fractures involving
involving the 4th through 10th ribs.
IMPRESSION:
1. Predominantly left-sided acute stable fractures of the lower
thoracic and lumbar transverse processes and multiple rib
fractures. Left quadratus lumborum and peri-psoas edema and
hematoma.
2. Massive splenomegaly.
3. Multifocal areas of consolidation could represent pulmonary
contusion versus aspiration or atelectasis.
4. Cholithiasis.
CHEST (PA & LAT)
Reason: f/u
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with ?aaspiration pneumonia
REASON FOR THIS EXAMINATION:
f/u
TWO VIEW CHEST OF [**2103-2-19**].
COMPARISON: [**2103-2-17**].
INDICATION: Aspiration pneumonia followup.
Bibasilar areas of opacity have markedly improved with residual
left basilar patchy and linear opacification adjacent to a
moderately elevated left hemidiaphragm remaining. However, there
is a new patchy area of opacification in the right upper lobe.
Cardiomediastinal contours are stable in appearance. Note is
made of interval removal of endotracheal tube and nasogastric
tube.
Multiple rib fractures without change.
IMPRESSION:
1. Marked improvement in bibasilar opacities. New patchy right
upper lobe opacity, which may be due to either acute aspiration
or early-involving pneumonia.
2. Marked elevation of left hemidiaphragm, which may be due to
the known history of splenomegaly.
Brief Hospital Course:
Briefly, this is a 39 year old male who was transferred to [**Hospital1 18**]
for multiple stab wounds to the head and chest, an orbital
fracture and a back injury after falling from an approximately
2-story height. He was admitted to the Trauma Service and
transferred to the Trauma ICU for close monitoring.
Neuro: He was intubated in the field for combativeness and
arrived at [**Hospital1 18**] intubated and sedated. He was evaluated by
Ophthalmology and Plastics because of his supraorbital fractures
and lid laceration; no globe entrapment was identified. He was
treated with 10 day course of Erythromycin eye ointment.
CV: He remained in a normal sinus rhythm and there were no
cardiac events during his hospital stay. His blood pressure and
HR have been stable. He did initially have fevers and was
cultured; it was later noted that he did have a respiratory
infection; treatment was initiated.
Resp: He was weaned off of the ventilator and extubated. He is
currently being treated for a positive sputum culture which grew
Haemophilus Influenza; initially treated with Zosyn, this was
later switched to Augmentin for a 7 day course. He does not
require supplemental oxygen; no tachypnea on exam.
GI: He was started on a H2 blocker for gastrointestinal
prophylaxis; he is currently tolerating a regular diet. He was
started on a bowel regimen.
GU: There have been no active issues; he is voiding without
difficulty.
MUSCULOSKELETAL: Orthopedic Spine Surgery was consulted given
his multiple transverse process fractures; there was no
operative intervention indicated. Pain control of these
fractures was goal of care. He was treated with prn Oxycodone;
the dose was adjusted to achieve adequate analgesia.
ID: He received a tetanus shot in the Emergency department and
was started on IV antibiotics for empiric therapy of a
contaminated wound. He is currently being treated for H. flu
respiratory infection as noted above. Current WBC is not
elevated (3.2).
Heme: He remained hemodynamically stable during his
hospitalization; his hematocrits have been stable ranging
between 29.2 - 32.2 with no active signs of bleeding.
Psych: Psychiatric consultation was initiated early after
admission; he has been followed closely. 1:1 sitters were
ordered and Olanzapine was initiated. There have been no
behavioral issues or aggressive behaviors noted; he has remained
cooperative with his care.
He was assessed by Physical therapy to assess function and
ability to perform ADL's. He was somewhat limited by pain but
has the capabilities to care for himself with minimal
supervision.
Medications on Admission:
Olanzapine
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) dose Ophthalmic TID
(3 times a day) for 2 days.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO Q4H (every 4 hours) as needed for agitation.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
s/p Fall
s/p Multiple stab wounds to chest
Bilateral supraorbital ridge fractures
Transverse process fractures; L1-L5, T9
Spinous Process fracture L3
Left posterior rib fractures posterior [**9-23**]
Discharge Condition:
Good
Discharge Instructions:
You should return to the hospital if you experience any
numbness/weakness in any of your extremities; headaches;
dizziness; visual changes; fevers; chest pain, shortness of
breath and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in [**1-14**] weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor (Dr. [**Last Name (STitle) 50274**] after
discharge from inpatient mental health facility.
|
[
"870.8",
"298.9",
"892.0",
"507.0",
"860.0",
"E987.1",
"805.4",
"805.2",
"875.0",
"802.8",
"807.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"08.81",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11057, 11072
|
7562, 10156
|
376, 383
|
11316, 11323
|
1668, 2475
|
11605, 11877
|
1389, 1406
|
10218, 11034
|
6661, 6705
|
11093, 11295
|
10182, 10195
|
11347, 11582
|
1421, 1423
|
275, 338
|
6734, 7539
|
411, 808
|
1437, 1649
|
830, 988
|
1005, 1373
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,344
| 162,769
|
47650
|
Discharge summary
|
report
|
Admission Date: [**2199-7-18**] Discharge Date: [**2199-7-24**]
Date of Birth: [**2140-10-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD on hemodialysis who has been called for kidney [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2199-7-18**]: Kidney [**Month/Day/Year **]
History of Present Illness:
58 y/o male with end-stage renal disease secondary to diabetes,
currently on hemodialysis for the last three years. He is
dialyzed every Monday, Wednesday, and Friday. He presents to the
hospital now for renal transplantation. He denied any fever or
chills. His appetite is excellent. He
denied any shortness of breath, cough, sputum, chest pain,
dizziness, or palpitations. He had no paroxysmal nocturnal
dyspnea or orthopnea. He had no nausea, vomiting, diarrhea,
constipation, rectal bleeding or melena.
Past Medical History:
Coronary artery disease - s/p PCI in [**2197-1-31**], NSTEMI, ESRD -
on hemodialysis and s/p AVF, Nephrotic Syndrome with
hypoalbuminemia, Diabetes mellitus, Hypertension,
Hypercholesterolemia, Retinopathy, Iron Deficiency Anemia, Bells
Palsy, History of Rhabdomyolysis, History of left [**Doctor Last Name **] lobe
pneumonia, s/p Hydrocele repair
Social History:
He is from El [**Country 19118**], and was a former sheet metal worker. He
now works as an electrician. He smoked previously, about 1
[**12-4**]-packs-per-day for 10 years, but quit about 15 years ago. He
stopped using alcohol on [**2195-12-3**]. Previously he drank
approximately 2 beers/week. He lives with his wife.
Family History:
Notable for diabetes in both his mother and father. His father
also had hypertension. There is no history of kidney disease in
his family.
Physical Exam:
V: T 98.6, P 73, BP 118/86, RR 20, O2 Sat 96% Room air,
Weight 89.7 kg.
GENERAL: He appears well, was pleasant in no distress.
HEENT: PERRL, EOMI, glasses in place. Oropharynx was clear,
pink conjunctivae, sclerae anicteric. Neck supple. No
lymphadenopathy and no bruits.
LUNGS: Lungs clear to auscultation bilaterally.
CV: Heart regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. Midline sternotomy scar from CABG. Right
subclavian dialysis catheter.
ABDOMEN: soft, obese, nontender, nondistended. Positive bowel
sounds. There were no masses or bruits.
EXTREMITIES: no clubbing, cyanosis, or edema. He had a right
upper chest hemodialysis catheter. He had many scars over his
left upper extremity of previous AV fistulas and grafts.
Pertinent Results:
On admission [**2199-7-18**]
WBC-9.4 RBC-3.47* Hgb-11.3* Hct-33.2* MCV-96 MCH-32.5* MCHC-34.0
RDW-16.6* Plt Ct-108*
PT-12.5 PTT-26.2 INR(PT)-1.1
UreaN-58* Creat-9.2*# Na-142 K-5.9* Cl-99 HCO3-30 AnGap-19
ALT-4 AST-19 AlkPhos-97 Amylase-40 TotBili-0.2
Albumin-4.0 Calcium-9.7 Phos-5.5* Mg-2.8*
On discharge [**2199-7-24**]
WBC-4.9 RBC-2.80* Hgb-8.8* Hct-26.2* MCV-94 MCH-31.3 MCHC-33.5
RDW-16.6* Plt Ct-83*
Glucose-103 UreaN-56* Creat-5.9* Na-139 K-3.9 Cl-102 HCO3-27
AnGap-14
ALT-2 AST-18 AlkPhos-90 Amylase-26 TotBili-0.2
Calcium-8.4 Phos-4.7* Mg-2.3
FK506-10.6
Brief Hospital Course:
Patient is a 58 y/o male with ESRD who presents for a cadaveric
kidney [**Month/Day/Year **]. [**Month/Day/Year 1326**] surgeon was Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. The
patient received standard immunosuppression to include Cellcept
prior to surgery, Solumedrol 500 mg and thymoglobulin 100 mg
intra-op. Of note he received a total of 400 mg thymo over the
course of 4 doses.
U/S was obtained on POD 0 showing no hydronephrosis and no
perinephric fluid collection. The RIs are 0.63, 0.67 and 0.75,
which are within the normal range. Normal vascular flow is
identified in the main renal artery and vein.
He was making minimal urine (200-300cc) in the post op period,
and was having continued hypotension in the PACU. Despite fluid
boluses and blood his blood pressure remained low, and he was
subsequently transferred to the SICU for close monitoring. He
was placed on dopamine. He received CVVHD for volume and
hyperkalemia.
He was transferred to [**Hospital Ward Name 121**] 10 on POD 4. He was receiving
hemodialysis in the SICU and then again when he was a patient on
[**Hospital Ward Name 121**] 10.
He was also followed by [**Last Name (un) **] (Type 2 DM) but was discharged
home on only an oral [**Doctor Last Name 360**].
He will continue hemodialysis as an outpatient with close
follow-up of labs through the [**Doctor Last Name **] clinic.
Medications on Admission:
Avandia 4 mg daily, Atenolol 100 mg daily, aspirin 81 mg
daily, lisinopril 5 mg [**Hospital1 **], Pravachol 20 mg daily, Renagel 2400
mg with meals, Renal caps one tablet daily.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QODHS
(every other day (at bedtime)).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
8. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ESRD now S/P kidney [**Hospital **]
Discharge Condition:
Good
Discharge Instructions:
Call the [**Hospital **] office at [**Telephone/Fax (1) 673**] if you experience any
of the following symptoms: fever, chills, nausea, vomiting,
diarrhea, inability to eat, pain over the incision site or
kidney. Monitor incision for redness, drainage or bleeding.
Do not drive if you are taking narcotics.
Take your medications exactly as directed. The oral blood sugar
medication is different from the Avandia, you are now taking
Actos (Pioglitizone) In addition you shouls check your blood
sugar before every meal and treat per the sliding scale of
insulin.
Have labs drawn this Friday, then every Monday and Thursday and
have them faxed to [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk
Phos, Albumin, T Bili and trough Prograf
Continue hemodialysis schedule at your home dialysis unit
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-7-26**] 1:10
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-7-29**] 2:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-7-29**] 3:00
Completed by:[**2199-7-26**]
|
[
"280.9",
"250.40",
"403.91",
"412",
"V45.81",
"276.7",
"272.4",
"V45.82",
"V18.0",
"458.29",
"585.6",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"99.04",
"55.69",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6009, 6067
|
3237, 4629
|
390, 438
|
6147, 6154
|
2649, 3214
|
7001, 7490
|
1705, 1846
|
4858, 5986
|
6088, 6126
|
4655, 4835
|
6178, 6978
|
1861, 2630
|
275, 352
|
466, 980
|
1002, 1351
|
1367, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,815
| 133,148
|
9711
|
Discharge summary
|
report
|
Admission Date: [**2192-8-28**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2148-6-7**] Sex: M
Service: TRANSPLANT SURGERY:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 32793**] is a 44-year-old
gentleman with longstanding history of insulin
dependent-diabetes mellitus, who is status post living
related kidney transplant on [**2191-3-2**] who has had
excellent kidney graft function, who presented on [**2192-8-28**] for a pancreatic transplant.
PAST MEDICAL/SURGICAL HISTORY:
1. Type 1 diabetes x37 years.
2. Status post living donor kidney transplant [**2191-3-2**]. He has had excellent kidney graft function.
3. Retinopathy. Decreased vision in the right eye.
4. Peripheral vascular disease. The patient is status post
femoral distal bypass on the right.
5. Coronary artery disease status post coronary artery bypass
graft.
6. Status post several toe amputations.
7. The patient had an ejection fraction of 25%.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Bactrim SS one tablet Monday, Wednesday, Friday.
2. Lipitor 10 mg q day.
3. Reglan 10 mg [**Hospital1 **].
4. Insulin. He is given 6 dose of Lantus 22 units at 4 pm.
He is on Humalog sliding scale.
5. CellCept [**Pager number **] mg tid.
6. Tacrolimus 1 mg [**Hospital1 **].
7. Prednisone 1 mg tid.
8. Aspirin 325 mg q day.
SOCIAL HISTORY: The patient lives alone. He has a sister
who lives nearby. He smokes one cigarette per day, and he
denies any tobacco use for the past week. He occasionally
drinks alcohol.
FAMILY HISTORY: Significant for breast cancer.
REVIEW OF SYSTEMS: He denies any headache, occasional dry
cough, no shortness of breath, no chest pain, no abdominal
pain, no change in bowel habits, no difficulty urinating, and
there is no history of bleeding.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.8, blood
pressure 120/80, heart rate 88, respiratory rate 20. His
height is 5'9", weight 62.4 kg. His preoperative fingerstick
was 263. Generally, he is a pleasant, well-nourished, and
well-developed male. Head, eyes, ears, nose, and throat:
Normocephalic, atraumatic. Extraocular movements are intact.
Pupils are equal, round, and reactive to light. Oropharynx
clear, moist mucous membranes, neck is supple, no
lymphadenopathy. Respiratory: Clear to auscultation
bilaterally. Cardiovascular: Regular, rate, and rhythm,
normal S1, S2. No murmurs, rubs, or gallops. He does have
an old CABG midline sternal scar. Abdomen: Nondistended,
bowel sounds present, soft, nontender. Scar over previous
kidney transplant site. No masses and no organomegaly.
Extremities: Nontender, no edema, decreased sensation
bilaterally in the lower extremities, full range of motion,
5/5 strength. Scars from bypasses.
LABORATORIES: White blood cells 5.9, hematocrit 50,
platelets 235. Coags: PT 13.3, PTT 26.6, INR 1.2.
Potassium of 4.8, BUN of 17, creatinine of 1.0, blood sugar
270 on fingerstick, however, as mentioned it was 263. ALT
20, AST 18, alkaline phosphatase 105, amylase 45, lipase 17,
total bilirubin 0.6.
He had a stress test done in [**2192-4-25**], which showed no
anginal symptoms or ischemic electrocardiogram changes at the
high workload achieved.
Chest x-ray showed no active cardiopulmonary process
preoperative. Patient's ejection fraction is 29%.
Electrocardiogram compared to prior tracing on [**2191-11-20**] showed an inferior myocardial infarction, but no acute
ST-T wave changes compared to a previous tracing.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname 32793**] is a 44-year-old
male with longstanding history of insulin dependent diabetes
mellitus, status post living related kidney transplant back
in [**2191-2-8**], who presented for pancreatic transplant
on [**2192-8-28**]. Consent was obtained and a complete full
preoperative workup was done. He is taken to the operating
room on [**2192-8-28**] after consent was obtained. Please
refer to the operative note for details.
In the operating room, the patient received thyroglobulin,
Solu-Medrol, daclizumab, Unasyn, as well as fluconazole. The
usual infectious disease prophylaxis was continued with
Bactrim, Valcyte, and nystatin postoperatively. He was
placed on Solu-Medrol taper 500 mg tid, tacrolimus 1 mg [**Hospital1 **],
and prednisone 1 mg tid, as well as thyroglobulin.
Aside from some soreness from the incision, patient was doing
very well. There was no erythema or drainage near the
incision. He was maintaining good urine output. Pain was
well controlled with PCA. Nasogastric tube was continued for
several days postoperatively. Patient was placed on an
insulin drip for adequate blood sugar control with a blood
sugar goal of 100-150. IV IG was given twice.
On postoperative day #2, the patient was complaining of some
nausea as well as some hiccups. A KUB was obtained which
demonstrated normal JP drain positioning. Later on
postoperative day two, the patient had an episode of
orthostatic hypotension. His systolic blood pressures is
80s-90s/50s-60s. IV fluids were increased and his blood
pressure medications were stopped. His blood sugar had
increased to as high as 300. At that time, his insulin drip
was adjusted accordingly.
By the following day, his insulin requirement had increased.
CT scan of the abdomen was obtained which indicated a lack of
enhancement of pancreas allograft. Plan was for
re-exploration. The patient was taken back to the operating
room on [**2192-9-1**] for pancreas removal for arterial
thrombosis of graft. Postoperatively, the patient was placed
back on his home regimen of insulin and evaluated by the
[**Hospital **] Clinic. Otherwise, the patient was hemodynamically
stable.
Patient's diet was advanced and tolerating solids by
postoperative day five. Valcyte and Fluconazole was
discontinued. By postoperative day six and three, the
patient was felt to be stable for discharge. The plan was to
relist the patient for pancreatic transplant. Patient was
discharged on [**2192-9-4**] with followup appointment
scheduled with Dr. [**Last Name (STitle) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Arterial thromboses of transplanted pancreas, status post
pancreatic graft removal.
2. Insulin dependent-diabetes mellitus.
3. Status post living kidney transplant in [**2191-2-8**],
which he had excellent kidney graft function.
4. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Tacrolimus 1 mg tablet one tablet po bid.
2. Amlodipine 5 mg tablet one tablet po q day.
3. CellCept [**Pager number **] mg tablet one tablet po tid.
4. Pantoprazole 40 mg tablet one tablet po q day.
5. Insulin: The patient is to follow insulin-sliding scale
on a fixed dose regimen provided by the [**Hospital **] Clinic.
6. Bactrim one tablet SS 3x a week.
7. Prednisone 3 mg tablet po q day.
FOLLOW-UP PLANS: Patient is to followup with Dr. [**Last Name (STitle) **] at
the Transplant Center at telephone number ([**Telephone/Fax (1) 3618**] with
an appointment arranged by [**Doctor First Name **] Grayshaw, the transplant
nurse. The patient is to continue his laboratory work
schedule as before this previous admission.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2192-9-5**] 11:44
T: [**2192-9-14**] 09:38
JOB#: [**Job Number 32794**]
|
[
"250.51",
"V45.81",
"443.9",
"453.9",
"997.79",
"V42.0",
"996.86",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.6",
"52.82"
] |
icd9pcs
|
[
[
[]
]
] |
1571, 1603
|
6165, 6426
|
6449, 6849
|
1031, 1360
|
3545, 6110
|
1840, 3516
|
6867, 7432
|
1623, 1817
|
175, 1005
|
1377, 1554
|
6135, 6144
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,110
| 163,195
|
31091
|
Discharge summary
|
report
|
Admission Date: [**2104-9-8**] Discharge Date: [**2104-9-13**]
Date of Birth: [**2074-1-30**] Sex: M
Service: SURGERY
Allergies:
acetaminophen / Codeine / latex
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
motor vehicle crash
Major Surgical or Invasive Procedure:
[**2104-9-8**]- L femur IM nail, ORIF R ankle
History of Present Illness:
30M restrained driver s/p MVA at unknown speed on highway.
Pt reports struck by care coming into [**Male First Name (un) **]. Patient unlcear as
to LOC. Patient reports severe L thigh pain. Noted to have
gross deformity and placed in [**Doctor Last Name **] traction and transferred to
ED
by EMS. Pt reports feeling anxious, causing difficulty
breathing. States feels sore all over, but severe pain L femur.
c/o traction being to tight at ankle, and numbness foot distal
to
strap.
Past Medical History:
Anxiety
Asthma
Social History:
Unemployed. Smokes [**1-28**] ppd. Denies EtOH.
Physical Exam:
PE:
GEN: AxOx3, appears somewhat anxious
RESP: CTAB
CVS: RRR
ABD: Soft, nontender, nondistended, normal bowel sounds.
MSK: left femur wound and R ankle fracture wound c/d/i and
appropriate.
Pertinent Results:
[**2104-9-9**] 12:00AM GLUCOSE-119* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-27 ANION GAP-7*
[**2104-9-9**] 12:00AM CALCIUM-7.8* PHOSPHATE-1.4* MAGNESIUM-2.1
[**2104-9-9**] 12:00AM WBC-9.6 RBC-2.49* HGB-7.1* HCT-21.9* MCV-88
MCH-28.6 MCHC-32.5 RDW-16.2*
[**2104-9-9**] 12:00AM PLT COUNT-96*
[**2104-9-9**] 12:00AM PT-12.8* PTT-26.8 INR(PT)-1.2*
[**2104-9-8**] 07:55PM HCT-23.0*
Brief Hospital Course:
The patient was transferred to the trauma ICU for close
monitoring. His injuries include:
Grade 3 liver lac
L open femur fx
R rib 5,6 fx
L rib 3 fx
R tri-malleolar fx
N: He was initially somnolent in the ICU. C-collar remained in
place overnight; narcotics were initially held given his mental
status. He became more responsive on HD 2 and his c-spine was
cleared. Chronic pain service was consulted. Pain was well
controlled with IV dilaudid; this was transitioned to PO prior
to transfer out of the ICU. Pt had good PO intake while on floor
up until his diacharge on [**2104-9-13**].
CV: Intermittent tachycardia with low hematocrit, but otherwise
no issues. Hematocrit improved and was stable on the floor.
Pulm: He remained stable on room air.
FEN/GI: He was initially kept NPO given his somnolence and
transfusion requirements; as he was more alert on HD2 and his
hematocrit stabilized, he was advanced to a regular diet.
GU: Foley catheter was placed in ED; urine output was monitored
closely and remained >30cc/hr. Foley was d/c's prior to
discharge.
Heme: Hematocrit was monitored closely throughout his stay. He
required a total of 4u pRBC while in the ICU; on HD 3 he was
given 1u for Hct of 23 which increased his Hct to 27. Serial
hcts were continued, and his hct remained stable at 25.9->25.6
on the day of his discharge.
ID: No issues
MSK: Orthopedics took him to the OR for L femur IM nail and ORIF
of the right ankle on [**2104-9-8**]. He tolerated the procedure well
and was brought back to the ICU for further management. Physical
therapy began to work with him while he was in the ICU, and
continued to work with him while he was on the floor up until
his discharge to [**Hospital3 **] on [**2104-9-13**]
Medications on Admission:
None
Discharge Medications:
1. Adderall XR *NF* (amphetamine-dextroamphetamine) 25 mg Oral
[**Hospital1 **] Reason for Ordering: Wish to maintain preadmission
medication while hospitalized, as there is no acceptable
substitute drug product available on formulary.
2. Enoxaparin Sodium 40 mg SC Q 24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
grade 3 liver laceration
left femur fracture
right ankle fracture
right non-disp 5,6 rib fractures
left disp 3 rib frx
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 sustained an injury to your liver, a left femur fracture,
and several rib fractures. You will be going to [**Hospital3 **]
for recovery. You should go to the nearest Emergency department
if you suddenly feel dizzy or lightheaded, as if you are going
to pass out. These are signs that you may be having internal
bleeding from your liver/spleen injury.
Your liver/spleen injury will heal in time. It is important that
you do not participate in any contact sports or any other
activity for the next 6 weeks that may cause injury to your
abdominal region.
As far as your left femur fracture wound, continue to use dry
dressings. For your R ankle fracture keep the splint on until
follow up with orthopedics.
Your rib fractures will heal over time. Continue to do breathing
exercises to expand your lung as your pain continues to improve.
Avoid aspirin producs, NSAID's such as Advil, Motrin, Ibuprofen,
Naprosyn, or Coumadin for at least 1-2 weeks unless otherwise
directed as these can cause bleeding internally.
Followup Instructions:
Please follow up in the Acute Care Surgery clinic in two weeks
for follow up of liver lac and rib fractures. Call [**Telephone/Fax (1) 600**]
for an appointment.
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Also follow up in Orthopedic surgery clinic two weeks from
[**9-8**] (OR date) with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP. Call [**Telephone/Fax (1) 1228**] for appointment.
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"807.03",
"285.1",
"V45.79",
"864.03",
"314.01",
"305.1",
"E812.0",
"824.6",
"821.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.21",
"79.36",
"78.55",
"79.06"
] |
icd9pcs
|
[
[
[]
]
] |
3733, 3860
|
1648, 3381
|
311, 358
|
4023, 4023
|
1206, 1625
|
5242, 5965
|
3436, 3710
|
3881, 4002
|
3407, 3413
|
4199, 5219
|
995, 1187
|
252, 273
|
386, 874
|
4038, 4175
|
896, 913
|
929, 980
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,216
| 174,714
|
43612+58637
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-3-23**] Discharge Date: [**2139-3-31**]
Date of Birth: [**2069-9-14**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
multiple medical problems CAD status post CABG in [**2129**] with
known metastatic melanoma, who presented to an outside
hospital with shortness of breath and right leg pain.
Patient had a positive Myoview as an outpatient and was going
to be arranged for outpatient catheterization. However, on
Friday he became acutely short of breath. Reportedly grabbed
an inhaler from a stranger and used it feeling better.
Was admitted to an outside hospital on Friday and noted to
have a troponin-I peak at 0.15, CK 143 with a MB of 1.9. A
BNP was 768. He had no fever or chills. He had multiple
falls last week, which were attributed to his chronic
Meniere's disease and dizziness. Recent Myoview demonstrated
reversibility in the anterior apical/inferoseptal area with
global hypokinesis with an EF of 27%. At the outside
hospital, the patient also had a head CT, which showed old
lacunar infarcts in the basal ganglia bilaterally. Bilateral
periventricular subcortical white matter hypodensities
consistent with small vessel ischemia. No acute hemorrhage
or mass effect. In addition, the patient had a lower
extremity ultrasound, which was negative for DVT.
PAST MEDICAL HISTORY:
1. History of TIAs.
2. Question of Meniere's disease.
3. Dizziness, chronic.
4. Hypercholesterolemia.
5. Melanoma Stage III B status post resection with metastatic
disease to the lymph nodes.
6. Recurrent cellulitis.
7. Asthma.
8. Hypertension.
9. Cervical disk disease.
10. Right CEA in [**2133**].
11. CAD status post CABG x5 in [**2129**] with LIMA to LAD, SVG to
OM, SVG to diag, SVG to AM PDA.
12. History of bradycardia in the 30s with ventricular
bigeminy. Recent catheterization on [**7-20**] revealed a 90% SVG
to diag, which was stented. Patient was entered on the PRIDE
study.
13. Status post MI in [**5-20**]. Echocardiogram on [**6-19**]
revealed an EF of 40-50% with inferior hypokinesis,
moderate-to-severe MR, moderate-to-severe TR, and biatrial
enlargement.
MEDICATIONS:
1. Cozaar 50 b.i.d.
2. Aspirin.
3. Nitroglycerin prn.
4. Lopressor 12.5 b.i.d.
5. Lasix 20 p.o. q.d.
6. Plavix 75 p.o. q.d.
7. Lipitor 20 p.o. q.d.
8. Paxil 40 p.o. q.d.
9. Singulair 10 p.o. q.d.
10. Wellbutrin 100 b.i.d.
11. Diclox 500 b.i.d.
12. Detrol two q.h.s.
13. Cardura 2 q.h.s.
14. Elavil 25 q.h.s.
15. Floredil.
16. Pulmicort.
FAMILY HISTORY: Brother died of a MI in his 50's.
SOCIAL HISTORY: He lives with his wife. His grandson
occasionally lives with him. He quit tobacco. No alcohol or
drugs. He quit tobacco 30 years ago.
ALLERGIES: Iodine dye and shellfish.
PHYSICAL EXAM: Temperature 98.7, blood pressure 158/80,
pulse of 73, respirations 18, and saturating 93% on room air.
General: Alert and disoriented, oriented x1. HEENT: Right
pupil was larger than his left, which is chronic. Moist
mucous membranes. Jugular venous pressure at 8 cm. Heart
was regular, S1, S2, no murmurs. Lungs: Decreased air
movement at the bases, no crackles. Abdomen was soft, obese,
nontender, and bowel sounds present. Extremities: Right
lower extremity with 2+ pitting edema to the thigh, increased
warmth, erythema of the right foot and patches of erythema of
the right leg and trace edema in the left lower extremity.
LABORATORIES: Potassium 4.1, BUN 13, creatinine 1.1, bicarb
30. Hematocrit 35.4, platelets 238.
EKG showed a sinus rhythm at a rate of 92 with a right bundle
branch block.
Patient was admitted and his hospital course was significant
for the following issues: Patient was supposed to undergo
catheterization on the 5th, however, this was postponed until
the 6th. On the night of the 5th, the patient received some
IV diuresis. His shortness of breath was thought to be
likely due to CHF essentially due to ischemia versus
exacerbation of his asthma and COPD. He was diuresed with
some improvement in his shortness of breath. He was
maintained on his [**Last Name (un) **] and Atrovent nebulizers. He was
premedicated for catheterization with Solu-Medrol.
The following day he went for a cardiac catheterization with
severe native three-vessel disease, severe biventricular
diastolic dysfunction, moderate pulmonary hypertension,
depressed cardiac index, culprit stenoses in the SVG to AM
PDA. Patient received two bare-metal stents to the SVG to
PDA. He was also noted to have elevated filling pressures on
the catheterization, both left and right-sided. He returned
to the floor after his catheterization, and was noted to be
very disoriented, very aggressive sitting up. His 8 French
sheath still in his right femoral artery.
Six to eight persons were required to keep the patient still.
He received 10 of IV Haldol, 50 of Fentanyl with some
calming effect, however, became even more aggressive and
refused to lie still. A code purple was called, and the
patient was put in leather restraints. Decision was made to
electively intubate the patient since he needed to lay still
for eight hours given the risk of bleeding in his right
groin, and the concern of an expanding hematoma in his right
thigh. Anesthesia was called for intubation, and the patient
was transferred to the CCU for further management. The
family was appraised of these developments.
In the CCU, the patient was gently hydrated. His hematocrit
was noted to be stable with no acute drop. He was quickly
weaned from the vent and extubated the following morning, and
returned to the floor.
An echocardiogram on [**3-25**] revealed an EF of 25%, elongated
left atrium, markedly dilated right atrium, moderate LVH,
overall left ventricular systolic function was severely
depressed with global hypokinesis. Right ventricular
systolic function also appeared depressed, mild AR, mild MR
with no pericardial effusion, just borderline pulmonary
artery systolic hypertension.
The patient was then transferred back to the floor, where he
remained disoriented, but alert and cooperative. His
disorientation was thought to likely be secondary to
delirium, secondary to medication toxicity, or steroids, or
Benadryl received prior to the catheterization. Upon return
to the floor, he was restarted on his psychiatric
medications, but benzodiazepines and narcotics were held.
Regarding his CAD, he had status post stents x2 to the PDA.
He was continued on atorvastatin, metoprolol, and losartan,
aspirin, and Plavix. He had a small groin hematoma, which
was stable and his hematocrit remained stable throughout the
rest of his hospital course.
CHF: The patient had severe diastolic and systolic
dysfunction by cardiac catheterization, and appeared somewhat
fluid overloaded. He was initially on 40 of IV Lasix b.i.d,
which was changed to p.o. once the patient no longer required
oxygen. He was continued on metoprolol for heart rate
control given his history of diastolic dysfunction. A chest
x-ray on [**3-26**] revealed low lung volumes with bibasilar
atelectasis, but no evidence of fluid overload.
Fever: The patient had spiked a fever to 101.5 while in the
CCU. He was continued on diclox for his chronic cellulitis,
which he takes chronically b.i.d. He had no further fevers
for at least 48 hours prior to discharge. Blood cultures
showed no growth to date. Sputum culture was also negative.
Multiple urine cultures were also negative.
Asthma: The patient was continued on albuterol, ipratropium,
and Montelukast, and also restarted on fluticasone b.i.d.
BPH: Patient had a Foley in place. He was continued on
doxazosin and Detrol.
Prior to discharge, the patient was still somewhat confused,
however, oriented x2-3. He denied any chest pain or
shortness of breath. He was seen by Physical Therapy and
Occupational Therapy, who recommended rehab. The patient was
asked to followup with Dr. [**Last Name (STitle) 93785**], his PCP, [**Name10 (NameIs) **] an appointment
was made for [**4-8**] at 1 p.m. He is also asked to followup
with Dr. [**Last Name (STitle) 11493**] within two weeks.
FINAL DIAGNOSIS: Coronary artery disease status post two
stents.
Patient also has an appointment with the Oncology Unit on
[**4-1**] at 9:45.
DISCHARGE CONDITION: Good. Ambulating without O2 with
assistance.
DISCHARGE MEDICATIONS:
1. Aspirin 325.
2. Clopidogrel 75 p.o. q.d.
3. Montelukast 10 p.o. q.d.
4. Bupropion 100 b.i.d.
5. Dicloxacillin 500 b.i.d.
6. Paroxetine 20 p.o. q.d.
7. Atorvastatin 20 p.o. q.d.
8. Albuterol 90 mcg 1-2 puffs q6.
9. Ipratropium 1-2 puffs q6.
10. Metoprolol 25 mg b.i.d.
11. Losartan 50 mg b.i.d.
12. Doxazosin 2 mg p.o. q.h.s.
13. Pantoprazole 40 p.o. q.d.
14. Fluticasone 110 two puffs b.i.d.
15. Furosemide 20 p.o. q.d.
DISCHARGE STATUS: He was discharged to rehab for physical
therapy and further occupational therapy.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 10195**]
MEDQUIST36
D: [**2139-3-27**] 08:15
T: [**2139-3-27**] 08:18
JOB#: [**Job Number 93786**]
Name: [**Known lastname 14803**], [**Known firstname 422**] L./SR. Unit No: [**Numeric Identifier 14804**]
Admission Date: [**2139-3-23**] Discharge Date: [**2139-3-30**]
Date of Birth: [**2069-9-14**] Sex: M
Service:
This addendum covers from [**2139-3-27**] to [**2139-3-30**].
ADDENDUM TO DISCHARGE SUMMARY: 1. Neurological: The
patient has been steadily improving in terms of his mental
status. On the day of discharge he was oriented times two to
two and a half, a little unclear about the month, although
oriented to year. He has better recollection of his family
and pets at home. He has been without a sitter for greater
then 24 hours and is cooperative and pleasant.
2. Coronary artery disease: The patient's Metoprolol was
titrated up. He was discharged on a dose of 50 b.i.d.
3. Groin hematoma: The patient's hematocrit has been
stable. He has had no expansion. He is swelling over his
_________________________ part of his chronic cellulitis as
well.
4. Fevers: The patient has been afebrile for the last four
to five days. He is continued on his Dicloxacillin for his
cellulitis.
He is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1180**] on [**4-1**] at 10:00
a.m. for continuous oncology. He also has a follow up with
his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4999**] on [**2139-4-8**] at 1:00 p.m.
DISCHARGE MEDICATIONS: Same as above with the exception of
Metoprolol 50 mg b.i.d.
The patient was seen by physical therapy and continues to
improve with his ambulation with a walker.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1095**]
Dictated By:[**Last Name (NamePattern1) 2685**]
MEDQUIST36
D: [**2139-3-30**] 08:09
T: [**2139-3-30**] 08:49
JOB#: [**Job Number 14805**]
|
[
"401.9",
"272.0",
"414.01",
"682.6",
"414.02",
"293.9",
"428.0",
"493.90",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"99.20",
"37.23",
"96.04",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
8308, 8355
|
2554, 2589
|
10684, 11154
|
8159, 8286
|
2800, 8141
|
190, 1385
|
1407, 2537
|
2606, 2784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,664
| 100,809
|
12462
|
Discharge summary
|
report
|
Admission Date: [**2113-1-27**] Discharge Date: [**2113-2-8**]
CHIEF COMPLAINT: Malaise.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 38707**] is an 81-year-old
gentleman with a history of coronary artery disease, obesity,
apnea, obesity, peripheral vascular disease, status post AAA
repair, status post right BKA who presents with "feeling
terrible" and diarrhea for one week. He presented with these
symptoms from an outside hospital. The patient complained of
leg pain, back pain, shoulder pain in the Emergency Room. He
denied any shortness of breath or chest pain. He reports
minor diaphoresis and low grade temperatures. In the
blood pressure of 78, heart rate of 27-45, he received
Atropine and Dopamine and was intubated, had a Swan Ganz
catheter placed and was sent to the ICU. It was found that
he had a troponin of 19.6 with a CK of 280 and a peak MB of
14.5. Of note, an echocardiogram was done on [**12-21**] which
revealed normal left ventricular function. The patient had a
CT scan of the chest and abdomen which revealed no evidence
of pulmonary embolism or ischemic bowel, however, chest CT
had evidence of bilateral pneumonia right greater than left.
He was started on Levofloxacin, Ceftazidime. His creatinine
and potassium were also found to be elevated, likely due to
acute renal failure from dehydration secondary to the
diarrhea. The patient was given Kayexalate and gentle
hydration. He was also started on Solu-Medrol for suspected
adrenal insufficiency. On [**1-25**] the patient failed ventilator
wean secondary to cardiogenic pulmonary edema. Since the
patient had a recent non Q wave MI and may have worsening
coronary artery disease, he was sent to [**Hospital1 190**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1) Chronic obstructive pulmonary
disease, on home oxygen three liters per minute by initial
cannula. 2) Coronary artery disease with cath in [**2109**] that
revealed normal EF with inferior base hypokinesis, RCA was
totally occluded and had collaterals from left to right.
Echocardiogram on [**12-21**] revealed normal left ventricular
function, mild AS, aortic insufficiency, LVH and trace MR.
3) Obstructive sleep apnea for which he does not tolerate
C-pap. 4) Obesity. 5) History of AAA repair five years ago,
right BKA secondary to compartment syndrome. Outpatient
management, Imdur 90 mg po q d, Verapamil 120 mg po tid,
Combivent 2 puffs inhaled qid, Albuterol inhaler 2 puffs q
4-6 hours prn, Nitroglycerin sublingual prn, Aspirin 81 mg po
q d, Probenecid 500 mg po bid, Lasix 20 mg po q d, Plavix 75
mg po q d, Lopressor 12.5 mg po bid.
MEDICATIONS: On transfer, Aspirin 325 mg po q d, Atrovent
and Albuterol nebs q 4 hours prn, Protonix 40 mg po q d,
artificial tears both eyes q 4 hours prn, Plavix 75 mg po q
d, Levofloxacin 250 mg po q d, Methylprednisolone 30 mg IV
bid, Nitro drip, Ceftazidime 1 gm q 8 hours, Senna 2 tablets
po q h.s., Heparin drip, Versed drip, Morphine drip, Dulcolax
10 mg po q d prn, Lopressor 2.5 mg IV q 4 hours, Reglan 10 mg
IV q 6 hours.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Lives with his wife, retired from the Air
Force. Smokes 1?????? packs of cigarettes per day and drinks
alcohol socially.
PHYSICAL EXAMINATION: Vitals on admission, temperature 97.9,
pulse 54, respiratory rate 14, blood pressure 136/62, satting
97%. He was on assist control with total volume of 800, rate
14, PEEP 8, 55% FIO2. In general he was in no acute
distress. Cardiovascular, regular but bradycardic, had a
grade 2/6 systolic ejection murmur at the right upper sternal
border. Had S3 heard at the apex. Respiratory, lungs were
clear to auscultation anteriorly, no wheezes heard. Abdomen
with good bowel sounds, soft, nontender, non distended.
Extremities, had a right BK, lower extremities were warm, he
had 1+ distal lower extremity pulses, no cyanosis, clubbing
or edema.
LABORATORY DATA: White count 9.7, hematocrit 30.5, platelet
count 81,000, PTT 15.3, PTT 20.9, INR 1.2, sodium 136,
potassium 4.4, chloride 103, CO2 24, BUN 47, creatinine 1.2,
glucose 110, CK 33, albumin 2.7, calcium 8.0, phosphorus 4.6,
magnesium 1.7. Uric acid 8.9. ABG 7.39, PCO2 47, PAO2 91.
Chest x-ray showed cardiovascular enlargement, bilateral
pleural effusions and patchy opacities in inferior perihilar
region consistent with CHF, probable left pleural effusion.
EKG showed normal sinus rhythm, left axis deviation, Q's in
lead 3 and AVF, ST depressions in V3 through V6. CT of the
abdomen and pelvis from the outside hospital revealed liver,
pancreas and spleen were normal. There are three gallstones.
There are simple cysts in both kidneys, no evidence of
ischemic bowel. CT of the chest also at the outside hospital
revealed no evidence of pulmonary embolism but evidence of
bilateral pneumonia, right greater than left. Here, at [**Hospital1 1444**] cardiac catheterization
revealed a 70% osteal lesion of left main with 100% occlusion
of RCA with collaterals from the left. His LAD and
circumflex revealed no significant obstructive disease.
Cardiovascular surgery was then notified to evaluate the
patient for CABG.
HOSPITAL COURSE:
1. Cardiovascular: Cardiovascular surgery was contact[**Name (NI) **] to
perform a possible CABG on the patient. They requested a TTE
which revealed that he had a left ventricular ejection
fraction of 55%, his AV gradient was 23 mmHg with a mean
gradient of 12. Aortic valve area is 1.72 cm sq which is
consistent with mild aortic valvular stenosis. His left
atrium was mildly dilated. He had moderate left ventricular
hypertrophy. AV leaflets were markedly thickened. He had a
mild 1+ AR and mild to moderate MR. Cardiovascular surgeons
declined to operate on the patient since he was at very high
risk of complications given his severe COPD, severe
peripheral vascular disease and mild aortic stenosis. He was
taken back to the cardiac catheterization lab where his left
main lesion was successfully stented. He will need repeat
catheterization in three months to evaluate the patency of
the stent. When he was extubated he became hypertensive and
tachycardic with a rhythm consistent with multifocal atrial
tachycardia. A combination of ACE inhibitor, calcium channel
blocker, low dose beta blocker, and nitrates successfully
controlled his hypertension and tachycardia.
2. Respiratory: Pulmonary records were obtained from outside
hospital which revealed that the pain did not have any
evidence of interstitial lung disease by a CT scan which was
performed last year. A repeat CT scan was performed on this
admission which confirmed these findings. He was then
started on Atrovent, Serevent and Flovent and Albuterol prn
for severe chronic obstructive pulmonary disease. The
patient then tolerated a pressor support wean and was then
successfully extubated.
3. ID: The patient remained afebrile for his entire
hospital stay. All cultures that were obtained were negative
for any signs of infection. Once the patient finished a 7
day course of Levaquin and Ceftazidime started at the outside
hospital for his pneumonia, antibiotics were discontinued.
He had no further signs of infection for the rest of his
hospital stay.
4. Heme: The patient was found to be thrombocytopenic on
admission. Heparin induced antibodies were sent and were
found to be negative. Eventually his thrombocytopenia had
resolved by the time of discharge.
5. Endocrine: The stress dose steroids started at outside
hospital were weaned to off.
6. Gastrointestinal: He was continued on tube feeds until he
was transferred to the medicine floor. A speech and swallow
consult was obtained which revealed that he had no signs of
aspiration. The patient was started on a cardiac diet.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehab facility.
DISCHARGE MEDICATIONS: Protonix 40 mg po q d, Verapamil 90
mg po tid, Imdur 60 mg po q d, Lisinopril 60 mg po q d,
Albuterol MDI 2 puffs q 4 hours prn, Atrovent MDI 2 puffs
qid, Serevent MDI 2 puffs inhaled [**Hospital1 **], Plavix 75 mg po q d,
Aspirin 325 mg po q d, Flovent 110 mcg 2 puffs [**Hospital1 **], Senna 2
tabs po q h.s., Lopressor 25 mg po bid, Nystatin swish and
swallow q d.
DISCHARGE INSTRUCTIONS: Return to the hospital if he
developed worsening shortness of breath or chest pain.
FOLLOW-UP: Follow-up with pulmonologist and cardiologist in
one week. He will need to have a repeat cardiac
catheterization in three months to evaluate the patency of
stent placed to the left main coronary artery.
PROBLEM LIST:
1. Coronary artery disease.
2. Severe chronic obstructive pulmonary disease.
3. Obstructive sleep apnea.
4. Obesity.
5. History of AAA repair.
6. Status post right BKA.
7. Pneumonia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2113-2-7**] 21:57
T: [**2113-2-7**] 22:06
JOB#: [**Job Number 38708**]
|
[
"491.21",
"285.9",
"410.71",
"440.20",
"287.5",
"V49.75",
"293.0",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"99.20",
"96.72",
"36.01",
"36.06",
"89.68",
"39.64",
"88.56",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3122, 3132
|
7898, 8267
|
5199, 7790
|
8292, 8594
|
3295, 5182
|
90, 100
|
129, 1759
|
8608, 9071
|
1782, 3105
|
3149, 3272
|
7815, 7874
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,357
| 100,553
|
28221+57581+57582
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-21**]
Date of Birth: [**2072-1-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Fluarix
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Common hepatic artery aneurysm
Major Surgical or Invasive Procedure:
[**2146-6-16**]
Resection of common hepatic artery aneurysm, with
right greater saphenous vein interposition graft.
History of Present Illness:
This is a 74-year-old male with a
history of chronic weight loss of unknown etiology, who,
while undergoing a workup, was found to have a 2- to 3-cm
common hepatic artery aneurysm. He was consented for
resection of the aneurysm.
Past Medical History:
HTN
DJD
hepatic artery aneurism
migraines
PSH:
status post cholecystectomy
bilateral carpal tunnel releases
recent biateral laparoscopic inguinal hernia repairs
C3-C4 posterior discectomy.
Social History:
current tobacco use - 7 cigarettes/day
no EtOH use
Family History:
non contributory
Physical Exam:
vss afebrile
Gen: thin male in nad
Neck: supple, no jvd, trach midline
Card: RRR
Lungs: CTA bilat
Abd: soft +bs, no m/t/o; incision c/d/i
Extremities: fem/dp/pt pulses palpable bilat
Pertinent Results:
[**2146-6-21**] 06:55AM BLOOD WBC-4.6 RBC-3.71* Hgb-11.7* Hct-33.2*
MCV-90 MCH-31.7 MCHC-35.4* RDW-14.2 Plt Ct-208
[**2146-6-20**] 08:10AM BLOOD WBC-4.9 RBC-3.69* Hgb-11.3* Hct-32.8*
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.3 Plt Ct-218#
[**2146-6-18**] 03:45AM BLOOD WBC-6.1 RBC-3.32* Hgb-10.6* Hct-30.8*
MCV-93 MCH-32.0 MCHC-34.4 RDW-14.7 Plt Ct-137*
[**2146-6-17**] 04:26AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-31.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.9 Plt Ct-204
[**2146-6-16**] 02:21PM BLOOD WBC-9.2 RBC-3.75* Hgb-12.0* Hct-35.2*
MCV-94 MCH-31.9 MCHC-34.0 RDW-14.9 Plt Ct-255
[**2146-6-21**] 06:55AM BLOOD Glucose-107* UreaN-10 Creat-0.8 Na-138
K-4.0 Cl-98 HCO3-35* AnGap-9
[**2146-6-20**] 08:10AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-133 K-3.8
Cl-94* HCO3-31 AnGap-12
[**2146-6-19**] 03:30AM BLOOD Glucose-152* UreaN-7 Creat-0.5 Na-133
K-3.8 Cl-97 HCO3-30 AnGap-10
[**2146-6-18**] 03:45AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-134
K-3.7 Cl-100 HCO3-30 AnGap-8
[**2146-6-17**] 04:26AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-137
K-4.0 Cl-104 HCO3-27 AnGap-10
[**2146-6-16**] 02:21PM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-140
K-4.6 Cl-111* HCO3-23 AnGap-11
[**2146-6-21**] 06:55AM BLOOD ALT-229* AST-44* AlkPhos-71 Amylase-77
TotBili-0.5
[**2146-6-20**] 08:10AM BLOOD ALT-333* AST-91* AlkPhos-72 Amylase-64
TotBili-0.5
[**2146-6-19**] 03:30AM BLOOD ALT-507* AST-355* AlkPhos-66 Amylase-66
TotBili-0.4
[**2146-6-18**] 03:45AM BLOOD ALT-555* AST-592* AlkPhos-63 Amylase-65
TotBili-0.3
[**2146-6-17**] 04:26AM BLOOD ALT-325* AST-336* AlkPhos-67 Amylase-88
TotBili-0.4
[**2146-6-16**] 02:21PM BLOOD ALT-316* AST-333* AlkPhos-71 Amylase-81
TotBili-0.3
[**2146-6-19**] 03:30AM BLOOD Lipase-30
[**2146-6-18**] 03:45AM BLOOD Lipase-30
[**2146-6-17**] 04:26AM BLOOD Lipase-42
[**2146-6-16**] 02:21PM BLOOD Lipase-88*
[**2146-6-21**] 06:55AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
[**2146-6-20**] 08:10AM BLOOD Calcium-8.1* Phos-3.6# Mg-1.9
[**2146-6-19**] 03:30AM BLOOD Albumin-3.0* Calcium-8.0* Phos-1.8*
Mg-1.4* Iron-20*
[**2146-6-18**] 03:45AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
[**2146-6-17**] 04:11PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7
[**2146-6-17**] 04:26AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0
[**2146-6-16**] 11:47PM BLOOD Calcium-8.1* Mg-2.4
[**2146-6-16**] 02:21PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.6
[**2146-6-16**] 2:20 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2146-6-19**]**
MRSA SCREEN (Final [**2146-6-19**]): No MRSA isolated.
Brief Hospital Course:
Mr. [**Known lastname 68553**] was admitted and underwent hepatic artery aneurysm
repair under general anesthesia with a tohoracic epidural on
[**2146-6-16**]. He tolerated the procedure well, was extubated and was
transfered to the CVICU postoperativey. He was hemodynamically
stable but did have some brief episodes of bradycardia which
resolved on their own. On POD 1 he was noted to have some
elevated LFTs, as expected. He was quite stable and was
transfered to the VICU for further recovery. In the vicu he
remained hemodynamically stable with good pain control. On POD 2
he tolerated a clear liquid diet and was OOB with assistance. A
nutrition consult was obtained given his recent weight loss and
preoperative status of having poor nutrition. He was advanced to
a regular diet on POD 3 with ensure supplements which he
tolerated well. He was transfered to the floor on POD 3 as well.
On POD 4 his epidural was removed. He tolerated PO pain meds
quite well. Later that day his foley was removed, and he voided
a small amount, however, by the evening he had not voided in
several hours and a bladder scan showed over 800cc of residual,
hence a foley was re placed. He was also started on flomax . His
jp drain was also removed on POD 4 without difficulty. He was
hemodynamically stable and able to ambulate without assistance.
On POD 5 he was tolerating his diet well and felt comfortable
with his foley and leg bag. He was evaluated by PT and found
stable to go home. He will follow up with his PCP on friday for
foley removal.
Medications on Admission:
Atenolol 50 mg orally once a day, lisinopril 10 mg
orally once a day, trazodone 150 mg at night, a multivitamin,
vitamin B12, and vitamin C supplements.
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
4. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Itching.
9. Resume
OTC vitamins and minerals
Discharge Disposition:
Home
Discharge Diagnosis:
Common hepatic artery aneurysm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-31**]
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 [**1-26**]
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
You had urinary retention and had your foley catheter replaced.
You will go home with a leg bag and catheter in place. Follow up
with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] in [**2-25**] days for
removal of the catheter.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2146-7-6**] 9:45
Dr. [**Last Name (STitle) 11302**] [**Name (STitle) **] 1115 am
- follow up and foley removal
Completed by:[**2146-6-21**] Name: [**Known lastname 11753**],[**Known firstname 7104**] J Unit No: [**Numeric Identifier 11754**]
Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-21**]
Date of Birth: [**2072-1-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Fluarix
Attending:[**First Name3 (LF) 5118**]
Addendum:
Patient was found to have a positive UA and was started on a 7
day course of Cipro 250mg [**Hospital1 **] for treament. His foley will be
removed on Friday [**6-24**] by his PCP
Discharge Disposition:
Home
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 2878**] MD [**MD Number(2) 5119**]
Completed by:[**2146-6-21**] Name: [**Known lastname 11753**],[**Known firstname 7104**] J Unit No: [**Numeric Identifier 11754**]
Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-21**]
Date of Birth: [**2072-1-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Fluarix
Attending:[**First Name3 (LF) 5118**]
Addendum:
Please note:
During his hospitalization Mr. [**Known lastname **] suffered from severe
malnutrition based on [**Hospital 8**] hospital criteria of albumin of 3.0,
BMI of 18.0 and a cachetic appearance.
Discharge Disposition:
Home
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 2878**] MD [**MD Number(2) 5119**]
Completed by:[**2146-8-1**]
|
[
"788.20",
"783.21",
"599.0",
"V85.0",
"305.1",
"346.90",
"261",
"401.9",
"442.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.46"
] |
icd9pcs
|
[
[
[]
]
] |
11020, 11167
|
3735, 5272
|
312, 431
|
6376, 6376
|
1225, 3712
|
9464, 10266
|
989, 1007
|
5476, 6271
|
6321, 6355
|
5298, 5453
|
6527, 8750
|
8776, 9441
|
1022, 1206
|
242, 274
|
459, 691
|
6391, 6503
|
713, 904
|
920, 973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,170
| 185,712
|
13792
|
Discharge summary
|
report
|
Admission Date: [**2127-1-17**] Discharge Date: [**2127-1-20**]
Date of Birth: [**2076-5-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
50 yo F w/ recent Dieulafoy's lesion clipping ([**1-7**]), EtOH abuse,
hypothyroidism, depression, micronodular cirrhosis, GERD
presents with hematemasis (BRB and clots) x2 on day PTA. (First
admission on [**2127-1-6**] for 6-7 episodes of melena and one episode
of hematemesis due to Dieulafoy's ulcer.) Denies melena
immediately prior to this admission. Since her discharge, pt
reports normal stools and no emesis. Yesterday, she had an
upset stomach (crampy, fullness) and at 7pm had significant
hematemasis x1. In the ED on [**1-16**], she had an NG lavage (2L)
which showed clot and coffee ground blood. Rectal exam revealed
brown stool which was guaiac+. Her Hct on arrival was 25. She
received 2u of pRBCs and GI was consulted. GI administered IV
erythromycin and did an endoscopy. The endoscopy showed normal
esophagus, erythema and congestion in the stomach c/w erosive
gastritis and normal duodenum (to 2nd part). No active bleeding
was noted, there was some evidence of portal gastropathy. Of
note, pt complained of LUE pain, an US showed "acute thrombus in
a 2 cm segment of the left cephalic vein, just central to the
intravenous catheter. No other evidence of DVT." All access
was removed from the left arm. Anticoagulation was not started
[**1-4**] to hematemasis.
Past Medical History:
Dieulafoy's s/p clipping (EGD [**1-7**])
Micronodular Cirrhosis presumably due to EtOH (Dx by biopsy at
[**Location (un) 745**] [**Hospital 3678**] Hospital in [**11-9**])
Depression
Hypothyroid
GERD
Social History:
Pt currently drinks 1 bottle wine/day. She has a h/o EtOH, has
been sober x 9 months, but started drinking again 1 mo ago. She
denies tobacco and drug use. She works as nurse [**First Name (Titles) **] [**Last Name (Titles) 2025**]. Pt is
experiencing a lot of stress in her life as her father is having
health problems and she recently went through a divorce.
Family History:
Brother h/o EtOH and cirrhosis died in [**2112**]
Mother- stroke
[**Name (NI) 12238**] htn, stroke, dementia
Physical Exam:
PE
VS: Temp 99.8 BP 120/70 HR 86 RR 20 O2sat 99% RA Pain
[**3-13**]
GEN: Pleasant woman, NAD, sitting up in bed
HEENT: NCAT, anicteric sclera, MMM, OP clear
NECK: Supple, no carotid bruits/thyromegaly/[**Doctor First Name **]/JVD
RESP: CTAB
CV: RRR, II/VI SEM heard best at the LUSB
ABD: Normoactive BS, no bruits, soft, nontender, slightly
distended
BACK: No spinal or CVA tenderness
EXT: No C/C/E, WWP, 2+ DP pulses bilat, TTP along lateral
borders bilateral upper arms, limited range of motion in
bilateral shoulders
RECTAL: Brown stool w/ +guaiac per ED
Pertinent Results:
CXR: [**2127-1-17**]: A feeding tube is seen extending below the
hemidiaphragms. Cardiac and mediastinal contours are unchanged.
Lungs are clear. There are no pleural effusions. There is no
free air noted under the hemidiaphragms. IMPRESSION: No
evidence of free intraperitoneal air.
.
LUS US [**2127-1-17**]: Acute thrombus in a 2 cm segment of the left
cephalic vein, just central to the intravenous catheter. No
other evidence of DVT.
.
EGD [**2127-1-17**]:
Impression:
Normal mucosa in the whole esophagus
Erythema and congestion in the stomach
Normal mucosa in the first part of the duodenum and second part
of the duodenum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
The pt is a 50 yo F w/ recent Dieulafoy's lesion clipping, EtOH
abuse, micronodular cirrhosis, and GERD who presented with
hematemesis x 2, now s/p EGD showing erosive gastritis.
.
# GI bleed: Pt was recently discharged from the hospital
following a Dieulafoy's lesion clipping. Presented with 2
episodes of hematemesis. EGD did not reveal any active bleeding
and clipping was intact. Only erosive gastritis was seen. She
was given 2 units of pRBCs in the MICU. She received IV
pantoprazole [**Hospital1 **], and serial Hct's were checked, with the option
to transfuse if Hct dropped to <21, but pt remained stable with
no further drops in Hct. Her diet was advanced to clear liquids
out of the MICU and to regular on the floor as tolerated.
Patient had no further episodes of hematemesis.
.
# LUE DVT: Pt had left arm pain and swelling in the MICU. A LUE
U/S showed an acute thrombus in the left cephalic vein. All
lines were removed from that arm. Anticoagulation was not begun
due to pt's recent episode of hematemesis.
.
# Hypothyroidism: Pt has a h/o hypothyroidism on Synthroid,
which was continued throughout this hospitalization.
.
# EtOH abuse: Pt has a h/o heavy alcohol use but denies drinking
any alcohol in the past 2 weeks, so no monitoring with the CIWA
scale was initiated. Thiamine and folic acid were given.
.
# Cirrhosis: Pt has a h/o recently-diagnosed micronodular
cirrhosis by biopsy, and is followed by her gastroenterologist
in [**Location (un) 745**]-[**Location (un) 3678**]. She is advised to follow up in the liver
clinic. Spironolactone and furosemide were held during this
hospital course due to decreased PO intake due to GI bleeding.
.
# Depression: Pt has a h/o depression and she was continued on
her out-patient regimen of Lexapro without changes.
.
Medications on Admission:
Iron 325 mg 1-2 tabs daily
Levothyroxine 75 mcg qdaily
Escitalopram 10 mg qdaily
prilosec 20 mg [**Hospital1 **]
Thiamine HCl 100 mg DAILY
Folic Acid 1 mg qdaily
Multivitamin qdaily
Furosemide 20 mg qdaily
Spironolactone 50 mg qdaily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: [**12-4**]
Tablets PO once a day.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Erosive gastritis
LUE cephalic vein clot
.
Secondary:
Hypothyroidism
EtOH abuse
Micronodular cirrhosis
Depression
Discharge Condition:
Good
Discharge Instructions:
You were evaluated for the blood in your vomit. Your workup,
including nasogastric tube lavage, lab work and endoscopy, was
positive for gastritis but negative for any ulcers or obvious
areas of bleeding. Your blood levels were followed and
stabilized while you were in the hospital.
An ultrasound was found to show a clot in a vein in your left
arm. Since you have had the upper gatrointestinal bleeding, no
anticoagulation was started.
You should resume your medication regimen as you were taking
prior to admission.
You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 233**] [**Last Name (NamePattern1) 634**], at
[**Telephone/Fax (1) 37178**], for optimal management of your bilateral upper
extremity and shoulder pain, hypothyroidism, and depression.
Please follow up with your GI/liver doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**],
for continued management of your cirrhosis and monitoring of any
continued GI bleeding.
Please return to the ED if you experience any rectal bleeding or
vomiting of blood, shortness of breath, chest pain,
lightheadedness/dizziness, or other concerning symptoms.
Followup Instructions:
You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 233**] [**Last Name (NamePattern1) 634**], at
[**Telephone/Fax (1) 37178**], for optimal management of your bilateral upper
extremity and shoulder pain, hypothyroidism, and depression.
Please follow up with your GI/liver doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**],
for continued management of your cirrhosis and monitoring of any
continued GI bleeding.
|
[
"537.89",
"571.2",
"V45.89",
"244.9",
"996.74",
"311",
"530.81",
"535.40",
"453.8",
"305.00",
"285.1",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6484, 6490
|
3704, 5499
|
326, 332
|
6657, 6664
|
2992, 3681
|
7899, 8393
|
2278, 2388
|
5784, 6461
|
6511, 6636
|
5525, 5761
|
6688, 7876
|
2403, 2973
|
274, 288
|
360, 1656
|
1678, 1880
|
1896, 2262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,895
| 109,309
|
7732
|
Discharge summary
|
report
|
Admission Date: [**2146-3-30**] Discharge Date: [**2146-4-1**]
Date of Birth: [**2066-6-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zestril
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Mechanical ventilation
Central line placement
History of Present Illness:
This is a 79-year-old woman with a pmhx. significant for
dementia, type DM2 (on insulin), PVD s/p bilateral amputation,
HTN, DLP, and CAD who is transferred from medical floor to ICU
for hypoxemic respiratory failure. Ms. [**Known lastname 8738**] was initially
admitted to [**Hospital1 18**] for 3 days of cough, shortness of breath, and
increased work of breathing. According to nightfloat admission
note (patient unable to give history), patient complained of
non-productive cough, shortness of breath (at rest), and sore
throat for the last few days. She also has had chest
discomfort, worsened by both inspiration and cough,
non-radiating, as well as discomfort in her upper abdomen,
phantom leg-pain, and reflux. She's unable to say how long the
chest pain lasted for when it came on. She had one episode of
watery diarrhea. She has not been on antibiotics recently and
had had no changes in medications. Her grandson who she is
around frequently was sick with a cold a few days ago. Her son
also thinks that she is more tired than usual. Her son has not
noticeed a fever.
.
In the ED, VS were: T 96.6, HR 85, BP 130/83, RR 16. She
triggered on arrival w/ O2 sat of 85% on RA, that improved to
high 90s on 2L nc. On exam pt found to have R sided crackles and
wheeze. In the ED BP ranged 160s-200s/70s-100s. Pt received
flagyl, levoquin, and combivent, IVF. ECG w/ sinus tachy 103
bpm, std in v3-v5. Overnight on the floor, she had low O2 sats
that responded to oxygen. On the morning of ICU transfer,
patient had HRs in the 140s with ST depressions V4-V6, 2 sets
0.02 from < 0.01. Patient was going to go for CTA but IV was
infiltrated. On transfer to the ICU vitals were HR: 100, BP:
139/109, RR 30, SP02: 99% on 100% facemask.
Past Medical History:
CAD s/p PCI to OM, w/ 3 vessel disease on cath in [**2140**]
Moderate to severe TR
Systolic and Diastolic CHF (EF 45-50%) per echo in [**2140**]
Pulm HTN
Left cataract surgery in [**2135-11-9**]
PVD s/p fem-peroneal, failed graft underwent left BKA
UTI with sepsis ([**2142**]), recurrent UTIs on suppressive
antibiotics
HTN
Hyperlipidemia
DM2
Positive PPD in [**2132**]
Anemia
CVA in [**2115**], s/p L carotid endarterectomy
Diabetic retinopathy, status post laser therapy x2
Social History:
Patient lives w/ son. At baseline she is A&Ox2-3 (self/place,
difficulty w/ year). She uses a wheelchair. She needs assistance
w/ transferring to wheelchair and ADLs. No history of cigarette
use. Denies ETOH/illicits.
Family History:
Non-contributory.
Physical Exam:
VS: 98.8 155/50 65 26 92/2L
GENERAL: Well-appearing man in NAD, speaking full sentences
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
LUNGS: +Wheeze anteriorly, poor respiratory effort, resp
unlabored.
HEART: Tachy, no MRG, nl S1-S2.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: Bl amputations
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox2
Pertinent Results:
Labs on Admission:
[**2146-3-30**] 09:54PM BLOOD WBC-9.7# RBC-3.69* Hgb-11.2* Hct-33.1*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.4 Plt Ct-244
[**2146-3-30**] 09:54PM BLOOD Neuts-81.4* Lymphs-11.2* Monos-4.3
Eos-2.6 Baso-0.4
[**2146-3-30**] 09:54PM BLOOD Glucose-174* UreaN-13 Creat-0.8 Na-132*
K-3.6 Cl-96 HCO3-26 AnGap-14
[**2146-3-30**] 09:54PM BLOOD cTropnT-<0.01
[**2146-3-30**] 09:54PM BLOOD Lactate-1.4
.
Studies:
[**2146-3-30**] CXR:
IMPRESSION: Markedly limited study. If clinically feasible,
consider PA and lateral views in the radiology suite for more
sensitive evaluation.
.
ECHO [**2146-4-1**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %) secondary to
inferior posterior hypokinesis. The right ventricular cavity is
dilated with depressed free wall contractility. There are focal
calcifications in the aortic arch. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CXR [**2146-4-1**]:
FINDINGS: In comparison with the study of [**3-31**], there is little
change in the appearance of the monitoring and support devices.
Enlargement of the cardiac silhouette is again seen with
evidence of pulmonary edema, though the vascular congestion is
less than on the prior study. Again, the possibility of
superimposed pneumonia would be difficult to exclude in the
appropriate clinical setting.
Brief Hospital Course:
This is a 79-year-old woman with a pmhx. of DM II, COPD, HTN,
hyperlipidemia, PVD, and CHF who is admitted with fever and
respiratory distress.
.
# HYPOXEMIC RESPIRATORY FAILRUE: Patient with an elevated a-a
gradient, respiratory distress, and fever, raising concern for
pneumonia. Sputum with gram positive cocci. Ms. [**Known lastname 8738**] was
treated broadly with antibiotics and anti-virals. However, she
continued to decline clinically, with increased O2 requirement
and eventual need for intubation. Her blood pressures decreased
as well, and although she was initially volume responsive,
pressors were eventually started to maintain adequate perfusion.
On [**4-1**], as patient's clinical status continued to worsen,
family decided to withdraw care. Patient was terminally
extubated and pressors were stopped. With her family at the
bedside, Ms. [**Known lastname 8738**] passed away peacefully on [**4-1**] at 10:25pm.
Family declined an autopsy.
.
# CHEST PAIN: Ms. [**Known lastname 8738**] had a bump in troponins upon arrival
in the MICU. This was felt to be likely from demand ischemia in
the setting of severe respiratory distress however, acute
coronary syndrome could not be ruled out. Patient was not a
candidate for catherization, and she was started on a heparin
drip. She was continued on beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **], and statin.
Medications on Admission:
ATORVASTATIN [[**First Name3 (LF) **]] 20 mg daily
CITALOPRAM 20 mg once a day
CLOPIDOGREL [PLAVIX] 75 mg Tablet daily
IMIPRAMINE HCL 25 mg QHS
INSULIN GLARGINE [LANTUS] 20 units qam
ISOSORBIDE MONONITRATE [IMDUR] 30 mg Tablet Sustained Release
once a day
LACTULOSE 15 CC po daily
METFORMIN 850 mg twice a day
METOPROLOL TARTRATE [LOPRESSOR] 150mg po daily
MIRTAZAPINE [REMERON] 30 mg at bedtime
NITROFURANTOIN (MACROCRYST25%) [MACROBID] 100 mg once a day
ROSIGLITAZONE [AVANDIA] 4 mg once a day
VALSARTAN [DIOVAN] 160 mg Tablet once a
day
ASPIRIN 325 mg once a day
CYANOCOBALAMIN 250 mcg once a day
MAGNESIUM OXIDE 400 mg once a day
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
|
[
"250.50",
"V58.67",
"428.42",
"272.4",
"440.4",
"414.01",
"787.91",
"401.9",
"440.20",
"V70.7",
"038.9",
"518.81",
"V66.7",
"362.01",
"V45.82",
"428.0",
"294.8",
"995.92",
"V12.54",
"416.8",
"584.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7355, 7364
|
5235, 6629
|
307, 365
|
7424, 7442
|
3388, 3393
|
7507, 7526
|
2895, 2914
|
7314, 7332
|
7385, 7403
|
6655, 7291
|
7466, 7484
|
2929, 3369
|
241, 269
|
393, 2143
|
3407, 5212
|
2165, 2643
|
2659, 2879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,493
| 134,464
|
31632
|
Discharge summary
|
report
|
Admission Date: [**2110-6-26**] Discharge Date: [**2110-7-1**]
Date of Birth: [**2055-1-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
Intubation
Endoscopy with injection therapy
Emergent TIPS placement
History of Present Illness:
History per report/chart as patient intubated: [**Known firstname **] [**Known lastname **] is a
55-year-old gentleman with alcoholic cirrhosis (s/p UGIB in
past) who initially presented to the ED with complaints of LE
edema. Work-up revealed decompensated cirrhosis, had ascites on
exam and encephalopathy. While in the ED, patient began vomiting
brown/maroon-colored liquid, which was guiaic positive, and NG
lavage revealed persistent UGIB. Patient was guiaic positive on
rectal exam, and Hct was found to be 24.1. He was transfused 2
units of unmatched blood while awaiting Type and Cross. He was
given 1g Ceftriaxone, IV PPI [**Hospital1 **], and Zofran for nausea. NG tube
revealed persistent maroon liquid, which later became frank red
blood. Patient maintained systolics > 100 during ED course.
Octreotide gtt was started. Patient was intubated for airway
protection. Liver team was consulted, and patient was brought
emergently to ED to be scoped upon arrival to ICU. Per hx,
patient had been seen in [**Country 149**] yesterday for his LE edema, had
diagnostic endoscopy was told to go emergently to the US. He
arrived in [**Location (un) 86**] from [**Country 149**] this morning and went straight to
the ED.
Past Medical History:
1. ETOH Cirrhosis (with decompensation in past)
Social History:
Spends half his time in [**Country 149**]. ETOH abuse history. Sister lives
in [**Name (NI) 6151**].
Family History:
Unknown
Physical Exam:
VS: T 96.3; BP 89/62; HR 99; RR 18; O2 100% TV 550 RR 18 PEEP 5
GEN: intubated, sedated, withdraws to pain
HEENT: ET Tube in place. PRRL. NG tube to suction with
continuous bright red blood.
LUNG: CTA B/L
HEART: Tachy S1S2
ABDOMEN: Distended. + fluid wave.
RECTAL: Guiaic positive in ED
EXT: 2+ Pitting edema LE
NEU: PRRL. withdraws to pain. sedated, so exam limited.
downgoing toes B/L.
Pertinent Results:
[**2110-6-26**] 04:15AM PT-21.3* PTT-45.5* INR(PT)-2.1*
[**2110-6-26**] 04:15AM PLT COUNT-151
[**2110-6-26**] 04:15AM NEUTS-72.9* LYMPHS-19.9 MONOS-5.3 EOS-1.6
BASOS-0.3
[**2110-6-26**] 04:15AM LIPASE-38
[**2110-6-26**] 04:15AM ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-125*
AMYLASE-94 TOT BILI-1.4
[**2110-6-26**] 04:15AM estGFR-Using this
[**2110-6-26**] 04:15AM GLUCOSE-106* UREA N-6 CREAT-0.5 SODIUM-133
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-11
[**2110-6-26**] 04:53AM COMMENTS-GREEN TOP
[**2110-6-26**] 06:56AM PT-20.5* PTT-51.4* INR(PT)-2.0*
[**2110-6-26**] 06:56AM ALBUMIN-1.9* CALCIUM-6.7* PHOSPHATE-4.2
MAGNESIUM-1.5*
[**2110-6-26**] 06:56AM GLUCOSE-131* UREA N-6 CREAT-0.5 SODIUM-135
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13
Brief Hospital Course:
Mr. [**Known lastname **] is a 55-year-old gentleman with ETOH cirrhosis who
presented with decompensation with esophageal variceal bleed. He
was admitted to the Intensive Care Unit and underwent an
emergent TIPS procedure, requiring large quantities of PRBC,
platelet, and cryoprecipitate transfusions. The patient
continued to experience respiratory difficulty after extubation.
Given the patient's poor prognosis, his health care proxy
decided to change his code status to DNR/DNI and proceed with
comfort measure only. The patient was transferred to the medical
floor, was put on a morphine drip, and died at 10:13 pm on
[**2110-7-1**].
Medications on Admission:
unknown/none
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatic failure
Discharge Condition:
Expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"V66.7",
"998.2",
"456.20",
"571.2",
"572.2",
"286.7",
"789.5",
"V11.3",
"572.3",
"518.81",
"285.1",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"54.91",
"99.05",
"99.04",
"99.06",
"96.04",
"96.71",
"88.47",
"42.33",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3791, 3800
|
3085, 3728
|
329, 399
|
3859, 3999
|
2287, 3062
|
1853, 1862
|
3821, 3838
|
3754, 3768
|
1877, 2268
|
275, 291
|
427, 1648
|
1670, 1719
|
1735, 1837
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,370
| 183,637
|
49029
|
Discharge summary
|
report
|
Admission Date: [**2200-4-10**] Discharge Date: [**2200-4-20**]
Date of Birth: [**2152-9-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Nausea/Vomiting/Diarrhea
Major Surgical or Invasive Procedure:
Central Line Placement
Intubation
History of Present Illness:
47yoF w/ HIV/AIDS (last CD4 302 1/08per ED record), PCP
pneumonia, HCV who had a syncopal episode while at a salon. Per
EMS record & ED record,
pt c/o of acute onset of abd pain, not described further. +
bilious vomiting/ + diarrhea. No HA, no CP, no SOB. Per ED
record, pt was vomiting profusely and had explosive darrhea.
Hypotensive, given 5L IVF and started on Levophed. RIJ cvl
placed. Pt was dyspneic, intubated.
Past Medical History:
HIV CD4 302 [**1-14**] at [**Hospital1 2177**]
PCP Pneumonia
HCV
[**Name9 (PRE) 167**] proximal femur fracture s/p ORIF
Social History:
Lives with daughter.
Family History:
Noncontributory
Physical Exam:
per [**4-10**] Surgical Consult note:
PE: Levophed@0.18
98.7 97 104/74 14 100%
AC 0.50 500x14 5
7.32 / 37 / 252 / 20 / -6
IVF 5000 UO 1570 OG 500
intubated, sedated but arousable
RR s1 s2 tachy
CTA b/l
soft min dist, tender b/l LQ, no peritonitis
lower midline incision well healed
copious diarrhea coming out, non-bloody
guaiac +
Pertinent Results:
[**2200-4-9**] 06:12PM BLOOD WBC-3.3* RBC-5.10 Hgb-13.9 Hct-42.3
MCV-83 MCH-27.3 MCHC-33.0 RDW-14.3 Plt Ct-390
[**2200-4-9**] 06:12PM BLOOD Neuts-45* Bands-28* Lymphs-19 Monos-4
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2200-4-10**] 03:46AM BLOOD Neuts-84* Bands-8* Lymphs-5* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-4-10**] 03:46AM BLOOD WBC-4.8 RBC-3.56*# Hgb-9.8*# Hct-29.5*#
MCV-83 MCH-27.5 MCHC-33.1 RDW-14.5 Plt Ct-293
[**2200-4-9**] 06:12PM BLOOD Glucose-122* UreaN-13 Creat-1.1 Na-136
K-4.3 Cl-101 HCO3-15* AnGap-24*
[**2200-4-9**] 06:12PM BLOOD ALT-36 LD(LDH)-268* CK(CPK)-115
AlkPhos-122* Amylase-246* TotBili-1.6*
[**2200-4-12**] 05:22AM BLOOD ALT-23 AST-30 LD(LDH)-128 AlkPhos-59
Amylase-876* TotBili-0.4
[**2200-4-9**] 06:12PM BLOOD Lipase-146*
[**2200-4-12**] 05:22AM BLOOD Lipase-1047*
[**2200-4-9**] 10:47PM BLOOD Type-ART pO2-252* pCO2-37 pH-7.32*
calTCO2-20* Base XS--6
[**2200-4-9**] 06:27PM BLOOD Lactate-4.0*
CT abdomen/pelvis w/ contrast [**4-9**]:
CT OF THE ABDOMEN WITH IV CONTRAST: There is mild dependent
atelectasis at
the lung bases. Mild periportal edema is noted of the liver,
which is a
nonspecific finding but can be seen with fluid resuscitation.
Patient is
status post cholecystectomy. Spleen, pancreas, adrenal glands
are
unremarkable. There are a few tiny hypodensities of the kidneys,
too small to characterize. Kidneys are otherwise normal and
enhance and excrete contrast symmetrically. Ureters are of
normal caliber and opacify well. There is no free
intraperitoneal gas or fluid. Nasogastric tube terminates in the
stomach. Small and large bowel are noted to be diffusely
fluid-filled. There is no inflammatory change or wall thickening
of large or small bowel. The appendix is normal.
CT OF THE PELVIS WITH IV CONTRAST: The uterus, adnexa are
unremarkable. A
Foley catheter is present within the decompressed urinary
bladder. Rectum is unremarkable. There is no free pelvic fluid.
BONE WINDOWS: Patient is status post ORIF of proximal right
femur. No
concerning lesions are seen.
IMPRESSION: Diffusely fluid-filled small and large bowel without
inflammatory
change or wall thickening is a nonspecific finding. This could
be seen with
gastroenteritis.
Brief Hospital Course:
Nausea/Vomiting/Diarrhea) Patient's initial presentation
appeared consistent with a significant enteric infection. On
presentation to the ED, she had 28 bands. Stool studies were
unremarkable. CD4 count during her admission was 270. Given
the patient's history of receiving a colonic just prior to her
n/v/d, the GI service consult believed that the patient's
initial presentation of n/v/d was likely toxin-induced. Her
diarrhea improved during her admission but at discharge the
patient still had loose, but no longer frequent watery, stools.
Hypotension) The patient required pressors in the MICU briefly.
The MICU team belives that the patient's hypotension was
secondary to a combination of hypovolemia and vasodilatory
sepsis. The patient was weaned off pressors by [**4-11**].
Pancreatitis) On presentation, the patient presented with
symptoms of a significant enteric infection. However, during
her hospital course she developed a significant pancreatitis.
In the past, the patient was diagnosed with possible
HAART-induced pancreatitis. RUQ U/S revealed unremarkable CBD,
no evidence of gallstones or duct dilatation. MRCP and upper
endoscopy were unrevealing. The pt.s diet was slowly advanced.
Stool cultures were all negative, including c. difficile assays.
HIV) The patient's HAART meds were held during her admission.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the decision was made to continue to hold her
HAART until she sees Dr. [**First Name (STitle) **] in follow up, as Dr. [**First Name (STitle) **]
plans to change the regimen over concerns that these drugs have
induced her GI complaints and possibly pancreatitis.
Right femur fx s/p ORIF) No active issues. Patient should
continue outpatient PT.
Medications on Admission:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Reyataz 300 mg Capsule Sig: One (1) Capsule PO once a day.
3. Norvir 100 mg Capsule Sig: One (1) Capsule PO once a day.
4. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day:
NOTE, PATIENT ON 100-300 tablet daily NOT 200-300 tablet.
5. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO once a
day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea.
8. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Zantac 300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ultram 50 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for pain.
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO once a
day.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea.
5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ultram 50 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for pain.
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Gastroenteritis
Hypotension secondary to hypovolemia
Discharge Condition:
Vital Signs Stable
Patient ambulating comfortably on own and can engage in her
outpatient physical therapy routine.
Discharge Instructions:
Return to ED if having worsening abdominal pain, nausea,
vomiting, fevers.
Dr. [**First Name (STitle) **] recommends that you stop your HIV medications until
you can see her in follow up, at which time she plans on putting
you on a new regimen of HIV medications, due to concerns that
your previous regimen caused your diarrhea and pancreatitis and
nausea.
Followup Instructions:
Patient to call PCP and schedule [**Name Initial (PRE) **]/u in 2 weeks, and call Dr.
[**First Name (STitle) **] for follow up for the soonest available appointment (at
least within one week of leaving the hospital).
|
[
"535.40",
"577.0",
"070.54",
"263.0",
"558.2",
"042",
"276.2",
"785.59",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.16",
"96.71",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7010, 7016
|
3610, 5373
|
304, 339
|
7126, 7244
|
1373, 3587
|
7650, 7870
|
988, 1005
|
6275, 6987
|
7037, 7105
|
5399, 6252
|
7268, 7627
|
1020, 1354
|
239, 266
|
370, 791
|
813, 934
|
950, 972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,953
| 115,323
|
23595
|
Discharge summary
|
report
|
Admission Date: [**2127-2-14**] Discharge Date: [**2127-2-28**]
Service: SURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Transfer from [**Last Name (un) 4068**] to [**Hospital1 18**] SICU
Major Surgical or Invasive Procedure:
s/p I&D ([**2-13**])
s/p Debridement ([**2-14**])
History of Present Illness:
Mr. [**Known lastname 31251**] is a 86 yo male transferred from [**Hospital1 **]-[**Last Name (un) 4068**]. He
developed right foot pain the Sunday prior to admission and was
seen by his Podiatrist, who diagnosed him with gout. He was
given colchicine and prednisone. Mr. [**Known lastname 31251**] then developed more
pain and warmth to his right foot later in the week and
presented to the [**Hospital1 **]-[**Last Name (un) 4068**] ED. At this hospital he underwent an
I&D ([**2-13**]) of a right foot infection and subsequently underwent
re-exploration ([**2-14**]) for developing necrotizing fascitis. He
was transferred to [**Hospital1 18**] for further care.
Past Medical History:
PMH: Prostate Ca, Glaucoma
PSH: RIH repair, s/p TURP, s/p thyroid excision
Social History:
EtOH
Physical Exam:
98.9, 93, 137/78, 16, 98%
GEN: NAD
HEENT: EOMI, anicteric, OP pink
NECK: no masses, supple
CV: RRR, no m/r
RESP: clear
GI: soft/NT/ND
EXT: R foot with erythema/swelling; muscle and tendons exposed,
with necrotic edges, some fibrinous exudate
NEURO: AxOx3
Pertinent Results:
MRI RLE [**2-17**]
"1. 7 cm linear fluid collection running between the anterior
and lateral muscle compartments, extending from a large area of
soft tissue loss seen in the distal lateral foreleg to roughly
the mid tibia/fibula, 18 cm distal to the knee joint line. The
collection is largest at its most proximal extent, measuring 1.4
x 0.7 cm in the transverse dimension.
2. Non-specific myositis involving multiple muscle groups in the
foreleg, most severe in the anterior, lateral, and posterior
deep compartments.
3. Tendinosis of the posterior tibialis and peroneus brevis
tendons. No tendon tear.
4. No evidence of abnormal bone marrow signal intensity or
intraosseous abscess."
RLE Angio [**2-17**]
"1. Mild but multifocal atherosclerotic disease involving the
infrarenal aorta and iliac arteries, with no significant
pressure gradient associated.
2. Significant segmental stenosis (approx. 5-6 cm long) in the
mid right superficial femoral artery.
3. High bifurcation of the popliteal artery at the knee level.
4. In the proximal calf, severe stenosis or occlusion of the two
terminal branches arising from this popliteal bifurcation
(likely the anterior tibial and the peroneal arteries). Two
significant focal stenoses of the distal right anterior tibial
artery. Right posterior tibial artery completely occluded.
5. Patent medial and lateral plantar arteries, filled through
collaterals arising mostly from the peroneal artery. Dorsalis
pedis artery not seen."
Brief Hospital Course:
Mr. [**Known lastname 31251**] was admitted to the TSICU. He was placed on
Penicillin G, Clindamycin. for empiric coverage of his wound,
with Group A strep growth from the [**Hospital1 **]-[**Last Name (un) 4068**] cultures. He was
transferred to the floor on HD#2. He continued to undergo [**Hospital1 **]
dressing changes.
Plastic surgery was asked to evaluate the patient. Per their
recommendations, silvadine was applied to the tendons to prevent
dessication.
Vascular surgery was also asked to evaluate the patient's right
lower extremity blood flow. An angiogram on HD#4 showed severe
tibial disease and moderate SFA disease, no DP artery was seen.
The vascular team recommended a femoral-peroneal bypass for
revascularization and performed this operation on HD #5. He
tolerated the procedure well, please see Dr.[**Name (NI) 1392**]
Operative Note for detail.
On POD#1, Mr. [**Known lastname 31251**] received 2 units of pRBCs for post-op
anemia (Hct 25). Mr. [**Known lastname 31251**] continued to be followed by
Infectious Disease, whose recommendations were to complete a [**12-26**]
week course of Penicillin G and Clindamycin after the foot was
completely debrided and the skin flaps completed. His wound
continued to heal well and by POD #6 a VAC dressing was placed.
He received a PICC on POD#7 for his long-term antibiotic
therapy.
At the time of discharge, Mr. [**Known lastname 31251**] had good pain control, was
tolerating a regular diet, had a well-healing wound treated with
a VAC dressing, and was to continue his IV PCN G and
Clindamycin. He was discharged to a rehab facility in fair
condition.
Medications on Admission:
Timolol .5%
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Right lower extremity necrosing fascitis
history of prostate cancer s/p TURP
glaucoma
Discharge Condition:
Fair
Discharge Instructions:
If you have any fevers/chills, nausea/vomiting, chest pain, foot
pain, please seek medical attention.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 6633**] in one week, call [**Telephone/Fax (1) 2998**]
for an appointment.
Follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks, call [**Telephone/Fax (1) 1393**] for an
appointment.
|
[
"V10.46",
"041.01",
"365.9",
"728.86",
"440.24",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.57",
"86.28",
"99.04",
"39.29",
"38.93",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
4641, 4725
|
2946, 4579
|
286, 337
|
4855, 4861
|
1448, 2923
|
5011, 5253
|
4746, 4834
|
4605, 4618
|
4885, 4988
|
1173, 1429
|
180, 248
|
365, 1037
|
1059, 1136
|
1152, 1158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,836
| 107,746
|
14216
|
Discharge summary
|
report
|
Admission Date: [**2127-10-8**] Discharge Date: [**2127-10-21**]
Date of Birth: [**2046-10-11**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ruptured abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2127-10-8**]: Endovascular aortic aneurysm repair.
[**2127-10-16**]: Abdominal aortogram. Balloon angioplasty of proximal
extension cuff of endograft(aorta) and left CIA and EIA.
History of Present Illness:
HPI: Pt is 80 y/o M with h/o CAD, PVD, bilateral carotid
endarterectomies within past year who presents with ~10cm,
leaking infrarenal AAA. Pt had an acute onset of abdominal pain
radiating to the back today and presented to OSH where
subsequent
CT scan revealed the AAA. No fevers or chills. Currently, no
chest pain, shortness of breath, lightheadedness or dizziness.
Past Medical History:
PMH: CABG in [**2-/2117**] with an LIMA to LAD and vein graft to the
first diagonal, obtuse marginal, and right coronary arteries
Carotid stenosis s/p bilateral carotid endarterectomies
COPD
hyperlipidemia
hypertension
mild congestive heart failure
anxiety
rotator cuff tear
sleep apnea
Social History:
FH: non-contributory
Family History:
SH: No ETOH or smoking. He is a remote smoker.
Physical Exam:
PE: T 97 P 56 BP 132/74 R 18 SaO2 95%
Gen: nad
Heent: an-icteric
Lungs: clear
Heart: RRR
Abd: mild periumbilical abd pain, soft, nondistended, nonrigid
Extrem: palpable femoral/popliteal/DP/PT pulses bilaterally
Pertinent Results:
[**2127-10-21**] 06:30AM BLOO
WBC-10.1 RBC-3.59* Hgb-10.7* Hct-32.8* MCV-91 MCH-29.9 MCHC-32.7
RDW-14.5 Plt Ct-529*
[**2127-10-21**] 06:30AM BLOOD
PT-13.8* PTT-32.0 INR(PT)-1.2*
[**2127-10-21**] 06:30AM BLOOD
Glucose-113* UreaN-14 Creat-1.3* Na-140 K-3.9 Cl-101 HCO3-28
AnGap-15
[**2127-10-21**] 06:30AM BLOOD
Calcium-8.4 Phos-2.6* Mg-1.8
CT ANGIOGRAM:
The patient is status post placement of endovascular stent.
There is no sign of migration of the stent compared to prior
study, with its proximal margin just at the origin of the SMA
and extending distally with the longer limb
extending into the left common/external iliac artery junction
while the
shorter right limb terminates at the right common iliac artery.
Again seen the endoleak in the aneurysmatic sac, in similar
amount as in prior study. In the late venous phase, there is
phasing out of the contrast
enhancement. On today's study, the impression is that the
endoleak originates from the area of overlapping stent- grafts
(endoleak type 3).
Both renal arteries arise at or just below the top of the
endovascular stent, with a very stenotic origin of right renal
artery. The left common iliac artery aneurysm is unchanged in
size (13 mm), with the endovascular limb feeding the left
external iliac artery and the excluded enhancing portion is
feeding the left internal iliac artery. Again seen thedifference
in enhancement between the right internal iliac artery and the
left internal iliac artery (which is fed by the excluded portion
of the left common iliac artery).
IMPRESSION:
Compared to prior study performed in [**2127-10-14**], again
seen is the
endoleak in the aneurysmatic sac. On today's examination, the
impression is of a Type 3 endoleak.
All the other previously described findings are unchanged
compared to prior study, as follows:
1. Left iliac artery aneurysm. Difference in contrast
enhancement of left and
right internal iliac arteries.
2. Hypodensities seen in spleen that could represent infarct; an
ultrasound
examination is recommended for further evaluation.
3. Simple cyst in left hepatic lobe.
4. Bilateral pleural effusion with adjacent atelectasis.
5. Incidental left lower lobe lung nodule. A dedicated chest CT
scan is
recommended for further evaluation of other nodules.
6. Atrophic right kidney with delayed nephrogram and no
excretory phase could
be secondary to a significant stenosi at the origin of the right
renal artery.
Brief Hospital Course:
[**10-8**]: Ruptured abdominal aortic aneurysm.
Pt urgently taked to the OR for EVAR.
PROCEDURE: Endovascular aortic aneurysm repair.
Introduction of catheter into the aorta.
Bilateral femoral artery exposure M-50
Zenith bifurcated modular graft placed
Right limb graft placed with extension.
Left femoral graft placed with extension.
He tolerated the procedure well. No complications. Intubated.
Precautions taken for hx of renal failure, Bicarb drip.
Transfered to the CVICU in stable condition post operative
[**10-9**]: CVIU intubated and sedated. Making good urine. Had bump in
creat to 1.6.
Lines remain in.
[**10-10**]: CVICU. Extubated. PO pain meds. Drop in HCT to 26. Making
good urine. Creat bump to 2.2. kept NPO. HCT followed.
Transfused 2 units PRBC.
[**10-11**]: Transfered to the VICU. Nitro for HTN. Creat improved to
1.9. Diet advanced. PT consult. HCT stable after PRBC. Making
good urine. OOB.
[**10-12**] - [**10-13**]: stable / ambulating / delined. Foley DC making
urine. IS support.
[**10-14**]: Creat stable at 1.5. Mucomyst PO and IV bicarb given in
preperation for CTA. recieves CTA. Endoleak seen. HCT stable.
EKG DC'd. Nitro weaned with PO HTN medications. Made floor
status.
[**10-15**] - [**10-16**]: Creat normalizes. HCT stable. Preperation for
Angiogram: Again given Mucmyst and bicarb protocol. Making good
urnine.
[**10-16**]: goes for angio under general:
OPERATION PERFORMED:
1. Exposure of left common femoral artery and primary repair
2. Introduction of catheter into aorta.
3. Abdominal aortogram.
4. Balloon angioplasty of proximal extension cuff of
endograft(aorta) and left CIA and EIA
Extubated in the OR. Sent to the PACU for recovery. IOnce
recovered from the PACU sent back to the VICU for recovery.
[**10-17**]: Delined. heplocked. Making good urine. Creat stable at
1.6. OOB to chair. foley left in. Diet advanced. Drop in HCT to
23 post op Transfused 2 units PRBC. Needs nitro for HTN:
Cardiology consult for persistant HTN; PO medications adjsted.
HTN adjusts.
[**10-18**] - [**10-20**]: Foley DC'd. Making good urine. Creat remains
stable. Normotensive with adjustment of pain meds. Ambulating
with PT. Had to be given lasix for fluid overlaod secondary to
CHF Systolic chronic stable. Creat stable at 1.5. Mucomyst PO
and IV bicarb given in preperation for CTA. recieves CTA.
Endoleak seen, much improved.
[**10-21**]: recieves PMIBI for future open AAA repair. Pt deciding
wether or not to have an open procedure. He is being DC'd today
understanding the risk of rupture. His creatinine is stable.
Normotensive on PO medications. Making good urine. HCT stable.
VNA to check HCT and BP at home.
Medications on Admission:
Meds: Aspirin 81',Zocor 80',Plavix 75',albuterol inhaler,Spiriva
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Simethicone 80 mg Tablet, Chewable Sig: 0.50 - 1.0 Tablet,
Chewable PO three times a day as needed.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Abdominal aortic aneurysm; persistent type I endoleak
I had a long talk with patient and family. he is pending
completion operative repair. he knows going home even for a few
days subjects him to potential risk of rupture and death. he
accepts those risks
Discharge Condition:
Improved
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* 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, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-5**] lbs) until your follow up appointment.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2128-2-2**] 10:40
Call Dr [**Last Name (STitle) 8888**] [**Name (STitle) 42274**] at [**Telephone/Fax (1) 1241**]. To discuss further
surgery.
Completed by:[**2127-10-21**]
|
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"414.01",
"496",
"327.23",
"V43.65",
"428.30",
"511.9",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.42",
"39.71",
"39.50",
"88.42"
] |
icd9pcs
|
[
[
[]
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] |
8106, 8189
|
4021, 6698
|
305, 489
|
8488, 8499
|
1560, 3998
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6724, 6791
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231, 267
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517, 891
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913, 1202
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1218, 1241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,976
| 174,863
|
35276
|
Discharge summary
|
report
|
Admission Date: [**2201-8-10**] Discharge Date: [**2201-8-13**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
"Foley catheter repalcement, UTI, ?pneumonia"
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
Foley placement by Urology [**8-10**]
History of Present Illness:
This is a 65 year old male with history of CVA (non-verbal at
baseline), multiple pneumonias (s/p trach/PEG [**3-/2200**]), atrial
fibrillation on coumadin, C diff s/p colectomy, type 2 diabetes
mellitus, peripheral vascular disease and recent admissions for
UTI and pneumonias who presents after his Foley catheter came
out and he needs it replaced. The nursing home mentioned that he
has an elevated WBC count and a chest x-ray that showed a
"slight infiltrate" but did not start antibiotics as pt has been
afebrile. They state that the patient's current mental status
presentation is at his baseline. EMS brought him in for further
evaluation.
.
In the ED, initial vs were: 98.5 77 92/58 20 96%. On PE, patient
was non-verbal but could answer yes/no questions, trach with
some yellow-ish discharge, lungs difficult to auscultate due to
gurgling breath sounds, abdomen soft/nontender to palpation,
G-tube and colostomy visualized. Labs were notable for K 5.5,
BUN 54 but Cr 0.9. WBC was elevated at 22 with 81% neut, no
bands. Lactate was wnl. UA was with lg leuk, >182 WBC, many
bact. Blood cx were sent. Pt was given CTX and IL IVF. CXR
revealed trace bilat effusions and left base opacity likely
atelectasis but infection could not be ruled out. Has a condom
cath on, as unable to replace Foley. Vitals on transfer were BP
109/65 T 97.5 O2 sat 100% on 35% trach mask RR 13 HR 58. Has PIV
x1.
.
On arrival to the ICU, pt appears comfortable, nonverbal. Is
able to follow simple commands like squeezing hand. Denies
chest pain, abd pain. Does seem to endorse back/flank pain.
.
Review of systems:
unable to obtain
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) -
Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**]
(outside facility, [**12/2198**] here)
Social History:
Prior resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], now at [**Hospital 16662**] Nursing Home.
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
Vitals: T: 97.2 BP: 137/89 P: 68 R: 15 O2: 100% on 35% trach
mask
General: Alert, noncommunicative, follows simple commands
HEENT: Sclera anicteric, MMM, oropharynx clear, no dentition
Neck: supple, JVP not elevated, no LAD, trach in place with
secretions in gauze
Lungs: Clear to auscultation anteriorly, +upper airway sounds
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, +G-tube,
+colostomy
GU: no foley
Ext: warm, well perfused, no edema
Neuro: EOMI, PERRL, unable to verbalize, unable to move
extremities, wiggles fingers in left hand, endorses sensation in
all ext
Pertinent Results:
Labs at Admission:
[**2201-8-12**] 08:10AM BLOOD WBC-10.8 RBC-5.12 Hgb-11.9* Hct-37.9*
MCV-74* MCH-23.3* MCHC-31.5 RDW-15.3 Plt Ct-229
[**2201-8-11**] 07:17AM BLOOD WBC-16.3* RBC-5.51 Hgb-12.8* Hct-39.9*
MCV-72* MCH-23.3* MCHC-32.2 RDW-15.5 Plt Ct-237
[**2201-8-10**] 05:30PM BLOOD WBC-22.0*# RBC-5.94 Hgb-13.3* Hct-41.4
MCV-70* MCH-22.4* MCHC-32.1 RDW-16.1* Plt Ct-270#
[**2201-8-12**] 08:10AM BLOOD Neuts-72.3* Lymphs-16.2* Monos-6.4
Eos-4.6* Baso-0.5
[**2201-8-10**] 05:30PM BLOOD Neuts-81.9* Lymphs-10.5* Monos-4.7
Eos-2.5 Baso-0.5
[**2201-8-11**] 07:17AM BLOOD PT-28.7* PTT-32.9 INR(PT)-2.8*
[**2201-8-12**] 08:10AM BLOOD Glucose-162* UreaN-32* Creat-0.6 Na-147*
K-3.5 Cl-109* HCO3-30 AnGap-12
[**2201-8-11**] 07:24PM BLOOD Glucose-111* UreaN-34* Creat-0.5 Na-148*
K-3.9 Cl-110* HCO3-28 AnGap-14
[**2201-8-11**] 07:17AM BLOOD Glucose-124* UreaN-45* Creat-0.7 Na-146*
K-4.5 Cl-107 HCO3-28 AnGap-16
[**2201-8-10**] 05:30PM BLOOD Glucose-157* UreaN-54* Creat-0.9 Na-141
K-5.5* Cl-102 HCO3-29 AnGap-16
[**2201-8-10**] 05:30PM BLOOD ALT-24 AST-42* LD(LDH)-383* AlkPhos-76
TotBili-0.4
[**2201-8-12**] 08:10AM BLOOD Phos-2.7 Mg-2.3
[**2201-8-11**] 07:24PM BLOOD Calcium-8.3* Phos-3.4 Mg-2.4
[**2201-8-11**] 07:17AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.5
[**2201-8-10**] 05:30PM BLOOD Albumin-3.9
[**2201-8-10**] 05:38PM BLOOD Lactate-1.2
Micro:
[**2201-8-11**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2201-8-11**] 11:18 am URINE Source: Catheter. URINE CULTURE
(Preliminary):
GRAM NEGATIVE ROD #1. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. >100,000 ORGANISMS/ML..
Imaging:
[**8-10**] CXR: FINDINGS: Single supine AP portable view of the chest
was obtained. The patient is rotated to the right. Tracheostomy
tube is again noted. There is blunting of the bilateral
costophrenic angles, which could be due to trace effusions.
Bibasilar atelectasis is seen. Patchy left base opacity most
likely relates to atelectasis, although underlying aspiration or
infection cannot be excluded, however, has improved in the
interval. No overt pulmonary edema is seen. Cardiac and
mediastinal silhouettes are stable.
Labs at Discharge:
[**2201-8-13**] 05:40AM BLOOD WBC-8.3 RBC-5.51 Hgb-12.5* Hct-41.1
MCV-75* MCH-22.8* MCHC-30.5* RDW-15.3 Plt Ct-251
[**2201-8-13**] 05:40AM BLOOD PT-35.3* INR(PT)-3.5*
[**2201-8-13**] 05:40AM BLOOD Glucose-170* UreaN-25* Creat-0.5 Na-146*
K-4.1 Cl-106 HCO3-30 AnGap-14
Brief Hospital Course:
#Pt's Foley was difficult to be replaced. Urology was consulted
and they were successful. They recommended outpatient f/u with
Dr. [**Last Name (STitle) 770**].
.
#Sepsis: WBC = 22,000 on admission. He had an impressive pyuria,
so the source was most likely UTI. He was started empirically on
Ceftriaxone and improved. He should receive 2 more days of IV
Ceftriaxone, then swithch to PO Cipro for 5 more days. His urine
from admission is growing out 2 strains of Gram negative rods
(>100K each) [**Last Name (un) 80454**] have not been speciated yet. Sensitivities
pending.
.
Hypernatremia: clinically euvolemic. Needs more free water. His
free water PEG flushes were increased to 250ml Q6hrs and his
serum sodium is slowly dropping.
.
#Possible bronchitis - patient initially had thich yellow sputum
from his trach, but otherwise no evidence of pulmonary
infection. It is possible but unlikely that this was causing his
leukocytosis. With antibiotics his sputum did become thinner
(and rusty in color, probably due to aggressive deep
suctioning).
.
# Atrial fibrillation: Pt was in sinus, not on any meds at home.
He iss supratherapeutic on Coumadin (likely due to
antibiotics), and his coumadin is being held. It should be
restarted once his INR is below 3
.
# Sacral decubitus ulcer: present on admission. Pt was
continued with appropriate wound care.
.
# Hypothyroidism: Pt was continued on home Levothyroxine.
.
# Tyle 2 diabetes mellitus: well-controlled, with complications
- continued on 34U [**Last Name (un) 8472**] + insulin sliding scale
.
# Peripheral neuropathy: Pt was continued on home Gabapentin,
Fentanyl patch. He continued to complain of this (by nodding yes
and pointing to area on body chart). In fact, this was his only
complaint. We did not give him Cymbalta as our pharmacy told us
it should not be crushed, but we did increase his Fentanyl patch
dose to 125 mcg/hr
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (un) **]: One (1) unit Inhalation four times a day.
2. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (un) **]: One (1)
Miscellaneous four times a day.
3. ipratropium bromide 0.02 % Solution [**Last Name (un) **]: One (1) Inhalation
four times a day.
4. baclofen 10 mg Tablet [**Last Name (un) **]: 1.5 Tablets PO QID (4 times a
day): Please give through G tube.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (un) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): Please
give through the G tube.
6. docusate sodium 100 mg Capsule [**Last Name (un) **]: Two (2) Capsule PO at
bedtime: Please give through the G tube.
7. fentanyl 100 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Transdermal
every seventy-two (72) hours.
8. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution [**Last Name (un) **]: One
(1) PO once a day: Please give through the G tube.
9. gabapentin 300 mg Capsule [**Last Name (un) **]: One (1) Capsule PO Q8H (every
8 hours): Please give through the G tube.
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): Please give through
the G tube.
11. [**Last Name (STitle) 8472**] 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Four (34) units
Subcutaneous at bedtime.
12. levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): Please give through the G tube.
13. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime): Please give through the G tube.
14. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Please give through the G
tube.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation q2h as needed for
shortness of breath or wheezing.
16. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) vial
Inhalation q2h as needed for shortness of breath or wheezing.
17. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): Please give through the G tube.
19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Please give through the G tube.
21. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
Thirty (30) ML PO QID (4 times a day) as needed for stomach
upset: Please give through the G tube.
22. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) mL
PO once a day as needed for constipation: Please give through
the G tube.
23. Glucerna Liquid [**Hospital1 **]: One (1) Application PO once a day:
1.2 via feeding pump at 75 mL/hr. Up at 2pm down at 10am.
24. Novolin R 100 unit/mL Solution [**Hospital1 **]: One (1) unit Injection
qac: Please refer to sliding scale for additional information.
25. multivitamin Liquid [**Hospital1 **]: Five (5) mL PO once a day:
Please give through the G tube.
26. warfarin 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily at 4pm:
Please adjust dose to keep INR between [**1-22**]. Please give through
G-tube.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] Skilled Nursing Facility
Discharge Diagnosis:
Sepsis, urinary source, catheter-related, with gram-negative
rods (facility-acquired)
Discharge Condition:
Mental Status: Complete expressive aphasia (non-verbal)
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for Foley catheter re-insertion (by
urology)and noted to have a complicated urinary tract infection.
You responded well to Ceftriaxone IV, and should complete a 10
day course of antibiotics. The exact bacteria and sensitivities
in the urine are still pending, so your current treatment is
empiric.
Followup Instructions:
Please contact Dr.[**Name2 (NI) 825**] office to make an poointment to
follow up for the indwelling Foley catheter. [**Name8 (MD) 770**], M.D., [**Doctor First Name 1158**]
P
Department:Surgery
Division:Urology
Organization:[**Hospital1 18**]
Office Location:[**Hospital1 **]. 5th FL: [**Location (un) 86**] [**Numeric Identifier **]
Office Phone:([**Telephone/Fax (1) 5278**]
|
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icd9cm
|
[
[
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23,929
| 198,056
|
46781
|
Discharge summary
|
report
|
Admission Date: [**2170-7-10**] Discharge Date: [**2170-7-13**]
Date of Birth: [**2104-1-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Nitrofurantoin / Cephalosporins / Reglan /
Ciprofloxacin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo F with h/o CAD c/b CABGx3, HTN, HLD, poorly-controlled
IDDM and recurrent resistent UTIs with recent admission for
flash pulmonary edema in the setting of hypertensive urgency who
presents with worsening dyspnea and found to be in acute renal
failure with hyperkalemia. Pt was admitted from [**Date range (1) 17057**] where
she had a CTA to r/o PE as the origin of her dyspnea. She was
diuresed with her home regimen of lasix 20mg po BID. Her blood
pressure medications were continued (metoprolol, lisinopril and
spironolactone) and she was started on amlodipine 5mg po qday.
She was also being treated for a UTI with doxycycline. The
patient reports she was feeling well at home without complaints
until the day of admission around noon when she felt
hypoglycemic and her BS was 52. She then felt very short of
breath when trying to walk to the bathroom and her BP taken by
her husband was 172/50 so he brought her to the emergency room.
She denies any chest pain, cough, fevers, increased peripheral
edema, lightheadenss, vision changes. She does report dysuria
and trickling of urine (which she reports she gets with UTIs).
In the ED Intitial VS were 97.8 48 154/56 22 98%. Per report,
patient was on a stretcher in the ED, triggered for tachypnea in
the 40s and was found to have a BP in the 200s. A CXR was
performed which showed pulmonary edema and she was started on
BIPAP and lasix drip for presumed flash pulmonary edema and
transferred to the CCU for Nitro drip.
On review of systems, s/he denies any prior history of stroke,
TIA, She reports being able to walk up a flight of stairs
without stopping. Occasionally feels her heart racing if she is
walking on stairs but not at baseline. She denies PND or
orthopnea.
Past Medical History:
-CAD s/p CABG LIMA to LAD and SVG to OM1 and OM2)- 5 years
previously
-Poorly controlled IDDM c/b diabetic nephropathy + gastroparesis
(confirmed via motility studies in [**2155**])
-Stage III CKD
-H/O neurogenic bladder with incomplete emptying
-Recurrent UTIs r/t neurogenic bladder (most recently with
highly-resistent Klebsiella and Citrobacter with sx of ascending
infection, tx with IV aztreonam)
-Recurrent dysuria and urine cultures positive for E. coli.
-HTN
-Hyperlipidemia
-Depression
Social History:
She is sexually active only with her husband. They live in the
[**Location (un) 86**] area. They have four children, a dog and a cat. She
previously worked as a plumber. FOrmer smoker 40pack year
history, no alcohol or other drugs
Family History:
Daughter: juvenile-onset diabetes.
sisters: One sister died at early age, one had ETOH cirrhosis
Mother: lung collapse of unclear etiology
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: 98.2, 61, 180/57, 18, 99% on 3L NC
GENERAL: Obese woman in NAD, sitting up in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. .
NECK: JVP at 6cm
CARDIAC: Bradycardic, regular rhythm, no MRG appreciated
LUNGS: Crackles at the bases bilaterally, no egophony,
Tympanitic to percussion. Speaking in full sentences
ABDOMEN: Obese, Soft, NTND. No audible bruits.
EXTREMITIES: 1+ pitting edema to the No c/c/e. No femoral
bruits.
SKIN: left shin with hyperpigmentation, no ulcers
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors
PULSES: 2+DP pulses bilaterally
Physical Exam on Discharge:
Tm 98.3 Tc 97.7 HR 48-64 BP 138-144/36-50 RR 18 O2 97-99%RA
Weight 74.4
GENERAL: NAD
HEENT: No pharyngeal ertythema, MMM, no LAD, JVD at 10cm.
CARDIAC: S1 ,S2 Normal in quality and intensity RRR no murmurs
rubs or gallops
LUNGS: CTABL with no wheezes, no rales, no rhonci
ABDOMEN: Obese, Soft, NTND. No audible bruits.
SKIN: No rash
NEURO: 5/5 strength in U/L extremities
PSYCH: Appropriate, does not appear depressed
Pertinent Results:
Admission Labs:
[**2170-7-10**] 07:15PM BLOOD WBC-7.9 RBC-3.73* Hgb-11.9* Hct-37.3
MCV-100* MCH-32.0 MCHC-32.0 RDW-13.4 Plt Ct-227
[**2170-7-10**] 07:15PM BLOOD Neuts-78.9* Lymphs-16.0* Monos-4.3
Eos-0.4 Baso-0.4
[**2170-7-10**] 07:15PM BLOOD PT-11.0 INR(PT)-1.0
[**2170-7-10**] 07:15PM BLOOD Glucose-246* UreaN-68* Creat-3.7*# Na-136
K-5.9* Cl-101 HCO3-22 AnGap-19
[**2170-7-10**] 07:15PM BLOOD Calcium-8.9 Phos-6.4* Mg-2.4
[**2170-7-10**] 07:15PM BLOOD proBNP-1709*
[**2170-7-10**] 07:15PM BLOOD cTropnT-0.05*
Discharge Labs:
[**2170-7-13**] 07:52AM BLOOD WBC-5.2 RBC-3.13* Hgb-10.3* Hct-31.3*
MCV-100* MCH-33.0* MCHC-33.0 RDW-13.3 Plt Ct-204
[**2170-7-10**] 11:03PM BLOOD Neuts-82.4* Lymphs-11.6* Monos-5.4
Eos-0.4 Baso-0.2
[**2170-7-13**] 03:45PM BLOOD Na-133 K-5.0 Cl-100
[**2170-7-13**] 07:52AM BLOOD Glucose-150* UreaN-73* Creat-2.6* Na-139
K-5.6* Cl-106 HCO3-23 AnGap-16
[**2170-7-13**] 07:52AM BLOOD Calcium-8.6 Phos-5.6* Mg-2.6
[**2170-7-13**] 07:52AM BLOOD Cortsol-26.7*
Imaging:
CXR [**2170-7-10**]: Mild pulmonary edema and small bilateral pleural
effusions. Mild bibasilar atelectasis.
.
Echo [**2170-7-11**]:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild thickening of mitral valve chordae. Calcified tips of
papillary muscles. No MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting bradycardia (HR<60bpm).
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The 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. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global systolic function. Borderline
pulmonary hypertension. Elevated estimated PCWP. Findings c/w
hypertensive heart disease.
Compared with the prior study (images reviewed) of [**2166-10-7**],
the findings are similar.
Renal Ultrasound [**2170-7-11**]:
1. Normal-sized kidneys with a simple cyst in the left lower
pole and no
other focal abnormalities.
2. No Doppler evidence of renal artery stenosis.
3. Markedly elevated resistive indices bilaterally, which may
imply either diffuse chronic parenchymal renal disease or small
vessel changes from prolonged hypertension.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Ms. [**Known lastname 99281**] is a 66 year old female with history of coronary
artery disease (CAD) status post CABG in [**2165**] with LIMA to LAD,
SVG to OM1 and OM2, insulin-dependent diabetes (IDDM), recurrent
urinary tract infections, who presented with dyspnea,
hypertensive emergency with renal failure and hyperkalemia. She
was managed with a nitroglycerin drip in the CCU originally and
then transitioned to oral isosorbide nitrate and hydralazine.
.
#Hypertensive emergency- the patient had a similar presentation
on her last admission with systolic blood pressures in the 200s
and dyspnea. On this presentation she had BPs elevated quickly
from 150s up to 200s in the ED and was on a nitroglycerine drip
on arrival to the CCU with BP still elevated. She reports
compliance with her home medications of metoprolol, lisinopril,
amlodipine, spironolaconte and lasix. After a discussion with
her outpatient PCP, [**Name10 (NameIs) **] was concern that her new onset
hypertension was a manifestation of secondary hypertension.
Thus, a workup was initiated including a renal artery ultrasound
with dopplers which showed no renal artery stenosis but
increased resistive indicies bilaterally indicating prolonged
hypertension. She had a TSH within the past month, which was
normal. She was advised to have workup as an outpatient for
obstructive sleep apnea due to her body habitus. She also had an
am cortisol level which was eleveted. She had an echo which
showed evidence of left ventricular hypertrophy and diastolic
dysfunction, which both indicate that her hypertension has
likely been more chronic than we initially thought. We deferred
additional testing for endocrine abnormalities for secondary
hypertension to the outpatient setting. She was transitioned off
the nitro gtt and able to control her blood pressures with oral
agents. Her discharge regimen was: amlodipine 10 mg daily,
isosorbide mononitrate 60 mg daily, clonidine 0.1 mg [**Hospital1 **], and
hydralazine 20 mg [**Hospital1 **].
.
#Hyperkalemia- On admission, patient with elevated K that is new
onset in the setting of acute renal failure. Pt is on
spironolactone at home, however less likely to be the sole cause
of the hyperkalemia. She has no peaked T waves. She was given
Kayexelate which she did not tolerate in the ED. Her K was
again mildly eleveated without symptoms on the morning of
discharge to 5.6. She was given 30mg keyexelate and her K
decreased to 5.0. She is to have her potassium rechecked on [**7-16**].
#Acute renal failure- patient has doubled Cr over the past two
days prior to admission. This could be due to contrast
nephropathy as she had a CTA on [**7-7**] and this is the appropriate
timing onset of this. Her urine sediment did not show casts to
suggest a nephritic process and her FeUrea was 31% which is just
slightly on the pre-renal side. Her renal ultrasound was not
concerning for obstructive cause. We held her lisinopril and
diuretics and these were not restarted on discharge as her
creatinine had not yet returned to baseline, although it was
downtrending. She will have her Cr checked on [**7-16**].
.
#CAD s/p CABG in [**2163**]- patient denies any angina. her last
Stress test was a PMIBI in [**2165**] which showed improved reversible
defects. Continued ASA 81mg po qday, pravastatin 80mg po qday.
Metoprolol and lisinopril were held during admission and should
be restarted at the discretion of her outpatient team.
#Recurrent urinary tract infections- patient was started on
doxycycline on [**7-6**] for UTI and history of recurrent
pansensitive UTIs, however patient has multiple antibiotic
allergies. She still complains of dysuria and frequency with
decreased urinary stream concerning for not properly treated
Ecoli UTI. Unfortunately the sample from [**7-6**] did not have
sensitivities to tetracycline so unclear if it is sensitive to
her current regimen. She was continued on doxycycline and has
f/u with ID outpatient.
.
# Diabetes- patient has poorly controlled diabetes. On her
previous admission, there was concern that her regimen at home
was different from what was presumed. Pt had episode of
hypoglycemia while at home today around noon. Therefore, while
inpatient she was given [**Month/Year (2) **] 60 mg qam with humalog sliding
scale.
.
TRANSITIONAL ISSUES:
- Please perform sleep study for obstructive sleep apnea, this
might be contributing to her difficult to control blood
pressures
- Would consider dexamethasone suppression test given elevated
am cortisol
- Please recheck creatinine and potassium at f/u to ensure
stabilization with the medication regimen
- Consider restarting patient on BBlocker for her CAD and ACEI
for her diabetic nephropathy
Medications on Admission:
amlodipine 5 mg by mouth DAILY
-aspirin 81 mg by mouth DAILY
-doxycycline hyclate 100 mg by mouth every twelve hours for 21
days: First day = [**2170-7-6**] Last day = [**2170-7-26**].
-furosemide 20 mg by mouth [**Hospital1 **]
-insulin glargine [[**Hospital1 8472**]] 80 units Subcutaneous qAM
-insulin glargine [[**Hospital1 8472**]] 90 units Subcutaneous at bedtime
-insulin lispro [Humalog] AS DIRECTED Subcutaneous QACHS
-lisinopril 40 mg by mouth once a day.
-metformin 1,000 mg Tablet qday (pt reports not taking this
currently)
-metoprolol tartrate 75 mg Tablet TID
-nystatin 100,000 unit/g Powder One (1) Topical [**Hospital1 **]-TID.
-pravastatin 80 mg Tablet po qday
-ranitidine HCl 150 mg Tablet po BID
-spironolactone 25 mg Tablet po qday
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 14 days. Capsule(s)
5. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous once a day.
6. [**Hospital1 8472**] 100 unit/mL Solution Sig: Ninety (90) units
Subcutaneous at bedtime.
7. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous twice a day.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
9. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q 12H (Every
12 Hours).
Disp:*120 Tablet(s)* Refills:*2*
10. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Please check Chem-7 on Monday [**2170-7-16**] with results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1968**] and [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] NP at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD 9 584.9
14. Outpatient Lab Work
Please check Chem7: serum Na, K, Cl, HCO3, Cr, and BUN and fax
results to:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] and [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] NP at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
Discharge Disposition:
Home With Service
Facility:
[**Doctor Last Name **] bank homecare
Discharge Diagnosis:
Hypertensive emergency
Acute on Chronic Renal failure
chronic diastolic heart failure
Secondary: Type II Diabetes- insulin dependent
Urinary tract infection
Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 99281**],
It was a pleasure taking care of you here at [**Hospital1 18**]. You were
admitted to the hospital for concern about your breathing and
your blood pressure. Your blood pressure was very high and
there was concern that it was affecting your kidneys so you were
in the cardiac intensive care unit. We were able to switch you
from IV to oral blood pressure medications and made the changes
noted below in your blood pressure regimen. It will be very
important for you to follow-up with your PCP to discuss these
changes and have your blood pressure monitored as an outpatient
closely. Please get a blood pressure cuff and check your blood
pressure daily at different times of the day. Keep a log of the
blood pressures to share with Dr. [**Last Name (STitle) 1968**] and [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**]. You
will also have your blood drawn on Monday [**7-16**] and the
results will be followed up by Dr. [**Last Name (STitle) 1968**] on your visit on
Wednesday, [**7-18**]. The following changes were made to your
medications:
Medications started:
1. Clonidine to lower your blood pressure
2. Isosorbide mononitrate to lower your blood pressure
3. Hydralazine to lower your blood pressure.
Medications stopped:
1. Metoprolol
2. Furosemide
3. Spironolactone
4. Lisinopril
medications changed:
1. Increase the amlodipine to 10 mg daily (double the dose)
2. Please talk to Your [**Last Name (un) **] doctor to discuss adjusting your
insulin to better control your blood sugars.
.
Please weigh yourself every morning before breakfast. Call Dr.
[**Last Name (STitle) 1968**] if weight increases more than 3 pounds in 1 day or 5
pounds in 3 days.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2170-7-18**] at 9:50 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: REHABILITATION SERVICES
When: FRIDAY [**2170-7-27**] at 7:40 AM
With: [**Name (NI) **] [**Name (NI) 99283**], PT [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2170-8-7**] at 3:00 PM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2170-8-1**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: GASTROENTEROLOGY
When: MONDAY [**2170-7-23**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
|
[
[
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[] |
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[
[
[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,135
| 163,192
|
6367
|
Discharge summary
|
report
|
Admission Date: [**2160-8-20**] Discharge Date: [**2160-9-15**]
Date of Birth: [**2090-6-26**] Sex: F
Service: MEDICINE
Allergies:
Cardizem / Lipitor
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Chest pain with respiratory distress
Major Surgical or Invasive Procedure:
Ventricular drain placed by neurosurgery
Central venous catheter placement
History of Present Illness:
70 y.o. F with a history of CABG x 2 in [**2149**] and [**2158**], s/p DES
to RCA-SVG in [**2160-2-27**], who was admitted to OSH ICU on [**8-5**]
from rehab complaining of shortness of breath with substernal
chest pain radiating to her back for 1 hour. CP was [**7-7**], and
resolved with SL nitro x3. Her EKG at that time was NSR and
unchanged from her baseline. Of note, patient has a history of
MVA trauma in [**2160-6-28**], as a result has multiple fractures
and is trach-vent dependent.
.
Patient was admitted to OSH ICU. She was ruled out for MI with 3
negative cardiac enzymes. CXR showed bilateral pulmonary
infilatrates. They were concerned for recurrent aspiration vs.
hospital acquired pneumonia vs. pulm edema. BNP was elevated.
Sputum culture grew MRSA. She was continued on Vancomycin.
Legionella antigen was negative.
.
During hospitalization, the patient was briefly extubated, but
developed recurrent respiratory distress on [**2159-8-20**], and the
ventilator was resumed. BNP 1800. She was diuresed with good
effect. Echo showed EF 35%, 2+ MR, 1+ TR. Her plavix for some
reason was stopped at rehab. It was resumed at OSH on [**8-18**].
Three days prior to admission she was found to have pneumonia at
rehab and was started on Vanc and Zosyn because she grew MRSA
from her sputum. Two days later she developed diarrhea, and was
treated with po Flagyl for presumed C.diff. She was transfused
1u PRBCs on [**8-20**] for HCT of 26.
.
The patient was transferred to [**Hospital1 18**] for cardiac
catheterization. On transfer vitals Tm 98, BPs 130-180/50-70, HR
70-80, 94% on 65% FiO2.
.
On arrival to the CCU, patient has some epigastric pain. She
denies chest pain or difficulty breathing. She nods her head yes
to having a frontal headache. She is non verbal and nods/shakes
her head yes/no.
Currently,
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Diabetes
- Dyslipidemia
- Congestive Heart Failure, Systolic
-CABG: at OSH in [**2149**] and [**2158**]
--Angiography in [**2159-11-29**]: severe 3 vessel disease
--Occluded LIMA graft to the LAD
--Patent side vein bypass graft to posterolateral branch, RCA
was a sequential graft supplying either the diag or circumflex
territories, those branches occluded. EF 25-30%
--Cath [**2160-2-27**]: Severe 2 vessel CAD (LAD and RCA), Mid LAD:
100% stenosis, 1st diagnoal -100% distal to graft anastomosis,
100% mid-RCA stenosis, Graft to the distal RCA: there was a
tubular 95% stenosis at the distal anastomosis. Global LV
function EF 40%, moderate MR, DES with balloon angioplasty on
95% lesion in the distal anastomosis of the SVG from the 1st
diagonal to the distal RCA.
- s/p MVA [**2160-6-28**]. She was hit by a car as a pedestrian, and
unconscious for 12 days. Injuries include SAH/SDH w/small
midline shift, R L2 transverse process fx, T12 burst fx, R
acetabular non-displaced fx, R inf and L sup pubic ramus fx, R
6th rib fx, L medial femoral condyle, proximal fibula
- s/p trach
- s/p multiple cervical and lumbar laminectomy
- Chronic pain
- h/o CVA in [**2156-12-29**] -R sided muscle weakness at baseline
- AAA
- PVD s/p aorto-bifem bypass
- Depression
Social History:
Daughter is a nurse. Pt lives at home w/ husband who has been
with her during much of this hospitalization.
-Tobacco history: Used to smoke 1ppd but quit 20 years ago.
Family History:
Mother died of MI. Father had heart problems and died young.
Physical Exam:
VS: T=98.2 BP=149/61 HR=79 RR=22 O2 sat= 95% on 0.65 FiO2
GENERAL: WDWN F with trach in place, in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP just above clavicle while sitting up.
Assessment partially obstructed by trach device.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Diffuse expiratory wheezes bilaterally.
Crackles at bases bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm, well perfused. 1+ LE edema bilaterally.
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+
NEURO: Interactable. 5/5 strength of LUE and LLE. Unable to move
RLE. 3/5 strength in RUE. [**1-1**]+ reflexes bilaterally.
Pertinent Results:
Labs on Admission:
[**2160-8-21**] 12:19AM BLOOD WBC-12.3* RBC-2.77* Hgb-8.6* Hct-24.8*
MCV-90 MCH-31.1 MCHC-34.8 RDW-15.5 Plt Ct-196
[**2160-8-21**] 12:19AM BLOOD PT-11.3 PTT-23.2 INR(PT)-0.9
[**2160-8-21**] 12:19AM BLOOD Glucose-193* UreaN-21* Creat-0.5 Na-134
K-3.4 Cl-92* HCO3-34* AnGap-11
[**2160-8-21**] 12:19AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.8
[**2160-8-21**] 03:44AM BLOOD calTIBC-176* Ferritn-1828* TRF-135*
[**2160-8-21**] 01:59PM BLOOD Type-ART pO2-72* pCO2-53* pH-7.46*
calTCO2-39* Base XS-11
LABS/STUDIES
OSH
[**8-19**] Blood cultures x2 negative
[**8-19**] respiratory culture +MRSA
[**8-17**] C diff negative
[**8-12**] urine culture: yeast
[**8-12**] sputum culture +MRSA
[**8-6**] resp culture +MRSA
.
[**8-14**] BNP 712
.
[**8-20**]: Trop 0.02, CK 19
[**8-19**] trop 0.04
.
[**8-6**] CTA (because of elevated D-dimer and SOB): negative for PE
.
[**8-20**] OSH CT
T spine
Fracutres of T7, T 11, T 12, L1
CT head: No intracranial hemorrhage or mass
.
EKG: NSR @ 79bpm. Nl axis. LVH. ST depressions in V3-V6, I,
II. ST elevations in aVR. T wave inversions diffusely in all
leads. ST depressions and TWI are more pronounced compared to
previous EKG on [**8-5**] (admission to OSH).
.
.
.
2D-ECHOCARDIOGRAM:
.
[**2160-7-11**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Regional
left ventricular wall motion is normal. No mid-cavitary gradient
is identified. No apical intracavitary gradient is present. The
right ventricular cavity is dilated with depressed free wall
contractility. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal systolic left ventricular systolic function
with small cavity size. Dilated right ventricle. Depressed right
ventricular systolic function. Mild mitral regurgitation.
Mild-to-moderate tricuspid regurgitation. Moderate pulmonary
hypertension.
.
[**2160-7-17**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is severe global left ventricular
hypokinesis (LVEF = 20 %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion
Compared with the prior study (images reviewed) of [**2160-7-12**],
the left ventricular function has deteriorated and the right
ventricular pressure and volume overload is more evident (the
anterior wall "dyskinesis" is a result of abnormal septal motion
and poor left ventricular systolic function).
.
pMIBI [**2153**]
No evidence of Dipyridamole-induced perfusion abnormality. Mild
global hypokinesis with a left ventricular ejection fraction of
42%. /nkg
Mini BAL cx: Klebsiella
.
[**8-30**] CT Chest/Abdomen/Pelvis:
IMPRESSION:
1. Diffuse bilateral ground-glass opacity and interlobular
septal thickening is slightly improved. Differential
considerations are wide and include pulmonary edema, ARDS, in
the right clinical setting pulmonary hemorrhage and PCP
[**Name Initial (PRE) 1064**].
2. Extensive mediastinal adenopathy may be reactive to the
inflammatory and infectious process involving the lungs.
.
[**8-31**] CXR:
The diffuse interstitial and ground-glass pulmonary abnormality
seen on chest CT on [**8-26**] has been subsequently stable.
Heart is not particularly enlarged and pleural effusion, if any,
is small and unchanged. Tracheostomy tube is in standard
placement, left jugular line ends low in the SVC. Right jugular
sheath and Swan-Ganz catheter have been removed. No pneumothorax
.
CXR [**9-2**]:
Provisional Findings Impression: New pneumomediastinum and
pneumopericardium is likely secondary to progression of
pulmonary interstitial emphysema in the setting of prior trauma.
Unchanged extent of mass of interstitial and ground-glass
abnormality, given clinical presentation, likely ARDS.
.
C.diff negative
.
[**8-30**] mini-BAL:
Negative PCP, [**Name10 (NameIs) 1065**], legionella.
[**9-11**] CT HEAD
1. New small amount of left intraventricular hemorrhage status
post left
ventricular shunt placement.
2. No change in the degree of hydrocephalus since [**2160-9-4**].
3. New left mastoid air cells and middle ear opacification.
Clinical
correlation for otomastoiditis is suggested.
[**9-14**] CT CHEST
1. Interval increase in the extensive diffuse ground-glass and
interstitial
abnormalities, in conjunction with clinical history and
presentation,
characteristic for worsening ARDS, however, superimposed
infection is also a consideration.
2. Interval increase in the bibasal effusions and basal
atelectasis.
3. Stable mediastinal lymphadenopathy, likely reactive.
4. Tracheostomy tube remains in standard position, and the cuff
appears
slightly overinflated
Brief Hospital Course:
Hypoxemic respiratory failure - Due to ARDS and
ventilator-associated pneumonia. Treated with mechanical
ventilation and antibiotics.
.
Acute respiratory distress syndrome - Attributed to MVC trauma
and ventilator-associated pneumonia. Treated with low tidal
volume ventilation via tracheostomy.
.
Ventilator-associated pneumonia - Treated with vancomycin and
meropenem based on sensitivities of staph aureus and klebsiella
oxytoca species isolated from bronchoscopy and sputum cultures.
.
Septic shock - Treated with aggressive fluid resuscitation,
broad-spectrum antibiotics, and ultimately neosynephrine
infusion.
.
Subarachnoid hemorrhage complicated by intracranial hypertension
- CT showed progressive ventriculomegaly since and a ventricular
drain was placed by neurosurgery. Treated with keppra for
seizure prophylaxis. Subsequent CT showed intraventricular
hemorrhage. Coma persisted despite weaning of sedation and
treating causes of toxic-metabolic encephalopathy.
.
Cardiopulmonary collapse - In light of little clinical progress
despite aggressive medical management and an overall poor
prognosis, the patient's family decided to withdraw support on
[**9-15**] in favor of comfort measures and the patient expired
peacefull at 7:20 AM. The medical examiner accepted the case for
postmortem examination.
Medications on Admission:
HOME MEDICATIONS:
(FYI - She was not on plavix at rehab)
1. Lantus +SSI
2. Solumedrol
3. Zosyn
4. Lovenox
5. Niacin
6. Keppra
7. Carvedilol
8. Lisinopril
9. Prevacid
10. Vancomycin
11. Flagyl
12. Lasix
13. MVI
.
MEDICATIONS ON TRANSFER:
1. IV access: Peripheral line Order date: [**8-23**] @ 1232 20.
Lisinopril 10 mg PO/NG DAILY
hold for SBP<100 Order date: [**8-27**] @ 0814
2. IV access: Peripheral line Order date: [**8-23**] @ 1232 21.
Meropenem 500 mg IV Q6H Order date: [**8-23**] @ [**2081**]
3. IV access: Temporary central access (ICU) Location: Left
Internal Jugular, Date inserted: [**2160-8-30**] Order date: [**8-30**] @
1618 22. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation
Patient must have adequate airway support prior to
administration of dose. Order date: [**8-28**] @ 2355
4. OK to use line Order date: [**8-30**] @ 1618 23. Morphine Sulfate
2-4 mg IV Q2H:PRN pain
hold for sedation or RR<12 Order date: [**8-26**] @ 0432
5. 1000 mL NS
Continuous at 10 ml/hr
KVO Order date: [**8-24**] @ 1540 24. Multivitamins 1 TAB NG DAILY
Order date: [**8-25**] @ 1227
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever
do not exceed 4g/day Order date: [**8-27**] @ 0814 25. Niacin 250 mg
PO BID
PO/NG. Order date: [**8-27**] @ 0814
7. Albuterol Inhaler 4 PUFF IH Q6H:PRN wheezing
while intubated Order date: [**8-23**] @ 1232 26. Norepinephrine
0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP of 55 Order date:
[**9-1**] @ 1455
8. Aspirin 325 mg PO/NG DAILY Order date: [**8-27**] @ 0814 27.
Nystatin Oral Suspension 5 mL PO QID
PO/NG Order date: [**8-27**] @ 0814
9. Carvedilol 25 mg PO/NG [**Hospital1 **]
hold for SBP<100 or HR<60 Order date: [**8-27**] @ 0814 28.
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**8-21**] @
0005
10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
Order date: [**8-23**] @ 1232 29. PredniSONE 40 mg PO BID Duration: 5
Days Order date: [**9-2**] @ 1329
11. Famotidine 20 mg PO/NG Q12H Order date: [**8-27**] @ 0814 30.
PredniSONE 40 mg PO DAILY Duration: 5 Days Start: [**9-7**] Order
date: [**9-2**] @ 1329
12. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date:
[**8-26**] @ 1236 31. PredniSONE 20 mg PO DAILY Duration: 11 Days
Start: [**9-12**] Order date: [**9-2**] @ 1329
13. Fluoxetine 20 mg PO/NG [**Hospital1 **] Order date: [**8-27**] @ 0814 32.
Simvastatin 40 mg PO/NG DAILY Order date: [**8-27**] @ 0814
14. Furosemide 60 mg IV BID
Hold for SBP<100 Order date: [**8-30**] @ 2319 33. Sodium Chloride
0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN. Order date: [**8-23**] @ 1232
15. Furosemide 60 mg IV ONCE Duration: 1 Doses Order date: [**9-2**]
@ 1613 34. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN. Order date: [**8-23**] @ 1232
16. Heparin 5000 UNIT SC TID Order date: [**8-25**] @ 1735 35. Sodium
Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN. Order date: [**8-23**] @ 2214
17. Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose Order date: [**8-31**] @ 1813 36. Sodium
Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN. Order date: [**8-30**] @ 1618
18. Ipratropium Bromide MDI 6 PUFF IH Q6H
while intubated Order date: [**8-23**] @ 1232 37.
Sulfameth/Trimethoprim 325 mg IV Q8H
Day 1 [**2160-9-2**] Order date: [**9-2**] @ 1329
19. LeVETiracetam Solution 1500 mg NG [**Hospital1 **]
PO/NG Order date: [**8-27**] @ 1255 38. Vancomycin 1250 mg IV Q 24H
Start: In am Order date: [**9-1**] @ 2216
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary collapse
Hypoxemic respiratory failure
Acute respiratory distress syndrome
Ventilator-associated pneumonia
Intracranial hypertension
Septic shock
Pneumomediastinum
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2160-9-15**]
|
[
"428.23",
"958.7",
"441.4",
"728.89",
"V46.11",
"518.5",
"428.0",
"V44.0",
"285.9",
"V54.19",
"997.31",
"041.12",
"E814.7",
"785.52",
"331.4",
"V44.1",
"416.8",
"852.00",
"250.00",
"276.1",
"V45.81",
"041.3",
"438.89",
"995.92",
"349.82",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.72",
"96.6",
"33.24",
"02.2",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15570, 15579
|
10498, 11815
|
315, 391
|
15802, 15811
|
5147, 5152
|
15863, 15897
|
3988, 4051
|
15542, 15547
|
15600, 15781
|
11841, 11841
|
15835, 15840
|
4066, 5128
|
11859, 12053
|
239, 277
|
419, 2497
|
6080, 10475
|
5167, 6071
|
12078, 15519
|
2519, 3785
|
3801, 3972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
85
| 116,630
|
10927
|
Discharge summary
|
report
|
Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-10**]
Date of Birth: [**2090-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2162-3-2**] Cardiac Catheterization
[**2162-3-3**] Aortic Valve Replacement (29mm CE pericardial valve),
Ascending Aorta Replacement (28mm gelweave graft), Coronary
Artery Bypass Graft x 2 (LIMA to LAD, SVG to OM)
History of Present Illness:
71 y/o male who has been followed by cardiologist for years for
asymptomatic aortic stenosis. [**Month/Day/Year **] stress test to determine
his functional capacity, d/t cardiologist concerned if his
Parkinson's could be masking symptoms of aortic stenosis. No EKG
changes, but after 46 seconds his BP dropped from 110/70 to
98/70 and the test was stopped. Echo did reveal severe aortic
stenosis with a bicuspid valve. In terms of symptoms he does
feel fatigued with dyspnea on exertion occuring after [**1-12**] block.
Referred for cardiac cath to further evaluate.
Past Medical History:
Aortic Stenosis, Parkinson's Disease, non-Hodgkin's Lymphoma s/p
chemo and stem cell transplant (in remission), Anxiety,
Gastroesophageal Reflux Disease, Benign Prostatic Hypertrophy
s/p TURP
Social History:
Married, does not work. Denies ETOH or Tobacco use.
Family History:
Non-contributory
Physical Exam:
VS: 92 16 104/71 6'2" 180#
Gen: NAD
Skin: Unremarkable
HEENT: EOMI, PEERL, NC/AT
Neck: Supple, FROM, -JVD, -Bruits
Chest: CTAB -w/r/r
Heart: RRR 2/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE
Discharge
Neuro Alert, oriented x3, MAE r=l strength no tremors
Pulm CTA decreased at bases bilat
Cardiac RRR no M/R/G
Abd Soft, nt, nd +BS
Sternal inc midline healing no drainage/erythema steris sternum
stable
Leg inc Left EVH steris no erythema/drainage
Ext warm +1 edema, pulses palpable
Pertinent Results:
[**2162-3-2**] CNIS: On the right, peak velocities are 65, 60, and 53
cm/sec in the ICA, CCA, and ECA respectively. This is consistent
with no stenosis. On the left, peak velocities are 50, 71, and
40 cm/sec in the ICA, CCA, and ECA respectively. This is
consistent with no stenosis.
[**2162-3-2**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system demonstrated a two vessel CAD. The LMCA
was patent. The LAD had a 70% proximal and a 90% mid vessel
stenoses. The LCx was patent but there was an 80% stenosis in
the OM1. The RCA had mild nonflow limiting disease. 2. Resting
hemodynamics revealed normal right and left sided filling
pressures with an RVEDP of 8 mm Hg and a mean PCWP of 10 mm Hg.
The cardiac index was preserved at 2.33 l/min/m2. 3. Left
ventriculography was deferred. 4. There was a severe aortic
stenosis with a peak to peak gradient of 45.89 mm Hg and a
calculated [**Location (un) 109**] of 0.62 cm2. 5. Peripheral angiography
demonstrated no right iliac disease. 6. Short run of SVT during
the case that terminated spontaneously.
[**2162-3-3**] Echo: PRE-BYPASS: 1. The left atrium is normal in size.
No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. 2. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). 3. Right ventricular chamber size and free wall
motion are normal. 4. The aortic root is mildly dilated at the
sinus level. The sino-tubular junction is preserved. The
ascending aorta is moderately dilated. The aortic arch is mildly
dilated. There are complex (>4mm) atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. 5. The aortic
valve is bicuspid. The aortic valve leaflets are severely
thickened/deformed and extremely calcified. There is severe
aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation
is seen. 6. The mitral valve leaflets are mildly thickened.
Trace to Mild (1+)mitral regurgitation is seen. POST-BYPASS: Pt
is being atrially paced and is on an infusion of phenylephrine
1. AV bioprosthesis well seated in good position. No significant
perivalvular gradient. Trace central valvular AI is noted, no
perivalvular leak seen. Aortic graft noted in ascending aorta.
2. No wall motion abn noted, maintained LV and RV function 3.
Aortic contours unchanged 4. Remaining exam unchanged
[**2162-3-4**] UE U/S: Grayscale and Doppler images of the left IJ,
subclavian, axillary, brachial, basilic, and cephalic veins were
performed. Normal flow, augmentation, compressibility, and
waveforms are demonstrated. Intraluminal thrombus is not
identified.
[**2162-3-2**] 07:40AM BLOOD WBC-5.4# RBC-4.23* Hgb-12.8* Hct-35.8*
MCV-85 MCH-30.2 MCHC-35.6* RDW-15.0 Plt Ct-133*
[**2162-3-3**] 03:34PM BLOOD WBC-6.4 RBC-2.24* Hgb-6.8* Hct-19.9*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.8 Plt Ct-172#
[**2162-3-7**] 05:45AM BLOOD WBC-6.2 RBC-4.08* Hgb-12.0* Hct-35.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 Plt Ct-133*
[**2162-3-2**] 07:40AM BLOOD PT-12.7 INR(PT)-1.1
[**2162-3-5**] 03:08AM BLOOD PT-12.8 PTT-32.0 INR(PT)-1.1
[**2162-3-2**] 07:40AM BLOOD Glucose-104 UreaN-27* Creat-1.2 Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
[**2162-3-7**] 05:45AM BLOOD Glucose-90 UreaN-28* Creat-1.2 Na-136
K-4.0 Cl-101 HCO3-28 AnGap-11
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 35501**] [**Last Name (Titles) 1834**] a cardiac cath on
[**2162-3-2**]. Cardiac cath revealed severe aortic stenosis along with
2 vessel coronary artery disease and a dilated ascending aorta.
He was then referred for surgical evaluation. [**Date Range **] all
pre-operative testing and was brought to the operating room on
[**2162-3-3**]. He [**Date Range 1834**] an Aortic Valve Replacement, Asc. Aorta
Replacement, and Coronary Artery Bypass Graft x 2. Please see
operative report for surgical details. He did have significant
amount of post-op bleeding that required multiple blood
products. Following surgery he was transferred to the CSRU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation awoke neurologically intact and extubated.
On post-op day one there appeared to be left arm edema with
bluish discoloration and left-sided neck bulge. All left arm
peripheral IV's and arterial line were removed, vascular surgery
was consulted and an upper extremity ultrasound was performed.
Ultrasound was negative for DVT. His chest tubes and epicardial
pacing wires were removed per protocol. Diuretics and
beta-blockers were initiated and he was gently diuresed towards
his pre-op weight. On post-op day two he was transferred to the
telemetry floor. He continued to improve post-operatively and
worked with PT for strength and mobility. Left arm swelling and
neck bulge has resolved. Clinically he appeared to be doing
well but needed additional PT and was discharged to rehab
facility on post-op day seven.
Medications on Admission:
Primidone 150mg qhs, Mirapex 0.5mg TID, Diazepam 4mg [**Hospital1 **],
Zyprexa 5mg qhs, Omeprazole 20mg prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis, Asc. Aortic Aneurysm, Coronary Artery Disease
s/p Aortic Valve Replacement, Asc. Aorta Replacement, Coronary
Artery Bypass Graft x 2
PMH: Parkinson's Disease, non-Hodgkin's Lymphoma s/p chemo and
stem cell transplant (in remission), Anxiety, Gastroesophageal
Reflux Disease, Benign Prostatic Hypertrophy s/p TURP
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, 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
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 10548**]
Dr. [**Last Name (STitle) 22741**] after discharge from rehab [**Telephone/Fax (1) 35502**]
Please call to schedule all appointments
Completed by:[**2162-3-10**]
|
[
"300.00",
"600.00",
"V42.82",
"332.0",
"530.81",
"998.11",
"E879.8",
"441.2",
"202.80",
"414.01",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.04",
"99.05",
"88.56",
"36.15",
"36.11",
"39.61",
"99.07",
"35.21",
"34.03",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7226, 7320
|
5471, 7068
|
340, 558
|
7693, 7699
|
2043, 5448
|
1454, 1472
|
7341, 7672
|
7094, 7203
|
7723, 8141
|
8192, 8514
|
1487, 2024
|
281, 302
|
586, 1154
|
1176, 1369
|
1385, 1438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
975
| 114,439
|
43495
|
Discharge summary
|
report
|
Admission Date: [**2139-2-1**] Discharge Date: [**2139-2-26**]
Date of Birth: [**2074-5-16**] Sex: M
Service: MEDICINE
Allergies:
Roxicet
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Fevers, fatigue
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] implantation [**2139-2-13**] DDD [**Company 1543**]
Electrophysiology study [**2139-2-5**]
History of Present Illness:
Mr. [**Known lastname 93612**] is a 64 yo man with history of bicuspid AV s/p [**Known lastname 1291**]
and MSSA endocarditis and repeat [**Known lastname 1291**], AFib on coumadin and
amiodaron, bronchiectasis and GIB who presented to [**Hospital1 18**]
complaining of fatigue and fevers. He was recently admitted to
[**Hospital1 18**] with a GIB in [**12/2138**] which resolved. He was in his usual
state of health until about two days ago when he began feeling
subjective fevers and weakness. Today he decided to call EMS
because he could not walk more than 10 steps. In the ED, he was
found to be febrile, to have a leukocytosis and hypotensive with
a pulse in the 30's. EKG showed a sinus rate of 140 and 1:3
block. Levaquin, gentamycin and [**Year (4 digits) **] were given. a RIJ was
placed despite an INR of >4.
.
On arrival to the CCU he was febrile, hypotensive, and
bradycardic. Tele showed complete heart block. EP was consulted
and a transvenous pacing wire was placed at the bedside with
fluoroscopic guidance.
Past Medical History:
1. Bicuspid AV-s/p [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1291**] in 92, MSSA endocarditis and
abscess- s/p redo in 5/00
2. Afib on amiodarone
3. Bronchomalecia and Bronchiectesis
4. Gastritis
5. CABG times 3- [**2132**] ([**2136**], LVEF>55%)
6. hypercholesterolemia
7. HTN
8. Diverticulosis and Lymphoid aggregates on Colonoscopy in [**2135**]
9. impotence
10. hernisted disc
11. STROKE ([**2137**]) ax
12. thoracic aneurysm
Social History:
Divorced, 2 sons, [**Name (NI) **] ETOH (per pt) but + h/o drinking 1 gallon
of wine daily in [**2133**] that pt always denied, no current tobacco,
4ppd times 30 years and quit in 92, no IVDU, divorced, can do
all ADLS. At baseline he walks a quarter of a mile every day.
He will get short of breath on walking quickly [**2-28**] blocks.
Family History:
NC per patient
Pertinent Results:
[**2139-2-1**] 08:07PM PT-52.3* PTT-66.0* INR(PT)-6.2*
[**2139-2-1**] 01:48PM GLUCOSE-102 UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11
[**2139-1-31**] 06:30PM WBC-23.0*# RBC-3.83* HGB-11.3* HCT-33.2*
MCV-87 MCH-29.5 MCHC-34.0 RDW-15.2
[**2139-2-1**] 06:27AM GLUCOSE-92 UREA N-19 CREAT-1.4* SODIUM-141
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-21* ANION GAP-13
RENAL U.S. [**2139-2-20**] 1:08 PM
IMPRESSION: No masses, stones, or hydronephrosis present within
the kidneys.
CHEST (PORTABLE AP) [**2139-2-15**] 5:16 PM
IMPRESSION: No significant interval change.
ECG Study Date of [**2139-2-14**] 10:41:52 AM
Regular ventricular pacing
[**Date Range **] rhythm - no further analysis
Since previous tracing, ventricular paced rhythm present
UNILAT UP EXT VEINS US RIGHT PORT [**2139-2-12**] 12:59 PM
IMPRESSION:
1) No evidence of deep venous thrombosis in the right upper
extremity.
2) Large hetergenous round area within the right axilla, likely
a hematoma. Right axillary vein was not visualized.
ECHO Study Date of [**2139-2-2**]
Conclusions:
There are complex (>4mm) atheroma in the descending thoracic
aorta. A well-seated bileaflet aortic valve prosthesis is
present. The aortic prosthesis discs appear to move normally.
There is a small 3mm fluttering echodensity is seen on the LVOT
side of the valve consistent with vegetation/thrombus. No aortic
valve abscess is seen. Mild (1+) aortic regurgitation is seen.
Mild to moderate ([**1-27**]+) mitral regurgitation is seen.
IMPRESSION: Small echodensity on the aortic valve disc
consistent with a
vegetation (or thrombus) as described above. Mild aortic
regurgitation.
Moderately dilated aortic arch and proximal descending aorta.
CT ABDOMEN W/CONTRAST [**2139-2-2**] 2:06 PM
IMPRESSION:
1. No evidence of abscess, as clinically questioned.
2. Gallstone.
3. Bilateral renal cysts.
4. Mild dependent atelectasis.
CT HEAD W/O CONTRAST [**2139-2-1**] 10:06 AM
IMPRESSION: No evidence of acute intracranial hemorrhage. No CT
evidence of brain ischemia.
Brief Hospital Course:
A/P: 64M w/ CAD s/p CABG, [**Year/Month/Day 1291**], MSSA endocarditis, repeat [**Year/Month/Day 1291**] and
bentall procedure, who presented with bradycardia, hypotension
and fever/leukocytosis. Found to have a likely vegetation on his
AV by TEE with CHB s/p PM on [**2139-2-13**].
.
#)AV node dysfuction, complete heart block evolved back to type
2, then type 1 heart block. Pt required a temporary wire early
in hospital course. Pt had EPS [**2-5**] which showed H-V interval in
the 80's (prolonged) and on faster rhythm he went in 2:1 block.
Had permanent [**Month/Year (2) 4448**] on [**2139-2-13**], heparin restarted. Also on
coumadin.
- in nsr on [**2-17**], intermittently v paced
- Interrogated by EP on [**2-20**].
- Outpatient follow up.
- Beta-blocker restarted without difficulty. In NSR on
discharge.
#) Hematoma right arm
- The patient developed a spontaneous hematoma on heparin on
[**2139-2-11**]. He was evaluated by vascular who recommended arm
elevation and ACE wrap. His Hct dropped from 31 to 26 but has
remained stable at 26.
- An ultrasound was obtained on [**2-12**] which showed no clot.
- Given his high risk of stroke with an [**Month/Year (2) 1291**], the heparin was
restarted around [**2-28**] pm on [**2-12**].
- Improved on [**2139-2-13**] and resolved by the time of discharge.
.
#) AF: The patient had been on Amiodarone- this was DC'd on [**2-10**]
as he developed 2nd degree AV block on tele but restarted on
[**2139-2-14**] without event post [**Date Range 4448**]. He was discharged on
coumadin.
#) HTN:
. His HCTZ and beta-blocker were restarted. ACE was held with
acute renal failure.
.
#) ARF
- Cr rose to 1.4 from 1.1 which was felt to be most likely from
gentamycin toxicity.
- His FENA was <1 with rare eos on UA. He was given IVF with no
improvement of his kidney function.
- We continue to hold his ACE.
- Renal ultrasound on [**2139-2-20**] showed no acute abnormalities.
- A Cr of 1.4 was deemed to be his new baseline.
.
#) Culture negative endocarditis: ID evaluated him inhouse and
subsequently signed off. Vegetation seen on TEE.
-The plan is for 6 weeks of Cefepime, Vanco, and initially 2 wks
gentamycin.
- No rifampin per ID given multiple drug interactions.
- Had acute rise in Cr on [**2-9**], therefore DC'd gentamycin and he
did not receive this for the remainder of his stay.
- His vanco was dosed by level, trough <15 with results as an
outpatient to be faxed to his ID specialist per their request.
- Prior to DC, his level had been greater than 15 and was held
two days prior to DC with permission to be restarted at 750 mg
IV QD as an outpatient.
-PICC placed on Tuesday in RUE.
.
#) CAD
- Restarted ASA 81 mg on [**2-10**]. Resarted BB. Held ACE with ARF.
Zetia, statin.
.
#) h/o GI bleed: The patient has known angioectasia and had GI
bleed without multiple diverticula as well. Was to have outpt
appointment with [**Doctor Last Name 519**] in surgery but missed it because of
hospitalization. This was rescheduled prior to DC.
- GI had seen the patient on [**2-4**] and felt no need for scope
this admission. -
- On [**2-9**], the patient noted black appearing stool (started iron
day before). Guaiac negative, hemo stable. Hct stable and
required no transfusions for this reason.
- This was not an active issue for the remainder of his stay.
.
#) Mechanical AV valve: Required prolong hospitalization for
heparin/coumadin bridge pre and post procedure. He required up
to 10 mg of coumadin in-house to get a therapeutic INR, goal
2.5-3.5.
- He formerly took 5 and 7.5 mg of coumadin at home.
- He will have his INR checked in 2 days and have the results
faxed to the coumadin clinic to adjust his coumadin dose
accordingly.
- Although coumadin 10 mg was required to achieve a therapeutic
INR, he will be discharged on coumadin 7.5 mg.
.
#) Anemia
- Concerning drop from 30->26 on [**2-13**] to 22 on [**2139-2-15**]. Guaiac
negative. The hct drop was felt to be secondary to his right arm
hematoma.
- He was transfused 2 units from [**2-15**] to [**2138-2-16**]. His Hct
remained stable thereafter and he required no further
transfusions.
.
#) Code status: full code.
.
#) dispo: Home with VNA.
Medications on Admission:
amiodarone 200mg daily, dicloxacillin 25omg q8, HCTZ 25mg daily,
lipitor 80mg, lisinopril 5mg daily, metoprolol XL 12.5mg daily,
MVI, protonix, coumadin 2.5mg daily, zetia 10mg daily
Discharge Medications:
1. Cefepime 2 g Recon Soln Sig: One (1) Intravenous twice a day
for 3 weeks.
Disp:*56 * Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
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. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*30 ML(s)* Refills:*3*
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for 5 days.
Disp:*50 ML(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*2 * Refills:*1*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
INR check 2 days after discharge with results faxed to PCP.
Vanco trough checked 2 days after discharge with results faxed
to PCP. [**Name10 (NameIs) **] should continue for trough <15.
18. Sodium Chloride 0.9 % Parenteral Solution Sig: One (1)
3 cc Intravenous once a day.
Disp:*30 * Refills:*3*
19. [**Name10 (NameIs) **] 500 mg Recon Soln Sig: 1.5 Intravenous once a
day for 3 weeks: 750 mg IV QD. hold for trough >15.
Disp:*30 * Refills:*3*
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
21. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Culture negative endocarditis
Complete heart block with [**Hospital 4448**] implantation
Paroxysmal atrial fibrillation
Gentamicin-induced renal insufficiency
Discharge Condition:
stable
Discharge Instructions:
Please continue your antibiotics [**Hospital **] and Cefepime for a
total of 6 weeks (last dose [**3-15**]).
Please fax [**Month (only) **] troughs to Dr. [**First Name (STitle) **], your infectious
disease specialist, weekly. Her fax is [**Telephone/Fax (1) 1419**].
The [**Telephone/Fax (1) 4448**] RN will call you at home [**2139-3-12**] to check PM (see
below).
Followup Instructions:
Please follow up with the infection specialist - Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2139-3-12**] 9:00
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2139-3-12**]
11:30
You have an appointment with your cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**],
on [**6-8**] at 2:00pm. His office is located on the [**Location (un) 436**] of
the [**Hospital Ward Name 23**] building. Please call ([**Telephone/Fax (1) 24798**] should you have
any questions.
You have an appointment with your electrophysiologist, Dr. [**Last Name (STitle) **]
[**Name (STitle) 26676**], on ***. His office is located on the [**Location (un) 436**] of
the [**Hospital Ward Name 23**] building. Please call ([**Telephone/Fax (1) 12468**] should you have
any questions.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 34552**] Date/Time:[**2139-4-6**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2139-3-9**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2139-3-5**] 2:30
|
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"458.9",
"998.12",
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"V58.61",
"996.61",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
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"38.93",
"37.26",
"37.72",
"88.72",
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icd9pcs
|
[
[
[]
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11251, 11309
|
4458, 8629
|
282, 399
|
11512, 11521
|
2371, 4435
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|
2336, 2352
|
8862, 11228
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11330, 11491
|
8655, 8839
|
11545, 11915
|
227, 244
|
427, 1454
|
1476, 1964
|
1980, 2320
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,920
| 179,195
|
42086
|
Discharge summary
|
report
|
Admission Date: [**2121-10-23**] Discharge Date: [**2121-10-28**]
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with two bare metal stents placed to the
RCA
History of Present Illness:
[**Age over 90 **]F with HTN, macular degenration, without known CAD with new
RCA STEMI s/p BMS x2.
.
Mrs [**Known lastname 46690**] first felt unwell at about 9:30 this morning. She
later developed [**2120-4-6**] chest pressure that radiated to her L arm
as well as nausea. She waited 15 minutes then her nephew brought
her to [**Hospital1 18**] where an EKG showed STE in II III AVF, with neg
troponin, a code STEMI was called and she was taken to the cath
lab. There she was found to have a tight stenosis of the
proximal RCA and complete occlusion of the distal RCA. These
lesions were angioplastied and two BMS were placed. She was also
noted to have 80-90% proximal LAD and 60-70% Circ stenoses. Her
CP completely resolved. Her groin was closed with a closure
device though she still had some oozing from the site.
.
Of note she has been having chest pressure associated with
exertion for approximately 1 year. She denies orthopnea or PND.
By report she does take some pill for lower extremity edema but
denies CHF history. There is a question of a possible CVA or TIA
in the past year. She also has someone stay with her 24 hours a
day because of forgetfulness.
.
On review of systems, she denies 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. However because of her mental status this history may
not be entirely accurate.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Carotid stenosis
?pAF (not on coumadin)
-Macular degeneration
- Melanoma of L thigh
B/L hip replacement
Social History:
Lives with 24 hour caretaker in [**Name (NI) **]. Has nephew and neice
who are very involved in her care. Has mild forgetfulness at
baseline. Limited ambulation at home but can cook and do small
chores.
- Tobacco history: None
- ETOH: Minimal
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: T= 97 BP= 110/71 HR=84 RR=23 O2 sat= 99 3L
GENERAL: NAD. A&Ox2-3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP not appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Anterior exam CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
GROIN: small oozing from femoral line, no hematoma or bruit
EXTREMITIES: No c/c/e. No femoral bruits. DP pulses dopplerable
b/l
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Discharge exam:
VS: Tmax/Tcurrent: 97.5/97.1 HR: 68-104, RR 20, BP:
134-155/84-85. O2 sat 99% RA.
In/Out:
Last 24H: 680/inc
Last 12H: 0/inc
Weight: 48.9 kg (49.6 kg)
.
Tele: SR, rate 80-107
.
GENERAL: well-appearing elderly female sitting up in the bed.
NAD. Oriented to person only. Alert and conversant.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa.
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: Severe kyphosis. Resp were unlabored, no accessory muscle
use. LS clear throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
GROIN: Right groin with mild ecchymosis, no bleeding/ hematoma
or bruit noted. DP/PT per doppler
SKIN: intact
Pertinent Results:
ADMISSION LABS:
[**2121-10-23**] 12:12PM GLUCOSE-176* UREA N-19 CREAT-0.5 SODIUM-141
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
[**2121-10-23**] 12:12PM estGFR-Using this
[**2121-10-23**] 12:12PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7
[**2121-10-23**] 12:12PM WBC-6.5 RBC-4.41 HGB-13.2 HCT-40.3 MCV-91
MCH-29.9 MCHC-32.7 RDW-12.1
[**2121-10-23**] 12:12PM NEUTS-71.3* LYMPHS-21.4 MONOS-4.5 EOS-2.5
BASOS-0.3
[**2121-10-23**] 12:12PM PLT COUNT-289
[**2121-10-23**] 12:12PM PT-13.8* PTT-150* INR(PT)-1.2*
.
PERTINENT LABS:
[**2121-10-23**] 12:12PM BLOOD cTropnT-<0.01
[**2121-10-23**] 07:03PM BLOOD CK-MB-107* MB Indx-19.2* cTropnT-3.26*
[**2121-10-24**] 04:18AM BLOOD CK-MB-68* MB Indx-16.1* cTropnT-2.47*
[**2121-10-25**] 11:10AM BLOOD CK-MB-8 cTropnT-0.78*
[**2121-10-25**] 05:28PM BLOOD CK-MB-7 cTropnT-0.82*
[**2121-10-23**] 07:03PM BLOOD ALT-17 AST-67* CK(CPK)-558* AlkPhos-125*
TotBili-0.3
[**2121-10-25**] 06:10AM BLOOD ALT-14 AST-34 AlkPhos-97 TotBili-0.3
[**2121-10-23**] 07:03PM BLOOD Triglyc-85 HDL-85 CHOL/HD-2.2 LDLcalc-88
.
DISCHARGE LABS:
[**2121-10-28**] 07:40AM BLOOD WBC-6.2 RBC-4.53 Hgb-13.5 Hct-41.0 MCV-91
MCH-29.9 MCHC-33.0 RDW-12.5 Plt Ct-247
[**2121-10-28**] 07:40AM BLOOD Glucose-81 UreaN-15 Creat-0.4 Na-140
K-3.6 Cl-100 HCO3-29 AnGap-15
.
EKG [**10-23**]
Baseline artifact at the end of the tracing. ST segment
elevation in
leads II, III, aVF and V6 with ST segment depression in the
lateral and
the anterior precordial leads suggestive of acute injury,
probable myocardial infarction. Poor R wave progression across
the precordium - cannot rule out prior anterior myocardial
infarction. No previous tracing available for comparison.
.
CATH [**10-23**]
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had
mild
plaquing, and a 20% ostial lesion. The proximal LAD was noted
to have
an 80-90% stenosis. It was notable for a cuff adequate for
endovascular
treatment of this lesion without necessarily involving the LMCA.
It was
noted to be very heavily calcified, and would thus consider
rotablation.
The LCx had a proximal 60-70% lesion. The RCA had a thrombotic
occlusion of the distal RCA. There was also a tight calcific
lesion
noted in the proximal RCA.
2. Limited resting hemodynamics revealed systemic arterial
normotension
with a central aortic pressure of 128/68, mean 94 mmHg.
3. Successful PCI to the dRCA lesion with a 3.5x18mm Vision BMS
and the
pRCA with a 3.5x15mm Vision BMS.
4. Perclose to the Right CFA.
5. No complications.
FINAL DIAGNOSIS:
1. Thrombotic lesion in the distal RCA with notable disease in
the LAD
and LCx as well.
2. Systemic arterial normotension.
3. Successful PCI to the dRCA and pRCA with two Vision BMS.
4. No complications of the procedure.
5. Patient is to remain on aspirin indefinitely and clopidogrel
for at
least 9-12 months given the setting of an acute MI.
.
EKG [**10-24**]
Baseline artifact. Sinus rhythm. Q waves in leads III and aVF
with
deep T wave inversion in the inferior and lateral precordial
leads, consistent with an evolving inferior myocardial
infarction. Poor R wave progression in leads V1-V3 suggestive of
a prior anteroseptal myocardial infarction. Compared to the
previous tracing of [**2121-10-23**] the diffuse T wave inversions are
new, as are the inferior Q waves, consistent with evolution of
the previously seen inferior myocardial infarction pattern.
ECHO: [**10-24**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to inferior, posterior, and
lateral hypokinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
CXR [**10-24**]
FINDINGS:
Evaluation is slightly limited due to severe levoscoliosis of
the thoracic spine. Within those limitations, the
cardiomediastinal silhouette and hila are normal. There is no
pleural effusion and no pneumothorax.
IMPRESSION:
Severe thoracic levoscoliosis, no acute cardiothoracic process.
.
Brief Hospital Course:
[**Age over 90 **]F with HTN, macular degeneration, without known CAD with new
RCA STEMI s/p BMS x2.
.
# CAD/RCA STEMI: Presented with RCA STEMI. SHe was treated with
aspirin plavix and taken to the cath lab with succesful PTCA and
BMSx2 placement with resolution of CP. Post catheterization EKG
demonstrated resolution of the STE but new Q waves in II and
AVF. Echo the following day demonstrated LVEF 35% and depressed
RV function. She was placed on atorvastatin 80mg, metoprolol,
lisinopril and imdur. Her cardiac cath also showed significant
CAD of the LAD and circumflex artetries but no intervention was
performed. These lesions will be treated medically for now.
.
#HTN: Had HTN prior to admission treated with diltiazem. After
her MI she was started on metoprolol, lisinopril, and imdur, and
her diltiazem was discontinued. Blood pressure was well
controlled at discharge.
#Acute Systolic Dysfunction: Has been on lasix 40 mg for lower
extremity edema. Her LVEF is 35% on recent echo thought to be
depressed from baseline. She looked mildly hypervolemic but was
not actively diuresed as she is likely preload dependent in
setting of her RV infarct. Her home lasix was retarted prior to
discharge.
.
#Hyperlipidemia: had history of HLD and was on pravastatin 20 mg
daily. This was changed to atorvastatin 80mg after her MI
.
#Macular degeneration: Stable
.
#Urinary tract infection:
Multiple episodes of urinary incontinance in past 24h since
foley removed. Pt denies incontinence at home. U/A positive,
started on ceftriaxone empirically and culture grew klebsiella
in urine, sensitive to ciprofloxacin. She will finish a 7 day
course of antibiotics with cipro for 4 days.
.
# Dementia.
Baseline at present, possible additional component of delirium.
Pt much clearer today, A+Ox3, following commands, conversant,
pleasant.
.
Transitional issues:
1. consider repeating u/a once antibiotics are finished
2. consider stress test in the future to assess for ischemia
given known occlusions
3. Chem-7 to be drawn in 3 days at rehabilitation as pt is newly
on lisinopril
4. BP and HR monitoring on new medicines
5. Repeat ECHO in 6 weeks to assess EF.
Medications on Admission:
Diltiazem 240 daily
lasix 40 daily
pravastatin 20 daily
detrol LA 2mg daily
KCL 10MEQ 2 pills daily
Ca 600 vit D 400 daily
omeprazole 20 daily
symbicort 80/4.5 2 puffs [**Hospital1 **]
Cortisporin eye drops 4 drops [**Hospital1 **]
Flonase 50mg daily
senna PRN
(confirmed with niece [**2121-10-28**])
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 days.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Detrol LA 2 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
10. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
11. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
13. Cortisporin 3.5-400-10,000 mg-unit/g-1% Ointment Sig: Four
(4) drops Ophthalmic twice a day.
14. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Coronary artery disease
Hypertension
? CVA [**2119**]
Dyslipidemia
Atrial fibrillation
Macular degeneration
Carotid stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hopital on [**2121-10-23**] with a heart
attack. You had a heart catheterization the same day and 2 bare
metal stents placed in your right coronary artery. You had
blockages in your left anterior descending artery and left
circumflex artery which are being treated with medication.
You should take Aspirin 325mg daily indefinitely and Plavix 75mg
daily for a minimum of [**8-11**] months. Do not stop either of these
medications unless instructed to do so by Dr. [**Last Name (STitle) 91316**].
Stopping either of these medications early COULD result in a
blockage inside your stents and cause another heart attack.
You were also treated for a urinary tract infection while you
were in the hospital. You should continue Ciprofloxacin
(antibiotic) 500mg for 4 more days.
You should take Lisinopril 5mg daily (for your heart failure and
high blood pressure). You will need labs repeated in 3 days.
The heart attack made your heart weak and you may retain extra
fluid. You are on medicines to help your heart pump better but
you need to watch for any swelling in your legs. Please weigh
yourself every morning, call Dr. [**Last Name (STitle) 91316**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Medication Changes:
Stop Pravastatin 20mg and start Lipitor 80mg daily (for
cholesterol)
Stop Diltiazem
Stop Prilosec and start Ranitidine (Zantac) 300mg daily (safer
medication for heartburn while you are on Plavix)
Start ASA and Plavix as above
Start Toprol 50mg daily (to take some work load away from your
heart)
Start Ciprofloxacin 500mg [**Hospital1 **] for 4 more days (urine infection)
Start IMDUR 15mg daily (to help with chest pain for blockages in
your heart)
Start Lisinopril (for weak heart and blood pressure)
Followup Instructions:
Cardiology: Dr. [**First Name (STitle) **] [**Name (STitle) 91316**]([**Hospital6 4620**])
[**Telephone/Fax (1) 18278**]
Tuesday [**2121-11-11**]:30am
-green building #562
|
[
"410.31",
"272.4",
"V43.64",
"530.81",
"414.01",
"599.0",
"428.0",
"041.3",
"433.10",
"401.9",
"294.20",
"276.51",
"428.20",
"362.50",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"00.46",
"88.56",
"00.66",
"36.06",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
12824, 12912
|
8861, 10697
|
246, 317
|
13081, 13081
|
4208, 4208
|
15049, 15224
|
2537, 2654
|
11372, 12801
|
12933, 13060
|
11046, 11349
|
6803, 8838
|
13257, 14501
|
5285, 6786
|
2669, 3442
|
2024, 2103
|
3460, 4189
|
10718, 11020
|
14521, 15026
|
196, 208
|
345, 1916
|
4224, 4737
|
13096, 13233
|
4753, 5269
|
2134, 2239
|
1938, 2004
|
2255, 2521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,005
| 179,180
|
35504
|
Discharge summary
|
report
|
Admission Date: [**2117-3-12**] Discharge Date: [**2117-3-22**]
Date of Birth: [**2041-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Progressive dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2117-3-15**] Aortic Valve Replacement(25mm [**Company 1543**] Mosaic Porcine)
and Three Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending artery, vein grafts
to obtuse marginal and PDA)
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old male with known severe aortic
stenosis. Over the past few months, he has complained of
progressive dyspnea on exertion. He subsequently underwent
cardiac catheterization which revealed severe three vessel
coronary artery disease including a 75% distal left main lesion.
Given the above findings, he was transferred to the [**Hospital1 18**] for
cardiac surgical intervention.
Past Medical History:
Hypertension
Peptic Ulcer Disease - History of Upper GI Bleed
Chronic Obstructive Pulmonary Disease
Spinal Stenosis
s/p Laminectomy
s/p Appendectomy
Social History:
Over 50 pack year history of tobacco, quit [**2116-6-23**]. Admits to
1-3 beers per day. Denies history of ETOH abuse. Retired, lives
with his wife.
Family History:
No premature coronary artery disease.
Physical Exam:
Admission:
Vitals: 159/88, 74, 18
General: elderly male in no acute distress
Skin: macular rash noted across lower back
HEENT: oropharynx benign
Neck: supple, no jvd
Chest: distant breath sounds throughout
Heart: regular rate and rhythm, s1s2, 3/6 systolic ejection
murmur heard throughout the precordium and carotids
Abdomen: benign
Extremities: warm, no edema
Neuro: grossly intact
Pulses: 2+ distally
Pertinent Results:
[**2117-3-12**] 07:10PM BLOOD WBC-8.1 RBC-4.58* Hgb-14.7 Hct-42.4
MCV-93 MCH-32.1* MCHC-34.6 RDW-14.6 Plt Ct-282
[**2117-3-12**] 07:10PM BLOOD PT-15.2* PTT-32.1 INR(PT)-1.3*
[**2117-3-12**] 07:10PM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-134
K-3.9 Cl-98 HCO3-27 AnGap-13
[**2117-3-12**] 07:10PM BLOOD ALT-13 AST-24 LD(LDH)-218 AlkPhos-143*
TotBili-0.7
[**2117-3-12**] 07:10PM BLOOD %HbA1c-5.3
[**2117-3-12**] 07:10PM BLOOD Albumin-4.5
[**2117-3-13**] Echocardiogram:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are complex (>4mm,
non-mobile) atheroma in the ascending aorta beginning at 4cm
above the aortic valve (clip #[**Clip Number (Radiology) **]). The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**12-25**]+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
[**2117-3-14**] Chest CT Scan:
1. Diffuse atherosclerotic calcifications as above. 2. Patchy
bilateral predominantly peribronchiolar nodules likely represent
chronic bronchiolitis from infection such as MAC or
hypersensitivity pneumonitis with likely reactive
lymphadenopathy. Imaging in three months can be obtained after
therapy as clinically indicated. 3. Compression fractures at L1
and L2 are of indeterminate age.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Given his critical
anatomy, intravenous Heparin was initiated. Workup included an
echocardiogram which confirmed severe aortic stenosis, and also
showed mild to moderate mitral regurgitation and normal left
ventricular function. Echocardiogram was also notable for a
dilated ascending aorta with plaque for which chest CT scan was
obtained. The CT scan showed that the aorta was normal in course
and caliber. There were moderate atherosclerotic calcifications
throughout the aorta without evidence of dissection or
penetrating ulcer. Preoperative course was otherwise uneventful.
He remained pain free on intravenous therapy and was cleared for
surgery. Given his inpatient stay was greater than 24 hours
prior to surgery, Vancomycin was utilized for perioperative
antibiotic coverage.
On [**3-15**] rd, Dr. [**Last Name (STitle) 914**] performed an aortic valve
replacement and coronary artery bypass grafting. For surgical
details, please see operative note. Following the operation, he
was brought to the CV ICU for invasive monitoring. Initially
hypotensive and anemic, he required inotropic support with
Levophed and vasopressin. Several units of packed red blood
cells were transfused. Over the next 24 hours, hemodynamics
improved and hematocrit stabilized. Pressors were weaned, he
remained stable, was weaned from the ventilator and was
extubated.
He was transferred to the floor on POD3. Beta blockers were
resumed, diuresis was continued along with aggressive pulmonary
care and bronchodilators. PT worked with him for strength and
mobility. He has baseline mobility issues, using a walker due to
instability from his spinal stenosis. There was some erythema
of the sternal wound and Keflex was given empirically.
Diuretics were changed to oral formulations at discharge. His
CXR demonstrated some intravascular fullness, but was
essentially clear. He denies SOB, despite his wheezing.
He developed atrial fibrillation for which Amiodarone was begun
and Lopressor was adjusted with rate control.. Anticoagulation
was begun with Coumadin for this as well. He progressed
satisfactorily and was ready for rehabilitation.
Diuretics were continued after transfer and will continue until
he reaches his preoperative weight, about 72 kg. The Atrovent
was changed to a more selective preparation given the severity
of his pulmonary disease.
Discharge precautions, medications and follow up instructions
were noted in the transfer paperwork and summary.
Medications on Admission:
Metoprolol 100 mg daily
Discharge Medications:
1. Influen Tr-Split [**2115**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): for 7 days then reduce to one tablet twice daily(200mg
[**Hospital1 **]).
13. Lopressor 50 mg Tablet Sig: 1 [**12-25**] Tablet PO three times a
day.
14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4h ().
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily):
hold K>4.5.
16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for sternal erythema for 5 days.
17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
18. Warfarin 2.5 mg Tablet Sig: as ordered Tablet PO once a day:
INR [**1-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Aortic Stenosis - s/p Aortic Valve Replacement
Coronary Artery Disease - s/p Coronary Artery Bypass Grafting
Chronic Obstructive Pulmonary Disease
Hypertension
Spinal Stenosis
Peptic Ulcer Disease, History of Upper GI Bleed
Discharge Condition:
Good
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 from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**3-28**] weeks, [**Telephone/Fax (1) 170**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-26**] weeks
Dr. [**Last Name (STitle) **] in [**1-26**] weeks, [**Telephone/Fax (1) 10381**]
please call for appointments
Completed by:[**2117-3-22**]
|
[
"276.6",
"414.01",
"285.9",
"458.29",
"496",
"533.90",
"V15.82",
"424.1",
"401.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.12",
"39.61",
"36.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8169, 8212
|
3728, 6315
|
351, 588
|
8480, 8487
|
1868, 3705
|
9312, 9625
|
1390, 1429
|
6389, 8146
|
8233, 8459
|
6341, 6366
|
8511, 9289
|
1444, 1849
|
280, 313
|
616, 1036
|
1058, 1208
|
1224, 1374
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,215
| 185,200
|
43912
|
Discharge summary
|
report
|
Admission Date: [**2172-9-29**] Discharge Date: [**2172-10-6**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
woman who presented on [**9-29**] with a three week history of
worsening shortness of breath, usually with exertion, but
also progressing now to rest. One month prior to admission
she could walk approximately 30 minutes without becoming
short of breath. Just prior to admission, however, she could
barely ambulate 10 feet. She denied any chest pain,
orthopnea, PND, diaphoresis, palpitations, lower extremity
pain or edema. She also denied fever, chills, nausea,
vomiting or headaches.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post cardiac catheterization in [**2171-3-9**]
showing diffuse hypokinesis and EF of 43%, 90% lesion of LPDA
that she underwent PTCA for, 50% occlusion of the D1 and mild
AS. An echocardiogram done on [**2172-6-5**] showed an EF of 25-30%
with diffuse hypokinesis, [**12-10**]+ MR, 1+ AR. Other past medical
history significant for lung cancer status post left upper
lobectomy in [**2166**], COPD, CHF, type 2 diabetes mellitus,
hypertension, hypercholesterolemia. This is a question of an
allergy to Lipitor with a rash. Her outpatient medications
include Aspirin 325 mg po q d, Glucophage 100 mg po bid,
Glyburide 10 mg po bid, Lasix 40 mg po q d, Iron 325 mg po q
d, Lescol 40 mg po q d, Zestril 40 mg po q d, KCL 10 mEq po q
d. She is a 60 pack year smoker who quit approximately 8
years ago.
HOSPITAL COURSE: On admission the patient had an EKG with no
significant ST-T changes. She was admitted for rule out MI
protocol and started on a Heparin drip. She underwent a
cardiac catheterization on [**2172-9-30**] which revealed global
hypokinesis, left ventricular ejection fraction of 25%,
calcification of the aortic valve with severe aortic
stenosis, 70% stenosis of the D1. Aortic valve area was
noted to be .78 cm. The patient was also noted to have a
urinary tract infection and was started on Bactrim which was
then changed to Levaquin. On admission patient's hematocrit
was noted to be low at 28. This was noted to be stable for
the patient and she is on iron therapy. The patient was
taken to the operating room on [**2172-10-2**] and underwent an
aortic valve replacement with a #23 CE valve. She tolerated
the procedure well and was transferred to the CSRU on
Milrinone, Neo and Propofol drips. Postoperatively she did
well and was extubated successfully the night of her surgery.
She was weaned off her Milrinone and neo drips and was
transferred to the floor on postoperative day #1. Lasix,
Lopressor and Aspirin were started. The patient received
nebulizer treatments for her COPD. The patient was seen by
physical therapy and was noted to have impaired functional
status compared to baseline and to benefit from [**Hospital 3058**]
rehab stay. The patient continued to do well on
postoperative day #2. Her hematocrit was noted to be low at
24, however, as the patient was asymptomatic at this point
her transfusion was held. Her respiratory status continued
to improve and she was restarted on her oral hypoglycemic
medications. Postoperative day #3 the patient was screened
for rehab. The patient is being discharged on postoperative
day #4 in good condition.
Physical exam on discharge is significant for a T max of
99.4, T current 98, blood pressure 97/52, heart rate 90,
respiratory rate 20, O2 saturation 100%. Her blood sugars
are well controlled, ranging from 100 to 177. She will
receive transfusion of one unit of packed red blood cells on
the day of discharge. Her hematocrit is noted to be 23.5.
Heart is regular. Her incision is clean, dry and intact
without any erythema or drainage. Her sternum is stable.
Her lungs are clear to auscultation bilaterally.
DISCHARGE MEDICATIONS: Include Combivent 2 puffs q 6 hours,
Protonix 40 mg po q d, Glucophage 100 mg po bid, Glyburide 10
mg po bid, Lasix 40 mg po q d, Iron 325 mg po q d, Lescol 40
mg po q d, KCL 10 mEq po q d, Lopressor 50 mg po bid, hold
for blood pressure less than 100, heart rate less than 60,
Levaquin 500 mg po q d to be discontinued on [**2172-10-8**].
CONDITION ON DISCHARGE: The patient is being discharged to
rehab in good condition.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 25727**]
MEDQUIST36
D: [**2172-10-6**] 12:00
T: [**2172-10-6**] 12:36
JOB#: [**Job Number **]
|
[
"396.2",
"429.9",
"414.01",
"411.1",
"285.9",
"599.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"35.21",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
3870, 4211
|
1549, 3846
|
137, 657
|
680, 1531
|
4236, 4572
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,715
| 178,632
|
38800
|
Discharge summary
|
report
|
Admission Date: [**2110-2-19**] Discharge Date: [**2110-2-24**]
Date of Birth: [**2053-12-16**] Sex: F
Service: SURGERY
Allergies:
Iodine / Hydromorphone / Talwin / Talwin NX / Codeine / MS
Contin / Cefazolin / Penicillins / Dicloxacillin /
Prochlorperazine / Nsaids / Duragesic / Fluconazole / Fish
Product Derivatives
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65F transfer from OSH s/p fall down 7 stairs at noon, [**2-19**]. She
states she was climbing stairs and lost her balance. Reports
loss of consciousness for approximately ten minutes. Called her
son at 5pm. Next memory is of EMS. On admission, mild memory
difficulties, with GCS 14. Compalaining of back and rib pain.
Past Medical History:
PMH: spinal cord injury, fibromyalgia, GERD, neurogenic bladder,
hypothyroidism, Crohn's disease
PSH: recent left shoulder surgery, hysterectomy, appendectomy,
lumpectomy left breast x4, cholecystectomy, centralobular
emphasyma
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
On presentation:
PE:
HEENT: PERRLA
Neck: Collar in place
Resp:Clear to ascultation throughout all fields, no crepitus
CA:RRR
GI: soft, nontender, nondistended, RUQ pain, nl tone
GU/GYN/pelvis: pelvis stable
Musculoskeletal: Left toes with minimal movement, Right leg
moving, Right shoulder pain, thoracic and lumbar, sacral notch
tenderness, no step off deformity, +pulses
Neuro: GCS=15, confused
Pertinent Results:
[**2110-2-19**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2110-2-19**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2110-2-19**] 08:50PM WBC-6.4 RBC-4.49 HGB-13.4 HCT-39.9 MCV-89
MCH-29.8 MCHC-33.5 RDW-13.6
[**2110-2-19**] 08:50PM PLT COUNT-326
[**2110-2-19**] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2110-2-19**] 08:50PM LIPASE-67*
[**2110-2-19**] 08:57PM GLUCOSE-103 LACTATE-1.4 NA+-146 K+-3.3*
CL--99* TCO2-28
[**2110-2-19**] 08:50PM UREA N-5* CREAT-0.7
CT Head: No acute intracranial abnormality.
CT C-spine: 1. No acute cervical fracture or malalignment.
2. Severe centrilobular pulmonary emphysema.
CT T-spine: 1. No acute thoracic spine fracture or malalignment.
2. Severe centrilobular pulmonary emphysema.
R Shoulder XR: No evidence of acute fracture or dislocation.
CXR: Underlying trauma board partially obscures the view, given
this,
no acute cardiopulmonary process.
Brief Hospital Course:
56F s/p fall down stairs with loss of consciousness and was
admitted for observation. Extensive CT imaging was preformed
which was determined to show no acute injury. A CT of her
C-spine ruled out fracture and her collar was removed, a soft
collar was provided for comfort.
The patient takes a large amount of narcotic medications for
chronic pain which were continued during her hospital admission.
On [**2110-2-20**] the patient was found to be unresponsive. A code blue
was called and responded to appropriately, it was determine that
the patient was in respiratory distress. She was given Narcan
and ventilated by Ambu until she began to respond. The patient
was able to breath on her own and was transferred to the TSICU
for further monitoring. Social work was consulted while the
patient was admitted to the TSICU and she was stable without any
further respiratory events.
The patient was transferred back to the floor [**2110-2-21**] and chronic
pain was consulted. The chronic pain team recommendations
included: 1) decreasing OxyContin to 60mg [**Hospital1 **] or 40mg TID 2)
continue oxycodone 5-10mg Q4h, 3) continue Amitriptyline 75mg
qhs, 4) continue Mirtazapine 15mg qhs, 5) continue Diazepam 5 mg
Q6H. DO NOT increase dose back to 10mg per home regimen, and 6)
Hold doses of narcotics or benzodiazepines for any signs of
sedation. These recommendations were carefully considered and
the appropriate orders were written.
An echocardiogram was preformed [**2110-2-21**] to rule out a cardiac
cause of the patients fall which showed normal left ventricular
function with an EF >55%.
Because of the complicated social history of the patient,
disorganization of thoughts during interviews, a high level of
frustration and anxiety when discussing her pain regimen, and a
concern for the patients safety as documented by the social work
department, the patient was seen by psychiatry. Psychiatry
recommended following recommendations made by chronic pain,
continuing to optimize established antidepressant regimen,
possible outpatient psychiatrist/therapist, and pastoral care
while inpatient.
Throughout the rest of the patients inpatient stay she remained
stable. Her blood pressure ran in the 90's systolically however
there were no episodes of hypotension or orthostasis. Because of
concern of a low oxygen saturation level while the patient was
in bed on [**2110-2-24**], her ambulating oxygen saturation level was
tested and she remained stable at 93% RA. Physical therapy was
consulted and she was evaluated as safe to return home.
Medications on Admission:
oxycontin 80''', oxycodone [**3-31**] QID, Hydroxyzine 25mg Q4H:PRN,
valium 10 QID, amitriptyline 75 QHS, amlodipine 5', mirtazapine
15 QHS, nystatin 1tsp QID:PRN, mycelex
Discharge Medications:
1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for itching.
2. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/pain.
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
dyspnea.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
15. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
16. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
17. Valium 5 mg Tablet Sig: One (1) Tablet PO four times a day.
18. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every eight (8) hours.
Disp:*qs Tablet Sustained Release 12 hr(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for breakthrough pain.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
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 are taking multiple medications prescribed by other
prescribers. Your medications were confirmed via a fax received
from Dr.[**Name (NI) 86128**] office. These medications were added to
your discharge medication list. The only medication that you
received a prescription for was for the reduced Oxycontin dose
that was recommneded by our Pain Service.
You were evaluated after a fall down stairs. You had multiple
imaging studies that do not show evidence of abnormalities. You
will likely feel sore for the next few days while you are
recovering from this injury. You also reported that you hit
your head during the fall and a CT scan of your head did not
show evidence of bleeding.
IT IS BEING RECOMMENDED THAT YOUR VALIUM DOSE BE REDUCED TO HALF
OF THE REGULAR DOSE.
You can take your regular pain medication for the aches from
this injury. You can also take tylenol every six hours and can
use ice for twenty minutes at a time.
It is important that you do not take to many pain medications at
the same time, this puts you at risk to loose conciousness or
stop breathing. You were seen by the chronic pain service for
managment of your pain and sedation. Your valium was decreased
from 5mg to 10mg. It is important to follow all of the
instructions for your medications carefully and correctly.
Followup Instructions:
Follow up with your primary care providers within the next week.
You will need to call for an appointment.
It is being recommended that you follow up with a Psychiatrist
as an outpatient for managing your psychiatric medications. Your
primary care doctor can make the referral for you.
Completed by:[**2111-9-3**]
|
[
"E929.9",
"336.9",
"908.9",
"338.29",
"348.89",
"780.09",
"E935.2",
"781.2",
"244.9",
"V15.88",
"338.11",
"304.00",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7273, 7279
|
2634, 5188
|
454, 460
|
7331, 7331
|
1560, 2184
|
8847, 9164
|
1110, 1127
|
5411, 7250
|
7300, 7310
|
5214, 5388
|
7513, 8824
|
1142, 1541
|
410, 416
|
488, 810
|
2193, 2611
|
7346, 7489
|
832, 1061
|
1077, 1094
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,183
| 176,405
|
50802
|
Discharge summary
|
report
|
Admission Date: [**2196-5-11**] Discharge Date: [**2196-6-3**]
Date of Birth: [**2128-12-10**] Sex: M
Service: OMED
HISTORY OF PRESENT ILLNESS: This is a 67-year-old male with
recent diagnosis of squamous cell carcinoma of the base of
the tongue, who was admitted for treatment of this new
cancer. The patient initially presented with difficulty
hearing and left ear pain, and noted to have a large
pharyngeal mass prompting a work-up including a CT scan. The
patient was seen in clinic for evaluation of his pharyngeal
cancer with possible biopsy. The patient was also evaluated
by anesthesia who wanted cardiac clearance for upcoming
surgery.
Head CT performed in [**2196-3-24**] showed a 4 cm left tongue mass
with positive lymphadenopathy. The patient underwent a
fine-needle aspiration consistent with squamous cell
carcinoma. The patient is to be seen by radiation oncology
for possible XRT with plans to place a Port-a-Cath for
adjunctive chemotherapy.
The patient reports adequate pain control today, tolerating
thick fluids. He has no nausea, vomiting, diarrhea or
abdominal pain. He hasn't had a bowel movement for several
days. He complains of generalized weakness and some fatigue
with only minimal ambulation. He denies fevers, chills,
night sweats, chest pain, shortness of breath.
PHYSICAL EXAMINATION: Vital signs were temperature 98.2,
blood pressure 110/70, heart rate 50, respiratory rate 16,
98% on room air. General: No acute distress, somewhat
anxious-appearing elderly male. HEENT: Pharyngeal mass of
the left palate and tongue, increased pigmentation of his
tongue. Neck: Mild tenderness on the left, positive
lymphadenopathy. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm with a 3/6 systolic
ejection murmur, normal S1 and S2, no rubs or gallops.
Abdomen: Midline incision with G-tube, soft, nontender,
nondistended with normal active bowel sounds. Extremities:
1+ pedal edema, cool, no evidence of cyanosis, 2+ brachial
pulses bilaterally, 1+ dorsalis pedis pulse on the right, no
dorsalis pedis on the left.
LABORATORY DATA: Complete blood count showed a white blood
cell count of 7.9, hematocrit 39, MCV 88, platelet count 388.
Coagulation studies were PT 12.8, PTT 30.1, INR 1.1.
Chemistries showed a sodium of 143, potassium 3.7, chloride
102, bicarbonate 30, BUN 14, creatinine 1.1, glucose 117,
albumin 3.4. Urinalysis showed a specific gravity of 1.018,
20 white blood cells, moderate bacteria, negative nitrites,
small leukocyte esterase.
CT of the neck ([**2196-4-7**]) showed a 4 cm mass at the tongue
base left of midline with inferior extension to
pre-epiglottic space, 1.4 cm lymph node lateral to the left
carotid bifurcation.
Chest x-ray ([**2196-5-9**]) showed increased opacity of the right
lower lobe.
HOSPITAL COURSE: 1. Hematology-oncology: The patient was
admitted with recently diagnosed squamous cell carcinoma of
his tongue. He was kept on his outpatient pain regimen with
MSO4 IV p.r.n. and Percocet 1-2 tablets p.r.n. for
breakthrough pain. The patient underwent XRT mapping and
initiated radiation therapy on [**2196-5-16**]. A Port-a-Cath was
placed on [**2196-5-16**] for initiation of chemotherapy. As the
patient was bout to undergo XRT on [**2196-5-16**], he refused to
undergo treatment secondary to fatalism, "I want to lay down
and die". By [**2196-5-18**] the patient had begun XRT, but over
the next several days became extremely combative with staff
members and required Haldol and a sitter. The patient had a
brief stay in the unit secondary to respiratory arrest and
once transferred back to the floor he continued to refuse
XRT. Psychiatry saw the patient on his return to the floor
and determined him to be competent to make this decision. A
family meeting was conducted with the attending and it was
decided to withhold XRT and chemotherapy at this time.
2. Cardiopulmonary: The patient was initially seen by
cardiology as a consultation for potential surgery on
hospital day number one. His [**Doctor Last Name **] Risk Index was three,
which placed him in Class I, determined to be a 1.3% risk of
death or major complication from surgery. They recommended
continuing his beta blocker, atenolol 25 mg p.o. q. day. The
patient was cardiovascularly stable until [**2196-5-22**] when he
suffered a hypoxic, hypercarbic respiratory arrest,
complicated by bleeding in his oropharynx during intubation.
The patient was transferred to the ICU and given clindamycin
and levofloxacin secondary to question of aspiration, as well
as a right-sided infiltration seen on chest x-ray. The
patient had a troponin that peaked at 3.0 and eventually
trended down. There was a question of an inferior defect and
the patient was maintained on low-dose aspirin throughout his
hospitalization.
On [**2196-5-24**] the patient's blood pressure was noted to have
decreased into the 80s. He was fluid resuscitated with one
liter of normal saline and two units of packed red blood
cells, as well as the use of Levophed. Chest x-ray at this
time showed worsened opacification. Sputum sample was sent
and became positive for MRSA. Vancomycin was added to his
antibiotic regimen. The patient was placed to ceftazidime
the following day. Throughout the rest of the patient's
hospitalization, his blood pressure was stable and he was
stable from a cardiovascular standpoint.
3. Infectious disease: On admission to the hospital the
patient was placed on levofloxacin for a question of urinary
tract infection, given his urinalysis which showed moderate
bacteria. He received a full seven-day course. After the
patient's hypoxic, hypercarbic respiratory arrest, the
patient was started on clindamycin and levofloxacin secondary
to a question of aspiration, as well as a right-sided
infiltration shown on chest x-ray. On [**2196-5-24**] the patient's
chest x-ray showed worsened opacification and the following
day MRSA grew out in his sputum. Because of continuing
fevers on his antibiotic regimen, the patient was switched to
vancomycin and ceftazidime. On the following day the patient
respiked a temperature to 103 and ceftazidime was
discontinued at this time. The patient has received 12 full
days of vancomycin IV and is to continue for a full 14-day
course as an outpatient.
4. ENT: The patient suffered a hypoxic, hypercarbic
respiratory arrest on [**2196-5-22**], which was complicated by
bleeding in his oropharynx during the intubation. The
patient at this time received a tracheostomy tube and was
followed by the ENT service. One week following the
placement of his tracheostomy tube, the patient was seen by
ENT and received a new tracheostomy tube. The patient was
seen by speech and swallow on [**2196-6-2**], who recommended
continuing a cuffed tracheostomy due to aspiration of thin
liquids seen on the swallow study. The patient has thick
tenacious sputum such that the speech and swallow
consultation team felt he could not handle, and recommended
leaving the cuff up while the patient is taking p.o. the
patient was also given a voice valve to be fit into his
tracheostomy tube to enable effective communication.
5. Psychiatry: On [**2196-5-14**] the patient was noted to be
verbally abusive to nursing about an alleged incident that
didn't occur, and became increasingly threatening to house
staff and hospital staff members. Psychiatry was consulted
and the patient was given Zyprexa q. day on [**2196-5-15**]. On
[**2196-5-16**], the patient refused XRT secondary to fatalism, and
the following day was confused about place and year, with
increasing hostility to staff members. On [**2196-5-18**] the
psychiatry consult felt that he was delirious and recommended
increasing the Zyprexa and checking psychiatry laboratory
studies. TSH was negative at that time. Vitamin B12 and
thiamine were also negative. The patient required a sitter
on [**5-18**] and was still combative the following day. On
[**2196-5-20**] a code purple was called when the patient threw a
chair at his sitter and swung a cane at he house staff
officer taking care of him. He was placed in restraints and
remained combative throughout the next several days. The
patient was transferred to the unit on [**2196-5-22**] for his
respiratory arrest and was minimally sedated throughout his
intensive care unit stay. On transfer back to the floor the
patient was noted to be more compliant and cooperative. His
Haldol dose was decreased from 5 mg t.i.d. to 3 mg t.i.d.
Psychiatry was reconsulted when the patient continued to
refuse XRT. They felt that he was competent to make this
decision and suggested that there was no evidence of
delirium, but possibly some mild dementia. They recommended
continuing Haldol at 3 mg p.o. t.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Squamous cell carcinoma of the tongue.
2. Methicillin-resistant Staphylococcus aureus pneumonia.
3. Mild dementia.
4. Coronary artery disease.
5. Anemia.
6. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram IV q. 12 hours x three days.
2. Haloperidol 3 mg p.o. t.i.d.
3. Morphine sulfate 1-2 mg IV q. 4 hours p.r.n. pain.
4. Fentanyl patch 58 mcg t.p. q. 72 hours.
5. Lorazepam 1 mg IV q. 3 hours p.r.n.
6. Metoprolol 12.5 mg p.o. b.i.d., hold for systolic blood
pressure of less than 110, heart rate less than 60.
7. Colace 100 mg p.o. b.i.d.
8. Senna 2 tablets p.o. b.i.d., p.r.n.
9. Multivitamin with minerals one tablet p.o. q. day.
10. Atorvastatin 10 mg p.o. q. day.
11. Aspirin 325 mg p.o. q. day.
12. Acetaminophen 325-650 mg n.g. q. 8 hours for fever.
13. Nystatin oral suspension 5 mg p.o. q.i.d. p.r.n.
FOLLOW-UP PLANS: The patient is being discharged to a
skilled nursing facility for continuation of his intravenous
antibiotics as well as his IV pain control. The patient will
require occasional suctioning from his tracheostomy tube.
The patient can take his p.o. medications through his PEG
tube. His PEG tube should also be the primary source of his
nutrition at this time. He can have thick nectar liquids and
purees for pleasure through his mouth. A Passy-Muir speaking
valve should be placed and his cuff deflated for all p.o.
Given the patient's reluctance to undergo chemotherapy or XRT
at this time, the family and Dr. [**Last Name (STitle) **] have decided that the
patient can follow up with him only on an as-needed basis.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Last Name (NamePattern1) 12216**]
MEDQUIST36
D: [**2196-6-3**] 10:27
T: [**2196-6-3**] 10:42
JOB#: [**Job Number 105652**]
cc:[**Name8 (MD) 105653**]
|
[
"V58.0",
"507.0",
"599.0",
"285.9",
"V58.1",
"518.81",
"141.0",
"482.41",
"196.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"31.1",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8858, 9041
|
9064, 9693
|
2852, 8803
|
1353, 2834
|
9711, 10724
|
166, 1330
|
8828, 8837
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,121
| 163,859
|
27522
|
Discharge summary
|
report
|
Admission Date: [**2102-8-10**] Discharge Date: [**2102-8-24**]
Date of Birth: [**2024-11-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Painless obstructive Jaundice
Pancreatic Mass
Major Surgical or Invasive Procedure:
Duodenal Wall Stent
PCT
History of Present Illness:
Mr [**Known lastname 20858**] is a 77-year old man with coronary artery disease s/p
CABG [**2100**] whow developed jaundice with epigastric discomfort
around the beginning of [**2102-5-25**]. He underwent ERCP and
common bile duct stent placement [**2102-6-6**]. A CT scan
revealed ampullary and uncinate process mass. This combined with
laboratory findings including markedly elevated alkaline
phosphatase and CA19-9 were very concerning for pancreatic
cancer. A local CT scan revealed an ampullary and uncinate
process mass. He was admitted to the hospital on [**8-10**] with
plans for a Whipple procedure.
.
On the operating table the patient went into atrial fibrillation
with rapid ventricular rate with associated hypotension and
hypoxia. The surgery was called off and he was transferred to
the MICU for further management.
Past Medical History:
CABG [**2090**]
CVA [**2088**] or [**2089**]
pancreatic cancer
prostate cancer s/p radiotherapy
diabetes type 2 on insulin, neuropathy
HTN
- OSH echo of [**2102-7-2**] shows 60% LVEF, no focal wall motion
abnormalities; mildly enlarged left atrium; mild MAC, trace MR,
mild TR, normal appearing aortic valve.
Social History:
married, supportive family, daughter-in-law is a
nurse; occasional alcohol; former smoker, quit 35y ago; no
herbals or illicits.
Family History:
sister died of pancreatic cancer. No early
cardiovascular disease in either parent.
Physical Exam:
On admission:
HR 98 RR 14 WT 195
Gen: alert, pleasant elderly white man
HEENT: perrl, mmm, no JVD, no carotid bruits, no thyromegaly,
no cervical lymphadenopathy
Chest: CTAB, no wheezing; normal respiratory effort
CV: regular s1, s2, no murmur
Abd: obese, soft, +bs
Extr: trace pitting edema to mid-shin, palpable radial and DP
pulses bilaterally, no clubbing or cyanosis
ECG obtained showed sinus tachycardia without concerning ST
segment deviations; tachycardia was shortly after patient
transfered from wheelchair to examination table with some
difficulty and resolved to HR of 90's within minutes.
Pertinent Results:
[**8-10**] EKG:
Atrial fibrillation with a rapid ventricular response. Rare
ventricular
premature beat. Low amplitude T waves in leads II, III, aVL and
aVF. Compared
to the previous tracing of [**2102-6-26**] rapid atrial fibrillation has
appeared.
[**8-12**] ABDOMEN CT:
There are new bilateral pleural effusions left greater than
right.
Intra- and extra-hepatic biliary duct dilatation is stable. CBD
stent is present extending from the duodenum to the bifurcation
of the common hepatic duct. Hypodense ill-defined lesion in the
pancreatic head, likely reflects the patient's known pancreatic
mass. Mild soft tissue stranding around it has somwhat
increased. Unchanged atrophy of the body and tail of the
pancreas. Small lymph nodes in the porta hepatis are again
demonstrated.
24-mm gallstone is in the gallbladder lumen. There is
gallbladder wall thickening. The liver, spleen, adrenal glands,
and kidneys are grossly unremarkable in this nonenhanced study.
Trace free fluid is seen in the left paracolic gutter. There are
no intra- abdominal fluid collections.
The aorta is normal in caliber. There is no retroperitoneal
lymphadenopathy.
The stomach is largely distended with NG tube tip in its lumen.
Otherwise, the small bowel loops are unremarkable.
Brief Hospital Course:
He was admitted to [**Hospital1 18**] for a planned Whipple procedure. In the
pre-operative holding area he was noted to be in A-fib to the
130's. He was admitted to [**Hospital Ward Name 121**] 9.
A cardiology consult was obtained and he was started on
Metoprolol 50mg TID. His HR was better rate controlled 90-100.
Cardiac enzymes were negative. Cardiology did not feel that
anticoagulation was needed at this time. He continue to be in
A-fib with a HR fluctuating between 70-140. His blood pressure
was 100/70.
.
On [**2102-8-15**] he went for an ERCP to stent his biliary tree with a
metal stent, but due to the gastric outlet obstruction a enteral
stent was placed. Post procedure, he was intubated in the ICU
for suctioning of undigested food in the stomach and duodenum.
.
Patient then brought to the OR for PTC drain placement. PTC
placement could not be done secondary to inability to pass the
wire. AFter 4 attempts and inability to access L hepatic duct,
patient then became hypotensive to SBP 60-80 and tachycardic to
130-150 with rapid A.fib and RVR without CP or SOB. RIJ TLC
placed, neo gtt started, Aline placed in RFA.
.
In MICU, patient was slowly weaned off neo and received IVFs. He
was also started on diltiazem gtt and drip was titrated off [**8-19**]
@ 2 am and patient was switched to PO BB and CCB. Patient
remains a high risk for a whipple, the minimally invasive
approaches have failed and Heme/Onc service has also raised the
concern that the pancreatic cancer has further advanced.
.
He was transferred to the floor with continuation of betablocker
and placed on telemetry. He was stable from a CV standpoint,
however his deconditioning was quite severe being able to sit up
in bed, developing severe [**Location (un) **]-sarca with hypoalbuminemia, and
being unable to tolerate much po intake. He was started on TPN.
Additionally he developed melena (although his hct was stable
during the first day of this). A family meeting was called to
discuss the poor prognosis of his cancer and the fact that he
was not an operative candidate at all. The decision was made to
work toward comfort measures. He was taken off TPN and placed
on maintinence IVF. He required supplumental oxygen. He was
kept on his cardiac medications but most other medications (such
as insulin) were d/c'd. He was given 5mg oxycodone for pain
which worked well, and compazine scheduled in the morning and
prn throughout the day for nausea with god effect.
.
On the evening of [**8-23**] it was decided by the family in
coordination with the palliative care team to discontinue his
cardiac medications and vital signs. He went into a rapid
irregular rhythm, most likely atrial fibrillation. His SaO2
decreased to 75% on shovel mask. He was kept comfortable with
morphine. He passed away from respiratory failure at 1pm on
[**2102-8-24**] surrounded by his family.
Medications on Admission:
toprol XL 25', lasix 20', lipitor 10', quinine 324', lantus 18,
HSS, protonix, detrol LA, FeSO4, ASA 325
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Pancreatic Mass
Atrial Fibrillation with RVR
Discharge Condition:
deceased
Discharge Instructions:
|
[
"V15.3",
"357.2",
"V10.46",
"250.60",
"427.31",
"707.07",
"287.5",
"401.9",
"578.1",
"537.0",
"273.8",
"199.1",
"157.0",
"V45.81",
"V58.67",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"87.54",
"96.08",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6798, 6813
|
3762, 6643
|
361, 387
|
6902, 6913
|
2472, 3739
|
1747, 1833
|
6834, 6881
|
6669, 6775
|
6943, 6943
|
1848, 1848
|
276, 323
|
415, 1251
|
1862, 2453
|
1273, 1584
|
1600, 1731
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,214
| 109,565
|
35795
|
Discharge summary
|
report
|
Admission Date: [**2170-1-15**] Discharge Date: [**2170-1-23**]
Date of Birth: [**2149-4-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
acetaminophen overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 year old generally healthy gentleman was found to be confused
and naked this morning. Patient states that he was depressed and
took 2 bottles of tylenol PM (150 tablets 500/125mg). He was
found by his friend. [**Name (NI) **] was taken to [**Hospital6 3105**].
His APAP level at 10:45 am was 323 with lactate of 8.1. He
received NAC loading dose of 150 mg/kg over one hour and then
drip per NAC protocol. He also received 2L of NS per verbal
report and was transferred to [**Hospital1 18**].
In [**Hospital1 18**] ED his vitals were T 98.4 BP 140/90 HR 100 RR 20 99%
RA. Patient received 2L of NS, zofran 4 mg IV once, tetanus shot
and NAC at 17 mg/kg/hr infusion. He experienced nonbloody
nonbilious vomitting in the ED.
On arrival to MICU his vitals were HR 107 BP 167/77 RR 18 98% in
RA. Patient denied any chest pain, shortness of breath or
abdominal pain. He felt depressed yesterday. He felt that he was
alone and has some trouble at work. He denied any prior
suicidal/homicidal attempts.
Past Medical History:
- MVC 3 days prior to admission
- Seizure when he was 7 years old, on dilantin for approx 2
years
Social History:
Lives by himself. Works at a grocery store. Mother and sister
lives nearby. Non smoker. Denies any street drug use. Occasional
ETOH. Last drink one week ago.
Family History:
Sister has depression
Physical Exam:
Vitals: HR 107 BP 167/77 RR 18 98% in RA
Gen: Awake and oriented x 3 (knows he is in ICU but called the
hospital as [**Hospital3 **])
HEENT: PERRL, EOM-I, OP clear, JVP not elevated
Heart: S1S2 Regular rhythm, tachycardic, no MRG
Lungs: CTAB
Abdomen: BS present, soft NTND, no appreciable mass/organomegaly
Ext: WWP, no edema
Neuro: CN II-XII grossly intact, strength 5/5 bilat, sensation
intact
Psych: Depressed mood
Pertinent Results:
[**2170-1-15**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-1-15**] 02:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2170-1-15**] 02:35PM PT-18.4* PTT-40.1* INR(PT)-1.7*
[**2170-1-15**] 02:35PM PLT COUNT-303
[**2170-1-15**] 02:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2170-1-15**] 02:35PM NEUTS-78* BANDS-2 LYMPHS-3* MONOS-14* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2170-1-15**] 02:35PM WBC-10.2 RBC-4.96 HGB-15.5 HCT-41.5 MCV-84
MCH-31.3 MCHC-37.3* RDW-12.6
[**2170-1-15**] 02:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-1-15**] 02:35PM URINE GR HOLD-HOLD
[**2170-1-15**] 02:35PM URINE HOURS-RANDOM
[**2170-1-15**] 02:35PM URINE HOURS-RANDOM
[**2170-1-15**] 02:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-272*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-1-15**] 02:35PM CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.6
[**2170-1-15**] 02:35PM LIPASE-65*
[**2170-1-15**] 02:35PM ALT(SGPT)-145* AST(SGOT)-96* CK(CPK)-248* ALK
PHOS-64 TOT BILI-1.1
[**2170-1-15**] 02:35PM estGFR-Using this
[**2170-1-15**] 02:35PM GLUCOSE-194* UREA N-10 CREAT-0.9 SODIUM-136
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-18* ANION GAP-19
[**2170-1-15**] 02:46PM LACTATE-2.7*
[**2170-1-15**] 02:46PM PO2-72* PCO2-32* PH-7.32* TOTAL CO2-17* BASE
XS--8 COMMENTS-GREEN TOP
[**2170-1-15**] 06:45PM ACETMNPHN-175.3*
[**2170-1-15**] 10:57PM LACTATE-1.1
[**2170-1-15**] 10:57PM TYPE-[**Last Name (un) **] PO2-88 PCO2-33* PH-7.35 TOTAL
CO2-19* BASE XS--6
[**2170-1-15**] 10:58PM PT-22.8* PTT-48.2* INR(PT)-2.2*
[**2170-1-15**] 10:58PM PLT COUNT-293
[**2170-1-15**] 10:58PM WBC-18.8*# RBC-4.80 HGB-14.9 HCT-40.1 MCV-84
MCH-31.2 MCHC-37.3* RDW-12.9
[**2170-1-15**] 10:58PM CALCIUM-8.6 PHOSPHATE-2.4* MAGNESIUM-1.8
[**2170-1-15**] 10:58PM ALT(SGPT)-147* AST(SGOT)-96* LD(LDH)-278* ALK
PHOS-59 TOT BILI-2.2*
[**2170-1-15**] 10:58PM GLUCOSE-75 UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-16* ANION GAP-18
[**2170-1-20**] 04:45AM BLOOD WBC-5.4 RBC-4.08* Hgb-12.9* Hct-34.1*
MCV-84 MCH-31.6 MCHC-37.7* RDW-12.1 Plt Ct-198
[**2170-1-19**] 05:45AM BLOOD WBC-6.7 RBC-4.28* Hgb-13.5* Hct-36.0*
MCV-84 MCH-31.6 MCHC-37.6* RDW-12.1 Plt Ct-176
[**2170-1-20**] 04:45AM BLOOD PT-13.7* PTT-37.2* INR(PT)-1.2*
[**2170-1-19**] 05:45AM BLOOD PT-14.4* INR(PT)-1.2*
[**2170-1-20**] 04:45AM BLOOD Glucose-77 UreaN-29* Creat-3.3* Na-142
K-3.5 Cl-109* HCO3-23 AnGap-14
[**2170-1-19**] 05:45AM BLOOD Glucose-75 UreaN-29* Creat-3.3* Na-141
K-3.3 Cl-108 HCO3-22 AnGap-14
[**2170-1-20**] 04:45AM BLOOD ALT-[**2065**]* AST-54* AlkPhos-64 TotBili-0.8
[**2170-1-19**] 05:45AM BLOOD ALT-3060* AST-171* AlkPhos-65 TotBili-1.1
[**2170-1-20**] 04:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.2
[**2170-1-19**] 05:45AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3
.
REPORTS:
[**1-15**] CT Head: No acute intracranial pathology.
[**1-15**] CT C-spine: No evidence of acute fracture or malalignment.
.
[**1-16**] TTE: The left atrium is normal in size. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). 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. There is
no pericardial effusion.
.
[**1-16**] RUQ U/S: Unremarkable ultrasound. Patent vasculature.
.
[**1-18**] Renal U/S: Increased renal parenchymal echogenicity,
likely due to medical renal disease. No hydronephrosis.
.
[**1-22**] Left Upper Extremity U/S: Findings consistent with clot
formation of the antecubital vein without extension into the
brachial, basilic or central veins as described above.
Brief Hospital Course:
20M s/p tylenol overdose suicide attempt w hepatotocity and
acute renal failure. The pt ingested a total of 75g of tylenol
and 18.5g of benadryl. He presented to the OSH 12hr after the
ingestion and was started on a NAC protocol. At the time, his
tylenol level was 272. He was taken to the MICU, where
supportive measures were implemented and he was assessed for
transplantation. However, he did not meet criteria. His LFTs
maxed on [**1-16**] with ALT [**Numeric Identifier 81416**], AST [**Numeric Identifier 16106**], INR 4.1. In the MICU,
he did not require ventilatory support. He did develop acute
renal failure, with a creatinine that rose from 0.9 [**1-15**] to 3.3
[**1-19**]. A renal consult was called; their assessment was that the
pt had intrinsic acute renal failure due to direct acetaminophen
toxicity. His creatinine was trended and his diet was advanced
slowly. NAC was d/c'd on [**1-18**], as INR had normalized, the pt's
LFTs were trending down and his APAP level was negative. From a
psychiatric perspective, the pt stated that the overdose was
pre-planned as a suicide attempt. He did not endorse suicidality
to the primary team during his stay. Psychiatry was consulted
and recommeded a sitter at all times and inpatient psychiatric
treatment when medically cleared. On [**1-21**], the patient was felt
to be medically stable from both a renal and hepatic perspective
for transfer to a psychiatric facility. On the same date, the
patient was noted to have a red, swollen region on his left
forearm. U/S showed superficial clot in the antecubital vein.
Because of the redness and a leukocytosis, the patient was given
IV antibiotics for 1 day and then converted to PO keflex for a 7
day total course. On [**1-23**], the redness and swelling was much
improved and the leukocytosis had resolved.
.
# Tylenol OD/ Acute Hepatic Injury: Time of ingestion around
10:30pm on [**2170-1-14**]. Tylenol level at 2:35 pm on [**2170-1-15**] was
272, 6 pm 175, 75 at 4AM. Tylenol level negative [**2170-1-18**].
Urine and serum tox screen was otherwise negative. Toxicology,
Hepatology, Neurosurgery, and Transplant have been following. At
time of discharge, coagulopathy had resolved and LFTs were
trending toward normal. The patient should be seen in follow up
at liver clinic as scheduled.
.
# Acute Renal Failure: Likely from Tylenol OD (renal impairment
usually occurs at 48-72 hours) from direct toxicity/ATN picture
w a prerenal component. Cr plateauing as of [**1-20**] at 3.3. The
patient did not require dialysis. He had excellent urine output
and was felt to have reversible ATN. At time of discharge, plan
to check creatinine at psych facility 1-2 times weekly to ensure
decline with follow up at renal clinic in 1 month.
.
# Suicidal attempt. Psych following while in house. At time of
discharge, patient was to be transferred to inpatient psych for
further evaluation.
.
On [**1-23**], the patient was felt to be medically stable by all
medical teams with improving labs and stable vital signs. He was
discharged with plan for follow up.
Medications on Admission:
vitamins
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 6 days.
Disp:*18 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**]- [**Hospital1 **] 4
Discharge Diagnosis:
Tylenol hepatotoxicity
Tylenol nephrotoxicity
Suicide attempt
Left Antecubital Vein Thrombophlebitis
Discharge Condition:
Good
Discharge Instructions:
You have been evaluated and treated in the hospital for your
tylenol overdose. You sustained liver and kidney damage from the
tylenol poisoning. Both have improved during your stay in the
hospital. You were initially treated in the intensive care unit
due to the severity of your liver injury.
.
You were also evaluated for your suicide attempt and other
mood-related symptoms. Psychiatry recommended that you recieve
inpatient psychiatric treatment once you are medically cleared.
.
Please call your primary care doctor or return to the emergency
department if you have:
- thoughts of hurting yourself or others
- chest pain or shortness of breath
- profuse bleeding
- inability to keep food down
- fever > 102F
- anything concerning
Followup Instructions:
Please follow-up at the appointments as indicated below. You
must identify a primary care physician before attending these
appointments and obtain a referral in order for you to be
covered under your insurance carrier.
Kidney Clinic [**Location (un) 436**] [**Hospital Ward Name 23**] Building --- [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**],
M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2170-2-22**] 1:00
Liver Clinic --- [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2170-4-16**] 12:10
|
[
"965.4",
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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|
6306, 9373
|
338, 344
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9785, 9791
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2164, 5147
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9661, 9764
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9399, 9409
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9815, 10551
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1724, 2145
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275, 300
|
372, 1373
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5156, 6283
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1395, 1495
|
1511, 1670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,996
| 145,629
|
34921
|
Discharge summary
|
report
|
Admission Date: [**2114-2-19**] Discharge Date: [**2114-2-20**]
Date of Birth: [**2039-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
As per notes, Mr [**Known lastname **] is a 75-year-old man w a history of
hypertension, hyperlipidemia, diabetes and CAD, s/p CABG in the
[**2075**]??????s and stenting in [**2108**], who was recently diagnosed with
carotid artery disease after PCP detected [**Name Initial (PRE) **] bruit. Diagnostic
carotid angiography revealed stenosis. Admitted to [**Hospital1 18**] for
treatment, carotid angiography done and XACT carotid stent
placed in the R ICA w no residual stenosis in the stent, no
dissection and normla flow.
.
On transfer to the floor, pt comfortable no complaints. No
headache, dizziness, chest pain, shortness of breath, no groin
pain.
.
Pt denies any prior history of stroke or TIA, and denies any
specific neurologic symptoms. Pt describes occasional exertional
angina, relived with SL nitroglycerin. He also describes
bilateral leg discomfort with walking less than one mile.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Major Surgical or Invasive Procedure:
right carotid artery stenting
History of Present Illness:
As per notes, Mr [**Known lastname **] is a 75-year-old man w a history of
hypertension, hyperlipidemia, diabetes and CAD, s/p CABG in the
[**2075**]??????s and stenting in [**2108**], who was recently diagnosed with
carotid artery disease after PCP detected [**Name Initial (PRE) **] bruit. Diagnostic
carotid angiography revealed stenosis. Admitted to [**Hospital1 18**] for
treatment, carotid angiography done and XACT carotid stent
placed in the R ICA w no residual stenosis in the stent, no
dissection and normla flow.
.
On transfer to the floor, pt comfortable no complaints. No
headache, dizziness, chest pain, shortness of breath, no groin
pain.
.
Pt denies any prior history of stroke or TIA, and denies any
specific neurologic symptoms. Pt describes occasional exertional
angina, relived with SL nitroglycerin. He also describes
bilateral leg discomfort with walking less than one mile.
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: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: [**2075**]
-PERCUTANEOUS CORONARY INTERVENTIONS: stenting in [**2108**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Myocarditis- age 28
MI age 61, s/p CABG in [**2079**] at [**Location (un) **] Hospital (no
specifics)
Coronary stenting at age 70 at [**Hospital1 2177**]
LE claudication
Hypertension
Bilateral Carotid artery disease
Diabetes Type II
Borderline elevated cholesterol
Remote bowel obstruction, s/p surgery
Remote Hemorrhoidectomy
Retrieval of kidney stones
GERD
Mild Prostatism
[**1-1**] Admit to [**Hospital1 18**] with small bowel obstruction
Mild emphysema per patient report
Abdominal hernia per patient report
Occasional vertigo
Social History:
Patient is married. and lives with his wife. [**Name (NI) **] one daughter
who works as a nurse [**First Name (Titles) **] [**Hospital6 **].
Occupation: Retired heavy equipment operator
Contact person upon discharge: [**Name (NI) **] [**Name (NI) 77002**] (son in law):
[**Telephone/Fax (1) 79911**]-home, cell: [**Telephone/Fax (1) 79912**].
No alcohol.
Family History:
Mother with heart problems- no specifics. Several siblings
also with heart issues- no details
Physical Exam:
VS: 96.5, 95/45, 50, 14, 95% RA
GENERAL: Elderly
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Groin dressing c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2114-2-19**] 10:45AM WBC-6.3 RBC-4.26* HGB-12.7* HCT-35.6* MCV-84
MCH-29.8 MCHC-35.7* RDW-14.9
[**2114-2-19**] 10:45AM NEUTS-76.5* LYMPHS-16.5* MONOS-4.4 EOS-1.7
BASOS-0.8
[**2114-2-20**] 06:06AM BLOOD Glucose-116* UreaN-26* Creat-1.5* Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
Cardiac enzymes:
[**2114-2-19**] 10:03PM BLOOD CK-MB-2 cTropnT-<0.01
[**2114-2-19**] 10:45AM BLOOD CK-MB-2
[**2114-2-20**] 06:06AM BLOOD CK-MB-2 cTropnT-<0.01
[**2114-2-20**] 04:32PM BLOOD CK-MB-2 cTropnT-<0.01
Brief Hospital Course:
75M w DM2, HTN, HL, CAD (s/p CABG and PCI), and carotid artery
dz, now s/p R ICA stenting for carotid stenosis.
.
# Carotid stenosis: The patient was enrolled in the EMPIRE
trial prior to uncomplicated R ICA stent placement. There was an
80% proximal R ICA stenosis immediately after the bifurcation.
Final angiography revealed no residual stenosis in the stent, no
dissection and normal flow. The right femoral arteriotomy site
was closed with a Perclose device. He was subsequently on a
nitroglycerin gtt titrated to SBP < 130. Other blood pressure
medications were held overnight for brief hypotension after the
procedure and restarted in the morning. Aspirin was increased
to 325 mg daily and clopidogrel was continued. There were no
neurologic deficits noted.
.
# Bradycardia: Patient was bradycardic to 40. Atenolol was
held. In conversation with his primary care physician, [**Name10 (NameIs) **]
[**Name11 (NameIs) 5901**] restarting the atenolol every other day, as the
patient had been stable with this heart rate for years.
.
# CORONARIES: Known coronary artery disease. Aspirin and
simvastatin were continued. Cardiac enzymes were cycled and
were negative. Nifedipine, atenolol, and clonidine were resumed
upon discharge.
.
# PUMP: Patient was apparently euvolemic.
.
# RHYTHM: He remained in sinus rhythm on telemetry.
.
# DM2: Oral hypoglycemics were held and insulin sliding scale
begun. Home regimen was restarted prior to discharge.
.
# Hypertension: Patient had a history of hypertension, was
initially slighltly hypotensive to SBP 90s after the procedure,
but was hypertensive to SBP 140 the next day. Nitroglycerin gtt
was given and titrated to SBP <130. This was discontinued and
his outpatient regimen restarted prior to discharge with SBP
120-130.
.
# Hyperlipidemia: Simvastatin was continued.
Medications on Admission:
Nifedipine 90mg one tablet every morning
Omeprazole 20mg daily every morning
Atenolol 25mg half a tablet every morning
Flomax 0.4mg daily every evening
Clonidine 0.1mg one tablet every morning, 2 tablets every
evening
Plavix 75mg daily every morning
Simvastatin 20mg daily every morning
Glipizide 5mg 2 tablets every morning, 1.5 tablets every evening
Aspirin 81mg daily every morning
Meclizine 25mg as needed
Nitroglycerin SL as needed
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
4. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
5. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in
the evening)).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Atenolol 25 mg Tablet Sig: .5 Tablet PO every other day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: carotid artery stenosis
secondary: coronary artery disease, claudication, hypertension,
type 2 diabetes mellitus
Discharge Condition:
stable, with bradycardia HR 40-45
Discharge Instructions:
You were admitted to the hospital to have a stent placed in your
carotid artery. You had a successful procedure and stent
placement. You heart rate was low after the procedure, so your
atenolol was stopped. Also, your kidney function was slightly
affected by the dye in the procedure. Your primary care
physician will need to check your blood test in a week to be
sure that your kidney function is improving.
Your aspirin dose was increased. We spoke with Dr. [**First Name (STitle) **] who
would like you to continue taking atenolol every other day.
Otherwise, none of your medications was changed. Please resume
all of your home medications.
Please return to the emergency room if you have chest pain,
shortness of breath, weakness or difficulty speaking, or other
symptoms that are concerning to you.
Followup Instructions:
Dr.[**Name (NI) 79913**] office will be calling you on the morning of [**2114-2-21**]
to arrange follow-up. If you don't hear from them that day,
please call [**Telephone/Fax (1) 6699**] to arrange an appointment.
We also made an appointment with Dr. [**Last Name (STitle) 7047**] for you:
Tuesday, [**3-13**] at 12:40 pm, [**Telephone/Fax (1) 8725**]
Completed by:[**2114-2-20**]
|
[
"V13.01",
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"427.89",
"250.00",
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"E878.8",
"414.00",
"443.9",
"401.9",
"997.1"
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icd9cm
|
[
[
[]
]
] |
[
"00.63",
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"88.41",
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icd9pcs
|
[
[
[]
]
] |
8473, 8479
|
5164, 6998
|
1390, 1422
|
8647, 8683
|
4632, 4632
|
9543, 9928
|
3685, 3781
|
7487, 8450
|
8500, 8626
|
7024, 7464
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8707, 9520
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3796, 4613
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2635, 2732
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4946, 5141
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275, 1352
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3529, 3669
|
1450, 2527
|
4648, 4929
|
2763, 3296
|
2549, 2615
|
3312, 3513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,960
| 146,394
|
49669
|
Discharge summary
|
report
|
Admission Date: [**2188-2-29**] Discharge Date: [**2188-3-5**]
Date of Birth: [**2101-7-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
neck and back pain, found to have severe hyponatremia
Major Surgical or Invasive Procedure:
central line right IJ placed [**2188-3-1**]
History of Present Illness:
Ms [**Known lastname 34298**] is a 86 year old woman presenting for back pain and
incidental hyponatremia noted in ED to 113 compared to baseline
of near 140. She has a history of type I diabetes,
hypertension, hyperlipidemia, coronary artery disease,
hypothyroidism, GERD and chronic atrophic gastritis. She
currently lives in assisted housing at [**Location (un) 5481**], in the
independant living portion of housing.
Her presentation begins 3 weeks prior to this ED visit: She went
walking with her daughter at this time along the [**Name (NI) **] [**Last Name (NamePattern1) **]
and fell while using her walker, sustaining abrasions to her
elbows. Thereafter, she developed back pain that progressed
over the last two weeks resulting in an evaluation at the
[**Location (un) 620**] ER on [**2-28**]. Lumbar x-ray was obtained which did not
reveal fracture. She was given tramadol and discharged. No
labs were drawn at this point. She returned to her [**Hospital 4382**], where she was transferred to the skilled nursing
facility for pain control. Despite this, her pain continued
unabated and she presented today to [**Hospital1 18**] ED. Her sodium upon
presentation was noted to be 117.
Over the past two weeks, her PO intake has been quite poor.
Denies vomiting, nausea, or diarrhea. She has been constipated
for the last five days with progressive distension of her
abdomen. She denied dizziness, syncope or seizure activity.
She has had prior admissions for hyponatremia a year ago which
was secondary to osmotic diuresis in setting of hyperglycemia
which resolved with fluid resuscitation. Review of systems
today is also positive for a significant amount of diureses over
the past few days despite poor PO intake and hydration. Her
last TSH was somewhat supratherapeutic in [**2185**] at 4.9 - she has
had thyroid failure for 20-25 years on synthroid. Her last
sodium prior to this visit was 139 in [**2187-8-25**]. Today,
she is oriented to person, to place, but not to time; she is
vaguely able to recount her reason for admission; her daughter
states she is quite confused. No new medications. In our
emergency department today, she received a CT abdomen / pelvis -
with no obvious fracture as source of her back pain. Colon is
full of stool with some distension of her colon but no
obstruction. She was admitted to the MICU for evaluation and
treatment of her hyponatremia. At time of transfer, she had no
acute complaints and has the orientation described above.
Past Medical History:
1. DM - type I x 50+ years
2. Osteoporosis.
3. Hypertension, hyperlipidemia, and coronary artery disease.
- MI at 65yo, medically treated
4. Hypothyroidism, on replacement.
5. Vitamin D deficiency, on replacement.
6. GERD -- endo/mild HH with a mild esophagitis and
presbyesophagus with a motility study showing a normal LES but
50% failed contractions [**2186-10-25**].
7. Chronic atrophic gastritis with intestinal metaplasia -- rule
out pernicious anemia.
8. h/o seizure - last in [**2178**]
9. Constipation
.
Prior Surgical Procedure:
1. Appendectomy.
2. TAH-BSO
3. Endoscopy in the [**2165**] and a colonoscopy, questionable time
Social History:
Patient lives in assisted care facility at [**Location (un) 5481**] - she
has a daytime caretaker [**Name (NI) 636**]. She lost her husband of 62 years
2 years ago. She has three children. Her daughter [**Name (NI) **] [**Last Name (NamePattern1) 4640**]
lives in [**Name (NI) 745**] and is her HCP. Pt graduated from college with a
degree in social work. She was a homemaker. She used to smoke a
little years ago. Denies any Etoh.
Family History:
NC
Physical Exam:
ON ADMISSION:
VS: HR 79, BP 146/60, RR 12, 96% RA, temp 98
Gen: Caucasian female, pleasant, but hard of hearing, in no
apparent distress; euvolemic in appearance
Neck: supple, no lymphadenopathy, no thyromegaly
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear bilaterally with normoactive breath sounds
Abd: soft but has distended abdomen, tympanic, normoactive bowel
sounds
Ext: no edema noted
Discharge exam
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no le edema good pedal pulses bilaterally
DERM: decubitus ulcer noted on back and coccyx
neuro: cn 2-12 grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
CT abd/pelvis [**2188-2-29**]
FINDINGS: Small-to-moderate simple pleural effusions are seen
bilaterally,
with compressive atelectasis of the dependent lower lobes. The
heart is enlarged. There is no pericardial effusion. Moderate
coronary arterial calcification is present.
The liver enhances homogeneously, without focal lesions or
biliary dilatation. The gallbladder is normal. The adrenal
glands and spleen are normal. Small sub-centimeter cystic areas
are seen in the body and uncinate process of the pancreas. The
main pancreatic duct is within normal limits. Both kidneys
enhance and excrete contrast symmetrically, without evidence of
hydroureteronephrosis. A subcentimeter hypodense lesion in the
interpolar region of the right kidney (2:28) is too small to
characterize in this study. The abdominal aorta has moderate
atherosclerotic calcifications, extending into both iliac
arteries, without aneurysmal dilation. Calcifications are seen
at the origins of the celiac axis and SMA. The renal arteries,
and inferior mesenteric artery are patent. No significant
retroperitoneal or mesenteric lymphadenopathy is seen. There is
no intra-abdominal free fluid or air. There is a moderate amount
of fecal load throughout the entire colon and rectum.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder,
distal
ureters, rectum and sigmoid colon are normal. The uterus is not
visualized. No pelvic lymphadenopathy or free fluid is seen.
BONES AND SOFT TISSUES: Old fractures of T9, 10, 11 are seen
with evidence of prior vertebroplasties. No new fractures are
seen in the lumbosacral spine. Bilateral pars defects at L5
seen with grade I anterolisthesis of L5 on S1. Irregularity in
the right superior and inferior pubic rami suggest old healed
fractures. Degenerative changes are seen in the pubic symphysis.
Bilateral sacroiliac joint degenerative changes are noted.
IMPRESSION:
1. No acute visceral traumatic injury or fracture identified in
this study.
2. Bilateral moderate-sized simple pleural effusion with
compressive
atelectasis of the dependent both lower lobes.
3. Extensive atherosclerotic disease of the abdominal and iliac
arteries,
without aneurysmal dilation.
4. Large fecal load throughout colon.
.
CXR [**2188-3-1**]
FINDINGS: Tip of right internal jugular vascular catheter is
partially
obscured by vertebroplasty material in the adjacent thoracic
spine. With this limitation in mind, it appears to traverse at
least to the level of the cavoatrial junction. There is no
evidence of pneumothorax. Cardiac
silhouette is upper limits of normal in size. New bibasilar
opacities have developed, appear to correspond to areas of
basilar atelectasis and pleural effusions on recent CT abdomen
study of one day earlier.
.
Head CT noncon [**2188-3-2**]
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or
infarction. Prominence of the ventricles and sulci reflects
age-related
global atrophy. Areas of periventricular and subcortical white
matter
hypodensity likely reflect sequelae of chronic small vessel
ischemic disease. There is no evidence of fracture. The
visualized paranasal sinuses and mastoid air cells are clear.
There are calcifications of the carotid siphons bilaterally.
IMPRESSION: No evidence of abnormalities related to recent
trauma. Findings suggesting chronic small vessel ischemia.
.
discharge labs
[**2188-3-5**] 04:11AM BLOOD WBC-5.8 RBC-2.91* Hgb-8.2* Hct-26.2*
MCV-90 MCH-28.2 MCHC-31.3 RDW-19.2* Plt Ct-226
[**2188-3-5**] 04:11AM BLOOD Glucose-147* UreaN-18 Creat-0.7 Na-131*
K-4.6 Cl-97 HCO3-27 AnGap-12
[**2188-3-5**] 04:11AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
Brief Hospital Course:
REASON FOR ICU ADMISSION:
86 yo F IDDM, hypothyroidism, found with with symptomatic
hyponatremia.
.
# Hyponatremia: On presentation pt was found to have
hyponatremia with sodium of 116. It was initially felt that her
volume status was hypovolemic-euvolemic. Urine sodium suggestive
of SIADH, potentially in the setting of pain. TSH and AM
cortisol within normal limits. CT head did not show any evidence
of cerebral process which could be causing salt-wasting.
Initially pt was given hypertonic saline at a slow rate but
developed hypotension in the setting of decreased PO intake to
80/40 requiring boluses of IV NS. Urine output had also dropped
off and this was felt [**12-27**] hypovolemia; resolved with fluid
resuscitation. Blood sodium was trended q4hourly. Her sodium
continued to trend up and hypertonic saline was discontinued in
favor of NS. Her fluid intake was restricted to 1500 cc daily
and started on salt tabs. Her mental status improved with
increasing serum sodium. Nephrology felt that this was likely
SIADH from her acute pain. She will continue on daily salt tabs
and needs follow sodium check on [**3-7**]
.
#agitation - pt with baseline dementia. She was extremely
agitated on admission. She required central line placement for
hypertonic saline and required 50mg tramadol and 2.5mg zyprexa
for agitation. These medications were extremely effective. Pt
also required another 1x dose of 2.5 zyprexa overnight. Would
use haldol in the future should pt require chemical restraint as
zyprexa could contribute to SIADH.
.
#back pain - pt continued to complain of back pain relieved by
lidocaine patch. CT did not show any acute fracture, but did
show some old fracture s/p vertebroplasty. She will need to
continue working with physical therapy. If the pain is not
improving in the next week, can consider further imaging with
MRI of the back.
.
# DMI: brittle diabetes. Currently on lantus 6 Units qhs and
novolog sliding scale.
. On discharge from [**Hospital1 **] she should follow up with [**Last Name (un) **]
Diabetes center
.
#TRANSITIONAL ISSUES:
-Follow up sodium on [**3-7**]. If sodium increasing to 135 can
liberalize fluid intake to 2L daily.
Medications on Admission:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
5. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous three times a day.
14. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a
day.
4. Lantus 100 unit/mL Solution Sig: One (1) 6 units Subcutaneous
at bedtime.
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO BID (2 times a day) as needed for
constipation.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
14. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous tid with meals: Please follow sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
hyponatremia
metabolic encephalopathy
back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with back pain and acute confusion and found
to have a low sodium. It corrected with hypertonic saline and
fluid restriction. Your confusion improved as the sodium
improved and on discharge your sodium was 131. Please continue
taking salt tabs daily and work with the physical therapist for
your back pain.
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2188-7-10**] at 11:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2188-10-6**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2188-10-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"244.9",
"272.4",
"724.5",
"733.00",
"268.9",
"276.1",
"294.20",
"530.89",
"535.10",
"348.31",
"412",
"307.9",
"530.81",
"414.01",
"250.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13316, 13394
|
8513, 10575
|
356, 401
|
13485, 13485
|
4854, 8490
|
13987, 14802
|
4058, 4062
|
12026, 13293
|
13415, 13464
|
10726, 12003
|
13635, 13964
|
4077, 4077
|
10596, 10700
|
263, 318
|
429, 2933
|
4091, 4835
|
13500, 13611
|
2955, 3592
|
3608, 4042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,253
| 135,905
|
42443
|
Discharge summary
|
report
|
Admission Date: [**2186-1-28**] Discharge Date: [**2186-2-13**]
Date of Birth: [**2159-12-27**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
MVC, spine fracture
Major Surgical or Invasive Procedure:
[**2186-2-1**]:
1. Posterior spinal instrumentation T8 to T10.
2. Posterior lateral arthrodesis T8 to T10.
3. Application of local autograft.
4. Application of allograft and demineralized bone matrix.
5. Open tx posterior fracture dislocation three column injury of
T9 without spinal cord injury.
History of Present Illness:
26yo RHD man who presents to [**Hospital1 18**] as a transfer from OSH where
he presented s/p MVC. He was driving (unrestrained) while
intoxicated, hit a pole and was ejected through the windshield
and onto the ground. No airbag deployment.
Currently he is having numbness and tingling in his hands and
feet, as well as the entire left arm. He also has some pain
throughout, worse in his left arm. He feels that his left arm is
weak throughout.
Past Medical History:
PMH: asthma
PSH: none
[**Last Name (un) 1724**]: none
Social History:
SH: +for EtOH and tobacco
Family History:
FH: Father with CAD
Physical Exam:
On Admission:
VS: 97.7 76 128/50 22 95% 2L NC
PE: Gen - A&Ox3, NAD CV - RRR Pulm - CTAB Abd -
S/NT/ND
Ext - warm, well perfused, weakness in the upper
extremities
bilaterally, left weaker than the right, sensation intact
bilaterally, neuro and motor intact in lower extremities
Pulses: Carotid Rad Fem DP PT
R palp palp palp palp palp
L palp palp palp palp palp
Sensory:
UE C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R intact intact intact intact intact
L intact intact intact intact intact
T2-L1 (Trunk) intact
LE L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R intact intact intact intact intact intact
L intact intact intact intact intact intact
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8) FinAbd(T1)
R 4 4 5 5 5 5 5
L 3 3 3 3 3 3 3
LE Flex(L1)Add(L2) Quad(L3)TA(L4) [**Last Name (un) 938**](L5) Per(S1) GS(S1-2/T)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5)BR(C5-6)Tri(C6-7)Pat(L3-4)Ach(L5-S1)
R 1 1 1 1 1
L 1 1 1 1 1
Clonus: NONE
Perianal sensation: intact
Rectal tone: decreased
Estimated Level of Cooperation: moderate
Estimated Reliability of Exam: moderate
Normal proprioception in upper and lower extremities
On discharge:
Vitals: 98.7 110/60 66 16 96%RA
Neuro: A&Ox3, speech clear and coherent
LUE 4/5 strength, +sensation, +PP
RUE reports mild tingling sensation in hand, no numbness, [**4-22**]
strength, +PP
Chest: Normal S1S2, Lungs CTAB
Abd: Soft, nontender, nondistended
LE: +PP/CSM, no edema
Pertinent Results:
[**2186-1-28**] 04:45AM WBC-19.8* RBC-4.62 HGB-14.5 HCT-40.8 MCV-88
MCH-31.4 MCHC-35.6* RDW-12.3
[**2186-1-28**] 04:45AM PLT COUNT-338
[**2186-1-28**] 04:45AM PT-10.7 PTT-25.3 INR(PT)-1.0
[**2186-1-28**] 04:45AM ASA-NEG ETHANOL-117* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-1-28**] 01:53PM GLUCOSE-88 UREA N-10 CREAT-0.7 SODIUM-139
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-14
[**2186-1-28**] 01:53PM CALCIUM-8.3* PHOSPHATE-4.2 MAGNESIUM-1.7
CT chest/abd/pelvis w/contrast ([**1-28**]): 1. no intrathoracic
injury. 2. small subcapsular hematoma of liver; no free fluid in
abdomen or pelvis. 3. horizontally-oriented fx through posterior
elements of T9 w/ minimal hematoma around right/anterior
vertebral body column at that level recommend MR [**First Name (Titles) **] [**Last Name (Titles) 11197**] for
ligamentous, disc, and cord injury.
CTA head and neck ([**1-28**]): R vertebral artery occlusion
MRI C-spine w/contrast ([**1-28**]): C4 facet fracture and C2 signal
abnormality
Labs at discharge:
[**2186-2-9**] 06:06AM BLOOD WBC-10.8 RBC-3.35* Hgb-10.4* Hct-29.1*
MCV-87 MCH-31.1 MCHC-35.8* RDW-12.5 Plt Ct-500*
[**2186-2-9**] 06:06AM BLOOD Plt Ct-500*
[**2186-2-6**] 02:14AM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2*
[**2186-2-9**] 06:06AM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-136
K-4.1 Cl-101 HCO3-26 AnGap-13
[**2186-2-9**] 06:06AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 91895**] arrived on [**2186-1-28**] to the ICU inebriated but
protecting his airway well. Patient went to CTA head and neck,
MRI C-spine w/contrast to evaluate possible central cord and/or
c-spine fracture. He was seen by Vascular surgery and
Neurosurgery as a R vetebral art occlusion was picked up on that
scan. A heparin gtt and ASA 325 were started for that occlusion
with the understanding that the heparin drip would be stopped
post-operatively when the spine surgery team was able to repair
his thoracic fracture. He did well overnight after started on
dilaudid PCA. He was kept on log-roll precautions in a C-collar
overnight.
The following morning ([**1-29**]) a chest showed complete
opacification of the left lung. At this point he was intubated
and subsequent bronchoscopy showed large mucus plug. ABG after
intubation showed resp acidosis. He developed possibly new LLE
weakness. Stat MRI/MRA head and neck were ordered which further
characterized the R vertebral artery occlusion as intramural
dissection v. thrombosis could not be ruled out. The scan also
showed slow diffusion of the Right hemisphere. Neurosurg
recommended continuing heparin gtt with goal PTT 50-60. A repeat
bronch on [**1-30**] showed no mucus plugs, BAL sent 2+ GPC,
coccobaccilus, started on vanc/cef/cirpo for VAP coverage. He
spiked a fever to 103.3 and cultures were sent. The following
day on [**1-31**] a repeat bronch showed RLL mucus plug, and CXR now
with diffuse haziness.
On [**2-1**] he was taken to the OR by Dr [**Last Name (STitle) 1352**] (spine surgery) for
PSIF thoracic spine. The procedure went well and his logroll
restrictions were removed. He was transferred back to the TSICU.
[**2-2**]--[**2-6**]: Postoperative course c/b bilateral pneumonias and
acute lung injury requiring prolonged ventilator support. He
underwent daily spontaneous breathing trials which failed due to
tachypnea, tachycardia and O2 saturations to the low 80s, high
70s. He continued to spike occasional fevers and a CT scan
demonstrated bilateral pneumonias. BAL from [**1-30**] grew H. flu,
for which he was appropriately covered by Cefipime. Blood and
urine cultures remained negative throughout. I&D consultants
assisted with antibiotic management and by [**2-6**] white count had
normalized, he was afebrile and all antibiotics were
discontinued. Tube feeds were given via NGT (dobhoff) and
advanced to goal without difficulty.
On [**2-7**] he was sucessfully extubated (HD#11 POD#6) and diuresed
3 liters. He remained hemodynamically stable. NGT & Foley were
removed. He started on PO's and tolerated a regular diet.
Physical therapy and occupational therapy were consulted to
evaluate his mobility, and he remained in TLSO brace when
ambulating and cervical collar at all times.
On [**2-8**] he was afebrile, hemodynamically stable with stable
respiratory status and was transferred to the surgical floor. On
the floor he continued to do well. His pain was well controlled
with an oral pain regimen and a clonidine patch. His LUE
remained with 4/5 strength and improving, and neurology was
following for this. A splint was placed to prevent contractures
to his arm. Incentive spirometry and pulmonary toileting were
continued and he remained afebrile without an elevated WBC
count. The 325 mg of aspirin was continued per vascular surgery
for right vertebral artery occlusion. He was tolerating a
regular diet and voiding adequate amounts of urine.
He remained in the cervical collar as well as the TLSO brace
when ambulating. His mobility improved while working with
physical and occupational therapy. On [**2186-2-13**] his physical
mobility had progressed and he was ambulating independently. He
was discharged home with follow up scheduled with ACS,
neurology, spine and vascular.
Medications on Admission:
None
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
s/p MVC:
Injuries:
1. Right vertebral artery occlusion
2. T9 chance fracture
3. C4 left articular process fracture with C6-7 compression
injury
4. Small subscapular liver hematoma
Secondary:
Ventilator-assisted pneumonia
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 after a motor vehicle crash.
You sustained multiple injuries including fractures in your
spine, an occlusion in your right vertebral artery, and small
injury to your liver which is stable.
Please follow up at the appointments listed below.
You should continue to wear your cervical collar at all times
and the hard back brace when out of bed ambulating.
You should continue to take the aspirin 325 mg daily until you
follow up with Dr. [**Last Name (STitle) **] at the appointment listed below. He
will discuss at this appointment how long you will need to
continue to take the aspirin for.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-27**] lbs until you follow-up with your
surgeon.
Avoid drinking alcohol, driving or operating heavy machinery
while taking pain medications.
Narcotic pain medications can cause constipation. It is
generally recommended that you take an over the counter stool
softener such as colace or milk of magnesia to prevent
constipation while taking narcotic pain medicine. You should
also increase your fluid intake and dietary fiber if possible.
Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2186-2-23**] at 1 PM
With: DRS. [**Name5 (PTitle) 43**] & [**Last Name (un) 10365**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2186-2-23**] at 3:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2186-3-2**] at 2:00 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] in ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SPINE CENTER
When: FRIDAY [**2186-3-24**] at 2:00 PM
With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2186-2-13**]
|
[
"276.3",
"305.00",
"E879.8",
"900.89",
"518.0",
"805.04",
"276.8",
"E912",
"493.90",
"473.8",
"507.0",
"864.01",
"873.42",
"E816.0",
"518.51",
"923.00",
"305.1",
"934.8",
"041.5",
"997.31",
"952.05",
"805.2",
"850.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"77.79",
"96.6",
"81.62",
"81.05",
"84.52",
"96.72",
"03.53",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9287, 9336
|
4557, 8363
|
323, 622
|
9613, 9613
|
3113, 4142
|
12033, 13405
|
1234, 1256
|
8418, 9264
|
9357, 9592
|
8389, 8395
|
9796, 12010
|
1271, 1271
|
2812, 3094
|
264, 285
|
4161, 4534
|
650, 1097
|
1285, 2798
|
9628, 9772
|
1119, 1174
|
1190, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,798
| 199,741
|
27656
|
Discharge summary
|
report
|
Admission Date: [**2111-7-15**] Discharge Date: [**2111-7-17**]
Date of Birth: [**2052-10-25**] Sex: M
Service: NEUROSURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Elective resection of brain metastasis
Major Surgical or Invasive Procedure:
Craniotomy
History of Present Illness:
58M w/recent dx of non-small cell lung cancer presents for
resection of solitary brain metastasis. First presented in [**2108**]
with peumonia and found to have nodule in right upper lobe which
was followed with serial chest CT q3 months. In [**2111-5-4**], a 2nd
lesion was seen in the same lung lobe and subsequent w/u showed
adenocarcinoma. Staging with head MR [**2111-6-26**] showed 1cm cystic
enhancing lesion in left frontal brain. He is completely
asymptomatic and neurologically intact withtou headache, nausea,
vomitting, seizure, weakness, double vision, urinary
incontinece, imbalance or recent falls.
Past Medical History:
Hypercholesterolemia
Coronary artery disease (MI in [**2106**] with sent placement)
No HTN, DM or COPD
Social History:
Smokes 2PPD x40 yrs, drinks EtOH occasionally.
Family History:
Grandfather died of lung CA (non-smoking related). Mother died
of MI. Father died of brain CA. Has 3 brothers who are alive but
a fourth died of complications of Hep C. Does not have children.
Physical Exam:
97.4 126/72 78 16
GNE: NAD, comfortable
HEENT: neck supple and there is no cervical, axillary or
supraclavicular lymphadenopathy
CV: RRR
Lungs: CTAB
ABD: soft, +BS
EXT: no c/c/e
Pertinent Results:
[**2111-7-15**] 12:46PM GLUCOSE-116* UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13
[**2111-7-15**] 12:46PM CALCIUM-6.9* PHOSPHATE-2.7 MAGNESIUM-1.8
[**2111-7-15**] 12:46PM WBC-8.1 RBC-3.66* HGB-11.1* HCT-32.5* MCV-89
MCH-30.4 MCHC-34.2 RDW-15.2
[**2111-7-15**] 12:46PM PLT COUNT-252
.
.
[**7-15**] head MRI: Since [**2111-6-26**], slight enlargement in size of a
peripheral ring- enhancing lesion in the left frontal lobe,
which likely represents metastasis.
.
.
[**7-15**] head CT: FINDINGS: There has been interval left frontal
craniotomy and resection of the previously seen ring-enhancing
left frontal lobe lesion. Postoperative changes with
pneumocephalus and a small amount of hemorrhage in the surgical
bed are seen. There is no mass effect. No other intracranial
hemorrhage is identified. There is no shift of normally midline
structures. [**Doctor Last Name **]-white matter differentiation elsewhere appears
preserved. This patient appears to have undergone bilateral
maxillary sinus antrostomies. Remaining visualized paranasal
sinuses are unremarkable.
IMPRESSION:
Postoperative changes in the left frontal lobe.
.
.
[**7-15**] tissue bx: Clinical: Left frontal mass; (Per online
record) 58-year-old man with two pulmonary nodules, one of which
contained poorly differentiated adenocarcinoma. Now has left
frontal mass.
Gross:
The specimen is received fresh in two parts, both labeled with
"[**Known firstname **] [**Known lastname **]" and the medical record number.
Part 1 is additionally labeled "frontal tumor, frozen pass" and
consists of multiple fragments of white friable tissue measuring
in aggregate 1.8 x 0.6 x 0.4 cm. Small portions of the tissue
are used to prepare an intraoperative smear. The intraoperative
diagnosis by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 122**] reads
"#1, Left frontal mass (smear):
Metastatic poorly differentiated carcinoma. Necrosis
present. Reactive brain.
Discussed with Dr. [**Last Name (STitle) **]. Final diagnosis pending
permanent section."
The remainder of the specimen is entirely submitted in A.
Part 2 is additionally labeled "#3, left frontal tumor"
(specimen #2 was taken by Dr.[**Name (NI) 6767**] laboratory) and consists of
several fragments of tan, white, and red soft tissue, 0.7 x 0.5
x 0.4 cm in aggregated. The specimen is entirely submitted in B.
.
.
[**7-17**] Head MRI:
FINDINGS: Status post left frontal craniotomy. Post-surgical
changes with areas of hemorrhage and air are noted in the left
frontal parenchyma. On the contrast images, there is small area
of contrast enhancement anteriorly as well as superior and
lateral to the area of the hemorrhage. Rest of the brain
parenchyma is unremarkable. The ventricles and extraaxial CSF
spaces are normal. The visualized paranasal sinuses and the
orbits and the rest of the skull are unremarkable.
IMPRESSION:
Post-surgical changes with small amount of blood the left
frontal lateral parenchyma.
Small area of residual enhancement anterior and superolateral to
the area of post-surgical blood products.
Brief Hospital Course:
Patient underwent left frontal craniotomy and resection of left
frontal cystic lesion without complication. Post-op patient's
vital signs were stable and he was neurologically unchanged. He
was transferred from the PACU to the floor. Patient tolerated
diet well and pain was controlled. Patient was ambulating
without difficulty per physical therapy evaluation. He was
discharged home with follow-up in [**Hospital **] clinic.
Medications on Admission:
aspirin 325mg QD
toprol XL 50mg QD
lipitor 10mg QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take while on percocet.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please take while on percocet.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): Slowly taper with 4mg PO Q8H x2days, 3mg PO Q8H x3days,
2mg PO Q8H x3days,
then 2mg PO BID, until follow-up in Brain [**Hospital 341**] Clinic.
Disp:*120 Tablet(s)* Refills:*2*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take until [**7-31**].
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal cystic lesion
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please take medications as prescribed. Please DO NOT take
aspirin until 2 weeks after discharge (may resume [**7-31**]).
Please keep your follow-up appointments.
Keep incision clean, dry do not get wet until sutures come out.
Watch incision for redness, drainage, bleeding, fevers greater
than 101.5, any neurological changes call Dr[**Name (NI) 9034**] office.
No heavy lifting greater than 10lbs.
No driving.
Followup Instructions:
Follow in Brain tumor clinic within 2 weeks of discharge. We
will schedule an appointment for you. Please call the clinic at
[**Telephone/Fax (1) 1844**] to confirm the time and date.
Completed by:[**2111-7-20**]
|
[
"348.8",
"414.00",
"V45.82",
"162.8",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6447, 6453
|
4728, 5156
|
317, 330
|
6523, 6547
|
1595, 2117
|
7010, 7225
|
1179, 1373
|
5257, 6424
|
6474, 6502
|
5182, 5234
|
6571, 6987
|
1388, 1576
|
239, 279
|
358, 973
|
2126, 4705
|
995, 1099
|
1115, 1163
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,865
| 139,606
|
45267+45268
|
Discharge summary
|
report+report
|
Admission Date: [**2188-2-14**] Discharge Date: [**2188-2-29**]
Service: [**Hospital1 212**]
PLEASE NOTE THAT THIS IS AN INTERIM NOTE UP UNTIL ADMISSION
TO THE MEDICAL INTENSIVE CARE UNIT.
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
male with a history of coronary artery disease status post
left anterior descending stent requiring LGIB, status post
history of arteriovenous malformation, colon cancer status
post colectomy and ileocolonic anastomosis. He presents with
black stools and lightheadedness times three days.
The patient presented to his primary care physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**], with subsequently decreasing hematocrit drop.
The patient's hematocrit had reportedly dropped from 37 to 35
to 29.6 within two days. The patient was complaining of
minor lightheadedness, however, declined any shortness of
breath, chest pain or abdominal pain. The patient was
instructed by his primary care physician to go to the [**Hospital1 1444**] Emergency Room.
On arrival, the patient's blood pressure was 115/63, however,
decreased to systolic 80s on two episodes. The patient had
undergone two transfusions of packed red blood cells, and was
reportedly hemodynamically stable. Gastrointestinal was
consulted and recommended tagged red blood cell scan and
subsequent esophagogastroduodenoscopy if the patient became
hemodynamically unstable again.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Three plus mitral regurgitation and hypertrophic
cardiomyopathy seen on echocardiogram on present admission.
3. Multiple arteriovenous malformations with 15 year history
of recurrent gastrointestinal bleeding.
4. Gastroesophageal reflux disease.
5. Duke's A colon cancer status post right hemicolectomy in
[**2176**].
6. Jejunal lipoma in [**2176**].
7. Status post cholecystectomy ten years ago.
8. Prostatectomy.
9. Left inguinal hernia repair by Dr. [**Last Name (STitle) 1305**] in [**2179**].
10. Dyslipidemia.
11. History of hemolysis previously in transfusion.
MEDICATIONS ON ADMISSION:
1. Atenolol 100 q. day.
2. Celexa 20 q. day.
3. Hydrochlorothiazide 12.5 mg twice a day.
4. Atorvastatin 10 q. day.
5. Prevacid 30 q. day.
6. Isordil 10 twice a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Quit smoking 35 years ago; currently
married, no alcohol use in greater than ten years.
FAMILY HISTORY: Mother with cerebrovascular accident at 67;
lung cancer at 87.
REVIEW OF SYSTEMS: Upon review of systems, the patient notes
shortness of breath times two days; melena at least once a
month.
PHYSICAL EXAMINATION: Temperature 99.0 F.; blood pressure
120/58; pulse 84; respiratory rate 20; weight 74.2 kilograms.
In general, the patient is in no apparent distress, alert and
oriented times three. HEENT examination: Anicteric.
Pulmonary examination was clear to auscultation bilaterally
with good breath sounds; no evidence of wheezing or crackles.
On cardiac examination: Demonstrated a holosystolic murmur
V/VI, loudest at the apex. Regular rate and rhythm, S1 and
S2 within normal limits; no gallops or rubs. Abdominal
examination nontender, nondistended. Bowel sounds positive,
guaiac positive. No hepatosplenomegaly appreciated. No
costovertebral angle tenderness. Extremities well perfused
with no cyanosis, clubbing or edema. Dorsalis pedis two plus
bilaterally. Skin examination: Mucous membranes were moist;
normal turgor. No focal abnormalities were evident on
neurological examination.
HOSPITAL COURSE: The patient was admitted and underwent a
very complicated hospital course. On [**2188-2-15**], the patient
underwent enteroscopy which demonstrated polyps in the
stomach body and fundus, blood in the duodenum and proximal
jejunum. No angiomas were seen at that time; otherwise
enteroscopy was normal.
The Gastrointestinal tagged red blood cell study on
[**2188-2-14**], had demonstrated very small amounts of
gastrointestinal bleeding in the left upper quadrant,
probably within the small bowel.
As the patient's hematocrit stabilized and he was not having
any more melanotic stools, he was transferred from the
Medical Intensive Care Unit to the Medicine Floor, at which
time the [**Hospital1 **] Team began his care.
The patient was maintained on the floor with close monitoring
of his hematocrit status. The patient's hematocrit's often
hovered between 30 and 31, occasionally dropping down to 29
or 28. When the patient's hematocrit fell to 28, he often
became symptomatic complaining of either lightheadedness,
substernal chest pain, diaphoresis, or minimal shortness of
breath.
The first episode of substernal chest pain without radiation,
the patient was placed on continuous Telemetry and ruled out
for myocardial infarction. Although the patient's troponin
were less than 0.1, they had trended up during that time to
0.01, 0.02 and 0.03, suggesting real demand ischemia. On a
separate occasion, the patient became very tachycardic and
his heart rate was ranging between the 110s and 120s. He was
symptomatic as well, complaining of chest pain with radiation
down the left arm, shortness of breath and diaphoresis. At
this time, the decision was made to start back beta blocker,
first putting him back on Metoprolol, 50 mg twice a day.
On a separate occasion when the patient's hematocrit was
28.1, he was being evaluated by Physical Therapy and walked
approximately five feet before feeling lightheadedness and
extremely diaphoretic. The episodes of drop in hematocrit
often coincided with melanotic stools, usually ranging from
150 to 200 cc with no obvious signs of bright red blood but
being darkly melanotic. The patient received a total of 12
transfusions previous to Medical Intensive Care Unit
admission.
As well, he underwent several studies with Gastroenterology
including esophagogastroduodenoscopy and duodenoscopy on
[**2188-2-19**], which demonstrated angiectasias in the second
part of the duodenum; thermal therapy was applied. As well,
there was diverticula in the second part of the duodenum;
otherwise showing normal ampulla with clear bile seen from
its orifice. The rest of the esophagogastroduodenoscopy to
the second part of the duodenum was normal.
Because of dropping hematocrits and recurrent melanotic
stools, the patient also underwent a pill study on [**2188-2-22**]
which demonstrated some fresh blood and active bleeding from
arteriovenous malformations in the proximal small bowel.
The decision was made on [**2188-2-25**], to repeat
esophagogastroduodenoscopy. Impressions of the study
demonstrated erythema and nodularity in the antrum compatible
with gastritis, angiectasias in the proximal jejunum at 1
meter. Thermal therapy was applied. Angiectasias in the
second part of the duodenum, thermal therapy was applied.
Blood in the jejunum and otherwise normal
esophagogastroduodenoscopy to the jejunum.
The patient's hematocrits were relatively stable for the next
couple of days with no melanotic stools reported; however on
[**2188-2-26**], the patient experienced one melanotic stool
around 05:30 a.m. He stated that he felt some reflux and
knew that something was wrong because this was an unusual
symptom for him. As well, he became very diaphoretic with
minimal shortness of breath and felt very lightheaded.
According to the night float, the patient was pale with a
blood pressure of 80/40, heart rate in the 90s. He denied
chest pain and abdominal pain.
The patient had two large bore intravenous lines; normal
saline was started wide open with improvement in blood
pressure to 135/80s. The patient improved mentation.
Gastrointestinal lavage demonstrated two liters of normal
saline with dark red material not fully cleared. The patient
was placed on suction.
EKG demonstrated T wave inversions and ST depressions in V3
through V5, although difficult for comparison because his EKG
at baseline is abnormal. Cardiac enzymes were drawn at that
time. Hematocrit was drawn which came back at 27 from 31 the
previous night. Two units of packed red blood cells were
ordered STAT. The first unit started at 06:45 a.m. and
finished by 07:25 a.m. The second unit beginning at 07:30
a.m.
The patient denied any chest pain, shortness of breath, and
the decision was made to transfer the patient to the Medical
Intensive Care Unit where he could be more closely observed.
This is the end of the interim dictation. Please see
Addendum for Medical Intensive Care Unit course and hospital
discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 96723**]
MEDQUIST36
D: [**2188-2-29**] 14:27
T: [**2188-2-29**] 15:41
JOB#: [**Job Number 96724**]
Admission Date: [**2188-2-14**] Discharge Date: [**2188-3-7**]
Service: [**Hospital1 212**]/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
male with a past medical history of coronary artery disease
status post left anterior descending coronary artery stent,
history of recurrent lower gastrointestinal bleeding with a
history of arterial venous malformations, colon cancer status
post colectomy and ileocolonic anastomosis who presented with
melanic stools and lightheadedness times three days.
Initially the patient presented to his primary care
physician's office complaining of dark tarry stools. Serial
laboratory work was noted that the patient's hematocrit was
decreasing dropping reportedly from 37 to 29.6 within several
days. At that time the patient continued to complain of
lightheadedness, but denies any shortness of breath, chest
pain or abdominal pain. He was instructed by his primary
care physician to go to the [**Hospital1 188**] Emergency Department for further evaluation. In the
Emergency Department the patient's blood pressure was labile
ranging from 80s to 115s systolic. He received 2 units of
packed red blood cells and thereafter was hemodynamically
stable. He was seen by the Gastroenterology Service who
recommended a tagged red blood cell scan followed by an
esophagogastroduodenoscopy.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post stent to the left
anterior descending coronary artery.
2. Hypertrophic cardiomyopathy with mitral regurgitation.
3. History of multiple arterial venous malformations with a
15 year history of recurrent gastrointestinal bleeding.
4. Gastroesophageal reflux disease.
5. History of Duke's A colon cancer status post right
hemicolectomy in [**2176**].
6. History of jejunal lipoma in [**2176**].
7. Status post cholecystectomy in [**2178**].
8. History of prostatectomy.
9. History of left inguinal hernia repair in [**2179**].
10. Hyperlipidemia.
MEDICATIONS ON ADMISSION:
1. Atenolol 100 mg po q day.
2. Celexa 20 mg po q day.
3. Hydrochlorothiazide 12.5 mg po b.i.d.
4. Lipitor 10 mg po q day.
5. Prevacid 30 mg po q day.
6. Isordil 10 mg po b.i.d.
ALLERGIES: The patient reports no known drug allergies.
SOCIAL HISTORY: The patient quit smoking approximately 35
years ago. He is married with several children. He reports
no alcohol or drug use.
FAMILY HISTORY: The patient's mother deceased from a
cerebrovascular accident at age 67.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
99.0, blood pressure 120/58, pulse 84, respiratory rate 20,
weight 72 kilograms. Generally, the patient was a well
developed thin male in no acute distress. Head and neck
examination revealed normocephalic, atraumatic. Sclera
anicteric. Pupils are equal, round and reactive to light and
accommodation. Mucous membranes are moist. Lungs clear to
auscultation with good breath sounds and air movement. No
rhonchi, rales or wheezing. Heart was regular rate and
rhythm with a grade 3 out of 6 holosystolic murmur heard best
at the apex. No rubs or gallops. Abdomen was soft,
nontender, nondistended. There were positive normoactive
bowel sounds. Stool was guaiac positive. No evidence of
hepatosplenomegaly. Extremities were warm and well perfuse
with no clubbing, cyanosis or edema. Distal pulses were
full.
HOSPITAL COURSE:
1. Gastrointestinal bleeding: The patient underwent a
tagged red blood cell scan on [**2188-2-14**], which
demonstrated a very small amount of gastrointestinal bleeding
mostly in the left lower quadrant most likely within the
small bowel. Therefore he underwent enteroscopy on [**2188-2-15**],
which demonstrated polyps in the stomach, body and fundus as
well as blood in the duodenum and proximal jejunum. No
angiomata were seen at that time, otherwise enteroscopy was
normal. He continued to have melena as well as lability in
his blood pressure and hematocrit. He was monitored with
serial hematocrits and transfused to keep his hematocrit
greater then 28 to 30. He underwent additional studies
including esophagogastroduodenoscopy and duodenoscopy on
[**2188-2-19**], which demonstrated angiectasias in the second part
of the duodenum, which was treated with thermal therapy.
Also noted were diverticuli in the second part of the
duodenum. Because of dropping hematocrits and recurrent
melanotic stools the patient underwent a pill study on
[**2188-2-22**], which showed fresh blood and active bleeding from
the arterial venous malformations seen in the proximal small
bowel. He continued again to have melanotic stools and had
repeat esophagogastroduodenoscopy on [**2188-2-25**]. This
demonstrated erythema nodularity in the antrum compatible
with gastritis, as well as angiectasias in the proximal
jejunum. Again thermal therapy was applied. Thermal therapy
was also applied to angiectasias in the second part of the
duodenum. The patient tolerated most of these procedures
well until [**2188-2-26**] when he had recurrent melena. This was
accompanied with diaphoresis, shortness of breath and
lightheadedness. Blood pressure fell to 80/40 with a heart
rate in the 90s. He was volume resuscitated with normal
saline. Gastrointestinal lavage demonstrated 2 liters of
normal saline with dark red material that was not fully
cleared.
Due to his instability he was transferred to the Medical
Intensive Care Unit at that time. Repeat
esophagogastroduodenoscopy on [**2188-2-27**] showed red blood and
clot overlying a prior cautery site in the mid to distal
duodenum. It was washed with no active bleeding. There was
significant blood and clot in the jejunum. The patient
therefore was taken to the Interventional Radiology Suite
where he underwent angiography and embolization of the
gastroduodenal and left gastric artery. This embolization
was performed after a heparin tissue plasminogen activator
challenge did not result in any bleeding. Status post
embolization the patient was monitored in the Intensive Care
Unit and was then was transferred out to the General Medical
Floor on [**2188-2-29**]. He continued to pass melanotic and grossly
guaiac positive stools. Repeat enteroscopy was performed on
[**2188-3-6**], which demonstrated red blood in the second part of
the duodenum and an ulcer ni the second part of the duodenum.
Basically the patient was afforded with serial transfusions
to keep his hematocrit appropriate above 30 in light of his
history of coronary artery disease. As an outpatient he will
have serial hematocrit checks and was arranged to have
outpatient blood transfusions if necessary.
2. Coronary artery disease/aortic stenosis: The patient has
a history of myocardial infarction with anemia.
Echocardiogram on [**2188-2-21**] showed hyperdynamic with EF 75%
with severe resting outflow tract obstruction left
ventricular hypertrophy as well as 3+ mitral regurgitation
consistent with hypertrophic cardiomyopathy. Therefore
treatment goals were to increase beta-blockade, increase
filling time and to keep the patient at least euvolemic to
decrease obstruction. We were unable to titrate the
beta-blocker up in light of his low blood pressure. His
previous medications of Atenolol, Hydrochlorothiazide and
Isordil will not be continued as an outpatient.
3. Depression: The patient was maintained on Celexa.
4. Tachycardia: The patient demonstrated several instances
of tachycardia mostly in the setting of volume depletion
during episodes of bleeding. Tachycardia improved after
volume resuscitation. Again in light of his history of
cardiomyopathy, the goal is to keep him maximally
beta-blocked as much as tolerable by his hypotension.
DISCHARGE CONDITION: Good. Hematocrit stabilized, melena
decreased and tolerating a regular diet. No chest pain or
shortness of breath. Visiting nurses are to check the
patient's hematocrit biweekly. He was to be transfused for a
hematocrit of less then 30 at the [**Hospital1 **]
[**First Name (Titles) **] [**Last Name (Titles) 94138**] Center. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] will be
responsible for following up on the patient's hematocrit
values and ordering transfusions as necessary.
DISCHARGE STATUS: The patient was discharged to home with
services.
DISCHARGE DIAGNOSES:
1. Recurrent gastrointestinal bleeding with a history of
multiple AVMs status post thermal therapy of jejunal
angiectasia.
2. Status post angio embolization of the left gastric and
gastric duodenal arteries.
3. Coronary artery disease status post percutaneous
transluminal coronary angioplasty of the left anterior
descending coronary artery in [**10/2180**], status post myocardial
infarction times two in the setting of anemia, baseline
electrocardiogram of right bundle branch block.
4. Anemia secondary to blood loss.
5. Diastolic dysfunction.
6. Aortic stenosis.
7. Status post cholecystectomy.
8. Hypercholesterolemia.
9. Gastroesophageal reflux disease.
10. History of colon cancer status post right hemicolectomy.
11. Status post prostatectomy.
12. Status post left inguinal hernia repair.
DISCHARGE MEDICATIONS:
1. Citalopram 20 mg po q.d.
2. Lipitor 10 mg po q.d.
3. Multivitamin one capsule po q.d.
4. Tylenol 650 mg po q 6 hours as needed.
5. Ambien 5 mg po q.h.s. as needed.
6. Mylanta 15 to 30 ml po q.i.d. as needed.
7. Lansoprazole 30 mg po q day.
8. Lopresor 12.5 mg po b.i.d.
9. Sucralfate 1 gram po t.i.d.
FOLLOW UP PLANS: The patient was instructed to call his
primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] and/or his
gastroenterologist Dr. [**First Name (STitle) 2405**] within a week following
discharge regarding his recent hospital stay. He was
instructed that if he noticed bright red blood in his stool,
increasing darkening stools, shortness of breath, chest pain,
fatigue or lightheadedness that he return to the Emergency
Room immediately. He was instructed that we added Metoprolol
to his medication regimen as this had long term beneficial
effects for people with heart disease. We instructed him to
discontinue taking his Isordil, Atenolol and
Hydrochlorothiazide until follow up with Dr. [**First Name (STitle) 216**]. He had
an appointment made with the Outpatient [**First Name (STitle) 94138**] Center on
[**2188-3-11**] if a blood [**Date Range **] was needed. He also had a
follow up echocardiogram on [**2188-4-16**].
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2188-5-6**] 06:03
T: [**2188-5-8**] 10:52
JOB#: [**Job Number 96725**]
cc:[**First Name (STitle) 96726**]
|
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icd9cm
|
[
[
[]
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[
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"38.91",
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icd9pcs
|
[
[
[]
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16517, 17104
|
11210, 11305
|
17125, 17936
|
17959, 19596
|
10805, 11048
|
12182, 16495
|
2680, 3576
|
2547, 2656
|
8946, 10163
|
11320, 12165
|
10185, 10779
|
11065, 11193
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,390
| 175,241
|
25354
|
Discharge summary
|
report
|
Admission Date: [**2136-7-16**] Discharge Date: [**2136-7-30**]
Date of Birth: [**2066-3-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
peri-hepatic fluid collection
Major Surgical or Invasive Procedure:
[**2136-7-17**] - CT-guided drainage of a gallbladder fossa collection
with percutaneous drain placement.
History of Present Illness:
This is a 70-year old male with history of unresectable
pancreatic cancer s/p ex-lap, open cholecystectomy and
retroperitoneal lymph node biopsies on [**2136-6-28**], discharged on
[**7-9**] with a post-op course complicated by gram negative
bacteremia and delirium. He was transferred from [**Hospital 1474**]
Hospital with 5 days of abdominal pain, nausea and vomiting. He
has been having less frequent bowel
movements (last was 3 days ago) and reported not passing flatus
for the past 2 days. He denied any fevers or chills. KUB was
without evidence bowel obstruction.
Past Medical History:
PMH: COPD, on home oxygen 2L continuously; Anxiety; Depression;
OSA; Hx of ARF; DMII, HTN, CAD s/p PTCA [**35**] yrs BU, ?seizures vs.
syncope
PSH: open appendectomy, tonsillectomy, bilateral carotid stents
Social History:
Patient retired (used to work for oxygen device company) and
lives with his mother in [**Name (NI) 7740**]. Has 5 children. Previously
smoked 3-4 packs/day x 45 years gradually decreasing for past 8
years, now 0.75 pack per day. Patient states he quit alcohol 30
years ago. Prior crack/cocaine x 2 yrs. Quit a few yrs ago.
Family History:
Mother CABG [**14**], alive 95. Father died at of pancreatic cancer at
age 72.
Physical Exam:
PHYSICAL EXAM (on admission):
Vitals: T 98.9 HR 86 BP 163/91 RR 16 SO2 96%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, mildly tender to palpation on RUQ
and periumbilical area, no rebound or guarding
DRE: normal tone, no gross or occult blood. Guaiac neg.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2136-7-16**] 03:15PM BLOOD WBC-26.0*# RBC-4.05* Hgb-12.3* Hct-39.7*#
MCV-98 MCH-30.4 MCHC-31.0 RDW-17.0* Plt Ct-637*#
[**2136-7-16**] 03:15PM BLOOD Neuts-88.4* Lymphs-8.9* Monos-2.2 Eos-0.3
Baso-0.2
[**2136-7-16**] 03:15PM BLOOD PT-14.7* PTT-21.7* INR(PT)-1.3*
[**2136-7-16**] 03:15PM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-144
K-3.6 Cl-101
HCO3-31 AnGap-16
[**2136-7-16**] 03:15PM BLOOD ALT-65* AST-103* AlkPhos-958* TotBili-1.1
[**2136-7-17**] 04:25AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.2*
[**2136-7-18**] 06:30AM BLOOD Vanco-21.7*
[**2136-7-16**] 03:32PM BLOOD Lactate-1.6
[**2136-7-16**] CT ABD & PELVIS WITH CONTRAST - In the right lobe of the
liver, there is a rim enhancing collection measuring 4.0 x 5.6
cm that contains foci of air, concerning for abscess. Increased
ascites compared to the prior exam. Increased intrahepatic
biliary duct and pancreatic duct
dilation, likely secondary to known pancreatic mass.
[**2136-7-17**] CT GUIDED NEEDLE PLACTMENT - Technically successful
CT-guided aspiration drainage of a gallbladder fossa collection.
8 French [**Last Name (un) 2823**] catheter placed. 30 cc of purulent material
were aspirated to bag and gravity. 1 cc was sent for
microbiology specimen. No immediate complications.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV pain medication on
admission and transitioned to PO narcotic medication with
adequate pain control on HOD#X once oral intake was tolerated.
The patient remained neurologically intact and without change
from baseline during their stay. His home dosing of
benzodiazepines was continued without evidence of delirium or
mental status change. The patient remained alert and oriented to
person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable. The
patient was maintained on IV anti-hypertensive medication, with
transition to their oral home anti-hypertensives on HOD#[**3-15**].
Their vitals signs were closely monitored. The patient's home
anti-hypertensive medications were resumed on HOD#3.
Unfortunately, the patient developed ventricular tachycardia
prior to ERCP in the setting of hypokalemia and hypomagnesemia.
He required amiodarone boluses and synchronized cardioversion to
revert to sinus rhythm. He was transferred to the ICU for
monitoring. Patient treated with esmolol drip overnight and
remained in sinus rhythm throughout. Esmolol drip stopped and
patient placed back on home metoprolol. He tolerated this well
and cardiology agreed with this management. He was transfered
out of the ICU and did well on oral metoprolol up to discharge
without any hemodynamic instability.
RESPIRATORY: The patient had no episodes of desaturation or
pulmonary concerns. The patient denied cough or respiratory
symptoms. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation.
GASTROINTESTINAL: The patient was NPO on admission and on HOD#2
experienced significant abdominal distention and episodic emesis
requiring nasogastric tube placement. The NGT was discontinued
on HOD#3 and was replaced on HOD#6 when complained of increasing
abdominal discomfort and epigastric bloating. The second NGT
placement resulted in 2.5L of bilious return. He was eventually
showing improvement, the NGT was removed and clear liquids were
tolerated. He did receive 2-days of supplemental TPN, but this
was discontinued and the patient was again allowed to maintain a
regular diet, as tolerated.
The patient underwent a CT of the abdomen and pelvis on
admission that showed a right lobe of the liver rim enhancing
collection measuring 4.0 x 5.6 cm that contained foci of air,
concerning for abscess. There was increased ascites compared to
the prior exam and increased intrahepatic biliary duct and
pancreatic duct
dilation, likely secondary to known pancreatic mass. He
underwent CT-guided aspiration and drainage of a gallbladder
fossa collection on HOD#2 with placement of an 8-French [**Last Name (un) 2823**]
catheter, and 30 cc of purulent material were aspirated to bag
and gravity. 1-cc was sent for microbiology specimen. The
culture returned mixed bacterial flora and he was started on
Vancomycin and Zosyn IV on admission. He was continued on these
antibiotics until PO intake was established, at which time the
patient was transitioned to oral Augmentin. IV antibiotics were
resumed when his ICU transfer was instated, and a 10-day course
was completed. The drainage catheter was removed prior to
discharge.
Patient underwent ERCP with placement of mental biliary stent.
The duodenal was not obstructed as previously thought and no
stents were placed. Oncology and palliative consults were
obtained. He was discharged with heme/oncology and palliative
care follow-up regarding possible chemotherapy and hospice
services.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed on admission to monitor urine output and was removed on
HOD#2, at which time the patient was able to successfully void
without issue. The patient's intake and output was closely
monitored for urine output > 30 mL per hour output. The
patient's creatinine was stable.
HEME: The patient's hematocrit was stable and trended closely.
He did have a single episode of bloody bowel movement which
resolved without issue; and serial hematocrits were stable. The
patient remained hemodynamically stable and did not require
transfusion. The patient's coagulation profile remained normal.
The patient had no evidence of bleeding.
ID: The patient was admitted with a WBC of 26.0 which trended
down following drainage and IV antibiotic treatment. The patient
underwent a CT of the abdomen and pelvis on admission that
showed a right lobe of the liver rim enhancing collection
measuring 4.0 x 5.6 cm that contained foci of air, concerning
for abscess. There was increased ascites compared to the prior
exam and increased intrahepatic biliary duct and pancreatic duct
dilation, likely secondary to known pancreatic mass. He
underwent CT-guided aspiration and drainage of a gallbladder
fossa collection on HOD#2 with placement of an 8-French [**Last Name (un) 2823**]
catheter, and 30 cc of purulent material were aspirated to bag
and gravity. 1-cc was sent for microbiology specimen. The
culture returned mixed bacterial flora and he was started on
Vancomycin and Zosyn IV on admission. He was continued on these
antibiotics until PO intake was established, at which time the
patient was transitioned to oral Augmentin. However, he was
restarted on IV antibiotics when transfered to the ICU and these
were completed during his hospitalization. The drainage catheter
was kept in place on discharge. Blood and urine cultures were
unrevealing. He remained afebrile on admission, despite the
above collection.
ENDOCRINE: The patient's blood glucose was closely monitored
with Q6 hour glucose checks. Blood glucose levels greater than
120 mg/dL were addressed with an insulin sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately once cleared by physical therapy. The patient also
had sequential compression boot devices in place during
immobilization to promote circulation. GI prophylaxis was
sustained with Protonix/Famotidine when necessary. The patient
was encouraged to utilize incentive spirometry, ambulate early
and was discharged in stable condition with follow-up with
hospice and heme/oncology appointments. He will have VNA nursing
services and PT support as a bridge to hospice care.
Medications on Admission:
albuterol 5 mg/mL neb prn, alprazolam 1 mg'''', plavix 75 mg',
effexor 75 mg' QOD, finasteride 5 mg', fluticasone-salmeterol
250/50 mcg', glipizide 2.5 mg'', ipatroprium-albuterol 18/103
mcg'', lisinopril 10 mg', metoprolol 100 mg', percocet 5/325 mg
QID prn, promethazine 6.25 mg/5 mL' 0.5 (One half) teaspoon
daily, aspirin 325 mg', docusate 100 mg', flaxseed oil,
magnesium oxide 400 mg'', omega-3 FAs 1000 mg'', Lidocaine 5 %
Topical Cream as needed
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
8. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QOD ().
9. morphine 10 mg/5 mL Solution Sig: [**6-19**] mL PO Q4H (every 4
hours).
Disp:*300 mL* Refills:*0*
10. 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*
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety, agitation, signs of withdrawal.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
peri-hepatic abscess/fluid collection
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 Dr.[**Name (NI) 9886**] surgical service for
evaluation and management of your peri-hepatic fluid collection.
You are now being discharged home. Please follow these
instructions to aid in your recovery:
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication.
* Please take any new medications as prescribed.
* Please take the prescribed analgesic medications as needed.
You may not drive or operate heavy machinery while taking
narcotic analgesic medications. You may also take acetaminophen
(Tylenol) as directed, but do not exceed 4000 mg in one day.
* Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
* Avoid strenuous physical activity and refrain from heavy
lifting greater than 10 lbs., until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Please also follow-up with your primary care physician.
Followup Instructions:
You will be contact[**Name (NI) **] by Hospice of [**Name (NI) 86**] & Greater [**Hospital1 1474**]
regarding Hospice options. There number is [**Telephone/Fax (1) 39156**] - please
contact them this week regarding follow-up with them.
You will be contact[**Name (NI) **] by the outpatient hematology/oncology
service regarding a follow-up appointment; if you don't hear
from them in [**2-12**] days, please call their office at ([**Telephone/Fax (1) 63419**].
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-8-17**] 11:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2136-8-17**] 12:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 611**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-8-17**] 12:00
|
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"293.0",
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icd9cm
|
[
[
[]
]
] |
[
"51.87",
"38.93",
"50.91",
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] |
icd9pcs
|
[
[
[]
]
] |
11799, 11854
|
3430, 9759
|
332, 440
|
11936, 11936
|
2156, 3407
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,092
| 130,016
|
17088
|
Discharge summary
|
report
|
Admission Date: [**2197-6-7**] Discharge Date: [**2197-6-14**]
Date of Birth: [**2124-8-21**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
woman who fell three to seven days ago. She has a history of
dementia. She was taken to an outside hospital where a head
CT showed a left subdural hematoma with a 2 cm midline shift.
The patient noticed change in mental status with right-sided
weakness. The patient was transferred to [**Hospital1 346**] for further management.
PHYSICAL EXAMINATION: On examination the patient was
pleasant and cooperative in no acute distress. Temperature
was 96.4, pulse 61, blood pressure 167/64, respiratory rate
16, saturations 98% on room air. Pupils were equal, round
and reactive to light. Extraocular movements were full.
Chest was clear to auscultation. Cardiac was regular rate
and rhythm. The patient was neurologically oriented to self.
Cranial nerves II-XII were intact. The patient had a
right-sided drift with right lower extremity weakness as
well. Reflexes were 2+ throughout. She had a negative
Babinski.
LABORATORY DATA: White count was 4.8, hematocrit 38.1,
platelet count 174, sodium 137, K 3.8, chloride 103, CO2 20,
BUN and creatinine were 17 and 1.0, glucose 107. Head CT
showed a large left frontotemporoparietal subdural hematoma
with midline shift. The patient had bedside drainage of the
subdural hematoma in the intensive care unit without
complications. The drain remained in place until [**2197-6-8**]
where repeat head CT showed good evacuation of the subdural
hematoma. The patient's drain was discontinued on [**2197-6-9**]
and the patient was transferred to the regular floor. She
was awake, alert and oriented x 3, moving all extremities
with resolution of the right-sided weakness. She was seen by
physical therapy and found to be safe from a physical
standpoint to discharge home, although the patient continue
to have poor short-term memory due to her dementia. It was
felt that the patient was unable to be discharged home
without 24-hour supervision. Therefore her discharge was
delayed secondary to placement. The family did consent to
take her home and she was discharged on [**2197-6-14**] with her
sister for 24-hour supervision and follow up with Dr. [**Last Name (STitle) 1132**]
in one month with repeat head CT.
DISCHARGE MEDICATIONS:
1. Trazodone 25 mg p.o. q.h.s. p.r.n.
2. Famotidine 20 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable at the time of discharge.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] in one month
with repeat head CT.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2197-6-14**] 09:42
T: [**2197-6-14**] 10:03
JOB#: [**Job Number 48034**]
|
[
"E878.8",
"294.8",
"253.6",
"998.12",
"852.20",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.09"
] |
icd9pcs
|
[
[
[]
]
] |
2396, 2467
|
2538, 2888
|
558, 2373
|
173, 535
|
2492, 2526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,848
| 151,372
|
35753
|
Discharge summary
|
report
|
Admission Date: [**2183-1-20**] Discharge Date: [**2183-1-25**]
Date of Birth: [**2112-11-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
[**2183-1-20**] Four Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending, vein grafts to
diagonal, obtuse marginal and left PDA)
History of Present Illness:
Mrs. [**Known lastname **] is a 70 year old female with exertional angina for
several years. She reportedly has a positive nuclear stress
testing from [**2182-12-12**] which prompted a cardiac
catheterization which revealed severe two vessel coronary artery
disease. She has normal LV function on echocardiogram without
valvular disease. She was referred for surgical
revascularization.
Past Medical History:
Coronary Artery Disease
Hypertension
Dyslipidemia
NIDDM
Obesity
Chronic Renal Insufficiency
Anemia
Fatty Liver
Back Pain
GERD
History of Asthma
History of Skin Cancer
Bilateral Breat Lumpectomies
Prior Cholecystectomy
Social History:
Quit tobacco [**2161**]. Denies ETOH. Retired Inspector
Family History:
Brother with MI, s/p stenting in his 50's.
Physical Exam:
BP 142/76, P 92, R 16
Height 64 inches
Weight 198 lbs
General: Elderly female, over weight, no acute distress
Skin: Unremarkable, left facial scar
HEENT: PERRLA, EOMI, sclera anicteric, oropharynx benign
Neck: Supple, no JVD
Chest: Clear bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft 2/6 systolic
murmur
Abdomen: soft, NT,ND with normoactive bowel sounds
Ext: Warm, no edema
Neuro: Severe tremor o/w non-focal
Pulses: 1+ distally, ??transmitted murmur noted over carotid
regions
Pertinent Results:
[**2183-1-20**] Intraop TEE:
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
atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. Right ventricular chamber size is normal. with normal
free wall contractility.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Trivial
mitral regurgitation is seen.
POST-CPB: On infusion of phenylephrine. A-pacing. Preserved
biventricular systolic function. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Ascending
aorta contours intact.
[**2183-1-24**] 04:30AM BLOOD WBC-10.4 RBC-2.98* Hgb-9.3* Hct-26.2*
MCV-88 MCH-31.1 MCHC-35.4* RDW-14.9 Plt Ct-171
[**2183-1-24**] 04:30AM BLOOD Glucose-73 UreaN-37* Creat-1.5* Na-135
K-3.7 Cl-98 HCO3-31 AnGap-10
[**2183-1-25**] 05:41AM BLOOD UreaN-35* Creat-1.4*
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please
see dictated operative note. Following the operation, she was
brought to the CVICU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated without
incident. She was weaned from her pressors and her chest tubes
were removed. She was transferred to the surgical step down
floor, where her epicardial wires were removed. She was seen in
consultation by the physical therapy service. By post operative
day 5 she was ready for discharge to home.
Medications on Admission:
Simvastatin 20 qd, HCTZ 12.5 qd, Zantac 75 qd, Amaryl 1 qd,
Lisinopril 20 qd, Amlopidine 10 qd, Aspirin 81 qd, MV, Zoloft 50
qd, Metoprolol 50 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-13**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*qs * Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
Disp:*30 * Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 3 weeks.
Disp:*42 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 3 weeks.
Disp:*42 Tablet(s)* Refills:*0*
13. 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:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypertension
Dyslipidemia
NIDDM
Obesity
Chronic Renal Insufficiency
Anemia
Fatty Liver
Discharge Condition:
Good
Discharge Instructions:
1)No driving for at least one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery.
3)Do not apply creams, lotions or ointments to surgical
incisions.
4)Shower daily and wash surgical incsions daily with soap and
water only. Pat dry incisions, no rubbing. No baths or swimming.
5)Please call cardiac surgeon immediately if there is concern
for wound infection. [**Telephone/Fax (1) 170**].
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-16**] weeks, call for appt
Dr. [**Last Name (STitle) 5874**] in [**1-14**] weeks, call for appt
Dr. [**Last Name (STitle) 8049**] in [**1-14**] weeks, call for appt
Completed by:[**2183-1-25**]
|
[
"571.8",
"413.9",
"493.90",
"V88.01",
"530.81",
"V15.82",
"V45.79",
"V10.83",
"V17.3",
"250.00",
"278.00",
"403.90",
"414.01",
"285.9",
"272.4",
"V58.67",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.93",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5876, 5935
|
3407, 4047
|
293, 468
|
6101, 6108
|
1792, 3384
|
6576, 6810
|
1215, 1259
|
4243, 5853
|
5956, 6080
|
4073, 4220
|
6132, 6553
|
1274, 1773
|
236, 255
|
496, 884
|
906, 1125
|
1141, 1199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,761
| 175,628
|
14670+56568
|
Discharge summary
|
report+addendum
|
Admission Date: Discharge Date: [**2184-5-28**]
Date of Birth: [**2135-3-30**] Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE: The patient was taken to the cardiac
catheterization laboratory on [**2184-5-19**] which showed a normal
left ventricular ejection fraction with normal left
ventricular systolic function, 50% left main stenosis with
distal eccentric plaque, subtotal in-stent restenosis in an
ostial proximal portion of the left circumflex stent. In
addition, there was a jailed ramus, high marginal with
subtotal ostial proximal narrowing. The patient was referred
for evaluation by Cardiac Surgery.
The patient was taken to the Operating Room with Dr.
[**Last Name (STitle) 70**] on [**2184-5-20**] for a CABG times three, LIMA to LAD,
free RIMA to OM3, sequential graft to the ramus. Please see
the operative note for further details. The patient was
transferred to the Intensive Care Unit in stable condition.
The patient was weaned and extubated from mechanical
ventilation on the first postoperative night.
After the patient was extubated, the patient began
complaining of jaw pain which had previously been his anginal
equivalent. Multiple EKGs were performed, none of which
showed any ischemic changes. The patient was placed on a
nitroglycerin drip without any change in the jaw pain.
On the morning of postoperative day number one, it was
decided to have the patient return to the catheterization
laboratory to evaluate his graft in light of the continued
jaw pain. In the Cardiac Catheterization Lab, it was shown
that there was a lesion at the touchdown of the free RIMA
graft with the OM1 with a 99% occlusion. It was decided by
Dr. [**Last Name (STitle) 70**] to have the patient return to the Operating
Room for revision of this graft.
On postoperative day number one, the patient was taken back
to the Operating Room for a reduced CABG times one, at which
point a saphenous vein graft was placed as a Y graft from the
ramus to the free RIMA. The patient also tolerated the
procedure well, required dobutamine immediately
postoperatively for maintenance of cardiac output and was
transferred to the Intensive Care Unit in stable condition.
Please see the second operative note for further details.
The patient had elevated chest tube output on postoperative
day number one after his reoperation and required several
transfusions of platelets and packed red blood cells. The
patient remained intubated on mechanical ventilation with
significant hypoxia and a chest x-ray that showed pulmonary
edema. The patient began aggressive diuresis in attempts to
wean him from mechanical ventilation. The patient was able
to wean off the dobutamine on [**2184-5-22**] with adequate cardiac
output.
On postoperative day number two, the patient continued to be
intubated on mechanical ventilation with hypoxia. The
patient remained sedated on propofol for his comfort and
aggressive diuresis continued. By postoperative day number
three, the patient's hypoxia was improving and the amount of
support that the patient was receiving from mechanical
ventilation was weaned down. The patient was extubated from
mechanical ventilation on postoperative day number three
which he tolerated well. The patient continued to have
aggressive diuresis.
He began ambulating with Physical Therapy on postoperative
day number four. On postoperative day number five, the
patient was transferred from the Intensive Care Unit to the
regular floor. The patient continued to ambulate with
Physical Therapy. The patient's oxygen requirement decreased
dramatically as the patient was able to tolerate diuresis.
By postoperative day number six, the patient had completed a
level V with physical therapy, was able to walk 500 feet and
climb one flight of stairs without difficulty. The patient
had remained hemodynamically stable without any further
complaints of chest or jaw pain. The patient had been in
stable rhythm with adequate blood pressure. The patient's
epicardial pacing wires had been discontinued without
difficulty and by postoperative day number seven, the patient
was cleared for discharge to home.
PHYSICAL EXAMINATION ON DISCHARGE: T maximum 98, pulse 74,
sinus rhythm, blood pressure 108/60, respiratory rate 14,
room air oxygen saturation 94%. Neurologically, the patient
was awake, alert, and oriented times three, anxious to leave
the hospital. Cardiovascular: Regular rate and rhythm, no
rub, no murmur. Respiratory: Breath sounds were clear
bilaterally. GI: Positive bowel sounds, soft, nontender,
nondistended, tolerating a regular diet. The sternal
incision was clean and dry without erythema. The vein
harvest site was clean and dry without erythema.
LABORATORY/RADIOLOGIC DATA: White blood cell count 9.6,
hematocrit 30.2, platelet count 486,000. Sodium 138,
potassium 4.9, chloride 104, bicarbonate 24, BUN 13,
creatinine 0.7, glucose 98.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Zantac 150 mg p.o. b.i.d.
3. Percocet 5/325 mg one to two tablets p.o. q. six hours
p.r.n.
4. Aspirin 81 mg p.o. q.d.
5. Imdur 30 mg p.o. q.d.
6. Verapamil 20 mg p.o. q. eight hours.
7. Lopid 600 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post CABG with reoperation for postoperative
anastomotic lesion.
3. Hypercholesterolemia.
4. Remote 45 pack year smoker.
5. History of nephrolithiasis.
FOLLOW-UP: The patient is to follow-up with Dr.
.................... for Cardiology in two weeks. The
patient is to follow-up with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17029**], in two weeks. The patient is to follow-up with
Dr. [**Last Name (STitle) 70**] in five to six weeks. The patient is to return
to [**Hospital Ward Name 121**] II in two weeks for a wound check.
DISPOSITION: The patient is to be discharged to home in
stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 43187**]
MEDQUIST36
D: [**2184-5-28**] 05:05
T: [**2184-5-28**] 18:57
JOB#: [**Job Number 43188**]
Name: [**Known lastname 7897**], [**Known firstname 2147**] Unit No: [**Numeric Identifier 7898**]
Admission Date: [**2184-5-19**] Discharge Date: [**2184-5-28**]
Date of Birth: [**2135-3-30**] Sex: M
Service: CARD [**Doctor First Name 1379**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 48 year old
gentleman who has a prior history of a non-Q wave inferior
wall myocardial infarction status post percutaneous
transluminal coronary angioplasty and stent to the mid left
anterior descending and distal right coronary artery in [**2183-5-24**]. Shortly after he had this procedure done, he had
the recurrence of jaw discomfort which had been his anginal
equivalent. The patient had multiple further imaging
procedures of his coronary disease and was managed medically
for his continued angina; however, the patient has had a two
month history of recurrent exertional chest pain progressing
to unstable angina. The patient was referred to [**Hospital1 960**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypercholesterolemia.
3. Forty-five pack year smoker who quit one year ago.
4. Nephrolithiasis.
ALLERGIES: Lipitor, Plavix and Metoprolol.
PREOPERATIVE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Verapamil 240 mg p.o. q. day.
3. Lopid 600 mg p.o. twice a day.
4. Imdur 60 mg p.o. twice a day.
5. Welchol.
6. Zydia.
7. Folic acid.
PHYSICAL EXAMINATION: On admission,
Report incomplete.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2184-5-28**] 16:51
T: [**2184-5-28**] 18:35
JOB#: [**Job Number 7899**]
|
[
"996.72",
"412",
"V45.82",
"414.02",
"272.0",
"411.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"36.16",
"88.52",
"36.11",
"88.55",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4952, 5203
|
5224, 6512
|
155, 4183
|
7501, 7677
|
7701, 8075
|
4198, 4929
|
6542, 7275
|
7297, 7475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,122
| 101,961
|
4733
|
Discharge summary
|
report
|
Admission Date: [**2126-3-1**] Discharge Date: [**2126-3-3**]
Date of Birth: [**2079-4-2**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Shellfish Derived
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 46 year old man w/hx of CAD s/p inferolateral MI
[**3-25**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to proximal LCx into OM1 who presented to the
ED with chest pain. The patient reports [**4-24**] chest tightness
which started while he was walking to work this morning. He
works at [**Hospital1 **] and continued to walk from [**Location (un) 19903**]to the ED.
By the time he reached the ED, the chest tightness was [**7-25**], a
band sensation across his chest. No radiation to arm, jaw, or
back. He denies diaphoresis or nausea but does report
associated SOB. He did not take NTG. He reports rare instances
of chest pain since his MI [**3-25**] but did have an episode [**4-23**] for
which he was evaluated in the ED and it was determined to be
non-cardiac. He had an exercise tolerance test at that time
which was normal. He does not take NTG at home and does not
have any. Total time of chest pain prior to arrival to ED was
20 minutes.
.
In the ED, initial vitals were T99.2, BP175/86, HR99 RR18 O2 sat
99%. ECG showed ST elevations in II, III, AVF. He received
aspirin 325mg x 1, Plavix 600mg x 1, Morphine 4mg IV x 1. NTG
gtt, heparin gtt and integrillin gtt were started. A code STEMI
was called and he was taken to the cath lab with door-to-balloon
time of 40 minutes.
.
In the cath lab, his prior [**Month/Year (2) **] in OM1 was occluded with an acute
thrombus. An export wire extracted the clot and the patient
became chest pain free. A balloon angioplasty was performed and
IVUS showed the stent to be intact. He was given Prasugrel 60mg
X 1 in the cath lab.
.
On arrival to the CCU, the patient feels well and denies chest
pain, pressure or tightness, shortness of breath, nausea,
vomiting, headache, abdominal pain, calf pain. Of note, he
admits to missing several [**Month/Year (2) 4319**] of Plavix in the last few
months. His aspirin dose was recently decreased from 325mg to
81mg daily.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. He states that he
has had a rash in his groin area recently. All of the other
review of systems were negative.
.
Cardiac review of systems on admission is notable for absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CAD s/p inferolateral MI [**3-25**] with 2 overlapping Cypher stents
to occluded LCx into OM1
prior RCA stenting [**6-19**]
Angioedema after starting Lisinopril [**3-25**], resolved
Pneumonectomy s/p MVA
Social History:
Social history is significant for the absence of current tobacco
use, quit in [**2121**], 1ppd prior. There is no history of alcohol
abuse. Lives with his wife and 2 children. Works in purchasing
at [**Hospital1 18**].
Family History:
There is family history of premature coronary artery disease in
his father at age 41.
Physical Exam:
VS: T=97.8 BP=142/59 HR=84 RR=16 O2 sat= 99% 2L NC
GENERAL: Alert and oriented x 3, NAD. Mood, affect appropriate.
HEENT: NCAT. Slight reddened appearance to face and neck area.
Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
appreciable rash.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Right femoral cath site is clean, dry and intact with a small
soft hematoma palpable. No femoral bruits.
Pertinent Results:
ADMISSION LABS:
[**2126-3-1**] 07:59AM BLOOD WBC-8.5 RBC-4.72 Hgb-13.5* Hct-40.6
MCV-86 MCH-28.5 MCHC-33.2 RDW-14.4 Plt Ct-310
[**2126-3-1**] 07:59AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0
[**2126-3-1**] 07:59AM BLOOD Glucose-143* UreaN-12 Creat-1.1 Na-141
K-4.0 Cl-106 HCO3-21* AnGap-18
[**2126-3-1**] 07:59AM BLOOD CK(CPK)-212
[**2126-3-1**] 07:59AM BLOOD cTropnT-<0.01
----------------
DISCHARGE LABS:
----------------
STUDIES:
.
EKGs:
pre-cath: NSR at 7bpm. nl axis, nl intervals. 3mm ST elevations
in II, III, AVF, V4-V6 with ST depression sin AVL, V1, V2, V3.
Hyperdynamic T waves in V3, V4, V5.
post-cath: resolving ST elevations which are not quite as
pronounced.
.
Cardiac Cath [**3-1**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two vessel disease. The LMCA had no
angiographically apparent disease. The LAD had an origin 30%
stenosis. The LCx had a 30-40% origin stenosis and moderate
thrombus within the mid stented segment. The RCA had widely
patent stents and a 30-40% mid stenosis.
2. Limited resting hemodynamics revealed normaly systemic
arterial blood pressure with SBP 103mmHg and DBP 69mmHg.
3. Successful thrombectomy and PTCA of the OM stent thrombus
with a 3.5mm balloon.
4. Successful closure of the right femoral arteriotomy site with
a 6F Perclose device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Thrombus within mid LCx stent successfully treated with
thrombectomy and PTCA.
.
TTE [**3-1**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2124-4-14**], no change.
Brief Hospital Course:
Mr. [**Known lastname **] is a 46yo M with CAD s/p prior inferolateral MI and [**Known lastname **]
to OM1 [**3-25**] who presented to the ED with chest pain, was found
to have a STEMI and taken to the cath lab were OM1 stent showed
acute thrombus.
.
# STEMI: Patient presented with inferior STEMI, and
door-to-balloon time was 40min. In the cath lab, patient was
found to have thrombosis in the OM1 stent. An export wire
extracted the clot and the patient became chest pain free. A
balloon angioplasty was performed and IVUS showed the stent to
be intact. This acute thrombosis in the stent may be due to
missed Plavix dosing; however it is also possible that he has
failured plavix. As a result, plavix was switched to Prasugrel.
Pt was given 60mg loading dose in cath lab, and was kept on 10mg
PO qday. Patient was also continued on aspirin 325mg daily,
Metoprolol 25mg PO BID, Toprol XL 25mg daily and lipitor 80mg
daily. Patient came back from the cath lab on nitro gtt which
was promptly turned off, and he was chest pain free during the
rest of his hospital stay.
.
# PUMP: No evidence of heart failure; prior echo [**3-25**] showed
posterolateral hypokinesis with EF 50%. Repeat TTE was done on
[**3-2**], which showed EF 50-55% and mild regional left ventricular
systolic dysfunction with infero-lateral hypokinesis, not
significantly different compared to the one from approximately 2
years ago.
.
# RHYTHM: Patient was in sinus rhythm. Toprol 25mg daily was
continued.
.
# FEN: Patient received cardiac, heart-healthy diet, and he
tolerated POs well.
# PPX: Patient was on SC Heparin for DVT prophylaxis.
.
# CODE: FULL, confirmed on admission.
.
# COMM: wife [**Name (NI) 19904**]: [**0-0-**] (cell); [**Telephone/Fax (1) 19905**] (home)
Medications on Admission:
Lipitor 80mg PO qday
Plavix 75mg PO qday
Toprol XL 25mg PO qday
ASA 325mg PO qday
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Myocardial infarction
- Coronary artery disease
Discharge Condition:
Afebrile, hemodynamically stable, chest pain free
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You
were admitted to [**Hospital1 69**] after
having chest pain. You underwent a cardiac catheterization and
a blood clot was removed from the stents supplying blood to your
heart. Your Plavix was changed to Prasugrel 10mg by mouth once
a day to help prevent a clot from reforming. It is very
important that you take this medication, along with your
aspirin, every day. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
As Prasugrel was not available at your home pharmacy in [**Location (un) 10059**]
today, a prescription was sent to CVS at [**Location (un) 19906**] in
[**Location (un) 86**] that you can pick up when you are discharged.
Your other medications have not been changed. Please continue
to take lipitor, toprol XL, and full dose aspirin (325mg daily).
Followup Instructions:
You need to see Dr. [**Last Name (STitle) **], your cardiologist, within the next
two weeks. We will try to make an appointment for you this
weekend, and please call the cardiology office at ([**Telephone/Fax (1) 2037**]
on Monday to confirm your appointment. If for any reason there
is no appointment made for you over the weekend, please make one
with the receptionist at that time.
Please see you primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] V., within
1-2 weeks after discharge. Please call [**Telephone/Fax (1) 4775**] to make an
appointment.
|
[
"414.2",
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"414.01",
"V45.82"
] |
icd9cm
|
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icd9pcs
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,654
| 164,386
|
18549
|
Discharge summary
|
report
|
Admission Date: [**2198-3-19**] Discharge Date: [**2198-3-22**]
Date of Birth: [**2141-9-16**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Hypotension, bradycardia
Major Surgical or Invasive Procedure:
Central Line Placement: Right Internal Jugular Vein, Left
Internal Jugular Vein, Left Subclavian Vein ([**2198-3-19**] and
[**2198-3-20**])
History of Present Illness:
Mr. [**Known lastname 4281**] is a 56 year old male with a history of CAD s/p DES
x2 (LCx and mLAD), DM, OSA, CHF and HTN who presented to [**Hospital1 18**]
ED after 1 day of fatigue, bilateral leg pain and left arm pain.
The patient was in his usual state of health until the day prior
to admission, when he woke up with L arm pain in addition to
weakness and achiness in his legs bilaterally. His left arm pain
resolves with 2 tablets of nitroglycerin. He also reports
feeling "rotten" with general fatigue. These symptoms persisted
all day, and prompted the patient to see his cardiologist Dr.
[**Last Name (STitle) **] on the day of admission. Dr. [**Last Name (STitle) **] felt that the patient's
appearance and symptoms were significantly off of baseline and
found the patient to be hypotensive and sent him to the [**Hospital1 18**]
ED.
Of note, the patient has had several other symptoms off of his
baseline recently. He reports feeling light-headed
intermittently over the past 2 months with changes in position,
and needs to take a pause to steady himself after standing from
supine or sitting recently. In addition, he reports in the past
3-4 weeks developing mild chest pain with exertion such as
lifting objects and climbing stairs which resolves with rest. He
also develops leg achiness after prolonged walks. Of note,
patient also had a brief 20 minute of L-sided weakness on
awakening about 3-4 weeks ago for which he was going to get a
head MRI later this week. He denies dyspnea, PND, orthopnea,
palpitations, new leg swelling. No fever, chills, night sweats,
n/v/d, cough or URI symptoms, abdominal pain, changes in
bowel/bladder habits. Patient also denies any history of thyroid
disease, headaches, rashes or other skin changes, any new or
changed medications or any deviation from his normal medication
regimen/adherence in the past weeks/months.
In the ED, the patient's vitals were 96% 2L 115/75 afebrile, 54,
13. Because of concern for stroke, the patient had a CT Head
which was negative for acute intracrnial process. Shortly after
arrival to the ED, the patient became hypotensive to the 70-80's
with some latered mental status. A RIJ central line was placed
and shortly afterwards, the patient's HR went down to 35, and
responded to atropine going up to 63. He received levophed and
his BPs improved to 148/80.. The patient also receieved 4.5g IV
Zosyn while in the ED and a CT Thoarx which showed no acute
processes.
On the floor, the patient's vitals were T Afebrile, HR 54, BP
126/76, RR 12, O2 Sat 95% 4L. He was stable and comfortable,
though had some clotted blood in his mouth which appeared to be
epistaxis.
Past Medical History:
Severe obstructive sleep apnea: CPAP with 3l nc
CAD status post MI and PTCA in [**2181**]
- s/p LCX stenting (2.5x18 mm Cypher) on [**2190-11-2**]
- s/p mLAD stenting (2.5 x 24mm Taxus)on [**2191-6-14**]
- Inferior ischemia after 4.5 minute stress test on [**2196-3-23**]
- [**2196-3-29**] PTCA showed widely patent stents and elevated
LV and RV filling pressures
Hyperlipidemia
HTN
Bilateral hip replacements
S/P hernia repairs
DM
"Fatty liver"
CHF
Lower back pain
Chronic R shoulder pain
Chronic hip pain
Bladder CA s/p resection
Social History:
Patient lives with girlfriend but has multiple family members
close by. Patient walks with cane secondary to bilateral hip
replacements. Quit tobacco in [**2190**] (3ppd for ~16 years) and quit
heavy EtOH use in [**2180**]. Denies IVDU. Patient works as a cook. He
is disabled. Daughter, [**First Name4 (NamePattern1) **] [**Known lastname 4281**] can be reached at [**Telephone/Fax (1) 50966**].
Family History:
Mother died in 50's, unknown cause, Father w/ CAD, passed away
72. 10 siblings, one with CAD.
Physical Exam:
Admission Physical Exam:
T Afebrile, HR 54, BP 126/76 (augmented), RR 12, O2 Sat 86% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx coated with dark,
guaiac positive fluid. No temporal tenderness.
Neck: supple, JVP 7-8cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema. Tenderness
to palpation bilaterally below knees.
Neuro: MS grossly normal. CN II-XII normal, no nystagmus, PERRL.
2+ biceps/brachioradialis/knee/ankle reflexes. 5/5 strength in
UE and LE bilaterally except for hip extensor/flexor which was
[**5-8**] bilaterally. Finger to nose testing normal, patient unable
to perform heel-to-shin testing because of leg weakness.
.
Discharge Physical Exam:
VS: 98.2 128/80 (128-188/80-96) 58 20 94% RA
GEN: NAD, AAOx3, comfortable appropriate
HEENT: mild tenderness of midclavicle near subclavian puncture
site. No hematoma.
Lungs: CTAB
Heart: nls1s2 RRR, no m/r/g
Abd: soft, NT, ND, +BS
Ext: wwp, no edema
Pertinent Results:
============================LABORATORY
DATA================================
Admission Labs:
[**2198-3-19**] 04:30PM BLOOD WBC-9.7 RBC-4.43* Hgb-14.2 Hct-38.8*
MCV-88 MCH-32.1* MCHC-36.6* RDW-13.3 Plt Ct-169
[**2198-3-19**] 04:30PM BLOOD Neuts-61.1 Lymphs-32.5 Monos-4.8 Eos-1.1
Baso-0.6
[**2198-3-19**] 04:30PM BLOOD PT-11.8 PTT-23.5 INR(PT)-1.0
[**2198-3-19**] 04:30PM BLOOD Glucose-85 UreaN-40* Creat-1.7* Na-134
K-4.3 Cl-94* HCO3-28 AnGap-16
[**2198-3-19**] 09:59PM BLOOD ALT-22 AST-23 LD(LDH)-164 CK(CPK)-56
AlkPhos-61 TotBili-0.9
[**2198-3-19**] 09:59PM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.9 Mg-1.9
.
Other notable labs:
[**2198-3-19**] 04:30PM BLOOD cTropnT-<0.01
[**2198-3-19**] 09:59PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-336*
[**2198-3-20**] 02:42AM BLOOD CK-MB-2 cTropnT-<0.01
[**2198-3-20**] 12:22PM BLOOD CK-MB-2 cTropnT-<0.01
[**2198-3-21**] 05:49AM BLOOD calTIBC-274 Ferritn-206 TRF-211
[**2198-3-19**] 09:59PM BLOOD VitB12-628
[**2198-3-20**] 01:14AM BLOOD %HbA1c-5.5 eAG-111
[**2198-3-19**] 09:59PM BLOOD TSH-0.39
[**2198-3-21**] 05:49AM BLOOD Cortsol-22.9*
[**2198-3-19**] 09:59PM BLOOD Cortsol-1.0*
[**2198-3-19**] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2198-3-21**] 05:49AM Iron-94
.
Discharge Labs:
[**2198-3-22**] 06:00AM BLOOD WBC-6.3 RBC-3.78* Hgb-12.2* Hct-33.8*
MCV-90 MCH-32.4* MCHC-36.3* RDW-13.2 Plt Ct-114*
[**2198-3-22**] 06:00AM BLOOD Glucose-96 UreaN-20 Creat-1.1 Na-141
K-3.8 Cl-107 HCO3-28 AnGap-10
[**2198-3-22**] 06:00AM BLOOD Cortsol-1.8*
[**2198-3-22**] 07:00AM BLOOD Cortsol-15.2
.
=
=
=
=
=
=
=
=
=
=
=
=================MICROBIOLOGY===================================
.
[**2198-3-19**] 4:30 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2198-3-20**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor First Name 50967**] ON [**2198-3-20**] AT 18:10.
.
RAPID PLASMA REAGIN TEST (Final [**2198-3-21**]):
NONREACTIVE.
Reference Range: Non-Reactive.
.
=
=
=
=
=
=
=
=
=
=
=
=================IMAGING========================================
CT HEAD W/O CONTRAST Study Date of [**2198-3-19**] 4:25 PM
FINDINGS: There is no intracranial hemorrhage. The [**Doctor Last Name 352**]-white
matter
differentiation is preserved. There is no edema or mass effect.
Ventricles
and sulci are normal in size and configuration. The paranasal
sinuses and
mastoid air cells are clear.
IMPRESSION: No acute intracranial process; please note MR is
more sensitive
for the detection of acute infarct.
.
CHEST (PORTABLE AP) Study Date of [**2198-3-19**] 4:55 PM
FINDINGS: The cardiomediastinal and hilar contours are
unchanged. The lung
volumes are low but clear. There is no large pleural effusion or
pneumothorax. Exam is somewhat suboptimal due to patient body
habitus.
IMPRESSION: No acute cardiopulmonary process.
.
CT CHEST & ABD & PELVIS W/O CONTRAST Study Date of [**2198-3-19**] 6:14
PM
FINDINGS: CHEST: The visualized portion of the thyroid
demonstrates a hypodense nodule in the right lobe, 16 mm in
diameter (2;2). There is no axillary, hilar, or mediastinal
lymphadenopathy. The aorta is of a normal caliber along its
course with mild calcified atherosclerotic disease at the aortic
arch branch origins. The pulmonary artery is of a normal caliber
at its trunk. Calcified atherosclerotic disease is also noted in
the coronary arteries. There is no pericardial or pleural
effusion. Mild
bibasilar atelectasis is seen. There is a small hiatal hernia.
Incidental note is made of the right central line tip coursing
into the left
brachiocephalic vein.
ABDOMEN: Within the limits of a non-contrast study, the liver
demonstrates no focal abnormality. The gallbladder is distended
with a small amount of dense material that may represent sludge
or small stones; there is no
pericholecystic stranding or fluid. The spleen is normal in size
and appearance. The pancreas and adrenal glands show no masses.
The kidneys demonstrate no hydronephrosis or perinephric fat
stranding. A small fat density in the right lower pole is most
consistent with an AML. Calcified atherosclerotic disease is
seen in a tortuous splenic artery. Calcified atherosclerotic
disease is also seen throughout the abdominal aorta and into the
iliac branches. The small and large intestine show no evidence
of obstruction. There is no free air or free fluid. There is no
lymphadenopathy.
PELVIS: Bilateral hip replacements obscure much of the pelvis.
The bladder
and rectum appear grossly unremarkable. The appendix is
visualized and is
normal.
BONES: There are no aggressive-appearing lytic or sclerotic
lesions. Again
bilateral total hip arthroplasties are seen with extensive
streak artifact
limited their status. Lucency is seen about the right femoral
component,
concerning for loosening. Additionally, a lucent line may
represent a
periprosthetic fracture of indeterminate age. Grade 1
spondylolisthesis of L5 over S1 is noted.
IMPRESSION:
1. Right central line tip in left brachiocephalic vein,
repositioning
recommended.
2. Right femoral periprosthetic lucency, concerning for
loosening or even
periprosthetic fracture - dedicated radiographs/orthopedic
evaluation
recommended for better assessment.
3. Right thyroid nodule - nonemergent ultrasound is recommended
for further
evaluation.
4. No CT findings to explain hypotension.
.
Portable TTE (Complete) Done [**2198-3-20**] at 11:57:12 AM
Exremely limited image quality. The left ventricular cavity size
is normal or small; systolic function appears grossly normal.
The right ventricular cavity appears dilated and
hypocontractile.
.
CHEST (PORTABLE AP) Study Date of [**2198-3-20**] 3:52 AM
FINDINGS: In comparison with study of [**3-19**], the IJ line has been
removed.
There is no evidence of pneumothorax. Increasing prominence of
the pulmonary vessels suggests elevated pulmonary venous
pressure with left basilar atelectatic change. Of incidental
note is an impression on the lower cervical trachea on the
right, raising the possibility of a thyroid mass.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2198-3-20**] 4:40 PM
FINDINGS: Grayscale and Doppler son[**Name (NI) **] of bilateral common
femoral,
superficial femoral and popliteal veins were performed. There is
normal
compressibility, flow and augmentation.
IMPRESSION: No evidence of lower extremity deep vein thrombosis
in either the left or right lower extremity.
Brief Hospital Course:
HOSPITALIZATION COURSE:
Mr. [**Known lastname 4281**] is a 56 year old male with a history of CAD s/p DES
x2 (LCx and mLAD), DM, OSA, CHF and HTN who presented to [**Hospital1 18**]
ED after 1 day of fatigue, bilateral leg pain and left arm pain
found to have hypotension with response to IV steroids.
.
ACTIVE ISSUES:
#Hypotension: Patient presented with hypotension of unclear
etiology. Sepsis, cardiogenic and hypovolemic causes were
quickly ruled out. While in the MICU patient received IV
steroids for possible adrenal insufficiency which improved
hypotension. Patient was continued to steroids given positive
response. Endocrine was consulted to address of question for
cortisol insufficiency. Cortisol stimulation showed that the
patient and an inappropriate response indicating adrenal
insufficiency. Endocrine postulated that it may be chronic
suppression of the adrenal access from chronic opioid use. Given
results of stim test, patient was discharged on steroid taper
and to follow up with endocrine as an outpatient.
.
# Hypoxia: Patient developed hypoxia in setting fluid overload
on top of chronic hypoxia from severe OSA. With resuming home
bumex, patient was able to ambulate with difficulty or hypoxia.
.
# Bradycardia: In setting of placing central venous catheter,
patient had vagal episode resulting in bradycardia requiring
atropine. After readjusting CVL, patient no longer had
bradycardia
.
# Acute Renal Failure: Patient had elevated Cr in setting of
hypotension with fluid resuscitation and improvement of
hypotension, Cr returned normal.
.
# Hypertension: Given presenting hypotension, anti-hypertensives
were held on admission. Patient remained largely normotensive
after instituting steroids. Metoprolol 12.5mg [**Hospital1 **] was restarted
and lisinopril was d/c'ed.
.
# Diabetes: Patient had normal A1c on admission (although in
setting of reduced hemoglobin) as well as normal finger sticks
off oral hypoglycemics and lantus dose. Given that lantus dose
was being weaned, it was stopped after consulting endocrine.
Patient was continued on metformin. Patient should have blood
sugars monitored as outpatient with further titration of
medications.
.
INACTIVE ISSUES: The following were inactive issues. No changes
in medications or interventions were necessary:
# Chronic Leg pain
# Hyperlipidemia
# Obstructive Sleep Apnea
Medications on Admission:
Certirizine 10mg daily
Plavix 75mg daily
Lipitor 20mg daily
Bumex 2mg daily
Baby aspirin daily
Lisinopril 5 mg daily
Ativan 5mg [**Hospital1 **]
Hi-CAl ORal Liqud daily
Folic ACid 1mg [**Hospital1 **]
Dilaudid 4mg PO q6-8h PRN
Ritalin 10mg TID
Magnesium 200mg [**Hospital1 **]
Gabapentin 300mg TID
Metopolol succinate 50mg daily
Omeprazole 40 mg daily
Potassium chloride 20mg daily
Metformin 1000mg daily
Vitamin B6 100mg daily
Celexa 20mg daily
Lantus 6u qHS
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
12. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**7-11**]
hours as needed for pain.
13. prednisone 10 mg Tablet Sig: See Instructions Tablet PO
DAILY (Daily): Take 3 tabs for 2 days then take 2 tabs for 3
days, then take 1 tab for 3 days.
Disp:*15 Tablet(s)* Refills:*0*
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
15. Hi-Cal Plus Vit D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
16. diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for muscle spasm.
17. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
18. nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual As needed as needed for chest pain: Take one tablet
if having chest pain. If not relieved in 5 minutes, take another
tablet. You should notify your physician or call 911 immediately
if chest pain continues.
19. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a
day: Start on [**2198-3-31**].
Disp:*60 Tablet(s)* Refills:*0*
20. Outpatient Equipment
Automatic BP cuff
21. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
22. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0*
23. Outpatient Lab Work
Chem-7 on [**3-28**] and fax results to [**Telephone/Fax (1) 11145**] attn: Dr.
[**Last Name (STitle) 11139**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
Primary Adrenal Insufficiency
.
Secondary Diagnoses:
Diabetes Mellitis
Coronary Artery Disease
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Vital Signs Stable
Discharge Instructions:
You were admitted because you had very low blood pressure with
leg weakness. We think that your low blood pressure was from a
low steroid level in your body. We had the steroid experts (the
endocrinologists) evaluate you who recommended that you remain
on steroids until you seem them in clinic.
.
Please be sure to weigh yourself every day. If you experience a
change in greater than 3lbs, please call your doctor.
.
The following changes were made to your medications:
---- STARTED Prednisone 10mg. Please take 3 tabs for 2 more days
then take 2 tabs for 3 days then 1 tab for 3 days. On [**2198-3-31**],
start prednisone 7.5mg daily. You will remain on this dose until
you see your endocrinologist on [**4-20**].
---- STOPPED Lisinoprill. Please discuss restarting this with
your primary care physician.
[**Name10 (NameIs) **] STOPPED Lantus
---- REPLACED Metoprolol 50mg once a day with Metoprolol 12.5mg
twice a day
---- REDUCED Ritalin to 10mg daily. You told us that since you
stopped working that you only take it once a day and so will
recommend that you continue to take it once a day.
.
No other changes were made to your medications. Please be sure
to take them as directed.
.
We are also prescribing you a BP cuff; please take your BP
everyday and if the top number (systolic blood pressure) is less
than 100, please call your doctor.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 11142**], [**Location (un) **],[**Numeric Identifier 11143**]
Phone: [**Telephone/Fax (1) 11144**]
Appt: [**3-28**] at 11am
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
Appt: [**4-11**] at 1:30pm
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2198-4-20**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2198-3-29**]
|
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"414.01",
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"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17351, 17407
|
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317, 459
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,855
| 142,848
|
30513
|
Discharge summary
|
report
|
Admission Date: [**2124-5-19**] Discharge Date: [**2124-5-21**]
Date of Birth: [**2056-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central venous line placement
History of Present Illness:
This is a 68 YOM with significant CAD, CHF, and renal failure on
HD who presents with dyspnea. HE was hospitalized in [**2-16**] for
acute decompensated heart failure requiring ballon pump. After a
prolonged hospital stay was discharged to [**Hospital1 **] in [**3-15**]. He
had developed a VAP during he hospital stay and developed
difficult to treat c diff while at [**Hospital1 **]. Other than that he
states his rehab had been going well. Able to ambulate with out
dyspnea or chest pain. 2 days prior to admission developed
dyspnea while lying in bed. No changes in his medications at
rehab. No change in low salt diet. No missed dialysis sessions.
No fever or cough. No chest pain or paplitations. Significant
dyspnea at rest and orthopnea.
Past Medical History:
- NSTEMI [**1-16**] - adenosine MIBI at that time showed
lateral wall was down with distal anterior and septal ischemia,
EF 40%, treated w/ medical management
- Cardiogenic shock/CHF - in [**2-16**] requiring ballon pump. 3VD,
poor surgical candidate. Stents in [**2-16**] instead.
- VAP in [**2-16**] (enterobacter/MSSA)
- HTN
- DM - x 15+ yrs, on inuslin x 10 yrs
- CRI w/ baseline Cr 4.0, required CVVHD, Now on HD MWF
- Anemia
- blindness
- GERD
- hypercholesterolemia
Social History:
SH: Retired firefighter. Married. Used to smoke cigars and
occasionally cigarettes but quit in the [**2087**]. No EtOH.
Family History:
FH: mother - died in 50s suddenly, unknown causes; brother -
"heart problems"
Physical Exam:
Blood pressure was 108/90 mm Hg while seated. Pulse was
97beats/min and regular, respiratory rate was 30 breaths/min. He
appeared in respiratory distress, using accessory mouscles to
breath with paradoxical diaphragmatic movement. The patient was
oriented to person, place and time. The patient's mood and
affect were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVD up to the angle of the jaw. There was no thyromegaly. The
were no chest wall deformities, scoliosis or kyphosis. The lungs
decreased bilaterally with expiratory wheeze heard through out..
There were no thrills, lifts or palpable S3 or S4. The heart
sounds distant, revealed a normal S1 and the S2 was normal.
Unable to hear any rubs, murmurs, clicks or gallops.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities cool and had no
pallor, cyanosis, clubbing or edema. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed multiple weal healed ulcers.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 0 PT 0
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 0 PT 0
Pertinent Results:
C.Cath [**2124-2-22**]:
1. Severe left main and a three vessel coronary artery disease.
2. Cardiogenic shock requiring IABP for hemodynamic support.
3. Severe systolic and diastolic left ventricular dysfunction.
4. Severe MR improved with IABP and diuresis.
.
C.Cath [**2124-3-3**]:
1. Severe three vessel coronary artery disease.
2. Successful PCI of the major D1.
3. Partially successful PCI of LAD with focal in-stent
underexpansion
with high risk of restenosis.
.
EKG demonstrated sinus with bigeminy. rate 87. nl axis. nl
intervals. no st changes. TWI in V3 v4 v5, III, AVF
.
TELEMETRY demonstrated:sinus tach
.
2D-ECHOCARDIOGRAM performed on [**3-15**] demonstrated:
1.No atrial septal defect is seen by 2D or color Doppler.
2.There is moderate to severe regional left ventricular systolic
dysfunction with hypokinesia of the apex, mid and apical
portions of the inferolateral,lateral and inferior walls.
Overall left ventricular systolic function is moderately
depressed.
3.Right ventricular function is mildly depressed.
4.There are simple atheroma in the ascending aorta.
5.The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen.
7. Tip of the intraortic balloon pump in good position.
8. Post percutaneous intervention ejection fraction is slightly
improved.
.
CXR - Comparison is made to [**2124-3-13**]. The heart is normal in
size. Mediastinal and hilar contours are unremarkable. A double
lumen right tunneled central jugular venous catheter terminates
at the cavoatrial junction. There is mild interstitial edema
with fluid in the right minor fissure. There is also left
basilar retrocardiac opacity, which is vaguely defined and
mostly linear in character, which may represent atelectatic
change but is nonspecific. There is no pneumothorax.
.
CTA [**5-20**]:
IMPRESSION:
1. Left upper lobe bronchopneumonia/aspiration.
2. Bibasilar atelectasis/collapse.
3. Incompletely evaluated distended gallbladder and wall
thickening. Ultrasound can provide further information if
indicated as differential included third-spacing versus
acalculus cholecystitis.
4. Severe atherosclerotic coronary artery disease.
Brief Hospital Course:
# Dyspnea: Patient was admitted to the CCU due to his
hypotension requiring dopamine gtt. In the CCU he underwent
dialysis with improvement in his symptoms. On the evening of
admission, the patient was noted to be acutely unresponsive and
turned blue. Telemetry revealed an initial rhythm of PEA then
quickly converted to vfib. A code was called. During the code
he was shocked several times, given epi, calcium, d5, insulin,
and bicarb. He then had runs of VT and was shocked with that,
with intermittent loss of pulse. ECG was c/w inferior STEMI. He
was also given amiodarone 150 mg load and started on amio gtt.
He had a bradycardia and was started on dopamine and transiently
levophed. One etiology considered for his arrest was PE as he
was blue from shoulders up at the beginning of code. Heparin gtt
started for treatment of MI or PE. He was intubated and
remained stable overnight on pressors. Given the concern for PE
the patient underwent CTA which showed no evidence of clot.
.
# Hypotension: Following cardiac arrest the patient continued to
require pressors for BP support. On [**5-20**] his hemodynamics
continued to worsen requiring addition of more pressors for
support. On EKG he had worsening ST elevations in the anterior
leads. Given he was deemed to be not a surgical candidate he
was continued on medical management. Over the course of the
evening on [**5-20**] his status continued to worsen. He spiked a
temp. to 102 and was started on broad-spectrum antibiotics for
presumed sepsis. During this time he had recurrent episodes of
VT and was shocked for these with return to narrow-complex
rhythm. Given his worsening status despite multiple pressors
and recurrent arrythmias a discussion was had with the patient's
wife and decision was made to make the patient DNR. He was made
comfortable and expired at 5am on [**5-21**].
.
#C.Diff - Continued on PO Vancomycin.
.
#)CAD - Medical managment of probable STEMI. Continued ASA,
plavix, and statin, heparin gtt x48 hours. Beta blocker was
held.
.
#)DM - Continued NPH and SSI
.
#)Renal failure - at baseline. Patient underwent regularly
scheduled dialysis.
.
#)GERD - continued ppi
.
#)Depression - continued remeron and prozac
.
#)FEN - low salt diet
.
#)PPX - ppi, sc heparin
Medications on Admission:
guaifenesin 200 po q6hrs prn
lactulose 20 po qday prn
loperamide 2mg po q6hrs prn
MOM 30ml po prn
compazine 5mg po q6hrs prn
vancomycin 125 po tid
tylenol prn
artificial tears q2hrs prn
bisacodyl 10 pr prn
mag oxide 400mg po qday
miconzaole nitrte 2% crem topical
mirtazapine 15 po qhs
nephplex tab 1tab qday
nph 10 sq 1630, 22 sq 0800
RISS
regular insulin 2 u sq 0800
prevacid 30mg sr 1 tab po qday
plavix 75 po qday
dorzolamide/timolol op to left eye qday
prozac 20 po qday
heparin 5000u qday
asa EC 81 po qday
lipitor 40 qday
bacitracin ointment
ciclopirox olamine cream [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive Heart Failure
ESRD on dialysis
CAD
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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icd9cm
|
[
[
[]
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[
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[
[
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|
318, 387
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275, 280
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415, 1162
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1184, 1660
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1676, 1798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,813
| 149,407
|
39588
|
Discharge summary
|
report
|
Admission Date: [**2188-11-8**] Discharge Date: [**2188-11-13**]
Date of Birth: [**2119-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
leukocytosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 yo male with h/o of 3 strokes since [**Last Name (LF) **], [**First Name3 (LF) **] 10%, DM, HTN,
HL, CRI, ? protein S deficiency who presents with PNA and severe
sepsis. He was sent to the ED from [**Hospital1 **] of [**Location (un) **] for
evaluation of elevated WBC 28.3 today and elevated INR 5.22
yesterday and 3.65 today. The original plan was for transport by
EMS to NW but the ambulance was diverted to [**Hospital1 **] after there was
concern for vtach.
.
Vitals on arrival to the ED were 100.8 PR HR120 BP 131/94 RR19
85% RA. CXR was noted for a right sided PNA and pt had decreased
BS in lower right lung. Labs were notable for a lactate of 4.4,
WBC of 26.4, and HCT of 55 (49 is recent baseline). INR was 3.4.
Creatinine was 1.9 (recent baseline 1.5). Blood cx were drawn
and UA was negative for infection. EKG showed sinus tachycardia
with LBBB consistent with prior. He received vancomycin 1gram
IVx1 and levofloxacin 500mg IVx1. Cefepime was ordered but not
administered prior to arrival to the ICU. He received a 250cc
bolus of fluid and then fluid at 150cc/hr given low EF. he was
guaiac negative. Vitals prior to transfer were 98.6 Hr 120 BP
146/82 RR25 100% 4L NC.
.
Partient was most recently hospitalized here in 9/[**2187**]. Of note
he has had 3 strokes since [**5-/2188**] the first of which occured the
day prior to his planned ICD placement for EF of 10%. After
review of recent d/c summary and discussion with HCP patient is
at baseline able to follow basic commands. He was able to walk
on last discharge. He had trace right sided upper extremity
weakness. He is aphasic. He was able to sing Happy Birthday
reasonably well. Mr. [**Known lastname 35914**] had a swallowing study with video.
.
Unable to obtain history from patient or ROS
Past Medical History:
-Left MCA infarct in [**5-/2188**], [**8-/2188**]
-Left cerebellar stroke in [**8-/2188**]
-DM type 2
-HTN
-Dyslipidemia
-Chronic renal impairment
-CHF- EF 10 %, ECHO [**2188-8-29**] at [**Hospital1 2025**]
-s/p CVA times 2 (details not known)
-Protein S def?
-Bladder tumor - details unknown
Social History:
From [**Hospital1 599**] at [**Location (un) **]
Family History:
Unknown
Physical Exam:
Admission PE:
VS: 97, HR 110S, BP 115/50, RR 31, 93% ON 2L
GEN: Alert and responding to some questions with yes or no, not
to commands
HEENT: PERRL, unable to access EOM, mildly dry mm
EXT: pitting edema 2/3 up legs bilaterally, cool to palpation,
non palpable pedal pulses bil, delay cap refill ([**6-3**] secs on the
left toes)
A cutaneous skin examination including the face, neck,
trunk, back and bilateral upper and lower extremities reveals
the
following pertinent findings:
-- Left LE with well demarcated large ecchymotic, purpuric
plaque with irregular borders, some with retiform pattern with
superficial errosions. The ankle area is also noted for large
vesicle with confluent fluid. This area is tender to palpation.
Pt holding left leg with contracted knee and external rotation.
The whole leg from knee down if very cool to touch, cyanosis of
left foot.
-- Right LE also cool to touch from shin down, with areas of
erythematous papules with scab over it and linear areas of
excoriation wich appers to be to scratching scratching.
Discharge PE:
GEN: More alert today but still not following commands. NAD.
HEENT: PERRLA. MMM.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
anteriorly
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Lower Extremities: Feet cold and mottled bilaterally. No
peripheral pitting edema. Left shin bandaged with some areas of
erythema extending beyond the bandage demarcations.
Neuro/Psych: Grossly abnormal - left-sided facial drooping and
ptosis, moving UE spontaneously. Unable to perform full
neurologic examination.
Pertinent Results:
Admission Labs:
[**2188-11-8**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2188-11-8**] 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-11-8**] 09:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2188-11-8**] 08:32PM COMMENTS-GREEN TOP
[**2188-11-8**] 08:32PM LACTATE-4.4*
[**2188-11-8**] 07:52PM GLUCOSE-170* LACTATE-4.0* NA+-147 K+-4.8
CL--103 TCO2-26
[**2188-11-8**] 07:45PM UREA N-56* CREAT-1.9*
[**2188-11-8**] 07:45PM estGFR-Using this
[**2188-11-8**] 07:45PM LIPASE-19
[**2188-11-8**] 07:45PM cTropnT-0.08*
[**2188-11-8**] 07:45PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-2.3
[**2188-11-8**] 07:45PM WBC-26.4* RBC-5.86 HGB-17.7 HCT-55.0* MCV-94
MCH-30.3 MCHC-32.2 RDW-16.4*
[**2188-11-8**] 07:45PM PT-33.9* PTT-34.7 INR(PT)-3.4*
[**2188-11-8**] 07:45PM PLT COUNT-189
[**2188-11-8**] 07:45PM FIBRINOGE-847*
Imaging:
CXR [**11-8**]: Large right pleural effusion with hazy opacity,
particularly of the right lung base. Some prominent infectious
infiltrate cannot be entirely excluded. Hazy left retrocardiac
opacity likely indicates atelectasis, although multifocal nature
of pneumonia cannot be excluded.
.
Left Hip [**11-9**]: Two views of the left hip demonstrate no
fracture or malalignment.
.
CT Pelvis [**11-9**]: 1. No occult left hip or pelvic fracture is
identified. Osteopenia limits evaluation for subtle fractures,
and if there is continued clinical concern, bone scan or MRI
could be considered for further evaluation. 2. Degenerative
changes in the bilateral hips and lumbosacral spine. 3. Sigmoid
diverticulosis without diverticulitis. 4. Anasarca, which also
likely accounts for small amount of free fluid seen in the
pelvis.
.
CXR Portable [**11-10**]: In comparison with the study of [**11-8**], there
is diffuse haziness of the right hemithorax consistent with
large pleural effusion and compressive atelectasis. The
difference in the previous study reflects the change from an
upright to supine position. Retrocardiac opacification is
consistent with atelectasis and effusion. The possibility of
supervening pneumonia would have to be considered in the
appropriate clinical setting. The pulmonary vessels are
difficult to evaluate, though there is no definite
central engorgement.
.
LENIs Bilateral [**11-10**]: Non-occlusive thrombus within the left
superficial femoral and popliteal veins.
.
US Extremity [**11-10**]: No evidence of left lower extremity [**Hospital Ward Name 4675**]
cyst.
.
CT Ab-Pelvis [**11-10**]:
IMPRESSION:
1. Thrombosis of the mid SMA with distal revascularization by
collateral vessels. No evidence of bowel pneumatosis or specific
signs of bowel ischemia although this cannot be excluded.
2. Bilateral wedge-shaped hypodensities in the inferior poles of
both
kidneys, concerning for infarction. Patent renal arteries
bilaterally.
3. Complete occlusion of the common femoral arteries bilaterally
with distal reconstitution of the SFA/popliteal artery on the
left. Complete occlusion of distal flow on the right. No venous
enhancement in the lower extremities bilaterally, concerning for
extensive venous thrombosis or delayed venous return due to poor
arterial flow.
4. 8-mm filling defect in the left atrium. Though this study is
not gated for cardiac imaging, this finding is concerning for
thrombus within the heart or possibly a mass.
5. Large right and moderate left-sided pleural effusions with
associated atelectasis.
6. Moderate ascites as well as stranding within the
mesenteric/retroperitoneal fat and subcutaneous tissues
consistent with anasarca.
Discharge Labs:
None - CMO, no labs drawn the days prior to discharge
Brief Hospital Course:
69 yo male with h/o of 3 strokes since [**Last Name (LF) **], [**First Name3 (LF) **] 10%, DM, HTN,
HL, CRI, ? protein S deficiency who presents with leukocytosis
and leg pain.
.
# PNA, Sepsis:
PNA on exam and CXR, lactate of 4.4 with WBC of 26.4 on
admission. Admitted to the ICU, started on broad spectrum
antibiotic coverage with vanc/cef/flagyl after receiving
Vanc/Levo in the ED, and gently fluid resuscitated within the
limits of a low EF (10%). Made comfort measures only by the
[**Hospital 228**] health care proxy on ICU day 4, at which point all
medical care was stopped and care was focused on alleviating the
patient's pain and agitation. Sepsis was complicated by acute on
chronic renal failure as detailed below.
.
# Comfort Measures Only:
As discussed above, the patient was made CMO on ICU day 4.
Morphine IV and Haloperidol were started for pain and agitation.
Palliative care consulted and their recommendations were to stop
haloperidol, and to transition the patient to sub-lingual
morphine and sub-lingual ativan, titrated to comfort.
.
# Sytemic thromboses, hypercoaguable state: As above, multiple
studies showed systemic thrombi (arterial and venous) in
multiple organ systems, including the heart, colon, kidneys, and
lower extremities; this is in the setting of 3 strokes over the
past 6 months. On exam, the patient's lower extremities were
mottled, cold to touch, and painful to light palpation. The
etiology of the patient's hypercoaguable state is unclear, but
previous notes have raised the possibility of Protein S
deficiency. In the ICU he was started on argatroban, which was
stopped once the patient was made CMO.
.
# Acute on chronic renal failure: Creatinine on admission was
1.9 from 1.5 on last admission. Acute injury was presumed
secondary to pre-renal pathophysiology in the setting of sepsis.
Medications were renally dosed prior to being discontinued when
the patient was made CMO.
.
# Chronic sytolic heart failure: EF 10%. Home lasix, ACEi, and
BB were held in the setting of sepsis but digoxin was continued,
and the patient was gently fluid resuscitated due to his EF. Pt
was transitioned made CMO and all cardiac meds were
discontinued.
.
DNR/DNI for the duration of the hospitalization and made CMO by
HCP.
Medications on Admission:
-metoprolol tartrate 12.5mg po BID
-Lisinopril 5mg po daily
-digoxin 0.125mg po daily
-simvastatin 10mg po qhs
-lasix 60mg qam
-ranitidine 150mg po daily
-coumadin
-ativan 1mg q6hr prn agitation
-vit D 1000 units daily
-tums 1000mg qam, 500mg qpm
-protein powder 1 scoop [**Hospital1 **]
-MVI daily
-tylenol prn
-MOM 30ml prn constipation
-dulcolax suppository 10mg pr daily
-fleet enema prn constipation
-colace 100mg po BID
-senna 1 tab po daily
-Novolog SS (i units starting at [**2187**]
-glargine 12 units q am
Discharge Medications:
1. morphine concentrate 20 mg/mL Solution Sig: 5-15 mg PO Q3H
(every 3 hours) as needed for pain or agitation.
Disp:*1000 mg* Refills:*4*
2. lorazepam 0.5 mg Tablet Sig: 0.5-1 mg PO Q4H (every 4 hours)
as needed for dyspnea, agitation, anxiety: Sublingual.
Disp:*168 mg* Refills:*4*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnoses:
-Pneumonia
-Sepsis
-Hypercoaguable state of uncertain etiology
-Arterial clots in multiple arteries (femorals and legs mostly)
as well as venous clots in many veins (SMA, both illiacs, legs,
etc)
Secondary Diagnoses
-History of stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
You were hospitalized because you had a pneumonia and systemic
infection known as sepsis; you also were found to have multiple
clots in your organs, including your heart, kidneys,
gastrointestinal tract, and legs. You were treated with
antbiotics and fluids for your infection in the ICU, however
your health care proxy and family decided on your behalf not to
continue treatment of your multiple medical problems. In keeping
with these wishes, we transferred your care from the ICU to the
regular medical floor and withdrew medical care except for
medicines to provide comfort and alleviate pain and agitation.
All of your previous medications were stopped. Please take the
following medications as needed to maximize your comfort.
# START Sublingual Morphine
# START Sublingual Ativan
You have no follow-up appointments.
Followup Instructions:
None
|
[
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"486",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11129, 11219
|
7995, 10254
|
329, 335
|
11518, 11518
|
4243, 4243
|
12572, 12580
|
2532, 2542
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10821, 11106
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11240, 11497
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10280, 10798
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11654, 12549
|
7917, 7972
|
2557, 3602
|
3616, 4224
|
277, 291
|
363, 2133
|
4260, 7901
|
11533, 11630
|
2155, 2450
|
2466, 2516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,185
| 198,839
|
36228
|
Discharge summary
|
report
|
Admission Date: [**2150-7-14**] Discharge Date: [**2150-7-24**]
Date of Birth: [**2079-7-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
intermittent chest pain
Major Surgical or Invasive Procedure:
[**2150-7-15**] [**Month/Day/Year **] artery bypass times one (SVG to OM), mitral
valve repair
History of Present Illness:
Ms. [**Known lastname 60333**] reports having had a myocardial infarction in [**5-14**]
in [**Country 13622**] republic. She has had intermittent chest pain
since. She was taken to [**Hospital3 **] ED on [**6-15**] where she ruled
in for MI with troponin 0.27. Further cardiac workup was done
and the cardiac Cath revealed 4+MR [**First Name (Titles) **] [**Last Name (Titles) **] disease. She was
transferred to [**Hospital1 18**] for consultation with Dr.[**Last Name (STitle) **] for cariac
surgery.
Past Medical History:
hypertension
status post anterior myocardial infarction [**5-14**], and [**2150-6-15**]
anxiety
hypercholesterolemia
non-insulin dependent diabetes mellitus
renal calculi
*chronic urinary tract infection
status post tubal ligation
Social History:
Lives with son and does not smoke or drink alcohol.
Family History:
Unremarkable
Physical Exam:
Pulse: Resp:16 O2 sat:
B/P Right: 112/66 Left:112/66
Height:152cm Weight:79.4kg
General:WDWN in 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: none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2150-7-21**] 02:12AM BLOOD WBC-14.3* RBC-3.54* Hgb-10.7* Hct-29.9*
MCV-84 MCH-30.1 MCHC-35.7* RDW-14.1 Plt Ct-295
[**2150-7-14**] 07:15PM BLOOD WBC-8.3# RBC-4.33 Hgb-12.2 Hct-36.4
MCV-84 MCH-28.1 MCHC-33.5 RDW-12.5 Plt Ct-281
[**2150-7-19**] 01:43PM BLOOD PT-15.7* PTT-34.3 INR(PT)-1.4*
[**2150-7-14**] 07:15PM BLOOD PT-13.6* PTT-26.4 INR(PT)-1.2*
[**2150-7-21**] 02:12AM BLOOD Glucose-88 UreaN-58* Creat-1.4* Na-133
K-3.8 Cl-93* HCO3-30 AnGap-14
[**2150-7-14**] 07:15PM BLOOD Glucose-163* UreaN-33* Creat-1.1 Na-135
K-4.4 Cl-95* HCO3-29 AnGap-15
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 82124**] [**Hospital1 18**] [**Numeric Identifier 82125**]Portable TTE
(Focused views) Done [**2150-7-19**] at 11:47:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2079-7-3**]
Age (years): 71 F Hgt (in): 61
BP (mm Hg): 97/51 Wgt (lb): 185
HR (bpm): 64 BSA (m2): 1.83 m2
Indication: H/O cardiac surgery. Left ventricular function.
Right ventricular function. Tamponade. Valvular heart disease.
ICD-9 Codes: 423.3, 424.0, 424.2
Test Information
Date/Time: [**2150-7-19**] at 11:47 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]:
Doppler: Limited Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W017-0:00 Machine: Vivid [**8-10**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 46 ms
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.57
Mitral Valve - E Wave deceleration time: 164 ms 140-250 ms
TR Gradient (+ RA = PASP): <= 20 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2150-6-18**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Mildly thickened aortic valve leaflets (?#). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Calcified tips of papillary muscles.
Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Suboptimal image quality - bandages, defibrillator pads
or electrodes. Suboptimal image quality as the patient was
difficult to position. Emergency study performed by the
cardiology fellow on call. Left pleural effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Overall systolic function is good
(LVEF = 35-40%) with inferior and inferolateral hypokinesis. Due
to suboptimal technical quality, other focal wall motion
abnormalities cannot be fully excluded. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. A well-seated
mitral valve annuloplasty ring is present with normal gradient.
Moderate (2+) mitral regurgitation is seen.The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2150-6-18**],
the left ventricular cavity is smaller, a mitral annuloplasty
ring is identified, and the estimated pulmonary artery systolic
pressure is lower. The severity of mitral regurgitation is
reduced, but remains moderate. Global LVEF is slightly
reduced/similar. A left pleural effusion is now seen.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2150-7-20**] 09:34
?????? [**2144**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2150-7-15**] Ms. [**Known lastname 60333**] [**Last Name (Titles) 1834**] a [**Last Name (Titles) **] artery bypass
grafting times one (SVG to OM) and a mitral repair (#26mm
[**Company 1543**] annuloplasty ring). Please refer to Dr. [**Last Name (STitle) **]
operative note for further details. She tolerated the procedure
well and was transferred in critical but stable condition to the
surgical intensive care unit. POD#1 she was extubated and weaned
from her pressors. Lines and drains were discontinued in a
timely fashion. POD#2 she was transferred to the step down floor
for further monitoring and progression. Physical therapy
consulted and evaluation was performed. Her rhythm went into
atrial fibrillation and Beta-blocker was increased. Her white
blood cell count became elevated without fever, she was pan
cultured, central line removed, and empiric antibiotics were
initiated. POD#4 she was found to have hypotension and oliguria
with associated diaphoresis. CXR showed questionable increase in
cardiac silhouette. Ms. [**Known lastname 60333**] was transferred back to the
CVICU to rule out cardiac tamponade. Transthoracic
echocardiogram was performed and no pericardial effusion was
seen. Volume and diuresis augmented her urine output and her
creatinine improved. She remained hemodynamically stable and on
POD#6 she was transferred back to the step down floor. Physical
therapy was consulted and evaluation performed. She had a slight
amount of serosanguinous drainage from her mediastinal incision,
but it dissipated after two days and the incision was without
erythema. The remainder of her postoperative course was
essentially uneventful. She continued to progress and on POD# 9
she was cleared by Dr. [**Last Name (STitle) **] for discharge to home. All follow
up appointments were advised.
Medications on Admission:
ASA 325mg/D, nitroglycerin, Xanax, nexium , Remeron, Lopid
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: PCP to assess for ongoing need after 10 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
[**Location (un) **] artery disease
mitral valve regurgitation
hypertension
acute myocardial infarction [**5-14**]
anxiety
hypercholesterolemia
non-insulin dependent diabetes
renal stones
recurrent urinary tract infection
s/p Tubal ligation
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**]
Followup Instructions:
Dr [**Last Name (STitle) **] (cardiac surgeon) in 4 weeks ([**Telephone/Fax (1) 170**]) please
call for appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73614**] (PCP) in 1 week ([**Telephone/Fax (1) 82128**]) please call
for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2150-7-24**]
|
[
"300.4",
"410.12",
"424.0",
"458.29",
"584.9",
"250.00",
"403.90",
"414.01",
"428.0",
"427.31",
"285.9",
"585.9",
"599.0",
"272.0",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"35.12",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
10325, 10400
|
7437, 9263
|
344, 441
|
10685, 10692
|
1979, 5741
|
11203, 11609
|
1313, 1327
|
9374, 10302
|
10421, 10664
|
9289, 9351
|
10716, 11180
|
5790, 7413
|
1342, 1960
|
281, 306
|
469, 973
|
995, 1227
|
1243, 1297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,771
| 177,885
|
53984
|
Discharge summary
|
report
|
Admission Date: [**2110-6-19**] Discharge Date: [**2110-6-28**]
Date of Birth: [**2063-6-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
CHIEF COMPLAINT: transfer for hepatic encephalopathy
Major Surgical or Invasive Procedure:
EGD with 2 bands placed
IR guided paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 46 y/o male with ETOH cirrhosis, previous
hepatitis C infection with spontaneous clearance in [**2109**] (recent
HCV VL undetectable), polysubstance abuse with a one-year
abstinence per notes who is transferred from OSH with acute
kidney injury, ascites, and acute encephalopathy.
He initially presented in liver decompensation with variceal
bleeding, ascites, and encephalopathy in [**2109-6-2**], and recently
established care with the transplant center in [**2110-5-4**]. His
endoscopies have shown isolated gastric varices and esophageal
varices (grade II) which have been banded x 3.
Of note, in [**2110-5-4**] while establishing care at our liver
center, he was on lasix and aldactone for ascites. His Cr was
normal at 0.6 at that time. He has also had h/o three large
volume paracentesis, partly felt to be due to poor compliance
with low salt diet. At that time, he had mild hepatic
encephalopathy and was on lactulose, having [**4-6**] BM per day.
He has a long history of alcohol and substance abuse- having
consumed 1 bottle of vodka daily for many years before stopping
last [**Month (only) 116**] upon his diagnosis of cirrhosis. He has used
prescription drugs, heroin, and methadone in the past, though
has been clean for a year. He is enrolled in AA.
Patient is currently transferred from [**Hospital **] hospital. Per Dr [**First Name (STitle) 3636**]
(pager [**Telephone/Fax (1) 110689**]), patient presented the night of [**6-17**] with
dizziness, hepatic encephalopathy, abdominal pain, n/v and [**Last Name (un) **].
She reports that he has not had a bowel movement in "a day or
so" and he was given lactulose X5 yesterday and only had 1 BM.
Per d/w patient's fiancee, he had been having abdominal pain,
nausea, and bilious vomiting 2 days PTA. 1 week PTA patient did
have tooth infection and was given amoxicillin as well as
motrin. He has been taking motrin 1x per day. Fiancee reported
that he has been adherent to medications and denied dietary
indiscretion. He has been taking aldactone 200 mg 2x/day and
lasix 80 mg qAM and 40 mg qPM at home prior to admission. He has
had 5 admissions at RIH in past 2 mo for liver decompensation.
Also, at RIH, renal was consulted and felt that [**Last Name (un) **] was
pre-renal in etiology given FEurea 12.39%. He was started on IVF
and diuretics were held. On [**6-18**], he underwent diagnostic and
therapeutic 5L paracentesis. This did not show SBP. RUQ and RUS
were performed, with results showing, "cirrhosis, portal htn,
reversal of portal venous flow, varices, and splenomegaly, mild
to moderate residual ascites s/p paracentesis, kidneys without
hydronephrosis." Lactulose was unable to be given on date of
transfer and was held due to AMS. NGT was reportedly
unsuccessful due to AMS.
On transfer, he is arousable but combative and they have started
lactulose enema's in order to prevention aspiration. Creat was
4.35. No other labs available due to poor access, but T-bili
2.8, INR 1.5, Creat 4.35. Of note, pt is in the transplant
evaluation process.
On the floor, patient is acutely agitated and without PIV
access. He is not oriented to self or place.
ROS: unable to be obtained [**3-6**] acute hepatic encephalopathy.
Past Medical History:
1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhsosis, c/b varices, encephalopathy, and ascites
requiring recurrent large-volume paracenteses
4. Grade II esophageal varices, grade I gastric varices, portal
gastropathy
5. History of hepatitis C, which cleared spontaneously.
6. Variceal UGIB [**12/2109**] s/p banding x 3
7. Hx of IVDU
8. Recurrent pancreatitis
Social History:
He lives alone. He has a fiancee who checks on him every day.
Mom is the HCP. The patient has one son. [**Name (NI) **] is unemployed
applying for disability. He used to work as salesperson. He has
VNA three times a week. He has past history of drug use such as
Percocet and OxyContin nonprescribed as well as methadone. He
also used IV heroin in the past. He has been clean from drugs
for over a year per notes. He smokes cigarettes almost one-half
pack per day.
Family History:
Negative for liver cancer, GI cancer or liver
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2, 125/80, 71, 16, 99 RA, BG 184
GENERAL: agitated male, looks older than stated age, in
restraints, not oriented to self or place
HEENT: mild scleral icterus. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 without murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB anteriorly, no crackles, wheezes or rhonchi.
ABDOMEN: moderately distended but soft, umbilical hernia present
which is reducible, non-tender to palpation, mild to moderate
ascites, hepatomegaly appreciated [**3-7**] fingerbreaths below costal
margin, ? splenomegaly, spider angiomas present
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Minimal non-pitting LE edema bilaterally.
NEURO: patient not cooperative with exam, in restraints,
agitated, not oriented to self or place, not following commands,
asterixis unable to be tested
DISCHARGE PHYSICAL EXAM:
VS: 98.3 110/75 75 20 97%RA
GENERAL: Sitting up in bed, appropriate, NAD. AOx3
HEENT: NC/AT, mild scleral icterus.
NECK: L IJ in place
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. regular rate, S1, S2 without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB without crackles, wheezes or rhonchi.
ABDOMEN: Moderately distended but soft, umbilical hernia present
which is reducible, nontender, hepatomegaly appreciated [**3-7**]
fingerbreaths below costal margin, spider angiomas present.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
NEURO: A&Ox3, no asterixis
Pertinent Results:
[**2110-6-19**] 08:55PM BLOOD WBC-5.1 RBC-3.61* Hgb-12.0* Hct-36.5*
MCV-101* MCH-33.3* MCHC-32.9 RDW-13.8 Plt Ct-106*
[**2110-6-20**] 09:00AM BLOOD WBC-4.6 RBC-3.39* Hgb-10.9* Hct-34.1*
MCV-101* MCH-32.3* MCHC-32.1 RDW-13.7 Plt Ct-105*
[**2110-6-21**] 05:55AM BLOOD WBC-5.0 RBC-3.62* Hgb-12.3* Hct-36.3*
MCV-100* MCH-33.9* MCHC-33.8 RDW-13.7 Plt Ct-108*
[**2110-6-22**] 05:10AM BLOOD WBC-11.1*# RBC-3.62* Hgb-12.2* Hct-37.3*
MCV-103* MCH-33.7* MCHC-32.7 RDW-14.0 Plt Ct-97*
[**2110-6-22**] 05:01PM BLOOD WBC-9.1 RBC-3.05* Hgb-10.3* Hct-31.0*
MCV-102* MCH-33.8* MCHC-33.3 RDW-14.1 Plt Ct-93*
[**2110-6-22**] 09:00PM BLOOD WBC-8.1 RBC-3.40* Hgb-11.4* Hct-34.3*
MCV-101* MCH-33.7* MCHC-33.4 RDW-14.8 Plt Ct-80*
[**2110-6-23**] 02:01AM BLOOD WBC-7.2 RBC-3.20* Hgb-10.7* Hct-31.9*
MCV-100* MCH-33.5* MCHC-33.5 RDW-15.2 Plt Ct-80*
[**2110-6-23**] 08:22AM BLOOD WBC-7.7 RBC-3.23* Hgb-11.0* Hct-32.3*
MCV-100* MCH-34.0* MCHC-34.0 RDW-15.3 Plt Ct-78*
[**2110-6-23**] 05:00PM BLOOD WBC-7.7 RBC-3.23* Hgb-10.7* Hct-31.8*
MCV-99* MCH-33.0* MCHC-33.5 RDW-15.1 Plt Ct-83*
[**2110-6-24**] 12:30AM BLOOD WBC-6.4 RBC-3.23* Hgb-10.8* Hct-32.3*
MCV-100* MCH-33.3* MCHC-33.3 RDW-15.9* Plt Ct-75*
[**2110-6-24**] 04:00AM BLOOD WBC-6.3 RBC-3.06* Hgb-10.2* Hct-30.4*
MCV-99* MCH-33.4* MCHC-33.6 RDW-15.8* Plt Ct-85*
[**2110-6-24**] 03:50PM BLOOD WBC-6.3 RBC-3.20* Hgb-10.7* Hct-31.9*
MCV-100* MCH-33.4* MCHC-33.4 RDW-15.8* Plt Ct-92*
[**2110-6-25**] 05:00AM BLOOD WBC-4.7 RBC-3.08* Hgb-10.0* Hct-30.7*
MCV-100* MCH-32.6* MCHC-32.7 RDW-16.0* Plt Ct-88*
[**2110-6-26**] 03:45AM BLOOD WBC-8.1# RBC-3.37* Hgb-11.3* Hct-34.9*
MCV-104* MCH-33.6* MCHC-32.4 RDW-17.0* Plt Ct-99*
[**2110-6-28**] 04:58AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.9* Hct-33.0*
MCV-100* MCH-33.2* MCHC-33.2 RDW-16.8* Plt Ct-88*
[**2110-6-19**] 08:55PM BLOOD PT-16.5* INR(PT)-1.6*
[**2110-6-20**] 09:00AM BLOOD PT-19.2* PTT-37.2* INR(PT)-1.8*
[**2110-6-21**] 05:55AM BLOOD PT-18.1* PTT-38.2* INR(PT)-1.7*
[**2110-6-22**] 05:10AM BLOOD PT-22.4* PTT-38.9* INR(PT)-2.1*
[**2110-6-22**] 05:01PM BLOOD PT-24.7* PTT-60.8* INR(PT)-2.4*
[**2110-6-23**] 02:01AM BLOOD PT-21.1* PTT-44.7* INR(PT)-2.0*
[**2110-6-25**] 05:00AM BLOOD PT-25.5* PTT-59.3* INR(PT)-2.4*
[**2110-6-26**] 03:45AM BLOOD PT-23.9* INR(PT)-2.3*
[**2110-6-27**] 05:20AM BLOOD PT-23.0* PTT-47.3* INR(PT)-2.2*
[**2110-6-28**] 04:58AM BLOOD PT-21.6* PTT-42.2* INR(PT)-2.1*
[**2110-6-19**] 08:55PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-136
K-4.6 Cl-102 HCO3-21* AnGap-18
[**2110-6-20**] 09:00AM BLOOD Glucose-120* UreaN-32* Creat-1.7* Na-141
K-4.5 Cl-104 HCO3-23 AnGap-19
[**2110-6-21**] 05:55AM BLOOD Glucose-113* UreaN-27* Creat-1.3* Na-143
K-4.1 Cl-109* HCO3-21* AnGap-17
[**2110-6-22**] 05:10AM BLOOD Glucose-164* UreaN-30* Creat-1.2 Na-139
K-4.0 Cl-104 HCO3-18* AnGap-21*
[**2110-6-22**] 05:01PM BLOOD Glucose-114* UreaN-29* Creat-0.9 Na-140
K-4.1 Cl-108 HCO3-19* AnGap-17
[**2110-6-23**] 02:01AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-139
K-3.7 Cl-103 HCO3-21* AnGap-19
[**2110-6-24**] 04:00AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-137
K-3.4 Cl-103 HCO3-23 AnGap-14
[**2110-6-25**] 05:00AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-136
K-3.2* Cl-99 HCO3-25 AnGap-15
[**2110-6-26**] 03:45AM BLOOD Glucose-115* UreaN-16 Creat-1.1 Na-137
K-3.6 Cl-102 HCO3-16* AnGap-23*
[**2110-6-27**] 05:20AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-136
K-3.5 Cl-100 HCO3-23 AnGap-17
[**2110-6-28**] 04:58AM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-135
K-3.7 Cl-97 HCO3-23 AnGap-19
[**2110-6-19**] 08:55PM BLOOD ALT-30 AST-49* LD(LDH)-240 AlkPhos-87
TotBili-3.5*
[**2110-6-20**] 09:00AM BLOOD ALT-29 AST-44* AlkPhos-71 TotBili-4.2*
[**2110-6-21**] 05:55AM BLOOD ALT-29 AST-46* AlkPhos-77 TotBili-4.3*
[**2110-6-22**] 05:10AM BLOOD ALT-27 AST-39 AlkPhos-63 TotBili-4.6*
[**2110-6-23**] 02:01AM BLOOD ALT-24 AST-34 LD(LDH)-185 AlkPhos-52
TotBili-7.3* DirBili-2.1* IndBili-5.2
[**2110-6-24**] 04:00AM BLOOD ALT-22 AST-33 LD(LDH)-174 TotBili-5.7*
[**2110-6-25**] 05:00AM BLOOD ALT-22 AST-34 AlkPhos-56 TotBili-4.9*
[**2110-6-26**] 03:45AM BLOOD ALT-23 AST-38 LD(LDH)-210 CK(CPK)-42*
AlkPhos-65 TotBili-4.3*
[**2110-6-27**] 05:20AM BLOOD ALT-24 AST-40 LD(LDH)-201 AlkPhos-69
TotBili-4.2*
[**2110-6-28**] 04:58AM BLOOD ALT-28 AST-44* AlkPhos-81 TotBili-3.9*
[**2110-6-22**] 05:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2110-6-22**] 05:10AM BLOOD CEA-5.9*
[**2110-6-28**] 04:58AM BLOOD HIV Ab-NEGATIVE
[**2110-6-22**] 05:10AM BLOOD HCV Ab-POSITIVE*
[**2110-6-22**] 05:14PM BLOOD Lactate-3.1*
[**2110-6-22**] 09:12PM BLOOD Lactate-2.9*
[**2110-6-23**] 02:30AM BLOOD Lactate-2.2*
[**2110-6-26**] 04:01AM BLOOD Lactate-10.6*
[**2110-6-26**] 09:42AM BLOOD Lactate-1.7
[**2110-6-22**] 05:10AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2110-6-19**] 11:58PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2110-6-26**] 06:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2110-6-19**] 11:58PM URINE RBC-6* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
[**2110-6-19**] 11:58PM URINE Hours-RANDOM UreaN-862 Creat-148 Na-30
K-45 Cl-12
[**2110-6-19**] 11:58PM URINE Osmolal-520
[**2110-6-23**] 04:30PM ASCITES WBC-160* RBC-790* Polys-35* Lymphs-8*
Monos-0 Mesothe-2* Macroph-55*
[**2110-6-23**] 04:30PM ASCITES TotPro-1.3 Glucose-131 LD(LDH)-71
Amylase-10 TotBili-1.2 Albumin-1.0
KUB [**6-20**]:
IMPRESSION: Nonspecific bowel gas pattern with mild small bowel
dilation. Early or partial obstruction cannot be excluded.
RUQ U/S [**6-20**]:
IMPRESSION: Cirrhosis with findings of portal hypertension.
Reversal of flow within the left portal vein and antegrade flow
within the main portal vein.
KUB [**6-22**]:
IMPRESSION: Supine and left decubitus views show there is no
pneumoperitoneum. However moderate generalized distention of
large and small bowel has progressed since [**6-20**], and
appreciable wall thickening
particularly in the transverse colon and in small bowel loops in
the left
lower abdomen is new. This is not a pattern of obstruction, but
of ileus and requires careful attention for the possible
contribution of ischemia.
CT Abdomen [**6-22**]:
IMPRESSION:
1. Diffuse small bowel wall thickening and dilation most likely
secondary to ascites, portal hypertension, and hypoalbuminemia.
There is no evidence of small-bowel obstruction.
2. There is no flow within the intrahepatic portal veins,
despite adequacy of bolus timing. Doppler ultrasound from two
days ago did show flow in the intra-hepatic branches (reversed
on the left), but the waveforms were not robust. Further
evaluation is recommended with multi-phasic CT or abdominal MRI
to confirm the suspicion of portal vein thrombosis
3. Nodular liver contour, extensive splenic and esophageal
varices consistent with cirrhosis and portal hypertension.
CXR [**6-26**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Low lung volumes. Normal size of the cardiac
silhouette. Normal hilar and mediastinal structures. No
pleural effusions. No pneumonia, but areas of atelectasis at
the left lung base. No pneumothorax. The monitoring and
support devices are constant.
CT Head [**6-26**]:
IMPRESSION: No acute intracranial hemorrhage or mass effect.
Correlate
clinically to decide on the need for further workup.
CT Neck [**6-26**]:
IMPRESSION:
1. No acute cervical spine fracture. No canal or foraminal
stenosis. Correlate clinically to decide on the need for further
workup.
2. A 2.1x1.8cm mass lesion in right parotid- ?
node/neoplasm-correlate with ultrasound/soft tissue MRI neck on
a non-emergent basis.
Brief Hospital Course:
46 y/o male with ETOH cirrhosis, previous hepatitis C infection
with spontaneous clearance in [**2109**] (recent HCV VL undetectable),
polysubstance abuse with a one-year abstinence per notes, who is
transferred from OSH with acute encephalopathy, acute kidney
injury, and ascites. On [**6-22**] had tachycardia and
hematochezia/[**Hospital 58799**] transferred to the MICU and found with portal
gastropathy/duodenopathy and esophageal varices which were
banded. Stablized and transferred from the unit. On [**6-25**], the
patient had a fall from a likely seizure with elevated lactate
to 10 and transferred to the MICU. Again, he was stabilized in
the ICU and called out to the floor on [**6-26**], without any change
in his previous management.
# Seizure: On [**6-26**] patient was witnessed to fall by roommate
with associated convulsions and bowel incontinence. The patient
was post-ictal afterwards and had an elevated lactate to 10,
which downtrended back to 1 prior to discharge. He had a normal
head CT and neck (only small parotid gland mass noted). Neuro
was consulted who recommended 24 hour EEG, which by report
showed no epileptiform activity however final read is pending at
the time of discharge. The patient has report of seizure-like
activity by fiance in the past when withdrawing from alcohol,
but otherwise has no seizure history. Neurology ultimately
recommended outpatient MRI of the brain to rule out intracranial
mass and felt that there was no indication for AEDs at this
time.
# Upper GIB: On [**6-22**] was noted to be sinus tachycardic to
120-130 with hematochezia, transferred to the unit for emergent
EGD. Bleed likely [**3-6**] esophageal varices (3 cords of grade II
varices) and severe portal gastropathy/duodenopathy. Varices
banded x2. Placed on octreotide gtt with transition to nadolol
upon discharge. HCTs stable after 2u PRBC and 2u FFP till time
of discharge without any further episodes of hematemesis or
hematochezia.
# Hepatic encephalopathy: Transferred from [**Hospital 792**]Hospital
for dense encephalopathy and acute renal failure. Attempt was
made to clear the patient with PO lactulose however this
produced no effect. On admission here it was felt that the
patient's distended abdomen and nausea/vomiting to any PO was
consistent with an obstructive process, so KUB was performed
which showed a likely small bowel ileus. The encephalopathy was
managed with PR lactulose initially with some clearing of mental
status. Eventually when ileus resolved was switched to PO
lactulose with good effect and had stable normal mental status
upon discharge.
# Acute renal failure: Resolved after albumin resuscitation. Cr
reportedly 4.35 at RIH. Renal was consulted and felt that [**Last Name (un) **]
was pre-renal in etiology given FEurea 12.39%. RUS was without
obstruction and no hydronephrosis noted. He was started on
IVF/albumin and diuretics were held, with improvement in Cr back
to baseline.
# Suspected portal vein thrombosis: Suspicion for this based on
CTA on [**6-22**]. From scans it was unclear whether this was a true
thrombosis so anticoagulation was deferred in setting of GIB.
# Ileus: Initially presented with nausea/vomiting at home for 2
days prior to presentation. After 5L paracentesis at OSH, it
was noted that his abdomen continued to be tense and tympanic to
percussion. KUB was consistent with early ileus vs SBO. CT
abdomen ruled out SBO definitively but did note dilated and
edematous loops of bowel. Eventually his ileus resolved with
standard of care therapy, at which time he was transitioned from
PR to PO lactulose with good effect.
# ETOH cirrhosis: c/b grade II esophageal varices, ascites,
encephalopathy. 5 admissions at RIH in past 2 mo for liver
decompensation. On this admission, complicated by encephalopathy
and GIB, ascites not an issue after restarting home diuretics.
The transplant workup continued. Outstanding tests include
further imaging studies of the parotid mass noted on CT neck
(per radiology, evaluate with ultrasound or MRI) as well as
PFTs.
Transitional Issues:
- possible MRI brain for seizure workup
- MRI vs ultrasound of parotid mass for transplant workup
- PFTs for transplant workup
- possible MRI for portal vein thrombosis workup
Medications on Admission:
- docusate 100 mg [**Hospital1 **]
- lactulose titrate to 4 BM per day
- lasix 40 mg qPM
- lasix 80 mg qAM
- nexium 40 mg daily
- oxycontin 40 mg q12 hrs
- prochlorperazine prn
- propanolol 10 mg tid
- aldactone 200 mg [**Hospital1 **]
- tramadol 50 mg q6 hrs prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate up or down to 3-4 bowel movements daily.
3. furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
Small bowel ileus versus obstruction
Acute renal failure
Upper GI bleeding
Suspected Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from [**State 792**]Hospital for further
management of multiple issues.
You had encephalopathy, acute renal failure, decompensation of
cirrhosis, small bowel ileus, acute gastrointestinal bleeding
and had what was likely a seizure.
We treated all of this and you improved.
Note the following changes to your medications:
STOP
Propranolol
Oxycontin - you did not need this while hospitalized here,
instead just use tramadol for pain
Compazine
START
Rifaximin 550mg by mouth twice per day
Nadolol 20mg by mouth once per day
Sucralfate 2g by mouth twice per day for one month only
Otherwise take all medications as prescribed.
Please follow-up with the liver team as below. It is also
important to get a MRI of your brain. Please discuss scheduling
this with your primary care doctor.
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2110-7-3**] at 1:15 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2110-7-3**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2110-7-3**] at 3:40 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"560.1",
"V12.09",
"572.3",
"537.89",
"571.2",
"303.93",
"456.20",
"789.59",
"276.2",
"305.93",
"452",
"305.1",
"780.39",
"584.9",
"401.9",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19741, 19747
|
14167, 18225
|
359, 408
|
19907, 19907
|
6489, 14144
|
20894, 21786
|
4571, 4618
|
18738, 19718
|
19768, 19886
|
18450, 18715
|
20058, 20374
|
4633, 4643
|
4665, 5700
|
18246, 18424
|
20404, 20871
|
283, 321
|
436, 3664
|
19922, 20034
|
3686, 4074
|
4090, 4555
|
5725, 6470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,276
| 114,680
|
1708
|
Discharge summary
|
report
|
Admission Date: [**2121-9-30**] Discharge Date: [**2121-9-30**]
Date of Birth: [**2061-5-27**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
hypoxia after ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
60 yo M with h/o HTN here for elective ERCP this am for
resection of an ampullary adenoma. After sedation with Versed
3.5, Fentanyl 75, and Phenergen 25 pt was noted to be apneic
with an O2 sat of 77%. Bag ventilation was initiated with an
increase in his sats to 100%. He was given Narcan 400 mcg IM and
Flumazanil 200 mg IV. He is currently sleeping with a O2 sat of
100% on a NRB. His BP and pulse were maintained throughout.
Past Medical History:
- HTN
- Barrett's esophagous
- hypercholesterolemia
Social History:
Married
Family History:
non-contributory
Physical Exam:
Tc 95.0 BP 141/68 HR 55 RR 8 Sat 100% 2L NC
Gen: snoring, appears comfortable
HENNT: dried blood in mouth, anicteric
Neck: large, no LAD
CV: Regular, brady, nl S1S2, No M/R/G
Lungs: anteriorly upper airway coarse breath sounds
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: sleeping but easily arousable, moving all extremities
Pertinent Results:
[**2121-9-30**] 07:30AM BLOOD WBC-6.7 RBC-4.70 Hgb-14.3 Hct-42.2 MCV-90
MCH-30.4 MCHC-33.9 RDW-13.6 Plt Ct-251
[**2121-9-30**] 07:30AM BLOOD PT-11.9 INR(PT)-1.0
[**2121-9-30**] 07:30AM BLOOD Glucose-112* UreaN-21* Creat-1.2 Na-142
K-5.1 Cl-104 HCO3-26 AnGap-17
[**2121-9-30**] 07:30AM BLOOD ALT-26 AST-47* AlkPhos-76 Amylase-111*
TotBili-1.0 DirBili-0.1 IndBili-0.9
[**2121-9-30**] 07:30AM BLOOD Lipase-41
[**2121-9-30**] 07:30AM BLOOD Albumin-4.7 Calcium-9.0 Phos-3.6 Mg-2.5
Brief Hospital Course:
# Apnea/Hypoxia secondary to sedation. Improved with
administration of Flumazinal and Narcan. Pt may have sleep apnea
as well. He was monitored in ICU, and did well and was
saturating 96% on room air. He was not somnolent. GI had raised
the possibility of sleep apnea, and an appointment was made for
him to follow-up in the sleep clinic at [**Hospital1 18**] to further
evaluate apnea.
.
# HTN: Patient was instructed to restart home BP meds when he
returns home.
.
# Ampullary adenoma. Resection not completed given hypoxia. Pt
will f/u with Dr. [**Last Name (STitle) **] as an outpatient.
.
# FEN. Regular diet.
.
# Code: Presumed full.
.
# Communication: Wife
Medications on Admission:
- Atenolol
- Lipitor
- Protonix
- Lisinopril
- ASA 81 mg daily (stopped 2 days ago)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia after sedation for an elective ERCP
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience shortness of breath or have any other
concerns.
Please resume all your home medications.
Followup Instructions:
The following appointment has been made for you in the Sleep
Clinic located on [**Hospital Ward Name 23**] 8:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**].
Date/Time:[**2121-10-15**] 10:30AM. Please arrive 15 minutes early. The
location is the [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 860**] Building, room B23.
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-2**] weeks.
Please follow up with Dr. [**Last Name (STitle) **] regarding rescheduling your
ERCP.
|
[
"272.0",
"E937.8",
"211.5",
"799.02",
"780.57",
"401.9",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
2629, 2635
|
1828, 2494
|
335, 342
|
2723, 2732
|
1328, 1805
|
2954, 3583
|
917, 935
|
2656, 2702
|
2520, 2606
|
2756, 2931
|
950, 1309
|
277, 297
|
370, 800
|
822, 876
|
892, 901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,616
| 187,951
|
38140
|
Discharge summary
|
report
|
Admission Date: [**2139-7-8**] Discharge Date: [**2139-7-12**]
Date of Birth: [**2092-11-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 46 yo female with minimal PMH who presents with
acute onset dyspnea. She injured her left ankle stepping in a
pothole about two weeks ago and subsequently developed left calf
cramping which she attributed to her injury. This continued
until today, when she got up from a chair and noticed acute
onset dyspnea. Her calf pain stopped right about the same time.
She noticed chest discomfort and lightheadedness at that time.
She went to an OSH where a CTA was positive for a large saddle
embolus. She was given 90mg of lovenox and sent to [**Hospital1 **].
In the ED, initial vs were: 98.7 122 149/105 22 100%4L. She
remained tachycardic but o/w HD stable and satting in the upper
90s on RA. She received 1500cc NS. A bedside echo showed
moderate RV dilation and mild pulm HTN. She was admitted to the
MICU for monitoring.
On the floor, she is comfortable and pleasant with no current
complaints.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
none
Social History:
Denies tobacco. Lives with husband, works from home. has one
son. [**2-7**] glasses of wine 2x/week.
Family History:
NC
Physical Exam:
Vitals: 97.6 109 146/98 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + split S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses. left ankle with
contusion/bruise over lateral maleolus. slight edema, positive
warmth. positive left calf ttp.
Pertinent Results:
[**2139-7-8**] 09:55PM GLUCOSE-96 UREA N-11 CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
[**2139-7-8**] 09:55PM estGFR-Using this
[**2139-7-8**] 09:55PM WBC-13.5* RBC-4.97 HGB-15.6 HCT-46.0 MCV-92
MCH-31.4 MCHC-33.9 RDW-13.9
[**2139-7-8**] 09:55PM NEUTS-82.4* LYMPHS-14.3* MONOS-2.3 EOS-0.7
BASOS-0.3
[**2139-7-8**] 09:55PM PLT COUNT-315
[**2139-7-8**] 09:55PM PT-12.5 PTT-28.1 INR(PT)-1.1
CTA chest from outside hospital:
Extensive filling defect within the pulmonary arterial tree with
saddle embolus at the bifurcation of the main pulmonary artery.
There is PE extending into nearly every lobar segment. There is
apparent flattening of interventricular septum which could
reflect right heart strain. No pathologically enlarged node is
noted. No pericardial effusion is visualized. No pleural
effusion is noted.
Linear atelectatic changes of the lingula and right middle lobe
noted. There is no evidence of infarct. No worrisome nodules.
The visualized part of the upper abdomen including adrenal
glands, kidneys and spleen appear unremarkable.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
IMPRESSION: Extensive bilateral pulmonary emboli with possible
right heart
strain.
Echo: [**7-9**]
The left atrium is normal in size. 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 ventricular cavity is moderately dilated with focal basal
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Dilated right ventricular cavity with basal right
ventricular hypokinesis and right ventricular pressure and
volume overload consistent with right ventricular strain in the
setting of pulmonary emboli.
Brief Hospital Course:
Assessment and Plan: 46 yo female with no PMH who presents with
DVT/PE in the setting of OCPs and left ankle injury.
DVT/PE: Presented with submassive pulmonary embolism with
evidence of right heart strain on CT and ECHO. Known risk
factors include recent left ankle injury with immobilization and
longterm OCP use. Age-appropriate cancer screening is up- to-
date and no family hx to suggest prothrombotic state. Large clot
burden with some evidence of RH strain but HD stable. No
absolute indication to lyse.
Given lovenox at the OSH prior to transfer and continued
throughout hospitalization. OCP was discontinued given
thrombogenic potential. Monitored on telemetry for first 24hrs
of hospital stay with no evidence of arrhythmia. Patient
elected for long term treatment with lovenox instead of
transitioning to oral anticoagulation given frequent travel for
work. Started on vitamin D and calcium given risks of
osteoporosis with LMWH. She will follow up with hematology to
determine whether she needs a more thorough evaluation for
thrombophilia. Patient will need at least 3 mths of
anticoagulation.
Medications on Admission:
seasonique
percocet prn
Allergies:
NKDA
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours) for 6 months.
Disp:*60 syringes* Refills:*6*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
submassive pulmonary embolism
Secondary Diagnosis:
long term oral contraceptive use
left ankle injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital3 **] with a large pulmonary
embolism, or blood clot in your lungs. You were treated with a
blood thinner called lovenox, that you will need to take twice
daily for the next 3 to 6 months. Of note, this medication can
cause some thinning of the blood, which can cause easy
bruising/bleeding.
We have made the following changes to your medication regimen:
- BEGIN TAKING Lovenox SC injections twice daily
- BEGIN TAKING calcium supplements
- BEGIN TAKING vitamin D supplements
Please take your medications as prescribed and follow up as
suggested below. If you cannot make these appointment times,
please call to reschedule. In addition, because many medications
may interact with Lovenox and increase the risk of bleeding,
please check with your doctor before taking over-the-counter
medication or herbal supplements.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F
When: [**Last Name (LF) 766**], [**2139-7-20**]:00
Address: [**Apartment Address(1) 85098**], [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 13687**]
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2139-7-17**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"453.42",
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icd9cm
|
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icd9pcs
|
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[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,897
| 114,442
|
6202
|
Discharge summary
|
report
|
Admission Date: [**2135-12-2**] Discharge Date: [**2135-12-11**]
Date of Birth: [**2076-8-3**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Zestril / adhesive tape
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain, melena, lightheadedness
Major Surgical or Invasive Procedure:
[**12-5**] Colonoscopy
[**12-5**] Upper Endoscopy
[**12-9**] Small capsule study
History of Present Illness:
This is a 59 year old male with multiple cardiac co-morbidities
including CAD (s/p CABG abd multiple caths with PCIs), chronic
angina on methadone for pain control, mechanical aortic valve on
coumadin, who presents chest pain after 3 days of dark stools,
weakness and lightheadedness. He had an INR elevated to 4.9 on
[**11-29**] and held the dose. The next day he [**Last Name (un) 4996**] noticing dark
stools and gradually became lightheaded and weak over the next 2
days. He also felt nauseous and had poor po intake. He denies
abdominal pain. He denies any increase in his stools frequency
or change in consistency. He has been having one well formed BM
per day. He denies NSAID or steroid use. He has baseline chronic
angina which he rates as [**1-27**] pain. This morning he began to
have worsening chest pain, greater than baseline which began as
a [**4-26**] pain and increased up to [**7-27**]. His current chest pain is
associated with left arm pain as is his baseline chest pain. He
called his PCP and was referred to the ED given the dark stools
and chest pain he was sent to ED for evaluation.
.
In the ED, initial vs were: 6 T 98.0 P 75 BP 121/63 RR 18 O2 sat
100%. Labs were significant for hematocrit 19.1, INR 2.3,
troponin <0.01. Melena was seen on rectal exam. EKG shows LBBB
uchanged from prior. NG lavage showed flecks of blood but was
otherwise non-bloody. Patient was given pantoprazole 80 mg bolus
+ drip, 2 units blood. For his pain he was given morphine,
dilaudid 1 mg iv. His most recent vitals prior to transfer
were: T: 99.3, P: 68, RR 12, 100/62.
.
On the floor, patient was initially complaining of [**7-27**] chest
pain which improved to [**5-27**] after morphine 8 mg iv.
Past Medical History:
1. CAD RISK FACTORS: known CAD, HTN, dyslipidemia,
2. CARDIAC HISTORY:
-CABG: [**2119**] (LIMA to LAD) due to CCATH showing total occlusion
of the RCA and circumflex arteries and an 80% left main
stenosis.
-CCATH/PCI: [**2121**], [**2123**], [**2126**] - PTCA and DES x2 of the LMCA
bifurcation (LAD and ramus), [**2126**], [**2127**], [**2128**], [**2128**], [**2129**] - [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]/Lcx, [**2130**], [**2130**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], [**2130**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22594**] anastomotic site
of LIMA to LAD, [**2130**], [**2131**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-s/p St. [**Male First Name (un) 1525**] Aortic Valve Replacement [**2130**] - on coumadin
-"intractable angina" on methadone
-hypertension
-dyslipidemia
-h/o defibrillation in [**2121**]
-nephrolithiasis
-s/p lap cholecystectomy in [**2129**]
-dCHF
-Horner's syndrome - mild
Social History:
Married. on disability [**1-19**] chest pain. Quit tobacco in [**2119**] (25
pack-year history), no EtOH, never IVDA
Family History:
Brother died of MI at age 51. Father died of MI at age 72.
sister died of uterine cancer at 58. His mother also had 'heart
issues'.
Physical Exam:
Vitals: T: 99.1 BP: 122/35 P: 71 R: 16 O2: 98% on 3L NC
General: overweight, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: minimal bibasilar crackles, otherwise clear to
auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1, mechanical S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
On discharge:
VSS, satting 97-100% on RA, afebrile
No change in physical exam except crackles gone.
No signs of volume overload.
Pertinent Results:
[**2135-12-2**] 03:18PM BLOOD WBC-5.6 RBC-2.53* Hgb-6.9* Hct-20.7*
MCV-82 MCH-27.2 MCHC-33.3 RDW-15.8* Plt Ct-153
[**2135-12-2**] 10:30PM BLOOD WBC-6.4 RBC-2.81* Hgb-8.0* Hct-23.0*
MCV-82 MCH-28.5 MCHC-34.9 RDW-15.8* Plt Ct-158
[**2135-12-3**] 03:21AM BLOOD WBC-4.7 RBC-2.91* Hgb-8.2* Hct-24.0*
MCV-82 MCH-28.2 MCHC-34.3 RDW-15.8* Plt Ct-153
[**2135-12-3**] 08:25AM BLOOD WBC-5.2 RBC-3.43* Hgb-9.4* Hct-28.5*
MCV-83 MCH-27.4 MCHC-33.0 RDW-15.9* Plt Ct-168
[**2135-12-4**] 03:49AM BLOOD WBC-4.2 RBC-3.07* Hgb-8.4* Hct-25.1*
MCV-82 MCH-27.4 MCHC-33.7 RDW-15.8* Plt Ct-151
[**2135-12-4**] 12:07PM BLOOD WBC-5.7 RBC-3.36* Hgb-9.3* Hct-28.3*
MCV-84 MCH-27.6 MCHC-32.7 RDW-15.4 Plt Ct-164
[**2135-12-2**] 10:10AM BLOOD Neuts-79.0* Lymphs-13.9* Monos-5.6
Eos-1.2 Baso-0.5
[**2135-12-2**] 10:10AM BLOOD PT-24.5* PTT-40.4* INR(PT)-2.3*
[**2135-12-2**] 03:18PM BLOOD PT-24.8* PTT-38.1* INR(PT)-2.4*
[**2135-12-3**] 03:21AM BLOOD PT-23.6* PTT-40.9* INR(PT)-2.3*
[**2135-12-4**] 03:49AM BLOOD PT-23.0* PTT-38.8* INR(PT)-2.2*
[**2135-12-2**] 10:10AM BLOOD Glucose-125* UreaN-29* Creat-1.2 Na-136
K-3.8 Cl-99 HCO3-26 AnGap-15
[**2135-12-2**] 03:18PM BLOOD Glucose-88 UreaN-24* Creat-1.1 Na-139
K-3.5 Cl-107 HCO3-26 AnGap-10
[**2135-12-3**] 03:21AM BLOOD Glucose-92 UreaN-22* Creat-1.2 Na-138
K-3.6 Cl-107 HCO3-25 AnGap-10
[**2135-12-4**] 03:49AM BLOOD Glucose-91 UreaN-21* Creat-1.3* Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
[**2135-12-4**] 03:49AM BLOOD ALT-15 AST-29 CK(CPK)-197 AlkPhos-59
TotBili-2.1*
Cardiac enzymes:
[**2135-12-2**] 03:18PM BLOOD CK-MB-4 cTropnT-<0.01
[**2135-12-2**] 10:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2135-12-3**] 03:21AM BLOOD CK-MB-3 cTropnT-<0.01
[**2135-12-4**] 03:49AM BLOOD CK-MB-4 cTropnT-<0.01
Anemia workup:
[**2135-12-2**] 10:10AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-2+ Stipple-1+
Ellipto-1+
[**2135-12-2**] 10:10AM BLOOD Hapto-48
[**2135-12-2**] 03:18PM BLOOD calTIBC-398 Ferritn-15* TRF-306 Iron-32*
[**2135-12-7**] 07:20AM BLOOD Hapto-60
[**2135-12-2**] 10:10AM BLOOD LD(LDH)-222
[**2135-12-4**] 03:49AM BLOOD ALT-15 AST-29 CK(CPK)-197 AlkPhos-59
TotBili-2.1*
[**2135-12-6**] 07:20AM BLOOD ALT-21 AST-42* AlkPhos-69 TotBili-2.8*
DirBili-0.3 IndBili-2.5
[**2135-12-6**] 01:00PM BLOOD Ret Man-6.4*
[**2135-12-7**] 07:20AM BLOOD LD(LDH)-318* TotBili-3.1* DirBili-0.3
IndBili-2.8
[**2135-12-7**] 07:20AM BLOOD LD(LDH)-318* TotBili-3.1* DirBili-0.3
IndBili-2.8
Discharge Labs:
[**2135-12-11**] 06:22AM BLOOD WBC-4.3 RBC-3.79* Hgb-10.2* Hct-30.6*
MCV-81* MCH-26.8* MCHC-33.3 RDW-15.2 Plt Ct-175
[**2135-12-11**] 06:22AM BLOOD Neuts-65.5 Lymphs-21.2 Monos-8.1 Eos-4.4*
Baso-0.8
[**2135-12-10**] 07:20AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL
Tear Dr[**Last Name (STitle) **]1+
[**2135-12-11**] 06:22AM BLOOD PT-28.4* INR(PT)-2.7*
[**2135-12-11**] 06:22AM BLOOD Glucose-84 UreaN-20 Creat-1.2 Na-137
K-3.6 Cl-100 HCO3-28 AnGap-13
[**2135-12-7**] 10:07AM URINE Hemosid-NEGATIVE
Microbiology:
Urine culture x2= negative
Blood culture x4= negative
Studies:
CXRay [**12-7**]: IMPRESSION: Left lung consolidation, compatible
with pneumonia.
CXray [**12-8**]: IMPRESSION: Left lower lobe pneumonia.
Colonoscopy [**12-5**]:
Impression: Normal colonoscopy to cecum
Recommendations: Recommend capsule endoscopy for further
evaluation of melena. Colonoscopy in 5 years
Upper endoscopy [**12-5**]:
Impression: Small hiatal hernia
Erythema and erosion in the fundus
Erythema in the antrum
Otherwise normal EGD to third part of the duodenum
Recommendations: Will proceed to colonoscopy for evaluation of
melena.
Continue PPI.
Small capsule study:
1. Sub-optimal bowel prep with a moderate amount of food debris
in the stomach and segments of the jejunum.
2. Erythema in the stomach (gastritis).
3. A few petechiae in the proximal jejunum .
4. Two angioectasias in the proximal jejunum.
5. No active bleeding site found.
SUMMARY & RECOMMENDATIONS:
Summary: Sub-optimal bowel prep with a moderate amount of food
debris in the stomach and jejunum. Mild gastritis with two
angioectasias in the proximal jejunum. No active bleeding site
found.
Recommendations: Follow up with the PCP (Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]) and
consider a small bowel enteroscopy.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 year-old man with a PMH of CAD (s/p CABG and
multiple PCIs) on aspirin, aortic valve replacement on coumadin,
dCHF who presents with chest pain, lightheadedness and melena
found to have HCT of 19.1 transferred to MICU for GI bleed. Pt
was in stable condition so transferred to cardiology service
where he underwent EGD, colonoscopy, and small capsule study
without evidence of active bleed. Pt subsequently had fevers
[**2047-12-7**] to 102 and evidence on CXray of LLL pna. Pt
defervesced on antibiotics.
.
# GI Bleed/Anemia: Pt had lightheadedness, chest pain, melanotic
stools, and a HCT of 19 on [**12-2**] admission with ED noting heme
positive stool. Pt had a supratherapeutic INR to 4.9 on
[**2135-11-29**]. He received 2 units of packed red blood cells in the
ED and another 2 units in the MICU on [**2135-12-2**] before his
transfer to cardiology service. EGD, colonoscopy, and small
capsule study were negative for active bleeding source although
small capsule study did reveal two angioectasias in the jejunum.
Hypothetically, in the setting of an elevated INR while on
aspirin and plavix, the patient may have bled from this site
which resolved at the time of study. GI bleed likely resulted in
iron deficiency anemia as the patient's labs were mostly
consistent with this--a microcytic anemia with low ferritin, low
iron, low % transferrin saturation, hypochromatic cells with the
presence of ovalocytes. Although he was iron deficient, his
marrow showed appropriate response with a retic index of 2.65%.
Accordingly the patient was started on 325 mg FeSO4 [**Hospital1 **] which
will need to be taken for greater than 2 years in order to
replete the patient's iron stores. The patient can take TID if
the constipating effects aren't limiting as patient does have
history of constipation and is already taking opiates. Also of
note, the patient had a mildly elevated indirect bilirubin,
although it is unclear what the cause of this is--however, it
was only found after transfusion as was the presence of
schistocytes; thus there may have been some low level
intravascular hemolysis present post-RBC transfusion. Notably,
the patient's LDH and haptoglobin were normal on admission,
making it extremely unlikely the patient was undergoing any sort
of hemolysis at presentation. Furthermore, urine hemoglobin and
hemosiderin were negative further aruging against intravascular
hemolysis. Coombs test was negative strongly arguing against
extravascular hemolysis. Pt was maintained and will remain on
[**Hospital1 **] PPI for now, the duration of which can be determined by GI.
Plavix was stopped since patient's last stent was placed in [**2130**]
and risk of bleeding while also on coumadin and aspirin
outweighs benefit of preventing stent thrombosis in someone with
a stent placed four years ago. Dr. [**Last Name (STitle) **] was in agreement with
this. Pt will be followed by GI as outpatient with potential
small bowel enteroscopy.
.
# Pneumonia - Patient became febrile to 102 degrees on [**12-8**] and
continued to spike on [**12-9**] with cxrays x2 demonstrating LLL
pneumonia. The pt had no cough, adventitious sounds on physical
exam, or elevated white count and his only symptom was fever.
He otherwise felt extremely well. However, because blood and
urine cultures were negative and cxray was suggestive of pna,
the patient was initially started on HAP with vancomycin and
cefepime before transitioning to PO levofloxacin, which he was
discharged on after he was afebrile on this for >24 hours. He
will complete a week long course of abx.
.
#Aortic Valve replacement: Pt had a mechanical aortic valve
replacement in [**2130**]. Coumadin was held while pt had GI bleed and
was restarted after EGD/Colonscopy and stabilization of HCT.
The pt was bridged with heparin. Target INR is 2.0-3.0
.
#Angina/ CAD: Patient has extensive cardiac history including
prior CABG and multiple PCIs, aortic valve repair, last
intervention in [**2130**] who now has chronic angina. The acute
exacerbation of his angina on presentation was likely related to
demand from anemia in the setting of his GI bleed. The patient
ruled out for ACS. His chest pain diminished with an increased
HCT. He remained on his "angina protocol" which is listed in OMR
under problem list without issue. This consists of methadone,
imdur, lorazepam prn, morphine prn. The patient otherwise
maintained his home methadone, imdur, metoprolol, aspirin, and
atorvastatin. Plavix was stopped since the patient's last stent
was in [**2130**], his reocclusions with stents have been from
restenosis (neointimal) and not actual thrombotic
(platelet-driven) events, his CAD is stable, and the risk of
bleeding is too great for the benefit offered by plavix in this
setting.
.
# Chronic dCHF: Pt was mildly volume overloaded in the MICU and
was restarted on his home diuretics with good effect. He was
euvolemic on the floor. The pt will continue with his home
diuresis regimen, consisting of torsemide [**Hospital1 **], spironolactone,
and metolazone prn, as well as his other heart failure/blood
pressure meds including metoprolol, amlodipine, and
spironolactone.
.
# Hypertension: Pt was normotensive throughout his hospital
course. He was maintained on his home regimen as stated above.
He did have wide pulse pressures likely [**1-19**] to anemia.
.
# Dyslipidemia: He was continued on atorvastatin.
.
# Elevated indirect bili: Likely from low-level hemolysis,
possibly intravascular given presence of schistiocytes post
transfusion. Gilberts is another possibility although this
wouldn't cause the presence of schistiocytes and would be
unusual in someone with CAD.
.
# Mildly elevated AST: Only occurred x1. Can monitor for
resolution.
.
# Code: Full (discussed with patient)
.
Transitional: Monitor hematocrit. Follow up with GI for
possible push enteroscopy. Treat [**Doctor First Name **]. Make sure fevers resolve
after pna treatment. Monitor pts INR as pt seems to have GI
bleeding tendency when INR is supratherapeutic. Trend
bilirubin. Monitor for resolution of elevated AST.
Medications on Admission:
Nitroglycerin 0.4 mg Sublingual Tab Sublingual prn
Toprol XL 50 mg 24 hr Tab [**Hospital1 **]
Aspirin 81 mg Tab Oral daily
Folic acid 1 mg Tab daily
Celexa 15 mg Tab daily
Lipitor 80 mg Tab Daily
Ativan 1 mg Tab Oral 1 - 2 Tablet(s) Twice daily prn
Coumadin as directed
Imdur 120 mg 24 hr Tab daily
Amlodipine 6.25mg daily
Plavix 75 mg Tab Oral daily
Xanax 0.25 mg Tab Oral TID
Methadone 15 mg Tab Oral TID
torsemide 20 mg Tab Oral [**Hospital1 **] (twice weekly two pills in am)
Miralax 17 gram
Aldactone 25 mg Tab Oral daily
Metolazone 2.5 mg Tab Oral daily
Klor-Con M20 20 mEq Tab Oral daily
Soma 250 mg Tab Oral TID
Fluocinonide 0.05 % Topical Cream Topical [**Hospital1 **] prn
Vicodin
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
[**Hospital1 **]:*6 Tablet(s)* Refills:*0*
2. Outpatient [**Hospital1 **] Work
Please have your INR drawn on Monday [**12-12**]
Please have your INR and HCT drawn on Wednesday [**12-14**]
Please have these results faxed to Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] at
[**Telephone/Fax (1) 18702**]
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
[**Telephone/Fax (1) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: can take up to 3
tabs in 15 minutes.
5. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO twice a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ativan 1 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for anxiety.
11. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: Do not take a 10 mg dose while you are on levfloxacin
unless directed by Dr. [**Last Name (STitle) **].
12. Imdur 120 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. amlodipine 2.5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
14. methadone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
15. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
17. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
19. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed: take 1 tab 1/2 hour before torsemide.
20. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO twice a day.
21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
22. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: GI bleed, Pneumonia, Iron deficiency anemia, Acute on
chronic diastolic CHF
Secondary: CAD, [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] aortic valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for chest pain accompanied by black stools, weakness,
and lightheadedness. Your HCT was 19 on admission and you were
found to have a Gastrointestinal bleed. You were transfused a
total of 5 units of PRBC with good response.
A colonoscopy, upper endoscopy and small capsule study were
conducted which revealed abnormal blood vessel dilations in the
proximal jejunum but no sites of active bleeding.
You developed fevers as high as 102 which resolved with
antibiotics. The only source that we have found is a chest x
ray concerning for left sided pneumonia. You will need to
continue treatment with levofloxacin for 6 more days.
Because you started levofloxacin, you need to closely monitor
your INR as this drug can increase the effects of coumadin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
Started levofloxacin for pneumonia
Started pantoprazole for GI bleed
Started iron pills for anemia
Stopped plavix
Your Celexa was increased to 30mg daily
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2135-12-20**] at 4:00 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], 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
Completed by:[**2135-12-19**]
|
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|
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12,483
| 199,482
|
24735
|
Discharge summary
|
report
|
Admission Date: [**2132-2-8**] Discharge Date: [**2132-3-13**]
Date of Birth: [**2071-8-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
muscle twitching and weakness to OSH
Major Surgical or Invasive Procedure:
Paracentesis [**2132-2-8**]
Paracentesis [**2132-2-12**]
TIPS procedure [**2132-3-6**]
Paracentesis [**2132-3-13**]
History of Present Illness:
This is a 60 year old woman with alcohol-induced cirrhosis, now
sober > 6 months, currently undergoing evaluation for liver
transplant, transferred from [**Hospital3 3583**] for further
management. The patient was most recently admitted to [**Hospital1 18**]
between [**1-8**] and [**2132-1-11**] for a colonoscopy and EGD with
polypectomy and biopsy.
The pt has known ascites and is on a stable regimen of lasix
and aldactone but still requires weekly paracentesis to control
her ascites (Normally >5L removed at a time by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10733**]). She presented to [**Hospital3 **] endoscopy suite for
her usual paracentesis and reported feeling weak with muscle
twitches on [**2132-2-6**]. Blood pressure at the time was found to
be 70/50 leading to an ED evaluation where the blood pressure
was confirmed and in addition she was found to have a K of 7.5
and Na of 117. In addition, she had a BUN/Cr of 79/2.6, T.Bili
of 1, Alb of 2.4, INR of 1.07 and Ammonia of 9. She was given
bicarb, insulin/d50 and oral kayexalate. ECG demonstrated no
peaked T waves (however this was done after treatment). K
decreased to 6.7. She was subsequently admitted to the ICU for
further management. The pt was hydrated overnight with increase
in systolic BP to 80s. In addition, she was given albumin and
Ceftriaxone IV. On [**2132-2-7**], paracentesis was performed with
removal of 2L of fluid. The ascites fluid (after antibiotics)
demonstrated RBC of 19,000 and WBC of 165 with 48% polys.
BUN/Cr improved to 62/1.6 but urine output remained poor. The
pt was also given a dose of lactulose as she had not had a BM
since Tues. Patient was subsequently transferred to the floor.
Past Medical History:
1. Alcoholic cirrhosis
-regular therapeutic paracentesis
-no hx GI bleed, no h/o varices
-no hx encephalopathy
2. Tubulovillous adenoma of the colon
3. Osteopenia with hx of T11 compression fracture
Social History:
EtOH: quit [**7-/2131**], states that [**Holiday **] eve, she celebrated 6
months of being sober.
Tobacco: Smoked since she was 13 years old, 1ppd now, at the
most, she was smoking 2-3ppd. No h/o IVDA.
Family History:
Mother with h/o MI, CVA. Father with h/o colon cancer.
Physical Exam:
Vitals: Temp 96.4 BP: 74/57 P: 100 RR: 16 O2sat: 97% RA
General: chronically ill-appearing cachectic female in NAD.
Lying flat and breathing comfortably on room air.
HEENT: PERRL, EOMI. No scleral icterus. MM slightly dry,
oropharynx clear.
Neck: JVD elevated ~10cm. No LAD. Supple, good ROM.
Lungs: bibasilar crackles
CV: Tachycardic with RRR S1 and S2 audible, soft systolic murmur
heard at apex
Abd: Prominent ascites, umbilicus protruding, with prominent
veins over abdomen. Tympanitic to percussion. Decreased bowel
sounds. No masses. Unable to feel liver or spleen [**3-13**] ascites.
Peripheral vasc: Brownish discoloration to lower legs
bilaterally with dry skin, stasis changes.
Neuro: motor [**6-13**], sensory [**6-13**], no asterixis, cn 2-12 intact.
appropriate in speech and conversation. AOX3.
Pertinent Results:
STUDIES AT [**Hospital **] HOSP:
CXR Portable [**2132-2-6**] at OSH: "Unremarkable with clear lungs"
Na: 123 (inc. from 117 at time of admission) K: 3.9 ([**Month (only) **]. from
7.5 at time of admission) Cl: 93 CO2: 22 BUN: 62 Cr: 1.6
Glucose: 120 Ca: 7.8
.
WBC: 14 Hct: 39.9 Plt: 149
.
INR: 1.14 PT: 12
.
Tot Prot: 4 Albumin: 2.2 Tot. bili: 1 Alk Phos: 77 ALT: 37 AST:
29
.
Colonoscopy [**2132-1-11**]: Polyp in the proximal ascending colon s/p
polypectomy.
.
EGD [**2132-1-11**]: Polyp in the duodenum s/p polypectomy
(reactive/inflammatory cellular change vs. adenomatous tissue
insufficient amunt of tissue for dx), nml esophagus, nml
stomach, No varices.
.
Abdominal CT [**2131-10-26**]:
1. Cirrhotic liver. No mass lesion demonstrated on the current
CT.
2. Large amount of intra-abdominal and pelvic ascites with
mildly nlarged spleen and portosystemic collaterals including
small enhancing esophageal varices in keeping with background
portal hypertension.
3. Cholelithiasis.
4. A 1.3-cm right adrenal nodule versus adjacent venous varix.
5. Variant hepatic arterial anatomy as described.
.
P-MIBI [**2131-12-17**]: No anginal type symptoms or ischemic EKG changes
with stress and normal myocardial perfusion with normal left
ventricular cavity size and function (EF 78%).
.
TTE [**2131-12-10**]:
-LA: normal in size.
-LV: wall thickness, cavity size, and systolic function are
normal (LVEF>55%).
-RV: chamber size and free wall motion are normal.
-Aortic valve: No AI, AS
-Mitral valve: trivial mitral regurgitation.
-PA pressure: estimated PA systolic pressure is normal.
.
HEPATIC HUNT TIPS [**2132-3-6**]: Angiographically successful
placement of a TIPS from the right portal vein to the middle
hepatic vein. Portosystemic gradient before TIPS was 24 mmHg.
Portosystemic gradient after TIPS was 9 mmHg
.
ABD/PEL UA [**2132-3-7**]: Patent TIPS with wall to wall flow. Flow
velocities in the patient's TIPS range from 56 cm proximally to
199 in the mid TIPS, and 162 in the distal TIPS. Expected
reversal of flow in the left portal vein and anterior right
portal vein is present. Unchanged large quantity of ascites in
this patient with evidence of cirrhosis.
.
[**2132-3-10**] CXR: Slightly increased right lower lobe opacity with
volume loss, most likely representing atelectasis. If there is a
strong clinical suspicion for pneumonia, further evaluation by
PA and lateral views may be helpful
Brief Hospital Course:
This is a 60 year old woman with alcoholic cirrhosis, presented
as transfer from [**Hospital3 3583**] after found to be weak with
muscle twitching on [**2132-2-6**]. K at that time was 7.5 with Na
117, treated with bicarb, insulin/d50 and oral kayexalate with
resultant K 3.9. Her Na improved to 123. Also noted at OSH to
be in ARF with Cr 2.6, improved to 1.6 after IVF hydration, felt
most likely to be prerenal given recent increase in both
spironolactone and lasix, and not hepatorenal given improvement
with diuretics being held and IVF hydration. Platelets noted to
be 149, INR 1.17. The pt usually undergoes large volume
paracentesis with weekly draining of 5-6L. She has not had
abdominal tenderness, fever, WBC at OSH 14, however, she
underwent paracentesis [**2132-2-7**] at [**Hospital3 3583**] with 2L
removed, showing 165 WBC AFTER Ceftriaxone given. She also
received albumin at OSH. Of note, she has been undergoing liver
transplant eval with Dr. [**Last Name (STitle) 497**].
.
While at [**Hospital1 18**] she was changed from ceftriaxone to cipro for SBP
pprx. She had a paracentesis on [**2-7**] (3 liters), [**2-12**] (2
liters), and [**2-14**] (2 liters) all of which were negative for SBP.
Unfortunately her renal function continued to worsen (1.0 ->
2.2). Sodium also stayed in the 120's despite fluid restriction.
Furthermore she remained hypotensive 60's to 70's. Difficult to
assess patient's volume status so renal and liver felt patient
could be better managed with closer hemodynamic monitoring. In
the MICU, CVL was placed. Per renal, it was felt pt had HRS and
ATN. Initially her UO was low, so after albumin was ineffective
in treating her BP, she was started on levophed. She underwent
paracentesis x2 with 2 L taken off on [**2-17**] and 6 L taken off on
[**2-19**]. On [**2-18**] the pt was started on ceftriaxone for tx of ?SBP
on gram stain from [**2-17**] paracentesis (elevated WBC in setting of
being on abx). She received frequent PRBC and albumin while in
the unit. The pt was found to have C diff and was started on
flagyl on [**2-19**]. She was also found to have yeast in her urine
so her foley was changed. The pts levophed gtt was weaned off on
[**2-21**] and the pt was transferred to the floor. The pt underwent 5
L volume paracentesis on the floor on [**2-21**]. Early am of [**2-24**] her
SBP was noted to be in the high 60's with a urine output of 27cc
over 8 hrs. Her creat increased from 1.0 to 1.5. She was
transferred back to the MICU for a levophed gtt until [**2-26**]. She
received multiple units of FFP, albumin, therapeutic
paracentesis on [**2-25**] and [**2-28**]. TIPs procedure was performed on
[**3-6**]. Patient remained stable after the procedure. A therapeutic
tap was performed on [**2132-3-13**] prior to discharge to rehab where
she will be followed by the Liver team at [**Hospital1 18**].
.
#?Spontaneous Bacterial Peritonitis: Of note, pt's paracentesis
at [**Hospital3 3583**] was significant for 165 WBC with 48% polys
(by criteria, neg for SBP, although pt DID receive Ceftriaxone
prior to paracentesis). IV Ceftriaxone was continued for
possible SBP. The pt has remained afebrile, with WBC ct 14 on
OSH labs. On arrival at [**Hospital1 18**], pt was afebrile, nl WBC ct with
minimal abdominal tenderness, though abdomen was very distended
3 days ago, tense, with umbilical hernia protruded and necrotic
area present on hernia. She is s/p paracentesis [**2132-2-8**], with
umbilical hernia less swollen, blue. Abdomen appeared less
tense but still distended, pt overall appeared to be improving
clinically. No nausea or vomiting. Paracentesis [**2132-2-8**]: WBC
222 with 30 polys, 45 lymphs, 14 monos. [**Numeric Identifier 56435**] RBC. epeat
paracentesis [**2-16**] was aborted (given her pressures were 60s/30s)
her baseline BP is 70s/40s. She is consented for a 2nd para.
For her low BP, she was given 50g albumin, positioned on left
side (compression of IVC given massive ascites?), with
improvement in BP. D/C'd IV Ceftriaxone [**2132-2-10**] and started po
ciprofloxacin. Pt received 50g albumin 25% during 1st
paracentesis, then was receiving qd albumin 25% 25g. Elevated
WBC on ascites fluid in setting of being on abx (300 WBC with
77%poly on [**2-17**], 344 WBC with 54% poly [**2-19**]) prompted
reinitiation of ceftriaxone on [**2-18**]. Pt was continued on
ceftriaxone (start [**2-18**]) until [**3-1**]. She underwent paracentesis
x2 with 2 L taken off on [**2-17**] and 6 L taken off on [**2-19**]. She
again underwent paracentesis on [**12-13**], [**2-28**], and [**3-3**].
Given that the pts ascites fluid did not grow out any organisms
on culture, it was felt the ceftriaxone no longer needed to be
continued. She was then switched to levofloxacin for SBP ppx
then eventually switched to ciprofloxacin 750mg qwk.
.
#Hypotension: Felt to be due to pts cirrhosis and HRS. Pt was
transferred to the MICU on [**2-16**] for low UO and hypotension. She
was continued on a levophed gtt until [**2-21**]. She was also
started on octreotide and midodrine. In the MICU, CVL was
placed. Per renal, it was felt pt had HRS and ATN. Initially
her UO was low, so after albumin was ineffective in treating her
BP, she was started on levophed. On transfer back to the floor,
the patient was still hypotensive down to SBP of 70, but
asymptomatic. Her SBP is normally in 70's since ascites started
to be a problem. She was also likely intravascularly dry. For
low BP, the pt received albumin 60 g on [**2-20**] gram [**2-21**].
Early [**2-23**] am her SBP was noted to be in the high 60's with a
urine output of 27cc over 8 hrs. Her creat increased from 1.0 to
1.5. She was transferred back to the MICU for a levophed gtt.
THe levophed drip was weaned off on [**2-26**]. She received multiple
NS boluses, albumin boluses, and FFP. On transfer back to the
floor the pts SBP ranged 80s-100s. On [**3-2**] the pts SBP fell
again to 77, requiring 25 gm albumin. The pt was started on
albumin 25 gm [**Hospital1 **] on [**3-3**], resulting in stabilization of her
pressures. Her octreotide was discontinued on [**3-4**], but her
midodrine was continued. Daily albumin was discontinued on [**3-8**].
Midodrine was discontinued on [**3-10**]. Patient was resumed on low
dose lasix and aldactone on [**3-11**] which were held on [**2132-3-12**].
Patient's BP remained in the high 80's to 90's up until
discharge to rehab.
.
#Low grade fever: Patient had low grade fevers from [**Date range (1) 62378**]
concerning for infection v atelectasis. No longer febrile.
repeat UA negative was negative. Blood cx from line and
peripherally no growth to date. Her central line was dicontinued
and now has PIV. Repeat CXR [**3-10**] prelim showed new atelectasis,
incentive spirometer to bedside. Rechecked for c diff given
recent history which was negative. Attempt at discontinuing
foley was unsuccessful. Patient's oxycodone was discontinued and
she would benefit from another voiding trial at rehab.
.
#Alcoholic cirrhosis: Pt of Dr.[**Name (NI) 948**] who had previously been
undergoing evaluation for liver transplantation. Pt appears to
have worsening ascites, h/o weekly large volume paracenteses
5-6L. No history of GI bleeding or varices (recent EGD [**2132-1-11**]
demonstrated no esophageal varices). Pt was not
encephalopathic, no asterixis. CHILD Class calculated at 7, or
CLASS B (based on most recent labs, however, pt receiving
albumin). MELD score of 14. s/p paracentesis [**2132-2-8**], drained
off ~3L fluid. Pt's umbilical hernia decreased,no longer blue,
still with necrotic erosion at tip. Repeat paracentesis [**2132-2-11**]
aborted. Pt given 2L paracentesis [**2-17**] and 6L on [**2-19**]. Tapped 5
L on [**2-21**] which had 156 WBC with 48 polys, SAAG greater than
1.1. Tapped 4L on [**2-25**] and 6 L on [**2-28**]. The pt was again tapped
4L on [**3-3**]. Para [**3-3**] with 4 L removed (with 4 units ffp, 50 gm
albumin) revealed: alb 2.3, WBC 250, 27%poly, RBC
[**Numeric Identifier 62379**])--negative for SBP, gram stain negative.
Pt was maintained on 1 L fluid restriction throughout her stay.
She was also maintained on lactulose. The pt was taken for TIPS
procedure on [**3-6**] given her diurectic refractory ascites. She
was given 2 U FFP and 3gm Unasyn prior to the procedure. RUQ
following the procedure revealed flow velocities in the
patient's TIPS range from 56 cm proximally to 199 in the mid
TIPS, and 162 in the distal TIPS. Daily albumin was discontinued
on [**3-8**]. A therapeutic tap was performed on [**2132-3-13**] prior to
discharge.
.
#Acute Renal Failure, Initially resolved, thought [**3-13**] prerenal
etiology: Pt with Cr found to be 2.6 on [**2132-2-6**], highest was
3.1, improved to 1 after IVF hydration. Held spironolactone and
lasix at OSH. Thought most likely to have prerenal etiology
given improvement after IVF hydration with diuretics held. The
pt was also felt to have a componenet of HRS. Continue to hold
diuretics during this admission. Pt was restarted on octreotide
and midodrine. She was kept on a low sodium diet with fluid
restriction to 1200cc/day as per nutrition recs/pt request. She
was initially placed on bicitra but this was changed to baking
soda.Pts Cr worsened again on [**2-24**] from 1 on [**2-23**] up to 1.8.
Again, this was felt to be prerenal/HRS. Urine chemistries
revealed a FENA of 0.15%. The pts Cr gradually resolved to 1.1
on [**2-28**]. Her Cr began to slowly increase up to 1.2 on [**3-2**], but
this resolved with starting daily albumin on [**3-4**]. Patient's Cr
was 0.5 on day of discharge.
.
#Hyponatremia: treated with fluid restriction, diuretics held.
Pt received frequent albumin as well. Resolved to the low 130s
initially and then up to the upper 130s. Her Na was noted to
decrease any time that she did not receive enough albumin. On
[**3-3**], the pts Na dropped back to 131, however it rose again to
the upper 130s with initiation of daily albumin on [**3-4**].
Resolved.
.
#C diff colitis: Pt + for c-diff colitis toxin on [**2-20**]: Flagyl
started PO and continued flagyl (start [**2-20**]) for 14 day course.
Multiple (>4) repeat culture for c diff were negative.
.
#LLL PNA: The pt was diagnosed with ?LLL PNA on CXR on [**2-19**].
Initially she was going to be continued one a 10 day course of
ceftriaxone(given that she was being treated for SBP as well),
however the Ceftriaxone was changed to levofloxacin given the
pts ascites fluid did not grow any organisms. Patient completed
a 10 day course of antibiotics with improvement of her
respiratory status.
.
#Anemia - Iron 20, TIBC 90, Ferritin 232, Transferrin 69.
Likely both anemia of chronic disease and iron deficieny. Pt
was started on iron supplementation. Patient received 1U PRBCs
on [**2132-3-12**]. Hct 31.6 on discharge.
.
#Osteopenia: continued calcium supplementation/multivitamin.
.
#*Funguria: +yeast in UA. Foley was changed. The pt received
an amphotericin bladder wash [**Date range (1) **]. She also was started on
fluconazole 100mg IV q24 hr on [**2-28**] for a 5 day course (finish
[**3-4**]).
.
#UTI: The pt was found to have an enterococcal UTI from urine cx
on [**3-2**]. The pts foley was changed and repeat UA was negative.
Given the pt had no fever or elevated WBC, she was not started
on abx. Attempt at discontinuing foley was unsuccessful.
Patient's oxycodone was discontinued and she would benefit from
another voiding trial at rehab.
.
#Coagulopathy: Likely related to liver dx. Patient was given Vit
K prn, FFP prn for procedure. But has not required these
otherwise.
.
# FEN: Dobhoff placed [**2-28**] for tube feeds with banana flakes;
also regular diet with BOOST. Pt was started on tube feeds
however is taking good amount of PO. Will need a calorie count
to re-evaluate intake. Repleted lytes PRN. Bicarbonate was
discontinued on [**3-10**].
.
#PPx: Heparin sub Q TID for DVT ppx, colace, senna, lactulose
and PPI for GI ppx.
.
#Communication: Daughter (HCP)
.
#FULL CODE
Medications on Admission:
MEDICATIONS AT HOME:
1. Spironolactone 200 mg QAM 100 QPM
2. Furosemide 80 mg QAM 40 mg QPM
3. Potassium 7.5 mEq twice a day.
4. Calcium 600 mg twice a day.
5. Multi-Vitamin Hi-Po One Tablet once a day.
.
MEDICATIONS ON TRANSFER out of ICU:
Albumin
Ceftriaxone 1 gm IV q 24 hr start [**2-20**]
Calcium carbonate 500 mg po TID
anzemet prn
hep sc
lactulose 30 tid to [**2-11**] BM
midodrine 15mg tid
mvi
Na Bicarb 650 [**Hospital1 **]
Vit D 50,000 Uqwk
octreotide 200mcg sc q8h
protonix 40mg qday
senna 1 tab qday
vit D 50,000 units qweek
ambien prn
oxycodone prn
atrovent neb prn
flagyl 500 mg tid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TH).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID WITH MEALS ().
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed: titrate to [**4-12**] BM /day.
14. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
15. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO 1X/WEEK
(WE).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Spontaneous bacterial peritonitis
2. Alcoholic Cirrhosis with ascites
3. Acute renal failure, hepatorenal syndrome
4. C diff Colitis
5. UTI
6. Hypotension, resolved
7. Hyponatremia, resolved
Discharge Condition:
Stable
Discharge Instructions:
If you experience any abdominal pain, fever, chills, nausea or
vomiting, please report to the emergency room immediately.
.
Please follow up with your doctors.
.
Please take all of your medications as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2132-3-19**] 1:00
.
Please follow up with your primary care phyisican Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10733**] within 1 week of discharge. Please call [**Telephone/Fax (1) 13266**] to
schedule the appointment.
Completed by:[**2132-3-13**]
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20487, 20699
|
18107, 18684
|
2764, 3582
|
274, 312
|
495, 2228
|
2250, 2454
|
2470, 2675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,151
| 153,468
|
50777+59287
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-4-7**] Discharge Date:
Date of Birth: [**2129-2-20**] Sex: M
Service: MICU
ADDITIONAL DIAGNOSES:
1. Respiratory failure.
2. Pulmonary embolism.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
male with a history of diabetes mellitus, chronic low back
pain and a recent L4-S1 laminectomy representing to [**Hospital1 1444**] Emergency Room from [**Hospital3 6373**] one day after his discharge with a chief
complaint of shortness of breath.
The patient was recently admitted to [**Hospital1 190**] for a laminectomy of L4 to S1 on [**3-31**] with
indication of sciatica and radiculopathy symptoms. However,
at rehabilitation he was noted to have shortness of breath
and dyspnea on exertion with decreased oxygen saturation to
79%. Of note, he has also reported weakness of his
extremities.
Postoperatively he had good strength throughout, however, on
postoperative day he was noted to have weakness. An MRI was
done which showed postoperative fluid without compression of
the [**Month (only) **] and any evidence of cauda equinus syndrome.
At rehabilitation he continued to have weakness and in the
Emergency Department here was also noted to have possible
four limb paralysis. In the Emergency Department, he had a
CT angiogram which showed subsegmental pulmonary embolisms,
multiple. Neurology was consulted for an evaluation.
PAST MEDICAL HISTORY:
1. Status post laminectomy L4-S1.
2. Noninsulin dependent diabetes mellitus.
3. History of transient ischemic attack in [**2171**].
4. Right carotid ectasia, congenital.
5. Chronic right lacunar infarction.
6. Hyperlipidemia.
7. History of transaminitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lipitor 20 mg.
2. Lisinopril 10.
3. Glucophage 1000 three times a day.
4. Iron sulfate.
5. Fragmin 5000 units.
6. Insulin subcutaneously.
7. Insulin sliding scale.
8. Percocet.
PHYSICAL EXAMINATION: On admission, temperature is 98.4 F.;
blood pressure 192/91; heart rate 99; respiratory rate 14 to
20; breathing on SIMV mode 700 by 15 respiratory with PEEP of
5 and FIO2 of 100%. Generally, he is an intubated sedated
male in a cervical neck collar. HEENT: Pupils were equal
and reactive at 2 millimeters but sluggish. Endotracheal
tube in mouth. Chest with coarse breath sounds bilaterally
without any wheezing. Heart is regular rate and rhythm with
no murmurs, rubs or gallops. Abdomen was soft, nontender,
positive bowel sounds. Extremities with right femoral groin
triple lumen, no edema. Right leg was placed in a boot.
Back had a laminectomy site without edema or any drainage.
Neurological: He was intubated and sedated.
LABORATORY: Initial labs showed a white blood cell count of
15,400, hematocrit 34.2, platelets 554. Chemistries were
sodium 138, potassium 4.8, chloride 102, bicarbonate 28, BUN
14, creatinine 0.7, glucose 198. He had an INR of 1.4 with a
PT of 14.3 and a PTT of 22.4.
Initial CK was 296 and MB 2, and a troponin of less than 0.3.
Chest x-ray showed low lung volumes, endotracheal tube 5
centimeters above the carina.
Head CT scan showed no bleed or no infarction.
CT angiogram showed multiple subsegmental pulmonary
embolisms, left lower lobe pneumonia and a right upper lobe
collapse.
He had an EKG which showed a sinus tachycardia at a rate of
104 with an old T wave inversion in III and a new incomplete
right bundle branch block.
HOSPITAL COURSE BY SYSTEM:
1. Neurological: Although the patient was evaluated by
Neurology in the Emergency Department and after weaning was
found to have a four limb paralysis without any elicitable
reflexes, the differential on neurology was a mass
compressing the spinal [**Last Name (LF) **], [**First Name3 (LF) **] infectious process or
Guillain-[**Location (un) **] syndrome, or also possibly another
cerebrovascular accident. The patient had an MRI of his
spinal [**Location (un) **] and brain which showed no new changes.
We than went on a presumptive diagnosis that he had
Guillain-[**Location (un) **] syndrome and was started on IVIG. Several
days after his initial admission, the patient had an EMG
which was significant for slowing of the majority of his
nerves consistent with a Guillain-[**Location (un) **] syndrome with sural
sparing. He completed his five day course of IVIG and
remained intubated since he was not able to breath on his own
secondary to diaphragmatic paralysis. His sedation was
weaned to off and he was alert and followed commands with his
eyes throughout all this.
On the final days of admission, he began to regain some
strength and at the time of this dictation was able to move
his shoulders bilaterally as well as some of his fingers on
his left hand.
2. PULMONARY: The patient was intubated on this admission
for respiratory failure, hypercarbic. This was first
initially thought secondary to pulmonary embolism, however it
was found that his paralysis was most likely due to his
Guillain-[**Location (un) **] syndrome. he was continued on assist control
ventilation with good oxygenation and ventilation. He then
had a tracheostomy placed without incident. It was felt that
he would eventually recover his respiratory strength on his
own.
He was also noted to have a left lower lobe pneumonia on his
admission and was treated with one week of ceftriaxone and
Levofloxacin and ceftriaxone was stopped. At the time of
this dictation, his infiltrate had resolved. He should
complete a full two week course of Levofloxacin.
3. GASTROINTESTINAL: The patient was noted to have guaiac
positive stool with a drifting hematocrit while in-house. A
gastrointestinal consultation was obtained. He had an
esophagogastroduodenoscopy significant only for duodenitis.
At the time of this discharge, they were still deciding
whether or not he should have a colonoscopy. He was given a
proton pump inhibitor and tolerated his tube feeds well
throughout this admission.
4. CARDIOLOGY: Hypertension; The patient with significant
hypertension during this admission although he was only on 10
of Lisinopril at home. He was initially managed on p.r.n.
Labetalol and at the time of this discharge most of his
hypertension had resolved. He was started on a beta blocker
and Lopressor in addition to his Captopril at that time.
5. ENDOCRINE: The patient with diabetes mellitus type 2, on
Glucophage at home. He had significant hyperglycemia to the
200s and he was started on an insulin drip which was still
being titrated at the time of this dictation. He should be
changed over to NPH insulin and sliding scale insulin for
rehabilitation.
6. HEMATOLOGY: The patient with a drifting hematocrit and
at the time of this dictation has received two units of his
own blood. He is guaiac positive, however, there is also
concern that since he had a femoral line that he may have a
retroperitoneal source given the fact that he is on
intravenous heparin. At the time of this dictation, we are
still considering colonoscopy.
7. PULMONARY EMBOLISMS: The patient with multiple
subsegmental pulmonary embolisms and was continued on
intravenous heparin during this admission. At the time of
this dictation, he had not yet been started on Coumadin as we
were still considering a colonoscopy.
8. ORTHOPEDICS: The patient was followed by the Orthopedics
Service while in-house. He did have a fluid collection on
his back which was stable and Orthopedics did not see the
need to tap it nor did they see any more interventions.
9. INFECTIOUS DISEASE: The patient did have two fevers, one
to 101.0 F. and one to 100.4 F. His blood cultures were
always negative and his chest x-ray remained clear after his
initial infiltrate. There was concern that the fluid
collection in the back might be a source, however, it was not
tapped at the time of this dictation.
10. SACRAL DECUBITUS ULCER: The patient developed a sacral
decubitus ulcer. He was followed by Plastic Surgery while
in-house and was given Duoderm dressing changes.
11. NUTRITION: The patient was given tube feeds which he
tolerated well throughout his time here.
12. LINES: The patient initially had a right femoral down
in the Emergency Department which was discontinued and he had
a right internal jugular placed which was eventually
discontinued and he had a right PICC line placed.
He had multiple arterial lines placed including two in the
right wrist and two in the left wrist. At the time of this
dictation, both of his lines have been discontinued.
DISCHARGE DIAGNOSES:
1. Pulmonary embolisms.
2. Guillain-[**Location (un) **] syndrome.
3. Hypertension.
4. Diabetes mellitus.
5. Pneumonia.
6. Upper gastrointestinal bleed.
7. Sacral decubitus ulcer.
8. Status post laminectomy.
9. Respiratory failure.
DISCHARGE MEDICATIONS: To be completed by the intern
picking up this patient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2174-4-16**] 20:52
T: [**2174-4-16**] 21:31
JOB#: [**Job Number 105620**]
Name: [**Known lastname **], [**Known firstname 116**] Unit No: [**Numeric Identifier 17196**]
Admission Date: [**2174-4-7**] Discharge Date: [**2174-4-25**]
Date of Birth: [**2129-2-20**] Sex: M
Service:
ADDENDUM:
1. NEUROLOGICAL: Guillain-[**Location (un) **] Syndrome. Neurontin
titrated for neuromuscular pain up to 600 three times a day.
Continue Physical Therapy; follow-up with Neurology.
2. PULMONARY: At the time of discharge, the patient
tolerated a trache collar with FIO2 0.35. Of note, the
patient with bradycardic episodes to 40s with initial attempt
to wean, however, this resolved with continued trials and
increased beta blockade. Continue chest Physical Therapy and
elevate head of bed; deep breathing. Follow-up with ENT for
trache care.
3. BLOOD LOSS ANEMIA: Negative esophagogastroduodenoscopy
and colonoscopy for work-up of guaiac positive stool with a
hematocrit decrease to 22. The patient was transfused
successfully. Hematocrit remained stable on
anti-coagulation.
4. CARDIOLOGY: Hypertension-continue Metoprolol and
Captopril.
5. ENDOCRINE: Continue NPH with sliding scale insulin;
titrate as needed for blood sugars 80 to 120.
6. PULMONARY EMBOLISM: Now on Lovenox until INR is greater
than 2.0. Will need anti-coagulation with Coumadin for at
least six months.
7. SACRAL DECUBITUS ULCER: Continue q. day wound care with
wet-to-dry dressing changes.
8. FLUIDS, ELECTROLYTES AND NUTRITION: On tube feeds via
PEG. Passed bedside swallow studies, video assessment to be
done at rehabilitation before initiating p.o.
9. LINES: PICC in place. Can be discontinued.
10. PROPHYLAXIS: On Lovenox and Coumadin. Continue PPI.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE INSTRUCTIONS:
1. Follow-up with Neurology on [**2174-5-3**], at [**Hospital Ward Name **] [**Location (un) 17197**], at 09:00 a.m. with Dr.[**Name (NI) 17198**].
2. ENT at [**Telephone/Fax (1) 1848**], in three to four weeks.
3. Dr. [**First Name (STitle) 17199**] at [**Telephone/Fax (1) 227**], primary care physician, [**Name10 (NameIs) **]
one to two weeks.
DISCHARGE MEDICATIONS:
1. Lovenox 80 mg subcutaneously twice a day; discontinue for
INR greater than 2.0.
2. Coumadin 5 mg p.o. q. h.s.; titrate for INR 2.0 to 3.0.
3. Metoprolol 25 mg p.o. twice a day.
4. Captopril 12.5 mg p.o. three times a day.
5. NPH 80 units subcutaneously twice a day; titrate for
fingerstick 80 to 120.
6. Insulin sliding scale.
7. Lansoprazole 30 mg solution twice a day.
8. Colace 100 mg p.o. twice a day.
9. Senna, 1 mg tablet p.o. twice a day p.r.n. constipation.
10. Ativan 1 to 2 mg p.o. p.r.n. anxiety.
11. Multivitamin p.o. q. day.
12. Zinc 220 mg p.o. q. day.
13. Vitamin C 500 mg p.o. q. day.
14. Neurontin 600 mg p.o. three times a day.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Doctor Last Name 17200**]
MEDQUIST36
D: [**2174-4-25**] 19:51
T: [**2174-4-28**] 17:42
JOB#: [**Job Number 17201**]
|
[
"276.1",
"482.9",
"357.0",
"707.0",
"285.1",
"276.2",
"E878.8",
"518.81",
"415.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"31.1",
"96.6",
"96.05",
"96.04",
"38.91",
"96.72",
"88.41",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
8544, 8786
|
11295, 12218
|
1745, 1934
|
10920, 11272
|
3468, 8523
|
1958, 3441
|
221, 1395
|
1417, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,446
| 160,155
|
33996
|
Discharge summary
|
report
|
Admission Date: [**2109-4-24**] Discharge Date: [**2109-5-6**]
Date of Birth: [**2064-7-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
transferred from OSH for GI bleeding, liver failure, ARF, and
coagulopathy
Major Surgical or Invasive Procedure:
EGD x 2
Colonoscopy
History of Present Illness:
44 M with end-stage liver disease [**1-26**] alcohol abuse, who
initially presented to [**Hospital6 33**] ED on [**2109-4-21**] with
jaundice, twenty-pound weight gain over three weeks, and lower
extremity swelling which had been treated with clindamycin for
presumptive cellulitis. During his stay at [**Hospital3 **], we was
noted to have worsening of his hepatic failure with elevated
bilirubin (17 up from 6), coagulopathy (INR 2.7), and albumin of
2.4, as well as ARF (up from baseline of 0.6 to 2.7) and
leukocytosis 26.7 with 8% bands, which they attributed to a LLL
consolidation on CXR. He was started on prednisalone 40 mg Daily
to treat alcoholic hepatitis and GI was consulted. He had an
abdominal US which showed a cirrhotic liver and mild to moderate
ascites, as well as Doppler studies which showed patent hepatic
vessels. He went on to develop a GI bleed, with BRBPR and HCT
drop from 34.8 to 26. He was started on IV protonix and
transfused 5 units of FFP and 4 units of cryoprecipitate without
significant clinical or lab impact. This combination of issues
prompted a transfer from [**Hospital6 **] to [**Hospital1 18**] for
further management.
On arrival, patient appears frankly jaundiced but denies having
any further blood or dark color to his stools today. His main
concern is his swollen L leg, which he says is very concerning
to him. He says it has been swelling up intermittenly for years,
but says that it has never been this bad.
Past Medical History:
ESLD - neg HEP B,C, anti-mitochondrial antibodies
Eczema
Left lower extremity edema
Social History:
Self-employed (concrete forms), lives with son. [**Name (NI) **] tobacco,
denies IVDU, + EtOH (one pint of vodka and 7-8 beers daily for
ten years/now two beers daily)
Family History:
+ alcoholism
Physical Exam:
VS: T: P: 85 BP: 135/83 RR: 12 O2 sat: 99% RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, +
icterus, OP clear, MMM, neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB except for decreased breath sounds at LLL, good air
movement
ABD: firm, distended, NT, + BS, +1 pitting edema on sides
EXT: warm, dry, +2 distal pulses BL, L foot grossly swollen,
almost double in size compared to R
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. +
asterixis
PSYCH: appropriate affect
Pertinent Results:
Admission labs:
[**Age over 90 **]|92|52
----------<350
3.6|24|1.5
estGFR: 51/62 (click for details)
Ca: 7.6 Mg: 1.7 P: 2.8
ALT: 64 AP: 234 Tbili: 17.7 Alb: 2.4 AST: 141
9.1
26.2>-< 9.1 135
25.6
MANUAL diff: N:82 Band:9 L:2 M:2 E:0 Bas:0 Atyps: 1 Metas: 3
Myelos: 1 Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: 2+
Polychr: OCCASIONAL
Plt-Est: Low
PT: 25.3 PTT: 47.1 INR: 2.5
BILATERAL LOWER EXTREMITY DOPPLER VENOUS ULTRASOUND - [**2109-4-25**]:
Grayscale and Doppler examination of the bilateral common
femoral, superficial femoral, and popliteal veins was performed.
Normal compressibility, augmentation, waveforms, and Doppler
flow are demonstrated. Several normal-appearing lymph nodes are
seen in the left groin. Left calf veins could not be evaluated
due poor acoustic window (bandage material).
CT ABDOMEN/PELVIS - [**2109-4-25**]:
There is a massive left pleural effusion and associated collapse
of the left lower lobe and partly visualized lingula. The heart
and great vessels are unremarkable. In the abdomen, there is
extensive ascites. This study is limited without IV contrast,
but there are no apparent hepatic lesions. The spleen is
enlarged. The kidneys and adrenals appear normal. The pancreas
is normal. There are splenic varices, Prominent veins are seen
in the retroperitoneum suggestive of venous stenosis or
occlusion. "[**Doctor First Name **] mesentery" and anasarca also suggest of venous
stasis. There is a calcified gallstone. The bladder and distal
ureters are normal. The prostate appears normal, and there are
prostatic calcifications. Pelvic loops of bowel appear normal,
and there is free fluid but no free air seen in the pelvis. No
suspicious lytic or blastic lesions. Healed right rib fractures
are seen.
CT CHEST - [**2109-4-26**]:
IMPRESSION:
1. Very large left pleural effusion with associated compressive
atelectasis. No definite endobronchial obstructive lesions are
identified.
2. Small right pleural effusion.
3. Cirrhotic-appearing liver, with ascites and varices,
incompletely evaluated on this study.
4. Cholelithiasis.
CYTOLOGY - Pleural Fluid [**2109-4-26**]:
NEGATIVE FOR MALIGNANT CELLS.
ECHO [**2109-4-29**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). 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
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The estimated pulmonary artery systolic pressure is
high normal. There is no pericardial effusion. There are
prominient bilateral pleural effusions (Left>right).
CT HEAD [**2109-5-2**]:
FINDINGS: There is no evidence of hemorrhage, mass lesion, shift
of normally midline structures or infarction. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. The intracranial cisterns
are preserved.
The extracalvarial soft tissues are within normal limits. The
orbital regions appear normal. There is mild mucosal thickening
in the right maxillary sinus. There is partial opacification of
several mastoid air cells bilaterally. IMPRESSION:
Normal brain CT.
CHEST XRAY [**2109-5-3**]:
FINDINGS: In comparison with study of [**5-1**], there is a small
decrease in the still-substantial left pleural effusion
following removal of the pigtail catheter. No evidence of
pneumothorax. Heart and lungs are essentially unchanged.
CHEST XRAY [**2109-5-1**]:
Large amount of left pleural effusion has gradually progressed
since [**2109-4-27**] when the chest tube was inserted and is
currently approximately of the size similar to [**2109-4-25**], but
still less than demonstrated on [**2109-4-27**] before insertion of
the pigtail. There is small right pleural effusion, grossly
unchanged. The lungs are clear. Old right lower rib healed
fractures are noted. There is no pneumothorax.
Hematology
CBC - [**2109-5-6**] WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
8.8 2.66* 8.8* 26.4* 99* 33.1* 33.5 18.1*
127*
BASIC COAGULATION - [**2109-5-6**]: PT PTT INR(PT)
24.5* 51.7* 2.4*
RENAL & GLUCOSE - [**2109-5-6**] Glucose UreaN Creat Na K Cl HCO3
AnGap
122* 16 1.1 136 3.6 103 26
11
ENZYMES & BILIRUBIN - [**2109-5-6**] ALT AST LD(LDH) AlkPhos Amylase
TotBili
23 54* 99 8.4*
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2109-5-6**] 05:10AM 7.6* 3.9 1.1*
HEPATITIS HBsAg HBsAb HBcAb HAV Ab
[**2109-4-26**] 05:15AM NEGATIVE NEGATIVE NEGATIVE NEGATIVE
ICTERIC
IMMUNOLOGY AFP
[**2109-4-26**] 05:15AM 1.91
ICTERIC
1 MEASURED BY [**Doctor Last Name 8721**] ELECSYS (ECLIA)
ANTIBIOTICS Vanco
[**2109-5-4**] 05:25AM 18.81
@ TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2107-8-24**] == REPRESENTS
THERAPEUTIC TROUGH
LAB USE ONLY RedHold
[**2109-5-1**] 06:25AM HOLD
HEPATITIS C SEROLOGY HCV Ab
[**2109-4-26**] 05:15AM NEGATIVE
EGD: Mosaic pattern in the stomach compatible with gastropathy
Ulcers in the pre-pyloric antrum
Esophageal varices
Colonsocopy: Single small rectal varix.
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to terminal ileum
Brief Hospital Course:
44 M with ESLD [**1-26**] alcohol abuse, transferred from OSH with GI
bleeding, ARF, coagulopathy, LLL PNA, hyponatremia, dysphagia
and LLE swelling.
# GI bleeding: After his initial admission to the ICU, the
patient had no further lower GI bleeding. He did had one episode
of hematemesis, after which he had an EGD which did not
demonstrate any actively bleeding lesions. The patient did have
ongoing anemia without an obvious source. He had both EGD and
colonoscopy, neither of which demonstrated any actively bleeding
lesions. He did lose blood with his thoracentesis. His
hematocrit had stabilized at discharge.
# Liver Failure: The patient had liver failure, attributed to
acute alcoholic hepatitis. Steroids were not started as the
patient had just had a GI bleed. He was treated with both
lactulose and rifaximin. His LFTs were trending down at the
time of discharge. The patient also had SBP by diagnostic para
[**2109-4-26**], for which he completed a course of antibiotics. He was
seen by social work and offered inpatient treatment for his
alcoholism, which he declined. He did accept information and
contact information for alcohol cessation counseling. He will
follow up with the Liver Center.
# ARF: Per OSH records his baseline creatinine is 0.6. He was
seen by a nephrologist who recommended IVF and d/c'ing
spironolactone. His creatinine improved to baseline by
discharge.
# Coagulopathy: The patient had coagulopathy on admission
secondary to his liver dysfunction. He originally received
cryoprecipitate for fibrinogen < 150 and a DIC appearing
picture, which rapidly resolved with treatment of his liver
failure.
# Odynophagia: The patient had discomfort on swallowing on
admission, however, there was no evidence of thrush or other
esophageal irritation on EGD. He received Magic Mouthwash with
some relief.
# Hyponatremia: The patient initially had a hyponatremia which
resolved spontaneously with treatment of his liver disease. He
was eventually started on both furosemide and spironolactone,
with stability of his sodium.
# LE Swelling: The patient had left lower extremity swelling out
of proportion to his right leg. This has been a chronic problem
for him. The patient was seen by both vascular surgery and
dermatology, who both felt there was likely a superimposed
cellulitis. The patient was treated with a seven day course of
vancomycin, following by high dose cipro for one week, after
which he was instructed to decrease the dose to SBP prophylaxis
levels. His legs were kept elevated and the left leg was ACE
wrapped to his thigh. The swelling was greatly improved prior
to his discharge.
# Leukocytosis: The patient had an elevated white count on
admission, likely due to a combination of LLL pneumonia,
alcoholic hepatitis, cellulitis and SBP. He was treated with
both Flagyl and levoflox prior to transfer. He completed a
short course of levo at [**Hospital1 **]. In addition, the patient had a
pleural effusion, which was tapped and required the placement of
a pigtail catheter for drainage. The effusion was likely
secondary to a hepatic hydrothorax. The catheter drained about
4 to 5 liters over several days, after which it was clamped and
subsequently removed. The patient was saturating well on room
air at discharge, with little to no discomfort at the site of
the catheter and improvement on chest xray.
Medications on Admission:
Medications on Transfer:
Levofloxacin 250 mg QDay
Lactulose 30 grams Q12 hours
Albuterol nebs PRN
Flagyl 250 mg Q8H
Protonix 40 mg IV BID
Home Medications:
Nystatin
Vitamin B
Clindamycin
Spironolactone
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
Disp:*4050 ML(s)* Refills:*2*
8. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day:
Please start this after completing the twice-daily regimen.
Disp:*30 Tablet(s)* Refills:*2*
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Please have your CBC, Chemistries (chem 10), liver function
tests, and renal function tests checked in 1 week and faxed to
the Liver Center at ([**Telephone/Fax (1) 1582**].
14. Terbinafine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily): pls apply to toes as needed for fungus.
Disp:*1 tube* Refills:*1*
15. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcohol hepatitis
SBP
GIB
Hepatic hydrothorax
Secondary:
Cirrhosis
Chronic venous stasis/lymphedema
Cellulitis
Discharge Condition:
Good, stable
Discharge Instructions:
You were admitted with liver failure from alcohol abuse. You
improved with certain medications and treatment while in the
hospital. It is extremely important you do not drink alcohol
again. You were given a list of counseling/treatment centers to
help with alcohol cessation.
It is also important that you continue all your medications as
prescribed.
Please return to the emergency room with any jaundice,
increasing abdominal pain, fevers, chills or any other
concerning symptoms.
Please adhere to a low sodium diet (2 grams daily) and a fluid
restriction of 1.5 liters daily.
Followup Instructions:
The following appointments have been scheduled for you:
Dermatology: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], [**2109-5-15**] at 4 pm. The office
is located at [**Apartment Address(1) 78489**]. The phone number
is [**Telephone/Fax (1) 3965**].
You have been scheduled to see Dr. [**Name (NI) **] from the Liver
Center on [**2109-5-17**] at 9 AM. The office is in the [**Hospital Unit Name 3269**], [**Location (un) 436**]. Please call [**Telephone/Fax (1) 673**] with any
questions about your appointment.
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2109-8-19**] 10:50
|
[
"789.59",
"457.1",
"787.20",
"286.9",
"459.81",
"456.21",
"682.6",
"276.1",
"529.0",
"692.9",
"486",
"511.8",
"584.9",
"569.3",
"537.89",
"562.10",
"285.1",
"571.5",
"455.6",
"305.00",
"571.1",
"531.90",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"34.91",
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13788, 13794
|
8329, 11712
|
347, 369
|
13959, 13974
|
2811, 2811
|
14605, 15290
|
2168, 2182
|
11966, 13765
|
13815, 13938
|
11738, 11738
|
13998, 14582
|
2197, 2792
|
11895, 11943
|
233, 309
|
397, 1859
|
2827, 8306
|
11763, 11877
|
1881, 1967
|
1983, 2152
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,812
| 157,663
|
48155
|
Discharge summary
|
report
|
Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-17**]
Service: MEDICINE
Allergies:
Mercury,Ammoniated / Shellfish
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
Internal Jugular Central Venous Line
History of Present Illness:
[**Age over 90 **]F with history of refractory C.diff with recent d/c of oral
vanco; dementia, admit with fever, cough, and hypotension.
Patient was seen for urgent visit in geriatrics today with cough
and fatigue and found to have HR 133 (BP 122/60), T 103.8, and
O2 sat 89% on RA. Sent from clinic to the emergency room with
concern of pneumonia.
.
In the ED, vitals T 102.6, HR 124, BP 128/52, R22, O2 sat
89-94%. Found to have WBCs 16.5, lactate 2.1, mild ARF with
creatinine 1.2 (from 0.9). Received vanco, cefepime, and
levofloxacin, and PO Vanc 125 mg x1. CXR with bilateral
opacities, atelectasis vs. pneumonia. SBP to 80s at times (also
75/41 once), got 5L fluids total. CVL placed. At transfer BP
112/48 with HR 105. O2 sat dropped to 91% on 3L so placed on NRB
with sats 100%.
In the ER received vanco/cefepim/levo and oral vanco after
discussion with ID given her refractory c.diff. A left IJ was
placed.
Past Medical History:
- Alzheimer's dementia - mild
- Right hip fracture s/p ORIF in [**2125-7-10**] status post fall.
- C. difficile, refractory since [**2125-8-10**]
- Depression.
- OA
- s/p wrist fracture
- Osteopenia
- cataract surgery
Social History:
No active tobacco, etoh. Lives near 5children who are very
involved in care. Independent with ADLs, walks with walker, goes
to day care 5x/week.
Family History:
+HTN
no significant illness that are contributory
Physical Exam:
PHYSICAL EXAM:
VS: Tm: 99.8 Tc: 96.2 104 121/51 19 97RA
GEN: NAD
HEENT: NCAT
NECK: supple
CHEST:CTAB at apices, decreased BS at bases
CV: RRR, S1S2
ABD: soft, nt/nd, +bs
EXT: wwp,
SKIN: nl turgor, diffuse blanchable erythema over chest, back,
arms
NEURO: CNs grossly intact
Pertinent Results:
Admission Labs:
[**2126-4-12**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2126-4-12**] 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2126-4-12**] 06:45PM URINE RBC-[**3-14**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2126-4-12**] 05:40PM GLUCOSE-148* UREA N-23* CREAT-1.2* SODIUM-135
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16
[**2126-4-12**] 05:40PM estGFR-Using this
[**2126-4-12**] 05:40PM ALT(SGPT)-27 AST(SGOT)-31 LD(LDH)-204
CK(CPK)-94 ALK PHOS-88 TOT BILI-0.2
[**2126-4-12**] 05:40PM CK-MB-3 cTropnT-<0.01
[**2126-4-12**] 05:40PM ALBUMIN-4.4
[**2126-4-12**] 05:40PM LACTATE-2.1*
[**2126-4-12**] 05:40PM WBC-16.5*# RBC-3.91* HGB-12.4 HCT-36.5 MCV-93
MCH-31.7 MCHC-33.9 RDW-13.6
[**2126-4-12**] 05:40PM NEUTS-85.4* LYMPHS-11.7* MONOS-2.5 EOS-0.2
BASOS-0.3
[**2126-4-12**] 05:40PM PLT COUNT-295
[**2126-4-12**] 05:40PM PT-13.3 PTT-23.4 INR(PT)-1.1
.
CXR [**2126-4-12**]:
UPRIGHT AP VIEW OF THE CHEST: Low lung volumes are present.
Cardiac
silhouette is within normal limits. The aorta is slightly
unfolded with
aortic knob calcifications present. The pulmonary vascularity is
normal, as are the hilar contours. Bibasilar patchy opacities
likely reflect
atelectasis, but pneumonia or aspiration is not completely
excluded. There is blunting of the right costophrenic sulcus,
suggestive of a small pleural effusion. No pneumothorax.
Degenerative changes are seen within the left hip as well as
within the lumbosacral spine.
.
IMPRESSION:
1. Low lung volumes. Bibasilar patchy opacities may reflect
atelectasis, but infection or aspiration is not excluded.
2. Probable small right pleural effusion
.
CTA chest [**2126-4-15**]:
CTA CHEST WITH AND WITHOUT CONTRAST
IMPRESSION:
1. No pulmonary embolism to the segmental level. Suboptimal
evaluation of
subsegmental bibasilar pulmonary arteries.
2. Small bilateral pleural effusions, dependent atelectasis and
minimal
smooth septal thickening, likely due to mild hydrostatic edema.
3. Bronchial wall thickening, suggesting chronic airway disease.
4. 2-mm left upper lobe ground glass nodule, of indeterminate
clinical
significance.
5. 9-mm right subclavicular lymph node, of uncertain clinical
significance. Left thyroid nodule, could be evaluated by thyroid
ultrasound if clinically relevant.
6. Mild aortic valve calcification, of uncertain hemodynamic
significance.
7. Degenerative changes of the spine, right sternoclavicular
region, and left shoulder.
8. Signs of previous granulomatous exposure.
.
ECHO [**2126-4-15**]:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic valve stenosis. Mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
MICU course:
The patient was admitted to the MICU after aggressive
resuscitation in the ED to include >5L crystalloid, CVL,
vancomycin, cefepime, levofloxacin and pan culture. Once
arriving in the MICU her vital signs stabilized with resolution
of her significant tachycardia and stabilization of her BP (no
pressors were required). Her Tmax was 100.7. As she continued
to improve her antibiotics were narrowed to
vancomycin/levofloxacin. The patient did develop a diffuse
macular rash on her back and abdomen, improved only by
hydroxyzine but not sarna or denoside cream. The cause of her
rash was thought to be related to her cefepime, though it was
not clear. On transfer to the floor, her micro data was
negative with negative C. diff and legionella. She was
continued on PO vanco for her history of C.diff colitis.
.
Medicine Floor course:
.
# Fever/ Leukocytosis/ Sepsis - Normotensive in MICU and on
floor, afebrile, all cultures negative (BCx from [**2126-4-12**] negative
to date but still pending as of [**2126-4-17**]). Leukocytosis resolved.
Antibiotics scaled back, IV Vanco, Cefepime d/c, patient did
well on PO Levoquin and PO Vanco. Had ID see her inpatient who
recommended 7d course of Levofloxacin 500mg QD with PO Vanco
coverage during that period and for 2 weeks after for CDiff
prophylaxis. CXR and CT showed no focal infiltrate, but patient
with bronchial thickening and productive cough and in setting of
fever and leukocytosis seen on admission, Abx course is
warrented. Of note, Legionella Ag was negative.
.
# Tachycardia - Persistent sinus tachycardia in the MICU and on
the inpatient medicine floor. HR down to 80's, 90's during the
last 2 days of admission. EKG showed sinus tachycardia. Patient
asymptomatic. CTA performed after D-dimer was markedly elevated
which was negative for PE but showed an enlarged supraclavicular
lymph node and a small thyroid nodule.
.
# ARF. Mild renal impairment - volume depletion/hypotension most
likely. Resolved with hydration.
.
# Hypoxia. With concern for pneumonia as above; initially was on
O2 in MICU but during time on inpatient floor patient was
without O2 requirement.
.
# Thyroid nodule. Seen incidentally on CTA - patient w/out SSx
of hyperthyroid except for sinus tachycardia. TSH sent. Pending
at time of D/C, needs to be f/u by PCP.
.
# Code status. Full
.
# Comms with pt's daughter/son
.
# Dispo. Seen and cleared by PT, at home with family following
closely. Safe for d/c tomorrow [**2126-4-16**] if tachycardia resolved
and pt afebrile.
Medications on Admission:
CALCITONIN 200 unit/dose 1 spray once daily
DONEPEZIL 10 mg Tablet atbedtime
MIRTAZAPINE 15 mg Tablet daily
CALCIUM CARBONATE-VITAMIN twice a day
MULTIVITAMIN once a day
OMEGA-3 FATTY ACIDS once a day
Recently on Xifaxin and PO vancomycin
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 weeks.
Disp:*84 Capsule(s)* Refills:*0*
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*QS * Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] VNA
Discharge Diagnosis:
pneumonia
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted for the hospital for respiratory failure and
fever that were likely due to an infection in your lungs. Your
symptoms improved with antibiotics and you are safe to go home
at this point. Please resume all of your home medications and
take the antibiotics that we have prescribed for you.
.
Please call your primary care physician or return to the
emergency department if you have any of the following symptoms:
* fever, chills
* shortness of breath, coughing up blood, or other difficulty
breathing
* chest pain, palpitations, dizziness, fainting
* any other concerning symptoms
Followup Instructions:
Please see your Primary Care Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD at your
newly scheduled appointment on Wednesday [**2126-4-24**] appointment at
10am.
Please call [**Telephone/Fax (1) 719**] if you will have any trouble making it
to this appointment.
.
Please call Dr[**Name (NI) 19995**] office as well to schedule a follow up
appointment for the next 3-4 weeks. His number is [**Telephone/Fax (1) 11486**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
|
[
"294.10",
"331.0",
"E930.5",
"482.9",
"785.52",
"584.9",
"311",
"241.0",
"038.9",
"693.0",
"518.81",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9396, 9451
|
5635, 8163
|
252, 290
|
9505, 9536
|
2024, 2024
|
10181, 10726
|
1659, 1710
|
8452, 9373
|
9472, 9484
|
8189, 8429
|
9560, 10158
|
1740, 2005
|
200, 214
|
318, 1237
|
2040, 5612
|
1259, 1480
|
1496, 1643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,217
| 190,074
|
48675
|
Discharge summary
|
report
|
Admission Date: [**2176-8-5**] Discharge Date: [**2176-8-14**]
Date of Birth: [**2101-5-10**] Sex: M
Service: MEDICINE
Allergies:
midazolam
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
Acute Renal Failure, Leukocytosis
Major Surgical or Invasive Procedure:
Placement of percutaneous L nephrostomy
IR drainage of pelvic fluid collections
History of Present Illness:
75 year old Male direct admitted with diarhea, acute renal
failure, thrombocytopenia and leukocytpsis. The patient's
hsitory begins with a squamous cell bladder carcinoma removed in
[**3-/2176**], with ultimately a resulting neobladder/urostomy and
ileostomy. He also had an admission for complicated UTI at the
beginning of [**Month (only) **], and he was discharged on Linezolid for
enterococci.
Since discharge he has had virtually constant diarhea. Over the
past few days prior to admissions, his wife states that she has
been able to easily firm up his stools by modifying his diet. He
is reporting chills over the day prior to admission, which his
wife states is what brought him in with his last serious UTI and
she is concerned that he is infected again. His wife has been
keeping an I&Os log at home, which notes overnight urostomy
outputs in the 1100cc range and occaisionally large volume
ileostomy outputs. He reports that he was able to mostly keep up
with his output, and knows when he doesn't by feeling thirsty.
He developed acute renal failure with his createnine up to 3.6.
Seen in [**Hospital **] clinic on [**2176-8-2**] and started on Cipro/Fluconazole
for a recurrent UTI with
Klebsiella/Yeast in his urine.
Labs on the day of admission in clinic showed worsening renal
failure, thrombocytopenia and leukocytosis, and no real
improvement in symptoms.
His wife notes that he has not needed his amlodipine since the
surgery as his BP has been in the 100-120 range without it.
Past Medical History:
Past Medical History:
hypertension and negative for myocardial infarction, angina,
diabetes, colitis, stroke, ulcer, lung disease, thyroid disease,
hepatitis, gout, sciatica, and glaucoma.
Past surgical history includes a TUR prostate [**2162-3-31**] by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] for 20 g of BPH. A bladder diverticulum was
described at that time.
-Pelvic exenteration with radical cystoprostatectomy and
ileal conduit performed by Urology and low anterior resection
with diverting ileostomy by General Surgery [**2176-5-20**]
-exploratory laparotomy, lysis of adhesions,
closure of enterotomy of ileal loop, placement of single J
ureteral stent. [**2176-5-31**]
PAST MEDICAL HISTORY:
Squamous cell cancer of the bladder with partial obstruction
of R ureter and invasion of rectum s/p pelvic exenteration
Hypertension
Hyperlipidemia
Hiatal hernia
CKD since pelvic exenteration (due to SCC bladder CA): [**5-/2176**]
PAST SURGICAL HISTORY:
- Remote hx of TURP [**2162-3-31**] (PSA of 2.4 [**2176-5-2**])
- Pelvic exenteration with radical cystoprostatectomy, LAR with
primary colorectal anastomosis, ileal conduit, and diverting
loop ileostomy on [**2176-5-20**]
- Exploratory laparotomy, lysis of adhesions, closure of
enterotomy of ileal loop, placement of single J ureteral stent
on [**2176-5-31**]
Social History:
He continues to work fulltime as an attorney (not since the
surgery).
He is accompanied by his wife who is a nurse and a healthcare
advocate. They have grown children and grandchildren in the
area. He notes no history of smoking, ETOH or illicits, and no
occupational exposures.
Family History:
No cancers in family history that he is aware of.
Mother: died at 96 without medical problems
Father: CAD
Physical Exam:
Admission:
PHYSICAL EXAM:
VSS: 97.4, 137/76, 74, 18, 100%
GEN: NAD
Pain: 0/10
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT, Urostomy and ileostomy sites CDI
EXT: - CCE
NEURO: CAOx3, Non-Focal
Discharge:
VS - Tc 97.9, BP 118/64, HR 60, RR 20, O2-sat 97%
GENERAL - NAD, lying in bed listening to music
HEENT - NC/AT, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - low heart sounds but RRR, nl S1-S2, no MRG
LUNGS - CTA anteriorly
ABDOMEN - soft/NT/ND, +BS, ostomy and urostomy sites appear
clean, ostomy bag with small amount of liquid brown stool
(recently emptied), urostomy bag with clear yellow output,
nephrostomy bag with clear yellow output
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - grossly intact
Pertinent Results:
[**2176-8-5**] 08:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2176-8-5**] 08:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2176-8-5**] 08:25PM URINE RBC-3* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-0
[**2176-8-5**] 11:13AM UREA N-73* CREAT-3.6* SODIUM-139
POTASSIUM-5.2* CHLORIDE-113* TOTAL CO2-17* ANION GAP-14
[**2176-8-5**] 11:13AM ALT(SGPT)-43* AST(SGOT)-30 LD(LDH)-186 ALK
PHOS-126 TOT BILI-0.2
[**2176-8-5**] 11:13AM CALCIUM-9.3 PHOSPHATE-2.6*# MAGNESIUM-2.1
[**2176-8-5**] 11:13AM HAPTOGLOB-436*
[**2176-8-5**] 11:13AM WBC-14.3* RBC-3.33* HGB-9.9* HCT-30.1* MCV-90
MCH-29.6 MCHC-32.8 RDW-15.4
[**2176-8-5**] 11:13AM NEUTS-72.8* LYMPHS-16.4* MONOS-5.8 EOS-4.7*
BASOS-0.3
[**2176-8-5**] 11:13AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL
TEARDROP-OCCASIONAL
[**2176-8-5**] 11:13AM PLT COUNT-148*
Brief Hospital Course:
75 year-old man with history of squamous cell carcinoma of the
bladder s/p pelvic exenteration with neobladder/urostomy and
ileostomy ([**2176-5-20**]) and placement of L nephrostomy ([**8-6**]) who
was admitted directly from clinic on [**8-5**] for Cr of 3.6, spent 1
day on the floor prior to transfer to the MICU for agitation,
then returned to the floor for management of persisent UTI,
acute renal failure and leukocytosis.
Acute Issues:
#) Acute on chronic renal failure:
Since surgery in [**Month (only) 547**], patient's baseline Cr has been gradually
rising from 1.5, peaked at 4.5, was 3.6 on admission. Most
likely cause is post-renal obstructive, in the context of rising
creatinine since recent radical surgery, that may have altered
his anatatomy in a way that predisposed him to developing
obstruction. Patient does report volume loss from excessive
ostomy output and recent poor PO intake thus pre-renal failure
could also be contributing. Initial u/s of kidneys done on [**8-6**]
showed moderate-to-severe left-sided hydronephrosis and proximal
hydroureter. A L percutaneous nephrostomy was placed under IR on
[**8-6**] and follow-up u/s done on [**8-12**] showed almost complete
resolution of hydronephrosis on the L. His creatinine trended
down during the admission and on discharge, was 2.6. He
maintained good urine output through the nephrostomy and
urostomy and had no electrolyte shifts from post-obstructive
diuresis. He will be discharged with nephrostomy in place and
will f/u with urology and nephrology regarding how long the
nephrostomy should be kept in place vs. possibility of needing
ureteral stent for stricture.
.
#) Urinary tract infection:
Most likely [**3-14**] obstructive uropathy as described above. All
blood cultures were been negative and urine culture from [**8-6**]
was growing yeast only (speciated as [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**]). He was
initially treated empirically with daptomycin, meropenem,
fluconazole, and micafungin but this was narrowed to fluconazole
only when sensitivities for his [**Female First Name (un) **] returned and given
continued negative blood cultures. Per ID, will need fluconazole
for 21 days (ending [**2176-8-26**]). Towards the end of his stay, his
WBC rose (detailed below) thus UA and UCtx were obtained from
his nephrostomy and urostomy. Urine from urostomy did have many
bacteria, +leuk esterase, 100 proteins, 15 WBC, but this is
likely due to contamination. Ctx still pending. He will
follow-up with ID as an outpatient.
.
#) Sepsis:
Patient has had intermittently have low-grade fevers with
leukocytosis that initially trended down upon arrival to floor
but has rose toward the end of his admission (14.2 on [**8-10**].1
on [**8-11**] on [**8-12**] and [**8-13**]). Thought initially to be caused by
UTI given negative blood cultures to date. C. diff was ruled
out x2. Patient does have prior pelvic imaging ([**7-16**]) notable
for simple fluid collections within, likely postoperative
lymphoceles. However, given his increasing white count, there
was suspicion that these fluid collections may have become
infected. The patient underwent IR sampling of the fluid
collections on [**8-13**] which returned as gram stain negative,
cultures pending. He remained hemodynamically stable throughout
his stay. On discharge, WBC was 16.3 and per ID, can f/u as
outpatient given is asymptomatic for infection. Patient knows
to return should he develop any signs/symptoms of infection.
.
#) High ostomy output:
Has been a chronic issue for the patient (normally puts out ~1L
daily at home), and patient has had a prior admission for
acidosis thought to be related to high ostomy output with high
stool bicarb concentration. Cdiff on this admission negative x
2. Colorectal team was followed him during this admission and
recommending increasing Imodium to 4 mg TID after which his
ostomy output decreased. He will need an ostomy take-down
(thought best not to do this during this admission, given were
actively treating him for infection), which will be done as an
outpatient likely within the next couple of weeks. Colorectal
surgery will be calling him to follow-up with this.
.
#) SCC of bladder:
Followed by Dr. [**Last Name (STitle) **] as an outpatient. Dr. [**Last Name (STitle) **] came to see him
once during this admission and felt that he had [**Doctor First Name **] and did not
warrant any adjuvant treatment.
.
#) AMS:
Had one episode of AMS during this admission prompting transfer
to the MICU. Likely [**3-14**] delirium. No further episodes, never
required any medications for this.
.
Chronic Issues:
#) Normocytic Anemia:
Likely [**3-14**] to his renal disease. RBC smear negative for
schistocytes. Tbili, LDH, and haptoglobin were not consistent
with hemolysis. Hct on discharge was 27.1
.
#HLD:
Stable, continued home medications (atorvastatin)
.
Transitional Issues:
1) Medication changes: please refer to discharge planning
2) F/u appointments: please refer to discharge planning
3) Outstanding tests: bacterial/fungal/anaerobic culture from
pelvic fluid collections ([**8-13**]), stool culture and campylobacter
culture ([**8-12**]), urine culture from nephrostomy and urostomy
([**8-12**]), blood culture ([**8-8**])
4) Antibiotics: please continue fluconazole 200 mg daily until
[**8-26**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atorvastatin 10 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Fluconazole 100 mg PO Q24H
4. Sodium Bicarbonate 0 mg PO TID
Take 3 tabs at breakfast and dinner and 4 tabs at lunch
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Fluconazole 200 mg PO Q24H UTI
RX *fluconazole 200 mg 1 Tablet(s) by mouth daily Disp #*13
Tablet Refills:*0
3. Sodium Bicarbonate 2600 mg PO LUNCH
RX *sodium bicarbonate 650 mg 4 Tablet(s) by mouth daily, at
lunchtime Disp #*120 Tablet Refills:*0
4. Sodium Bicarbonate [**2114**] mg PO BID
Take in the morning and at night
RX *sodium bicarbonate 650 mg 3 Tablet(s) by mouth twice daily
Disp #*180 Tablet Refills:*0
5. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN fever/pain
RX *acetaminophen 650 mg 1 Tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
6. Loperamide 4 mg PO TID
Please give before meals, pt may refuse, maintain ostomy output
b/w 600cc-1000cc per day
RX *Anti-Diarrheal (loperamide) 2 mg 2 capsule by mouth three
times daily Disp #*180 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Acute on chronic kidney injury
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you during your recent admission at
[**Hospital1 18**]. You came to the hospital directly from the nephrology
clinic on [**8-5**] given your rising creatinine in the context of
recurrent urinary tract infections. A left nephrostomy tube was
placed under IR on [**8-6**]. For your infection, you were initially
covered broadly with 2 antibiotics (daptomycin, meropenem) and 2
antifungals (fluconazole, meropenem) but this was narrowed to
fluconazole only given that all blood cultures were negative and
you were found to have yeast growing in your urine that was
sensitive to fluconazole. Your creatinine trended down during
your admission (was XXX on discharge) and renal ultrasound on
[**8-12**] showed no hydronephrosis on the R and minimal hydronephrosis
on the L. You had high ostomy output (up to 2.3 liters daily)
which improved upon increasing your [**Last Name (LF) **], [**First Name3 (LF) **]
recommendations from the colorectal team. Towards the end of
your stay, your white blood cell count increased up to 22,200,
which was concerning for infection although you had no clinical
signs or symptoms of infection on exam. Prior CT and ultrasound
had demonstrated two large pelvic fluid collections which we
were worried may have become infected. On [**8-13**], you underwent
sampling of the pelvic fluid collections which showed XXX. Your
WBC started to decrease... On discharge, ...
Medication Changes:
1) Please stop taking ciprofloxacin
2) Please continue taking fluconazole 200 mg daily until [**8-26**]
3) Please take acetaminophen (Tylenol) [**Telephone/Fax (1) 1999**] mg every 6 hours
for pain or fever
4) Please take loperamide ([**Telephone/Fax (1) 28303**]) 4 mg three times daily for
diarrhea
Follow-up Appointments:
Please see below
Dear Mr. [**Known lastname **],
It was a pleasure caring for you during your recent admission at
[**Hospital1 18**]. You came to the hospital directly from the nephrology
clinic on [**8-5**] given your rising creatinine in the context of
recurrent urinary tract infections. A left nephrostomy tube was
placed under IR on [**8-6**]. For your infection, you were initially
covered broadly with 2 antibiotics (daptomycin, meropenem) and 2
antifungals (fluconazole, meropenem) but this was narrowed to
fluconazole only given that all blood cultures were negative and
you were found to have yeast growing in your urine that was
sensitive to fluconazole. Your creatinine trended down during
your admission (was XXX on discharge) and renal ultrasound on
[**8-12**] showed no hydronephrosis on the R and minimal hydronephrosis
on the L. You had high ostomy output (up to 2.3 liters daily)
which improved upon increasing your [**Last Name (LF) **], [**First Name3 (LF) **]
recommendations from the colorectal team. Towards the end of
your stay, your white blood cell count increased up to 22,200,
which was concerning for infection although you had no clinical
signs or symptoms of infection on exam. Prior CT and ultrasound
had demonstrated two large pelvic fluid collections which we
were worried may have become infected. On [**8-13**], you underwent
sampling of the pelvic fluid collections which showed XXX. Your
WBC started to decrease... On discharge, ...
Medication Changes:
1) Please stop taking ciprofloxacin
2) Please continue taking fluconazole 200 mg daily until [**8-26**]
3) Please take acetaminophen (Tylenol) [**Telephone/Fax (1) 1999**] mg every 6 hours
for pain or fever
4) Please take loperamide ([**Telephone/Fax (1) 28303**]) 4 mg three times daily for
diarrhea
Follow-up Appointments:
Please see below
Followup Instructions:
Please call your PCP (Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 131**], [**Telephone/Fax (1) 133**]) to make an
appointment within the next 2 weeks.
The colorectal clinic will be contacting you in the next couple
of weeks to arrange for ostomy take-down.
Scheduled appointments:
[**2176-8-30**] 9:00a INFECTIOUS DISEASE
[**Hospital **] Medical Office Building, Suite GB
[**Last Name (NamePattern1) 439**]
[**Location (un) 86**] , [**Numeric Identifier **]
[**2176-9-25**] 10:30a [**Last Name (LF) **],[**First Name3 (LF) **]
DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
RENAL DIV-WSC (SB)
[**2176-10-10**] 10:30a [**Last Name (LF) **],[**First Name3 (LF) 275**] C.
[**Hospital6 29**], [**Location (un) **]
UROLOGY CC3 (NHB)
[**2176-10-24**] 02:00p XCT (TCC) [**Apartment Address(1) **] - for abdominal CT
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
RADIOLOGY
[**2176-10-31**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) **] S.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Completed by:[**2176-8-16**]
|
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"585.9",
"584.9",
"998.13",
"287.5",
"285.21",
"V10.51",
"276.7",
"593.4",
"V44.6",
"112.2",
"V44.2",
"272.4",
"787.91",
"591",
"276.51",
"997.5",
"998.59",
"V45.74",
"403.10",
"276.2",
"293.0",
"590.80",
"288.60",
"553.3",
"038.9",
"E879.8",
"995.91",
"V45.77"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
12216, 12287
|
5596, 10236
|
303, 385
|
12386, 12386
|
4557, 5573
|
16219, 17397
|
3602, 3709
|
11285, 12193
|
12308, 12365
|
10976, 11262
|
12537, 14003
|
2927, 3290
|
3750, 4538
|
16178, 16196
|
10522, 10525
|
15852, 16154
|
230, 265
|
413, 1914
|
12401, 12513
|
10252, 10501
|
2672, 2904
|
3306, 3586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,523
| 109,446
|
54382+59600+59601
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2150-7-3**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2070-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worsening aphasia, right sided weakness, and left facial droop.
Major Surgical or Invasive Procedure:
[**2150-7-4**] left crani with drain placement
[**2150-7-15**] Left sided extended craniotomy for re-evacuation of
subdural hematoma
[**2150-7-15**] Central line
History of Present Illness:
Mr [**Known lastname **] is a 80M who is well known to our service. He is s/p
left craniotomy for SDH evacuation on [**2150-6-8**]. He had an
unremarkable post-op course and was sent home with services.
Subsequently he has returned to the ER multiple times. On
[**2150-6-18**], he returned with increased headache, the CT at that
time showed a slight increase in his L hygroma, he was admitted
to neurology as no surgery was indicated and discharged home. He
once again presented to the ER on [**7-2**] with c/o slurred speech
and right hand weakness, he was admitted for overnight
observation then discharged home. He returns to the ER today
with c/o
worsening aphasia, right sided weakness, and left facial droop.
Neurology was consulted as well.
Past Medical History:
diabetes, prostate cancer status post radiation, hypertension,
GERD, hypercholesterolemia. He has had previous craniotomy on
the right side for an intracranial hemorrhage. L SDH (evacuated
[**2150-6-8**])
Social History:
Retired, used to work as a cabinetmaker. Lives
with his wife. [**Name (NI) **] tobacco use. Occasional ETOH. Denies illicits
Family History:
Not known to the patient
Physical Exam:
Awake, alert, left facial droop, tongue midline, L pupil 4-2mm,
R
pupil 3-2mm, EOM difficult to assess secondary to cooperation,
aphasic, unable to name objects, unable to answer orientation
questions, comprehension appears intact, + commands L>R. Left
side was full motor, RUE: delt 0/5, bic [**4-4**], tri [**4-4**], R grasp
[**3-5**]
RLE: IP/H [**3-5**], quad [**4-4**]. Sensation intact appears intact to
pain.
PHYSICAL EXAM UPON DISCHARGE:
AVSS
NAD, AxOx4, nods head and answers questions appropriately
although complex answers take significant effort to produce
words
significant expressive aphasia, comprehension intact
CNII-XII intact, no facial asymmetry, tongue midline
5- UE strength on R, 5 on L
5- LE strength on R, 4 on L
sensation grossly intact bilat.
extrems wwp, 2+ cr bilat.
Pertinent Results:
[**2150-7-3**]: NCHCT IMPRESSION: No change since prior study [**2150-7-1**].
[**2150-7-3**]: AP AND LATERAL VIEWS OF THE CHEST: There are again low
lung volumes causing bibasilar atelectasis and crowding of the
pulmonary vasculature. No focal opacities concerning for
infectious process are present. No pleural effusion or
pneumothorax is noted. Aorta is tortous, unchanged.
[**2150-7-5**] CT head
Post-surgical changes related to left frontal craniotomy as
described above. In comparison to [**2150-7-3**] exam, there is no
significant change in bilateral subdural collections.
Persistent 6-mm rightward shift of normally midline structures
[**2150-7-6**] CT head
1. Post-surgical changes related to left craniotomy with
interval removal of drain and slight decrease in size of
bilateral subdural collections.
2. Persistent 6 mm rightward shift of normally midline
structures, stable
from previous exam
[**2150-7-7**] EEG
This is an abnormal continuous video EEG telemetry due to
frequent intermittent left posterior slowing mostly in the delta
range
admixed with theta activity. The posterior dominant rhythm on
the left shows attenuation of voltage compared to the right
side. There are two pushbutton activations and neither of them
show EEG changes to suggest seizure. Automated and routine
sampling fails to show any epileptiform activity.
CT head [**2150-7-9**]
1. Study limited by streak artifact from overlying EEG leads.
The previously seen left subdural hematoma now has more
posterior extension, unclear if thisis due to redistribution.
Would consider continued followup.
2. Persistent 8-mm rightward shift of normally midline
structures,
approximately stable from previous exam
Echo [**2150-7-10**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
MRI Brain/MRA Brain and Neck [**2150-7-10**]
1. No acute infarction.
2. Similar appearance of moderate-sized left subdural
collection, with
hemorrhagic component. Extensive left-sided pachymeningeal
enhancement with appearance of transudation of contrast to the
subjacent CSF space.
3. Post-surgical changes, including small post-operative
pneumocephalus
account for the described MR abnormality. Prominent left-sided
cortical
vessels. No definite leptomeningeal or mass-like enhancement.
4. Tortuous intracranial vessels, as described, but no aneurysm
larger than 3 mm, arteriovenous malformation or flow-limiting
stenosis. Normal cervical vessels.
Carotid Series [**2150-7-10**]
Findings consistent with less than 40% stenosis bilaterally.
CXR [**2150-7-10**]
Again seen is bibasilar atelectasis. A small infectious
infiltrate
at either base cannot be totally excluded; however, the overall
appearance is similar to that from one week prior. The upper
lungs are clear. The aorta is tortuous, unchanged. There
continues to be mild cardiomegaly.
CT Head [**2150-7-11**]
Persistent left subdural hematoma measuring up to 25 mm in
maximal dimension in the inner table of skull with mass effect
on the adjacent sulci, greatest at the left frontal lobe, as
well as persistent rightward shift of normally midline
structures by 9mm, compared to 8 mm previously. Post left
frontal craniotomy changes are again noted with pneumocephalus.
Continued followup is recommended.
EEG [**7-12**]
This continuous EEG recording captured three automated events
without electrographic correlate. No epileptiform activity was
seen. The
presence of an asymmetric background typically correlates with
subcortical
abnormalities under the slower hemisphere, which, in this case,
would be the left.
[**7-14**] CT head: Large left-sided subdural hematoma slightly larger
since [**2150-7-11**]. Mild increase in the mass effect and rightward
shift of midline structures.
[**7-14**] Chest Xray: PA and lateral images of the chest are
essentially unchanged from [**7-3**]. There are again seen low
lung volumes and bibasilar opacities which are unchanged. There
is no evidence of new infiltrate or consolidation.
Cardiomediastinal silhouette is unchanged. Visualized osseous
structures are unremarkable.
[**7-15**] CT head - Status post evacuation of left hemispheric
subdural hematoma, with minimum residual left subdural fluid.
Significant improvement in the mass effect on the left
hemisphere and rightward shift of midline structures.
[**7-16**] CT Head - No change
[**7-17**] - Slight increase in in residual blood in left hemispheric
subdural collection. Mild mass effect and 5-mm rightward shift
of midline structures are unchanged.
[**7-18**] NCHCT
No changes since previous scan. No new hemorrhage and stable
midline shift
Brief Hospital Course:
The patient was admitted the ICU on [**7-3**] for close neurological
observation. He was prepped for surgery. On [**7-4**] he was taken to
the operating room and underwent a left cranectomy with drainage
of the hygroma with drain left in. This was performed without
complication. Post operatively the patient did well and was
transferred to the surgical ICU for monitoring. Repeat head CT
was stable with persistent 6-mm rightward shift.
on [**7-6**] the patient's exam was significantly improved from the
day of presentation with return of upper right extremity
strength, improved word finding ability and only minimal right
nasolabial fold flattening. He was draining minimal amounts of
serosanguinous fluid and drain was removed. Repeat CT head was
done in the afternoon for fluctuating neurologica exam.
Pneumocephalus and persisten SDH was noted. On [**7-7**] he was doing
well with only mild right pronator drift.
On [**7-7**] he began to have episodes of dysarthria and RUE weakness
that would last about 15 minutes with clear episodes of
improvement. Neurology was called and EEG was in place. There
was no clear seizures on report. He had a repeat CT head on [**7-9**]
that showed increased posterior expansion of the subdural
hematoma but stable midline shift. [**Last Name (un) **] continued to follow
and make recommendations for his diabetes management.
On [**7-10**] the patient had an MRI/MRA which showed no infarct and
no vascular abnormalities. Echocardiogram was also done and was
normal and carotid ultrasounds showed less than 40% stenosis
bilaterally. That evening the patient was noted to be more
confused with increasingly frequency episodes of aphasia and
right arm weakness. Urinalysis and blood cultures were sent to
check for underlying infection and continuous EEG was resumed on
[**7-11**]. The patient also had a repeat CT with reconstructions that
showed a persistent L SDH measuring 2.5cm in maximal thickness
with 9mm of MLS. On [**7-12**] he remained stable and on [**7-13**] EEG was
stopped as he was not noted to have any seizure activity. His
Antieplileptic regimen was changed to Keppra only as well.
On [**7-14**] his right arm was noted to be decreased in strength with
proximal weakness of [**12-1**] and distal weakness of 3. Ct head was
obtained that showed slight increase in the size of the SDH with
slight increase in mass effect and edema. In the evening of
[**7-14**] the patient's strength improved to [**4-4**] however he continued
to be dysphasic. Family meeting was held to discuss the option
of a third surgery to evacuate the hematoma and the family and
patient decided to defer surgery for now in the setting of his
improved strength.
On [**7-15**] patient's exam again worsened, he was having difficulty
speaking and was unable to move to his right arm. He was taken
to the operating room and underwent a extended left
frontal/temporal craniotomy for subdural hematoma evacuation.
Post operatively he was transferred to the ICU intubaed. He had
a head CT immediately after which showed much improvement in the
midline shift.
On [**7-16**] The patient remained intubated overnight due to concerns
that he was slow to awake. He was extubated successfully POD #1.
His subdural drain was removed. His exam revealed improved right
arm strength and facial droop but continued aphasia. Later in
the day the patient became tachycardic to the 120s. His cardiac
enzymes were negative but he had some ST changes concerning for
demand ischemia.
on [**7-17**] He had lower extremity ultrasounds which was negative
for DVTs. As no clear cause for sinus tachycardia could be
found, it was thought that is was most likely due to hydralazine
that was being given for blood pressure control. This was
discontinued and he was started on metoprolol. He started
working with physical and speech therapy.
On [**7-18**] Another repeat CT head was obtained which showed no
changes.
On [**7-19**], patient remained stable, more conversant and with good
strength. He was OOB with assistance and PT was consulted.
On [**7-20**] the patient was tranfered to the floor and continued to
improve with regards to his aphasia. The patient was discharged
the following day in good condition.
Medications on Admission:
Levetiracetam 500 [**Hospital1 **], Losartan 50 daily, Omeprazole
40 daily, Pravastatin 40 daily, Metformin 1700 qam and 850 qpm,
not sure if still taking Glipizide 10 daily, Finasteride 5mg
daily, Acetaminophen prn
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Losartan Potassium 50 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN headache
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain/ fever
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Metoprolol Tartrate 25 mg PO BID
Hold sbp <100, HR<60
12. Multivitamins 1 TAB PO DAILY
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Senna 1 TAB PO BID
16. GlipiZIDE 10 mg PO DAILY
17. MetFORMIN (Glucophage) 1700 mg PO BID
1700mg in AM 850 in PM
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
subdural hygroma
hyperglycemia
transient hemiparesis
aphasia
Discharge Condition:
Mental Status: Clear and coherent (expressive aphasia,
comprehension intact)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Craniotomy for Hemorrhage
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? **Your wound was closed with sutures. You may wash your hair
only after sutures have been removed.
?????? ?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**9-13**] days(from your date of
surgery) for removal of your sutures. This appointment can be
made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????**You may also have them removed at your rehab facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2150-7-21**] Name: [**Known lastname **],[**Known firstname 4076**] Unit No: [**Numeric Identifier 18277**]
Admission Date: [**2150-7-3**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2070-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 40**]
Addendum:
See [**7-21**] changes re: sliding scale and insulin changes.
1. Finasteride 5 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Losartan Potassium 50 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN headache
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain/ fever
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Metoprolol Tartrate 25 mg PO BID
Hold sbp <100, HR<60
12. Multivitamins 1 TAB PO DAILY
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Senna 1 TAB PO BID
16. GlipiZIDE 10 mg PO DAILY
17. MetFORMIN (Glucophage) 1700 mg PO BID
1700mg in AM 850 in PM
18. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2150-7-21**] Name: [**Known lastname **],[**Known firstname 4076**] Unit No: [**Numeric Identifier 18277**]
Admission Date: [**2150-7-3**] Discharge Date: [**2150-7-21**]
Date of Birth: [**2070-2-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 40**]
Addendum:
Metformin chnaged to 1000mg [**Hospital1 **] prior to discharge. Patient will
start glipizide 10mg daily on [**7-22**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2150-7-21**]
|
[
"V10.46",
"401.9",
"E942.6",
"E000.8",
"342.91",
"348.5",
"272.0",
"250.02",
"852.21",
"785.0",
"530.81",
"V15.3",
"784.3",
"E884.9",
"V14.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
17328, 17585
|
7857, 12087
|
338, 502
|
13283, 13283
|
2525, 6807
|
14653, 16558
|
1669, 1695
|
12354, 13033
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13199, 13262
|
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|
13508, 14630
|
1710, 2126
|
234, 300
|
2156, 2506
|
530, 1281
|
6816, 7834
|
13298, 13484
|
1303, 1510
|
1526, 1653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,294
| 103,298
|
33943
|
Discharge summary
|
report
|
Admission Date: [**2178-2-15**] Discharge Date: [**2178-2-26**]
Date of Birth: [**2123-5-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tylenol
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Fevers and hypotension
Major Surgical or Invasive Procedure:
Operative removal of IM nail from the left tibia
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is a 54 year old male h/o chronic left lower
extremity (LLE) osteomyelitis [**3-16**] traumatic fx and hardware
placement, deep venous thrombosus on coumadin, and recently
diagnosed aortitis who presents from an OSH with persistent
fevers and worsening LLE pain/swelling.
Mr. [**Known lastname **] states he was in his usual state of good health early
last year when a tire truck fell and crushed his L lower leg on
[**2177-6-9**]. He was taken to [**Hospital1 18**] where he was found to have
a L tibial shaft comminuted fracture in the distal [**2-14**] of the
bone, as well as chronic bursitis of the L knee. Dr. [**Last Name (STitle) 1005**]
placed an intramedullary nail and removed a prepatellar mass
consistent w/ the bursitis.
One week following discharge, Mr. [**Known lastname **] was admitted for
persistent fevers to 101*F, sweats, malaise, and chills along w/
L leg swelling and pain. He was hospitalized for 11 d and
treated for cellulitis w/ Vanc and cipro via PICC, to be
followed by ID. Seven weeks after abx initiation, Mr. [**Known lastname 78409**]
inflammatory markers remained positive, including ESR and CRP,
though clinically he was improving. IV abx were d/c'd on
[**2177-8-28**], nine weeks after the decline of markers and the
resolution of the majority of symptoms (inc temp), with the
exception of some pain and swelling. He was started on PO
doxycycline. At the time, ID was concerned for hardware
infection given the temporal course of the fevers and infection
and plan was for IM nail removal in [**3-23**]/
On [**2178-1-5**], Mr. [**Known lastname **] came for f/u in [**Hospital **] clinic and
complained of recurrent fevers to 101*F over the past several
weeks despite continuation of oral abx. He also had inc pain w/
ambulation and L leg edema. Per ID, he was continued on oral
doxy. Leg u/s revealed DVT and Mr. [**Known lastname **] was started on
anticoagulation. CT chest was neg for PE, but suggestive of 4mm
aortic thickening, read as possible intramural hematoma or
aortitis. Rhematology was consulted for vasculitis workup. MRI
was not suggestive of thickening, though arch abnormality was
visualized. Also noted were small pericardial and pleural
effusions.
Outpatient work-up for vasculitis was negative for temporal
arteritis on biopsy and inflammatory markers remained mildly
elevated to a CRP 64. F/u chest CT on [**2-10**] was significant for
repeated visualization of aortic thickening, unchanged, as well
as increased pericardial effusion. TTE also revealed
pericardial effusion without signs of tamponade, but possible
aortic regurg.
On [**2178-2-14**], Mr. [**Known lastname **] presented to [**Hospital3 **] ED
with increased lower leg pain, swelling, and warmth, with 3d of
fevers of 103 per visiting nurse services. In the ED he was
found to have a temp of 102.2 and BP 84/52. WBC was 27.7.
Transfer to [**Hospital1 18**] was arranged along with initiation of
Vancomycin, Zosyn, and dopamine.
At [**Hospital1 18**], Mr. [**Known lastname **] was admitted to the ICU.
ROS: Significant for GI upset and nausea. Pt. denies syncope,
change in taste, sight, olfaction, or hearing, dysphagia, chest
pain, palpitations, hemoptysis, vomiting, constipation,
diarrhea, hematuria, hematochezia, melena, change in bladder
habits, change in skin, new palpable masses.
Past Medical History:
# Presumed chronic osteomyelitis as detailed above
# Hypertension
# L popliteal DVT [**2178-1-5**], on coumadin at home.
# Chronic bursitis s/p resection [**2177-6-9**]
# Scoliosis
#? Gout.
Social History:
Mechanic for NSTAR electric vehicles. Widowed 4 years ago (wife
passed away from cancer). Currently lives with 14 yo son.
Denies tobacco or EtOH use.
Family History:
Non-contributory
Physical Exam:
Upon transfer to medical service:
VS:100.9 100.1 112/80 103 20 92 RA Glu 199
Gen: Obese male with prominent rhinophima appearing
significantly older than stated age with raspy voice,
continually rubbing eyes, and having difficulty recalling his
medical hx who is not in any acute pain or SOB.
HEENT: H:No signs of trauma, asymmetry. E: Pupils with minimal
reaction. 3->2.5mm. No scleral icterus. EOMs intact. N:
Prominent erythematous nose. No polyps or signs of ecchymosis.
T: Moist mucous membranes. No erythema or exudate.
CV: RRR. Audible S1, S2 with grade [**3-20**] diastolic murmur heard
best at UL sternal border. No radiation. No JVD appreciable.
No carotid bruits. No temporal bruits. Pulses [**Last Name (un) 55863**] in upper
and lower extremities, inc DP and PT. No delay in pulses.Pulsus
8mmHg. No splinter hemorrhages.
Pulm: Lungs clear to auscultation and percussion. Diaphragms
symmetric. No crackles, wheezes, rhonchi. Limited excursion on
inspiration.
Abd: Firm, non-tender to palp. Active bowel sounds. No liver
edge palp.
Extremities: Left lower extremity very warm to touch and with
edema and erythema from mid metatarsals to 3 inches below the
knee in comparison to R leg. Tender to palpation.
Neuro: Awake, alert, oriented x3. Language fluent, naming
intact, but easily distracted and tangential thought process at
times. CN II-XII grossly intact. [**6-16**] motor strength in all 4
extremities.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2178-2-15**] 12:52AM BLOOD WBC-20.1*# RBC-4.18* Hgb-12.3* Hct-35.8*
MCV-86 MCH-29.5 MCHC-34.4 RDW-14.1 Plt Ct-537*#
[**2178-2-15**] 12:52AM BLOOD Neuts-83.7* Lymphs-12.8* Monos-2.8
Eos-0.5 Baso-0.2
[**2178-2-15**] 12:52AM BLOOD PT-19.5* PTT-26.5 INR(PT)-1.8*
[**2178-2-16**] 07:30PM BLOOD WBC-13.6* Lymph-14* Abs [**Last Name (un) **]-[**2073**] CD3%-60
Abs CD3-1150 CD4%-48 Abs CD4-920 CD8%-12 Abs CD8-233
CD4/CD8-3.9*
CHEMISTRIES:
[**2178-2-15**] 12:52AM BLOOD Glucose-123* UreaN-20 Creat-1.2 Na-133
K-4.0 Cl-97
HCO3-25 AnGap-15
CARDIAC ENZYMES:
[**2178-2-15**] 12:52AM BLOOD cTropnT-<0.01
[**2178-2-15**] 05:13AM BLOOD CK-MB-4 cTropnT-<0.01
[**2178-2-19**] 12:53PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2178-2-15**] 12:52AM BLOOD CK(CPK)-115
[**2178-2-15**] 05:13AM BLOOD CK(CPK)-105
[**2178-2-19**] 12:53PM BLOOD CK(CPK)-58
THYROID:
[**2178-2-16**] 07:30PM BLOOD TSH-1.5
ADRENAL:
[**2178-2-16**] 07:30PM BLOOD Cortsol-27.1*
INFLAMMATORY MARKERS:
[**2178-2-17**] 02:57AM BLOOD CRP-199.4*
[**2178-2-18**] 09:30AM BLOOD CRP-184.9*
[**2178-2-21**] 03:45PM BLOOD CRP-146.4*
ADDITIONAL SEROLOGIES AND TESTING:
[**2178-2-17**] 10:42AM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS:
CBC:
[**2178-2-26**] 05:02AM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.5 3.39* 9.8* 29.0* 86 28.8 33.6 15.5 429
INR: 1.8
------------
MICROBIOLOGY:
[**2178-2-15**] 12:52 am BLOOD CULTURE SET1.
**FINAL REPORT [**2178-2-21**]**
Blood Culture, Routine (Final [**2178-2-21**]): NO GROWTH.
--------
[**2178-2-19**] 9:35 am SWAB Site: TIBIA
SWAB OF TIBIAL NAIL (LEFT) (SAVE FOR FUTURE USE).
GRAM STAIN (Final [**2178-2-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2178-2-21**]): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (HAIR/SKIN/NAILS) (Final
[**2178-2-19**]):
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
----------
[**2178-2-19**] 9:30 am TISSUE INTRAMEDULARY BONE LEFT TIBIA.
GRAM STAIN (Final [**2178-2-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2178-2-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
--------
[**2178-2-19**] 9:40 am TISSUE INTRAMEDULARY BONE REAMINGS LEFT
TIBIA.
GRAM STAIN (Final [**2178-2-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2178-2-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2178-2-19**]):
NO FUNGAL ELEMENTS SEEN.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
-------
[**2178-2-19**] 9:05 am SWAB DISTAL SCREWS SWAB.
GRAM STAIN (Final [**2178-2-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2178-2-21**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2178-2-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2178-2-19**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
---------
IMAGING:
L ANKLE XRAY [**2178-2-15**]: Four films are submitted of the tibia and
fibula showing an intramedullary rod
with fixation proximally and distally. The oblique fractures
through the
tibia and fibula have healed with callus formation more dense
than on the
prior films of [**2177-11-12**]. Some periosteal new bone formation
is seen
running down the medial aspect of the tibia below the old
fracture line, which could indicate an area of osteomyelitis.
Transthoracic ECHO [**2178-2-16**]:
Overall left ventricular systolic function is normal
(LVEF>55%). RV with borderline normal free wall function. The
aortic valve leaflets are moderately thickened. There is a
moderate sized pericardial effusion. Stranding is visualized
within the pericardial space c/w organization. There are no
echocardiographic signs of tamponade.
Transthoracic ECHO [**2178-2-20**]:
The patient was imaged, sitting up at 45 degrees. There is a
small pericardial effusion. The effusion is circumferential and
echo dense, consistent with blood, inflammation or other
cellular elements. There is little to no free-flowing fluid
around the heart. Left ventricular function is globally
preserved.
Compared with the prior study (images reviewed) of [**2178-2-16**], the
effusion appears substantially more consolidated and is overall
slightly smaller. The other findings are similar.
Transesophageal ECHO [**2178-2-23**]:
No spontaneous echo contrast or mass/thrombus is seen in the
left atrium/left atrial appendage or the right atrium/right
atrial appendage. The interatrial septum is intact to 2D and
color Doppler. There are simple atheroma in the descending
thoracic aorta to 40cm from the incisors. The aortic valve
leaflets are moderately thickened. A ~2 mm mobile echo density
(clips 34-36) is seen on the non-coronary leaflet of the aortic
valve consistent with possible vegetation vs focal calcium. No
aortic root abscess is seen. There is moderate (2+) aortic
regurgitation. The mitral valve leaflets are mildly thickened
but without focal vegetation or abscess. Mild [1+] mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderately thickened aortic valve leaflets with 2mm
mobile echodensity as described above and c/w vegetation (vs.
calcium). Moderate aortic regurgitation.
Brief Hospital Course:
This is a 54 year old man with a complicated history of presumed
chronic osteomyelitis and new diagnosis of aortitis who presents
with recurrent fevers and increased left lower extremity pain.
#Recurrent fevers: Following admission to the ICU, hypotension
resolved with fluid resucitation and breif course of pressors.
Vancomycin and Zosyn were continued and infectious disease,
rheumatology and cardiology consults were called. On the fourth
day on broad spectrum abx, Mr. [**Known lastname **] [**Last Name (Titles) 14976**]. Despite
extensive blood and bone cultures as well as testing for
syphilis, tuberculosis, HIV, aerobic, anaerobic, mycobacterial,
and fungal causes, the source of infection remains unclear. On
exam, his left lower extremity appeared suspicious for
osteomyelitis given swelling and pain though intraopertively the
bone did not appear infected and intra-operative tissue and
wound cultures have not grown anything. Patient had TEE to
assess for vegetations which showed a questionable vegetation on
the aortic valve. Plan is for patient to receive a [**5-18**] week
course of antibiotics:Ceftriaxone for a total of 4 weeks (last
dose on [**2178-3-14**]) and Vancomycin for a total of 6 weeks (last
dose [**2178-3-28**]). He has a repeat TEE scheduled in 4 weeks. At time
of discharge, patient remained afebrile with a normal white
blood cell count and downward trending CRP. He is to follow up
in infectious disease clinic on [**2178-3-12**]. Outpatient Lab Work
Weekly blood draws for CBC with Differential, BUN/Cr, AST, ALT,
Akl Phos, Total Bili, Chemistry 7, CRP, Vanco trough - results
to be faxed to [**Telephone/Fax (1) 78410**] atten Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.
# Pericardial effusion: Pericardial effusion, first noted as an
outpatient, has been followed as an inpatient by transthoracic
echocardiogram and clinical exam. ECHO indicates consolidation
of effusion. A pericardial tap was considered but given the
small amount of pericardial fluid the cardiology consult service
did not feel this procedure would be high yield and would be
high risk. Patient remained hemodynamically stable without and
without concerning events on telemetry.
# Status Post Intramedullary Nail Removal: Patient tolerated
operative procure well and has had an uncomplicated course
post-op. Pain has been well controlled with oxycodone. He is
currently able to partial weight bear on the LLE. Plan is for
patient to follow up with orthopedic surgery 1 week from
discharge to have staples removed.
#Aortitis ?????? Stable during this admission. Blood pressure
remained stable. Plan is for patient to follow up with Dr.
[**Last Name (STitle) 914**] in 6 months and have repeat CT scan. If patient's fevers
were to return would consider re-imaging aorta sooner.
# History of DVT: Coumadin held while an inpatient and started
on a heparin drip given need for procedures. Coumadin restarted
at time of discharge with lovenox bridge. He is scheduled to
have outpatient lab work following discharge.
# Mental Status - Patient had distracted affect and has
tangential thought process throughout stay on medicine service.
Per patient's family this is his baseline. Patient had a Head CT
also showed no evidence of acute intracranial abnormalities
without contrast that did not indicate an acute intracranial
process. A Head CT with contrast was also showed no evidence of
acute intracranial abnormalities(patient unable to complete MRI
head due to claustrophobia).
# Anemia of Chronic Disease: Iron studies consistent with anemia
of chronic disease. Hematocrit remained stable during this
admission.
Patient was a FULL code during this admission.
Medications on Admission:
Medications on transfer:
Vancomycin 1000 mg IV Q 12H
Piperacillin-Tazobactam Na 4.5 g IV Q8H
Heparin IV Sliding Scale
Niacin 500 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Nitroglycerin SL 0.3 mg SL PRN chest pain
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Metoprolol Tartrate 25 mg PO BID
Bisacodyl 10 mg PR HS:PRN constipation
Oxycodone 5-10 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID:PRN constipation
Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: You
will need to have your INR checked by home health. Your dose of
this med will be adjusted by your doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): To continue until INR therapuetic on coumadin.
[**Last Name (Titles) **]:*60 syringes* Refills:*0*
6. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4)
hours as needed for pain: Do not drive or operate heavy
machinery while taking this medication.
[**Last Name (Titles) **]:*15 Capsule(s)* Refills:*0*
7. 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.
8. Indomethacin 50 mg Capsule Oral
9. Niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
10. Calcium Carbonate Oral
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous twice a day for 41 days: Stop Date: [**4-7**]
To complete a 6 week course
Please give over 2 hours. .
[**Month/Year (2) **]:*41 QS* Refills:*0*
13. Ceftriaxone 2 gram Recon Soln Sig: One (1) Intravenous once
a day for 27 days: Stop Date [**3-24**] to complete a 4 week course.
[**Month/Year (2) **]:*27 QS* Refills:*0*
14. Outpatient Lab Work
Weekly blood draws for CBC with Differential, BUN/Cr, AST, ALT,
Akl Phos, Total Bili, Chemistry 7, CRP, Vanco trough - results
to be faxed to [**Telephone/Fax (1) 78410**] atten Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.
15. Outpatient Lab Work
Please check INR on [**2178-2-26**] and fax to ([**Telephone/Fax (1) 78411**] Attn: Dr.
[**Last Name (STitle) 59771**]
16. Saline Flush 0.9 % Syringe Sig: One (1) Injection six times
daily for 6 weeks.
[**Last Name (STitle) **]:*240 QS* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 32036**] Home care
Discharge Diagnosis:
PRIMARY: Presumptive culture-negative endocarditis , status post
intra-medullary nail removal
SECONDARY: Pericardial effusion, Aortitis, History of deep
venous thrombosis
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were transferred to this hospital to determine why you were
having recurrent fevers and to treat your low blood pressure.
Blood cultures could not identify a specific type of bacteria.
However, while you were here, you were given antibiotics which
helped to reduce your fever. Your left leg also appeared
inflammed and we were concerned for infection from the leg. You
underwent surgery to remove the nail from your bone. Though it
does not appear that your bone was the source of infection. You
were also noted to have fluid around your heart, which is now
stable. You had a procedure to look at your heart valves that
indicated a question of an infection involving one of your
valves. As noted above, you will be treated with antibiotics
that should treat this type of infection. There has been no
change in the inflammation in your aorta. At time of discharge
you remained without fever. You will be discharged on a 6 week
course of antibiotics.
You have been started on the following NEW medications:
-Vancomycin: this is an intravenous antibiotic that you need to
infuse twice a day.
-Ceftriaxone: this is an intravenous antibiotic that you need to
infuse once daily.
-Oxycodone: this is a pain medication that you can take by mouth
up to every 4 hours as needed for pain. Do NOT drive or operate
heavy machinery while using this medication.
If you experience fevers, chills, chest pain, shortness of
breath or passing out please contact your primary care physician
or go to the emergency department for evaluation.
Followup Instructions:
Please follow up with your Primay Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 59771**] in
[**2-13**] weeks. Please call ([**Telephone/Fax (1) 78412**] to schedule an
appointment.
[**Hospital **] CLINIC: Provider: [**Name10 (NameIs) **] XRAY (SCC 2)
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2178-3-12**] 8:20
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2178-3-12**] 8:40
Visiting nursing should remove your staples on [**2178-3-5**]
.
INFECTIOUS DISEASE CLINIC:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-3-12**]
11:00am
CARDIOLOGY CLINIC: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on [**2177-3-22**] at 3:00 pm in the
[**Hospital Ward Name 23**] Building. His office phone number is ([**Telephone/Fax (1) 1987**].
TRANSESOPHAGEAL ECHOCARDIOGRAM: You will need a follow up echo
to evaluate for endocarditis - you are scheduled for [**2178-3-27**] in
[**Hospital Ward Name **] 4 on the [**Hospital Ward Name 517**] of [**Hospital1 18**] at 7:30am. Please do not eat
anything starting at midnight on [**2178-3-26**] until after your
procedure.
CARDIOTHORACIC SURGERY: Dr.[**Name (NI) 9379**] office will schedule you
for a repeat CT scan to assess your aorta and will schedule you
for an appointment. If you do not hear from his office within
the next 4 weeks please call them at ([**Telephone/Fax (1) 1504**].
Completed by:[**2178-3-1**]
|
[
"447.6",
"285.29",
"995.91",
"401.9",
"423.9",
"996.67",
"511.9",
"V12.51",
"038.9",
"V58.61",
"421.0",
"293.0",
"730.16"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"78.67",
"77.67",
"88.72",
"77.47"
] |
icd9pcs
|
[
[
[]
]
] |
19459, 19526
|
13011, 16718
|
305, 376
|
19741, 19776
|
5669, 5669
|
21353, 22965
|
4170, 4188
|
17241, 19436
|
19547, 19720
|
16744, 16744
|
19800, 21330
|
6872, 7604
|
4203, 5650
|
9888, 10124
|
10160, 12988
|
6245, 6855
|
243, 267
|
404, 3771
|
5686, 6228
|
9740, 9849
|
16769, 17218
|
3793, 3985
|
4001, 4154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,119
| 152,965
|
15292+15293
|
Discharge summary
|
report+report
|
Admission Date: [**2145-8-24**] Discharge Date: [**2145-9-29**]
Date of Birth: Sex:
Service: THORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
male with a twenty three year history of smoking,
discontinued approximately fifteen years ago who presented
with a few months of stabbing and burning sensation over his
face, extremities and torso. Symptoms were worse at his
palms, feet and face and tongue. The symptoms improved
somewhat with Neurontin. Given his symptoms the patient had
an extensive workup which revealed a right lower lobe lung
mass. The MRI of the head and spine was negative. A CAT
scan was performed, which confirmed the mass in the right
lower lobe. No obvious lymphadenopathy was seen. The
patient was admitted for staging and a possible surgical
intervention given no gross involvement of his lymph nodes.
The patient had bone pain. A PET scan was positive for
primary disease, but no other involvement was observed.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia.
PAST SURGICAL HISTORY: None
MEDICATIONS ON ADMISSION: 1. Neurontin 300 mg q day. 2.
Lipitor 40 mg q.d. 3. Lisinopril 20 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Use of tobacco for approximately twenty
three years. Quit fifteen years ago. Moderate alcohol use.
PHYSICAL EXAMINATION: Alert and oriented and in no acute
distress. Vital signs temperature 98.1. Heart rate 101.
Blood pressure 120/84. Oxygenation 97% on room air. HEENT
examination no JVD. No masses. No lymphadenopathy palpable.
Cardiac regular rate and rhythm. Chest clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended without
hepatosplenomegaly. Extremities no edema, warm and well
perfuse.
LABORATORY STUDIES: White blood cell count 9.2, hematocrit
40.2, platelets 308. Glucose 78, BUN 13, creatinine 0.8,
sodium 138, potassium 4.4. Chest x-ray preoperatively showed
a 2.6 by 1.6 cm right base pulmonary nodule, which was
consistent with a given history of lung cancer.
HOSPITAL COURSE: The patient was admitted to the Thoracic
Surgery for further evaluation and management of his lung
cancer. On [**2145-8-24**] the patient underwent bronchoscopy,
mediastinoscopy, followed by right lower lobectomy. The
pathology showed adenocarcinoma that was moderately
differentiated with predominantly papillary features and
bronchial alveolar pattern. The bronchoscopy was normal.
The frozen section was negative for metastatic disease. The
procedure was without any complications. Estimated blood
loss was 100 cc. Please see the full operative note for
further details.
The patient's pain was controlled with the epidural. He was
transported to the regular floor in stable condition.
Aggressive pulmonary toilet was initiated. On [**2145-8-26**] in the
evening the patient was noted to have low oxygen saturation
and to be producing copious secretions out of his mouth.
Given his unstable condition a code was called. Gastric
contents were noted to be bubbling out of the patient's mouth
and he appeared obtunded when the code team arrived. He was
intubated and transferred to the Intensive Care Unit. The
chest x-ray at the time showed persistent evidence of
loculated basal and pneumothorax on the right side and
parenchymal density on the right side was suspicious for
aspiration. Bilateral central pulmonary densities were
thought to most likely represent pulmonary edema. The blood
gas at the time showed significant respiratory acidosis. The
patient was started on Ceftriaxone and Flagyl. Tube feeding
was initiated through a nasogastric tube. Bronchoscopy was
performed, which revealed copious secretions bilaterally and
culture of the secretions revealed gram negative rods.
On [**2145-8-31**] the patient spiked a temperature of 102
consequently Vancomycin was added to the antibiotic regimen
and blood cultures were sent, which were all negative. A
repeat sputum culture grew Klebsiella pneumoniae, which was
pan sensitive. The patient was continued to be monitored
centrally. The patient continued to receive bronchoscopies,
which again revealed large amount of thick secretions. The
patient's antibiotic regimen was continued as the vancomycin,
Flagyl and Ceftriaxone. The patient continued to have low
grade fevers. His urine culture from [**8-31**] grew enterococcus.
The patient's sedation was minimized. Infectious disease was
consulted on [**2145-9-2**] given persistent fevers. The infectious
disease consult recommended clostridium difficile given the
history of antibiotic use during hospitalization, to continue
Vancomycin, start Zosyn to cover microsomal pathogens. The
patient was also diuresed to help differentiate infiltrates
from pulmonary edema. A CT scan with and without contrast
was performed on [**2145-9-2**] to evaluate for possibility of a
stroke. The CAT scan showed no evidence of hemorrhage or
stroke at the time. The scan was performed given decreased
movement of the lower extremities and decreased response to
stimuli. In addition a PET scan of the abdomen was performed
on [**2145-9-2**] to rule out fluid collection. No fluid collection
was seen. Physical therapy was consulted, which continued to
follow the patient.
The patient was being slowly weaned off the ventilator. The
infectious disease workup did not show any clear source of
his fevers given the coverage with antibiotics. The
patient's prolonged respiratory failure was thought to be
consistent with ARDS (adult respiratory distress syndrome).
Chest x-ray done on [**2145-9-7**] did not show any significant
improvement. On [**2145-9-7**] the patient complained of right
upper quadrant pain and continued to have elevated white
blood cell count. Ultrasound of the gallbladder was
performed, which showed no evidence of cholecystitis and
showed echogenic liver consistent with fatty infiltration.
Follow up bronchoscopies showed a decrease amount of
secretions. The patient did have periods of increased
agitation and confusion. Given the history of alcohol use in
the past his symptoms and signs were closely monitored. On
[**2145-9-8**] the patient was extubated. He appeared agitated and
congested afterwards. He had copious amounts of thick yellow
secretions. Follow up chest x-ray showed little change in
the amount of infiltrates. The patient's blood gas was
improved. The patient's sputum grew Klebsiella. He was
continued on Zosyn and Vancomycin. On [**2145-9-10**] the patient
appeared to have decreasing white blood cell count,
decreasing infiltrate on the chest x-ray and no more fever
spikes, although he continues to have low grade temperatures.
He continued to bring copious amounts of secretions and
continued to be in a rather tenuous respiratory status after
being extubated a few days earlier.
The patient continued to receive aggressive chest therapy to
relieve his congestion. The patient was transfused with
packed red blood cells on [**2145-9-13**].
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2145-9-29**] 09:51
T: [**2145-9-29**] 10:46
JOB#: [**Job Number 44471**]
Admission Date: [**2145-8-24**] Discharge Date: [**2145-9-29**]
Date of Birth: [**2086-4-7**] Sex: M
Service:
HOSPITAL COURSE: The patient continued to slowly improve
while in the Intensive Care Unit. He completed a full
recommended course of intravenous Zosyn. On [**2145-9-15**], ................... lavage obtained from a bronchoscopy
showed a Staphylococcus aureus that was MRSA but sensitive to
Vancomycin. The patient still continued to have mild
leukocytosis. Given the sensitivities, intravenous
Vancomycin was started on [**2145-9-20**].
On [**2145-9-20**], a speech and swallow test was
performed. Speech and swallow test showed increased risk of
aspiration. The patient was transferred to the regular floor
on [**2145-9-24**]. The patient was continued on tube feeds.
The patient still continued to have a moderate amount of
secretions that were mostly yellowish in color and thick in
consistency. The patient was continued on intravenous
Vancomycin.
The patient was ambulating. His chest x-ray showed some
interval improvement. The patient remained in regular
rhythm. He was tolerating his tube feeds well. A
video-assisted speech and swallow was repeated on [**2145-9-27**], which still showed the risk of aspiration. The patient
was discharged to the rehabilitation facility on [**2145-9-29**], in stable condition.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To the rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Lung cancer status post right lower lobe resection.
2. Methicillin resistant staphylococcus aureus aspiration
pneumonia.
3. ARDS.
4. Hypertension.
5. Hypercholesterolemia.
DISCHARGE MEDICATIONS: Lopressor 150 mg p.o. t.i.d.,
Lisinopril 20 mg p.o. q.d., Lipitor 40 mg p.o. q.d.,
Neurontin 300 mg p.o. q.d., Vancomycin 1 g IV q.12 hours x 4
days to start on [**2145-9-29**], Colace 100 mg p.o. b.i.d.
p.r.n. constipation, Albuterol 4 puffs inhaler q.4 hours,
Ipratropium Bromide 4 puffs inhaler q.4 hours, Tylenol 325 mg
p.o. q.4-6 hours p.r.n. pain, Nystatin oral suspension 5 ml
p.o. q.i.d. p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) 175**], his surgeon, in approximately two weeks. The patient
is to follow-up with his primary care physician in
approximately 1-2 weeks. The patient is to follow-up with
Infectious Disease physician within the next month.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 177**] 02-177
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2145-9-29**] 10:09
T: [**2145-9-29**] 12:20
JOB#: [**Job Number 44472**]
|
[
"599.0",
"272.0",
"507.0",
"427.89",
"401.9",
"482.41",
"518.5",
"162.5",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.22",
"38.93",
"96.6",
"33.23",
"32.4",
"33.48",
"40.3",
"03.90",
"38.91",
"96.04",
"33.22",
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8727, 8760
|
8986, 9390
|
8781, 8962
|
1120, 1239
|
7450, 8669
|
9415, 9931
|
1087, 1093
|
1381, 2069
|
162, 995
|
1018, 1063
|
1256, 1358
|
8694, 8703
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,690
| 122,799
|
10799
|
Discharge summary
|
report
|
Admission Date: [**2173-10-17**] Discharge Date: [**2173-10-23**]
Date of Birth: [**2122-3-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 51 year old gentleman
with a history of coronary artery disease, status post
inferior myocardial infarction and stents times two who on
the day of admission began having left chest pain around 11
AM. The pain began at rest. He described the pain as [**3-2**],
aching and dull, worse with tensing his pectoralis muscles
but also says he has shortness of breath and numbness in both
arms. This is unlike his typical angina which is described
as more of a chest tightness.
The patient had recently had a cardiac catheterization on
[**10-12**] which revealed 70 to 80% stenosis of the left
main coronary artery. The left anterior descending had mild
to moderate diffuse disease. The left circumflex artery had
mild disease and there was 30% in-stent restenosis of the
obtuse marginal. The right coronary artery had insignificant
disease and the stent was patent. The patient had been
scheduled for an elective coronary artery bypass graft with
Dr. [**Last Name (STitle) 70**] for [**2173-10-18**].
PAST MEDICAL HISTORY:
1. Coronary artery disease, inferior myocardial infarction
on [**2173-7-5**], stent to obtuse marginal [**6-24**], stents to right coronary artery [**2173-7-5**],
cardiac catheterization [**2173-10-12**], see history of
present illness for details.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes for the past five years.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day
2. Vitamin E
3. Folate
4. Lopressor 50 mg p.o. b.i.d.
5. Metformin 1000 mg p.o. b.i.d.
6. Lipitor 20 mg p.o. q.d.
7. Zestril 10 mg p.o. q.d.
8. Glucotrol XL 10 mg p.o. q.d.
SOCIAL HISTORY: History of tobacco, claims she quit one
month. History of alcohol use, questionable amount.
FAMILY HISTORY: Denies family history of coronary artery
disease, hypertension or diabetes.
PHYSICAL EXAMINATION: Examination on admission revealed
vital signs of pulse 85, blood pressure 137/80, 15, 97% on
room air. General, pleasant, well appearing gentleman
appearing his stated age. Head, eyes, ears, nose and throat
shows pupils equal, round and reactive to light. Extraocular
muscles intact. Moist mucous membranes. Neck, no bruits, no
lymphadenopathy. Cardiovascular, regular rate and rhythm, no
murmur. Pulmonary clear to auscultation bilaterally.
Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. Rectal, coag negative. Extremities, no bruits, no
edema and 2+ pulses in all extremities. Neurological,
cranial nerves II through XII intact. Motor [**3-27**] in all four
extremities. Alert and oriented times three.
HOSPITAL COURSE: The patient was admitted to the [**Hospital6 1760**] and ruled out for myocardial
infarction by serial enzymes. On the day following admission
[**2173-10-18**] the patient went to the Operating Room
where he had a coronary artery bypass graft times four. He
had left internal mammary artery anastomosed to the left
anterior descending, saphenous vein graft to obtuse marginal,
saphenous vein graft to the diagonal, saphenous vein graft to
the posterior descending artery. Dr. [**Last Name (STitle) 70**] was the
surgeon of record. Please see previously dictated operative
note for more details. The patient tolerated the procedure
well. The patient was transferred from the Operating Room to
the Cardiac Surgery Recovery Unit in stable condition. He
was left intubated and was on Propofol drip on arrival to the
Cardiac Surgery Intensive Care Unit. The night of operation
he was extubated without incident and weaned off of
Neosynephrine which he needed for blood pressure support.
His hematocrit was 19.5 and he was transfused 2 units of
packed red blood cells. On postoperative day #1 the patient
was transferred from the Intensive Care Unit to the Patient
Care Floor. His repeat hematocrit after 2 units had gone
from 19.5 to 23.7 and therefore he was given a third unit of
packed red blood cells. After this his hematocrit went to
25.3. The patient remained stable during his hospital
course. His sternal wires, chest tube and Foley catheter
were all removed without incident. Unfortunately upon
removal of his Foley catheter the patient was unable to void
and required to be straight cathed times one. He had
residual volume of roughly 300 cc. The catheter was removed
and he was able to void several hours later spontaneously.
By postoperative day #5, the patient was ambulating and
cleared by physical therapy to be discharged to home. Pain
was controlled on oral medications and he was voiding without
problems.
DISCHARGE DISPOSITION: Home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft, four vessels.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times one week
3. Kayciel 20 mEq p.o. b.i.d. times one week
4. Colace 100 mg p.o. b.i.d. while on Percocet
5. Enteric coated Aspirin 325 mg p.o. q.d.
6. Glucotrol 10 mg p.o. q.d.
7. Lipitor 20 mg p.o. q.d.
8. Glucophage 1000 mg p.o. b.i.d.
9. Lopressor 50 mg p.o. b.i.d.
10. Ibuprofen 400-600 mg p.o. q. 4-6 hours prn
11. Percocet one tablet p.o. q. 4-6 hours prn
FOLLOW UP: The patient will see Dr. [**Last Name (STitle) **], his primary care
physician in three weeks. The patient will see Dr. [**Last Name (STitle) 70**]
back at [**Hospital6 256**] in three to four
weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2173-10-22**] 19:02
T: [**2173-10-22**] 19:19
JOB#: [**Job Number 35253**]
|
[
"272.0",
"250.00",
"411.1",
"412",
"414.01",
"V15.82",
"788.20",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4712, 4719
|
1895, 1972
|
4821, 5253
|
4741, 4798
|
1555, 1767
|
2750, 4688
|
5265, 5772
|
1995, 2732
|
161, 1174
|
1196, 1529
|
1784, 1878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,975
| 182,696
|
8747
|
Discharge summary
|
report
|
Admission Date: [**2107-8-28**] Discharge Date: [**2107-9-24**]
Date of Birth: [**2036-8-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Amlodipine / Percocet
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Left foot pain
Major Surgical or Invasive Procedure:
L foot debridement 9/14
L femoral artery, popliteal artery atherectomy [**9-5**]
History of Present Illness:
71 y/o male with DM 2, CAD severe 3v-d, Paroxysmal AFib, PVD,
ESRD on PD, admitted on [**8-28**] with a L plantar abscess. No signs
of osteo, was managed medically with abx until [**9-5**], pt went for
L SFA/popliteal atherectomy, went to OR for L plantar abscess
debridement. The pt developed post-op rapid A-fib, was treated
with dilt gtt and metoprolol 100 [**Hospital1 **], became hypotensive and
developed trop leak to 1.6, thought [**1-26**] demand ischemia with
hypotension related to the negative intropes. Rate remained
poorly controlled on dilt/metoprolol, amio started orally
without IV load, the pt was transferred to CCU for further
management. Enzymes are trending down.
Past Medical History:
1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing
ulcer on [**2-26**] s/p atherectomy of L SFA popliteal tbioperoneal
trunk with angioplasty x 2. Pt had recent right first toe
amputation and left TMA on [**2107-3-24**].
3)Paroxysmal atrial fibrillation
4)Type II DM: followed by [**Last Name (un) **]
5)Hyperlipidemia
6)Chronic bronchiectasis
7)EF 54%
8)BPH
9)Anemia of chronic illness
10)CRI on daily peritoneal dialysis
PAST SURGICAL HISTORY: Includes angioplasties of the left
common femoral, superficial femoral, tibioperoneal trunk in
[**2106-11-24**], left CEA in [**2102**] at [**Hospital1 2025**], coronary artery
bypasses, LIMA to the LAD and saphenous [**Hospital1 5703**] graft to the
obtuse marginal 1 and the ramus intermedius in [**2103-11-24**], cholecystectomy with exploratory lap with repair of
liver lacerations in [**2105-11-23**], PD catheter placement in
[**2106-9-24**], right eye cataract with intraocular lens, right
eye vitrectomy, right common femoral artery to posterior
tibial bypass graft with in situ saphenous [**Year (4 digits) 5703**] in [**2107-9-24**].
Social History:
He has been an active pharmacist until the surgery in [**Month (only) 958**]. He
is married and lives with his spouse. [**Name (NI) **] used to ambulate with
a cane but now requiring more assistance. He is a former smoker
of 1.5 pack per day x25 years and has not smoked for 20 years.
He denies alcohol use.
Family History:
Noncontributory
Physical Exam:
O: Vitals: 95.1 110/56 78 22 91%RA increased to 96%2LNC
FS: 135
Gen: NAD, lying in bed, somnolent
Neck: JVD@7cm
Cardio: RRR, S1S2,no m/r/g appreciated
Resp: CTAB.
Abd: soft, nt, nd, +BS. diffuse ecchymoses.
Ext: both LE bandaged and in protective boots
Neuro: PERRL. AAOx2
Pertinent Results:
REPORTS:
ATHERECTOMY:
1. Access: 7F antegrade in the left common femoral artery.
2. Left lower extremity: The SFA had severe diffuse disease. The
popliteal artery had severe diffuse disease. The PT was patent
to the
foot. The distal PT had mild disease at the level of the
previous PTA
site.
3. Successful atherectomy of the LSFA and popliteal artery with
the SX
and LSF SilverHawk device with excellent results (see PTCA
comments).
[**9-16**] EKG:
Sinus rhythm. Biatrial abnormality. Low limb lead voltage. Q
waves in the
anterior leads with ST segment elevation consistent with acute
infarction or
aneurysm formation. Diffuse non-specific ST-T wave changes.
Compared to the
previous tracing no significant change
[**8-28**] CXR:
IMPRESSION: Interstitial pulmonary edema and congestive heart
failure
[**9-16**] CXR:
FINDINGS: The left-sided central venous dialysis catheter ends
at the right atrium. The patient is status post median
sternotomy with normal alignment of the sutures. The
cardiomediastinal silhouette is stable. There is slight
improvement in the pulmonary edema.
[**9-21**] CXR:
Mild interstitial edema has improved substantially since
[**9-15**], less so since [**9-16**]. Small areas of
residual consolidation are present in the perihilar portions of
both lungs. A region of peribronchial infiltration in the right
lung apex may represent a new or recurrent pneumonia. Follow up
is advised.
MICRO:
WOUND CULTURE L FOOT (Final [**2107-8-31**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 1 S
PENICILLIN------------ =>0.5 R
LABS:
[**2107-9-17**] 08:20AM BLOOD WBC-10.8 RBC-3.86* Hgb-12.0* Hct-37.0*
MCV-96 MCH-31.2 MCHC-32.6 RDW-16.2* Plt Ct-437
[**2107-9-8**] 05:00AM BLOOD WBC-16.3* RBC-2.59* Hgb-8.3* Hct-26.3*
MCV-102* MCH-32.1* MCHC-31.6 RDW-16.7* Plt Ct-350
[**2107-8-28**] 11:50AM BLOOD WBC-15.2*# RBC-3.55* Hgb-11.5* Hct-35.8*
MCV-101* MCH-32.5* MCHC-32.2 RDW-16.5* Plt Ct-340
[**2107-8-28**] 11:50AM BLOOD Neuts-77.9* Lymphs-17.4* Monos-3.8
Eos-0.7 Baso-0.2
[**2107-8-28**] 11:50AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-3+
[**2107-8-30**] 09:55AM BLOOD Hgb A-97.8 Hgb S-0 Hgb C-0 Hgb A2-2.2*
[**2107-9-17**] 08:20AM BLOOD Plt Ct-437
[**2107-9-16**] 04:16AM BLOOD PT-17.9* PTT-29.8 [**Month/Day/Year 263**](PT)-2.2
[**2107-9-15**] 06:02AM BLOOD PT-21.1* PTT-36.4* [**Month/Day/Year 263**](PT)-3.2
[**2107-9-14**] 06:36AM BLOOD PT-24.0* PTT-43.3* [**Month/Day/Year 263**](PT)-4.2
[**2107-9-13**] 05:48AM BLOOD PT-23.8* PTT-44.8* [**Month/Day/Year 263**](PT)-4.1
[**2107-9-6**] 06:18AM BLOOD PT-15.9* PTT-37.5* [**Month/Day/Year 263**](PT)-1.7
[**2107-9-4**] 10:30AM BLOOD PT-34.2* [**Month/Day/Year 263**](PT)-8.9
[**2107-9-4**] 05:10AM BLOOD PT-31.6* [**Month/Day/Year 263**](PT)-7.5
[**2107-8-28**] 11:50AM BLOOD PT-16.7* PTT-29.7 [**Month/Day/Year 263**](PT)-1.8
[**2107-9-17**] 08:20AM BLOOD Glucose-135* Creat-4.3* Na-134 K-3.9
Cl-97 HCO3-23 AnGap-18
[**2107-9-16**] 04:16AM BLOOD Glucose-106* UreaN-33* Creat-3.4* Na-140
K-4.0 Cl-101 HCO3-27 AnGap-16
[**2107-9-15**] 06:02AM BLOOD Glucose-131* UreaN-31* Creat-3.3* Na-136
K-4.2 Cl-98 HCO3-25 AnGap-17
[**2107-9-4**] 05:10AM BLOOD Glucose-102 UreaN-36* Creat-3.3* Na-136
K-4.8
[**2107-8-28**] 11:50AM BLOOD Glucose-229* UreaN-42* Creat-3.3* Na-136
K-5.5* Cl-96 HCO3-27 AnGap-19
[**2107-8-30**] 08:10AM BLOOD Glucose-207* UreaN-54* Creat-3.7* Na-138
K-4.3 Cl-98 HCO3-24 AnGap-20
[**2107-9-11**] 06:06AM BLOOD ALT-21 AST-15 LD(LDH)-315* AlkPhos-120*
TotBili-0.4
[**2107-9-10**] 03:34PM BLOOD CK(CPK)-69
[**2107-9-6**] 05:50PM BLOOD CK(CPK)-269*
[**2107-8-30**] 09:55AM BLOOD ALT-44* AST-36 AlkPhos-240* Amylase-107*
TotBili-0.4
[**2107-8-30**] 09:55AM BLOOD Lipase-12
[**2107-9-10**] 03:34PM BLOOD CK-MB-NotDone cTropnT-2.51*
[**2107-9-8**] 05:00AM BLOOD CK-MB-9
[**2107-9-7**] 09:20PM BLOOD CK-MB-10 MB Indx-8.1* cTropnT-1.41*
[**2107-9-7**] 01:05PM BLOOD CK-MB-13* MB Indx-9.4* cTropnT-1.59*
[**2107-9-6**] 05:50PM BLOOD CK-MB-30* MB Indx-11.2* cTropnT-1.28*
[**2107-9-6**] 11:42AM BLOOD CK-MB-42* MB Indx-11.8* cTropnT-1.05*
[**2107-9-6**] 05:50AM BLOOD CK-MB-30* MB Indx-9.8* cTropnT-0.62*
[**2107-9-17**] 08:20AM BLOOD Albumin-2.6* Calcium-8.5 Phos-2.1* Mg-2.1
[**2107-9-16**] 04:16AM BLOOD Calcium-9.1 Phos-1.7*# Mg-2.1
[**2107-9-15**] 06:02AM BLOOD Mg-1.9
[**2107-9-3**] 09:30AM BLOOD Albumin-2.6* Calcium-8.4 Phos-5.4* Mg-1.7
[**2107-8-30**] 08:10AM BLOOD Calcium-8.4 Phos-5.8*# Mg-1.7
[**2107-8-30**] 01:45PM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE
[**2107-9-8**] 05:00AM BLOOD VitB12-278 Folate-GREATER TH
[**2107-8-30**] 01:45PM BLOOD Triglyc-89 HDL-36 CHOL/HD-2.3 LDLcalc-28
[**2107-8-30**] 09:55AM BLOOD Triglyc-95 HDL-37 CHOL/HD-3.6 LDLcalc-77
[**2107-9-8**] 05:00AM BLOOD TSH-14*
[**2107-9-8**] 05:00AM BLOOD Free T4-0.9*
[**2107-8-30**] 01:45PM BLOOD Free T4-1.2
[**2107-9-9**] 01:30PM BLOOD Vanco-13.6*
[**2107-9-3**] 09:30AM BLOOD Vanco-3.7*
[**2107-9-14**] 06:36AM BLOOD Digoxin-1.2
[**2107-9-11**] 06:06AM BLOOD Digoxin-1.0
[**2107-9-13**] 08:12AM BLOOD Type-ART Temp-37.8 pO2-70* pCO2-52*
pH-7.36 calHCO3-31* Base XS-2
[**2107-9-10**] 11:21AM BLOOD Type-ART pO2-68* pCO2-37 pH-7.44
calHCO3-26 Base XS-0
[**2107-9-8**] 09:52PM BLOOD Type-ART pO2-92 pCO2-34* pH-7.47*
calHCO3-25 Base XS-1 Intubat-NOT INTUBA
[**2107-9-6**] 06:09AM BLOOD Type-ART pO2-153* pCO2-34* pH-7.42
calHCO3-23 Base XS--1
[**2107-9-8**] 09:52PM BLOOD Lactate-2.9*
[**2107-9-6**] 06:09AM BLOOD Lactate-1.7
[**2107-8-28**] 11:57AM BLOOD Glucose-214* Lactate-2.8* K-5.0
[**2107-9-13**] 08:12AM BLOOD freeCa-1.18
[**2107-9-8**] 09:52PM BLOOD freeCa-1.14
[**2107-9-6**] 06:09AM BLOOD freeCa-1.13
Brief Hospital Course:
71 y/o male with severe PVD s/p multiple interventions,
paroxysmal AFib, CAD s/p CABG, CHF EF 30%, ESRD on HD, DM2. Pt
initially managed in the CCU, improved with fluid management
with hemodialysis and control of [**Hospital 30608**] transferred to floor.
.
1. Respiratory distress/CHF - pt initially develop post-op
decompensation [**1-26**] AFib with rapid ventricular resopnse as well
as fluid overload. Pt continued on hemodialysis while inpatient
with plans to eventually transfer back to peritoneal dialysis
only. After initiation of amiodarone, and lopressor pt remained
in NSR. In addition, started on captopril for CHF. CXR to
follow CHF and ? PNA showed improvement of CHF but still some
question of pneumonia. Pt was on Zosyn inpatient, with plans to
switch to clindamycin for his cellulitis and to cover any
possibly pulmonary infection. Pt will need 2 wks of antibiotics
after discharge until [**10-7**].
.
2. Mental status changes: initially developed in the setting of
infection, multiple pain meds, and ?ICU delirium.
-cont holding all sedating meds, gabapentin, amitrytiline
-lowest necessary dose of dilaudid.
-stopped haldol, use zyprexa as needed
-depression may also be contributing, and pt was started on
celexa 10mg daily on [**9-19**].
Mental status improved and patient was fully alert and oriented
at discharge with appropriate affect.
.
3. Pain syndrome:
-patient with multiple sensitivities previously. Managed with
Dilaudid po 2mg q4hrs prn, in addition started MSContin 15mg PO
BID 2 d prior to discharge, which he tolerated well.
.
4. Paroxysmal Afib: currently in sinus rhythm. Hemodynamically
stable when in a-fib.
-cont amiodarone 200mg daily (may interact with warfarin)
-continue metoprolol 50 tid.
-cont coumadin at 2mg po [**Name (NI) **], pt will need [**Name (NI) 263**] check (goal [**1-27**])
and may need adjustment of doses
.
5. CAD: No active coronary ischemia. Trops trended down from
demand ischemia with hypotension. trop peak 1.6 on [**9-7**], trended
down.
-cont aspirin, plavix, BB, statin, ACE
-monitor HCT, keep > 30, no obvious bleeding.
.
6. PVD: s/p L SFA/[**Doctor Last Name **] atherectomy [**9-7**]. debridement of L foot
abscess. OSSA from foot.
-continue asa, plavix, statin, bb
-on zosyn for 2 wks while inpatient, ok to switch to po per
vascular surgery, will continue additional two weeks of
clindamycin 450 mg po q6hrs.
.
7. ESRD: On HD, with plans to swithc back to peritoneal
dialysis.
-Renal following, HD initiated as peritoneal dialysis was not
sufficient to control fluid status. Presently much better
controlled, may possibly return to peritoneal dialysis only
eventually. Pt received dialysis during the day of discharge in
AM, he has hx of some mild hypotension to SBP of 90s following
dialysis, but has not been symptomatic from this.
.
8. F/E/N: taking PO with Nepro supplements. Nutrition
following, monitoring calorie count.
.
9. DM2- RISS with NPH 22 Units qAM and 6 Units qPM. Cont to
follow and titrate as needed.
.
10. Proph: Anticoagulated on warfarin. Bowel regimen. PPI
.
11. dispo: to inpatient rehab, follow-up with vascular surgery
and PCP.
Medications on Admission:
Discharge Worksheet-Discharge Medicatons-Last Updated by:
[**Doctor Last Name 30609**],[**Name8 (MD) 30610**], MD on [**9-2**] @ 0953
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 14 total days.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
12. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
16. Gentamicin 0.1 % Cream Sig: One (1) appl Topical qd ():
with PD changes.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
19. Clindamycin HCl 300 mg Capsule Sig: Four [**Age over 90 1230**]y (450)
mg PO four times a day for 14 days.
Disp:*86 capsules* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 30611**]
Discharge Diagnosis:
Left leg cellulitis
Discharge Condition:
stable
Discharge Instructions:
Please continue prescribed antibiotics (clindamycin). Continue
hemodialysis at outpatient dialysis center. Return to emergency
room if signs of infection occurs such as temperatures greater
than 101.4, increasing pain, redness in left lower extremity or
any discharge from previous incision. Call if there any other
questions or concerns.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1391**] in two weeks. Please call ([**Telephone/Fax (1) 29063**]
Call pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3109**], [**First Name3 (LF) **] [**Telephone/Fax (1) 3110**] to schedule f/u
appointment in the next 2 weeks.
Completed by:[**2107-9-24**]
|
[
"599.0",
"410.71",
"427.31",
"428.0",
"997.62",
"486",
"440.24",
"682.6",
"250.02",
"496",
"285.9",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"39.95",
"96.6",
"00.41",
"86.22",
"88.48",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
15581, 15629
|
9619, 12759
|
310, 392
|
15693, 15702
|
2958, 9596
|
16091, 16409
|
2632, 2650
|
13905, 15558
|
15650, 15672
|
12785, 13882
|
15726, 16068
|
1642, 2288
|
2665, 2939
|
256, 272
|
420, 1106
|
1128, 1619
|
2304, 2616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,868
| 122,942
|
21333
|
Discharge summary
|
report
|
Admission Date: [**2141-12-11**] Discharge Date: [**2142-1-10**]
Date of Birth: [**2094-6-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Admitted for Neurosurg anterior corpectomy and posterior fusion
Major Surgical or Invasive Procedure:
Anterior corpectomy and posterior fusion
Esophageal perforation repair with scm flap
Open gtube/jtube
History of Present Illness:
Ms. [**Known lastname **] is a 47yF with history of infected cervical spine
hardware removal, admitted for a scheduled C5, C6 and C7
corpectomy with an anterior cervical plate from C4-T1 and
posterior stabilization.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
1. C5-C6 laminectomy and anterior fusion
2. Esophageal rupture/perforation, potentially related to
traction diverticuli related to C5-C6 laminectomy and
anterior fusion.
3. Asthma.
4. Recurrent pneumonia.
5. History of tonsillectomy.
Social History:
Has two children. Ex-pharmacist. 25 pack year smoker. Rare
alcohol use. No drug use.
Family History:
Non-contributory
Physical Exam:
Per preprocedure assessment:
Gen: Thin, well appearing; AA&Ox3
Neck: Cervical LAD; Thyromegaly; neck supple
Heart: RRR
Chest: Coarse crepitations in both bases that completely clear
up on deep coughing and chest clearing of unifected looking
white sputum
Abd: flat, soft NT
Ext: edema; LUE picc
Pertinent Results:
[**2141-12-11**] 02:14PM GLUCOSE-132* UREA N-10 CREAT-0.6 SODIUM-136
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
[**2141-12-11**] 02:14PM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2141-12-11**] 02:14PM WBC-14.3*# RBC-3.91* HGB-12.3 HCT-36.5 MCV-93
MCH-31.4 MCHC-33.7 RDW-14.4
[**2141-12-11**] 02:14PM PLT COUNT-417
CT [**12-12**]
Status post anterior and posterior fusion of the C4 through T1
levels with no evidence of hardware loosening and grossly
preserved anatomic alignment. Moderate canal stenosis again
noted at C5-6 level is not significantly changed compared to MRI
dated [**2141-11-11**]. Note is also made of large amount of
post-operative subcutaneous right lateral neck emphysema.
XR [**12-13**]
IMPRESSION:
1. Stable small extrapleural apical hematomas and subcutaneous
emphysema in
the right neck and right axilla. Absence of pneumomediastinum or
pneumothorax favors no injury to esophagus or trachea.
2. Emphysema. PIC and other lines in standard placements.
XR [**12-19**]
No free intraperitoneal air is identified. A feeding tube
projects over the left upper quadrant of the abdomen, and
midline surgical clips overlie the lumbar spine. Within the
chest, there has been apparent removal of an endotracheal tube
as well as removal of a nasogastric tube. Cardiomediastinal
contours remain within normal limits, and lungs are grossly
clear except for minimal patchy atelectasis at the right base
Brief Hospital Course:
The patient is a 47yF admitted to Neurosurgery s/p anterior
corpectomy and posterior fusion. The patient tolerated the
procedure well and was transfered to the floor. On POD#2, the
patient developed respiratory distress and required acute
intubation. The patient developed purulent fluid leaking from
the wound, so Thoracic surgery was consulted for work up of
esophageal perforation, and the patient was taken to the OR for
repair of a 1cm posterior esophageal perforation. The patient
tolerated the procedure well and returned to the ICU
postoperatively. On POD#3 ([**12-14**]), the patient returned to the OR
for an open G-tube/J-tube insertion. On [**12-15**], the patient self
extubated herself without further complication. On [**12-17**], the
patient was transfered out of the ICU to [**Hospital Ward Name 121**] 2. Dressings were
changed frequently by Thoracics, and on [**12-19**] the wound was
debrided at bedside and found to have some brown discharge, so
the patient was brought back to the operating room on [**12-20**] for
washout and VAC dressing placement.
Plastic surgery was [**Last Name (un) 4662**] on to assist with wound closure. On
[**12-25**] she went to the OR with all three teams present for
cervical spine hardware removal, R pectoral flap, and esophageal
stent placement. The pectoral flap was revised by plastic
surgery on [**12-29**], and the esophageal stent was repositioned at
the same time. Subsequently she recovered very nicely, was
tolerating tube feeds at goal, and ambulating well with good
pain control, so she was discharged home on [**2142-1-10**].
Medications on Admission:
Albuterol, Flovent, Fluconzaole, Dilaudid, Levofloxacin, flagyl,
xanax, daptomycin
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Grams Intravenous Q 24H (Every 24 Hours) for 8 weeks.
Disp:*56 Grams* Refills:*0*
2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2
ml of 100 Units/ml heparin (200 units heparin) each lumen Daily
and PRN. Inspect site every shift. .
Disp:*100 ML(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 weeks: Crushed and via Jtube.
Disp:*168 Tablet(s)* Refills:*0*
4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Crushed and via Jtube. Tablet(s)
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Crushed and via Jtube.
Disp:*60 Tablet(s)* Refills:*2*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Crushed and via Jtube.
Disp:*60 Tablet(s)* Refills:*2*
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): Crushed and via Jtube.
Disp:*90 Capsule(s)* Refills:*2*
8. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) ML PO DAILY
(Daily): via Jtube.
Disp:*600 ML* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 weeks: Crushed and via Jtube.
Disp:*56 Tablet(s)* Refills:*0*
10. Methadone 10 mg/mL Concentrate Sig: Three (3) ML PO Q 8H
(Every 8 Hours): via Jtube.
Disp:*60 ML* Refills:*0*
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 8 weeks: Crushed and via Jtube.
Disp:*112 Tablet(s)* Refills:*0*
12. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for breakthrough pain: Crushed and via Jtube.
Disp:*60 Tablet(s)* Refills:*0*
13. Saline Flush 0.9 % Syringe Sig: [**4-21**] mL Injection once a
day: flush PICC line daily and PRN.
Disp:*60 * Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Esophageal perforation repair (sutures and SCM flap) after
Anterior CORPECTOMY C5-7 and C4-T1 Posterior FUSION
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) **] for any of the
following:
- Fever > 101.5 or chills
- Increased redness or drainage from your wounds or drain sites
- Increased shortness of breath, cough or sputum production
- Anything else of concern
Please call the [**Hospital **] clinic at [**Telephone/Fax (1) **] for any pain, redness,
or discharge from the PICC site.
Home nursing services will come to help care for your PICC, to
administer antibiotics, help with your wound care, and help with
your tube feeding.
You will go home with a tube feed pump, for which you will be
instructed on how to use it.
Flap: Apply curasol gel and xeroform dressings twice a day. You
will follow up with Plastic Surgery in 1 week. Keep your JP
drains in until then.
Neck: You will follow up with Dr. [**Last Name (STitle) 739**] in 1 month.
Keep your hard collar on until then.
Infectious Diseases: You will have your Vancomycin level, BUN,
creatinine, and CBC checked weekly with results faxed to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) **]
Physical therapy will work with you at home.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2142-1-17**] 10:30 on [**Hospital1 **] One
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 5343**]
Date/Time:[**2142-1-18**] 2:30 on [**Hospital Ward Name 23**] Three
Please call [**Doctor First Name 56392**] [**Doctor Last Name **] at 617-667-PAGE and page #[**Numeric Identifier 56393**] to
schedule a follow up with Nutrition in 2 weeks.
Please call your Psychiatrist/psychologist to set up an
appointment to discuss your grieving of the loss of your family
members.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2142-2-5**] 10:00
Please call Dr. [**Last Name (STitle) 739**] at [**Telephone/Fax (1) **] to schedule an
appointment for a one month follow up. Please tell the
secretary to set you up for a CT C-Spine with and without
contrast prior to your appointment.
Completed by:[**2142-1-10**]
|
[
"996.67",
"995.0",
"E935.2",
"518.5",
"996.59",
"V09.0",
"530.4",
"784.2",
"998.59",
"309.81",
"263.8",
"493.90",
"300.01",
"721.1",
"305.1",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.02",
"96.70",
"42.23",
"77.79",
"86.75",
"46.39",
"86.28",
"93.59",
"42.81",
"86.69",
"96.04",
"96.6",
"78.69",
"81.63",
"86.74",
"43.19",
"42.82",
"81.03",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
6507, 6565
|
2922, 4525
|
343, 446
|
6720, 6729
|
1465, 2899
|
7939, 9028
|
1116, 1134
|
4658, 6484
|
6586, 6699
|
4551, 4635
|
6753, 7916
|
1149, 1446
|
240, 305
|
474, 691
|
713, 993
|
1009, 1100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,466
| 193,986
|
2122
|
Discharge summary
|
report
|
Admission Date: [**2157-7-3**] Discharge Date: [**2157-7-4**]
Date of Birth: [**2126-1-16**] Sex: F
Service: MEDICINE
Allergies:
Lithium / Penicillins / Grapefruit
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Swallowed Foreign Body (plastic spoon)
Major Surgical or Invasive Procedure:
1. Elective endotracheal intubation
2. Upper Gastrointestinal Endoscopy to remove Foreign Body
History of Present Illness:
31 year old female with HIV, bipolar disorder and psychotic
features, and h/o foreign body ingestions, now transferred from
[**Hospital **] Hospital for possibly ingestion of plastic spoon.
Reportedly, she's had 5 EGD's in the past month at various
hospitals for foreign body retrieval.
.
In the ED, her vitals were: 98.2, 86, 115/64, 16, 98%RA. She
was agitated and combative and was put on leather restraints.
25mg of haldol, 5mg of ativan and 50mg of benadryl were given.
GI evaluated patient and wants her admitted to MICU for elective
intubation prior to EGD. In the past, she has not tolerated EGD
with just conscious sedation. Patient reportedly unable to
tolerate a CT at this time.
.
She denies pain or discomfort and currently perseverates on
wanting some food.
Past Medical History:
# HIV+ CD4 (ABSOLUTE) [**2155-9-22**] is 158, HIV viral load is not
known
# Hep C
# Bipolar d/o
# Psychosis w/auditory hallucinations, self injurious behavior
# Borderline personality disorder
# Eating d/o with emesis and electrolyte disturbance
# PTSD
# h/o of seizures
# Chronic anemia
Social History:
Pt lives at [**Hospital1 **] psych facility. Has legal guardian,
[**Name (NI) **] [**Name (NI) **]. Reported history of cocaine use, although
patient denies.
Family History:
Noncontributory.
Physical Exam:
VITALS: 96.7, 84, 95/71, 18, 98%RA
GEN: NAD, A+Ox2, sedated but still interactive, leather
restraints off
HEENT: OP clear, MMM
NECK: no LAD
CV: RRR, no m/g/r
PULM: CTAB, no w/r/r
ABD: Soft, NT, ND, +BS
EXT: no c/e/c
Pertinent Results:
[**2157-7-3**] 12:10AM GLUCOSE-90 UREA N-11 CREAT-1.2* SODIUM-141
POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-38* ANION GAP-12
[**2157-7-3**] 12:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-7-3**] 12:10AM WBC-4.7 RBC-4.82 HGB-13.7 HCT-38.7 MCV-80*
MCH-28.4 MCHC-35.4* RDW-15.6*
[**2157-7-3**] 12:10AM PLT COUNT-274
[**2157-7-3**] 12:10AM PLT COUNT-274
[**2157-7-2**] 11:30PM URINE HOURS-RANDOM
[**2157-7-2**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2157-7-2**] 11:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2157-7-2**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
EGD [**7-3**]: A foreign body( plastic spoon) was found in the
stomach.A snare was used to retrieve the spoon. The spoon was
taken out without complications.
Brief Hospital Course:
31 year old female with HIV, bipolar disorder and psychotic
features, and h/o foreign body ingestions, now admitted for
ingestion of plastic spoon. Pt was intubated and sedated for
endoscopy which was performed by the GI service the morning of
[**2157-7-3**]. A foreign body (plastic spoon) was found in the
stomach. A snare was used to retrieve the spoon. The spoon was
taken out without complications. The patient's sedation was
weaned and she was extubated without complication. She was
started on her home medication regimen following extubation and
her diet was advanced. Psych was consulted to advise regarding
her med regimen and disposition as was her outpatient
psychiatrist. She was discharged back to [**Hospital **] Hospital in
stable condition according to her section 78 paperwork with
instructions to allow no utensils for patient without one to one
supervision.
Medications on Admission:
# Haldol 10mg IM BID
# Ativan 2mg IM BID
# Benadryl 50mg IM BID
# Quetiapine 300 mg PO Q6H PRN
# Bupropion 100 mg SR QAM
# Fluoxetine 20 mg Daily
# Bactrim 400-80 mg Daily
# Valacyclovir 1 g Daily
# Prilosec 20mg Daily
# Thiamine HCl 100 mg Daily
# Calcium Carbonate 500 mg Daily
# Ferrous Sulfate 325 mg Daily
# Hexavitamin Daily
# Colace 100 mg [**Hospital1 **]
# KCL 40mEq PO QID
# Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H PRN
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Daily ().
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO every six
(6) hours as needed for anxiety.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO four times a day.
13. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Ativan 2 mg/mL Solution Sig: Two (2) Injection twice a day.
15. Haldol Decanoate 50 mg/mL Solution Sig: Ten (10) mg
Intramuscular twice a day.
16. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-7**] Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
17. Benadryl 50 mg/mL Solution Sig: One (1) Injection twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. Ingested Foreign Body (Spoon)
Secondary:
1. Bipolar disorder
2. HIV
3. hepatitis C
4. borderline personality disorder
5. psychosis
Discharge Condition:
Stable vitals. Stable labs. Without complaint.
Discharge Instructions:
Please take your home medications as previously prescribed.
Please follow up with your psychiatrist for further treatment.
Followup Instructions:
Please call to arrange follow up with your psychiatrist and your
regular doctor as needed
|
[
"309.81",
"070.54",
"296.7",
"V08",
"298.9",
"285.9",
"E915",
"935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"44.13",
"98.03"
] |
icd9pcs
|
[
[
[]
]
] |
5806, 5879
|
2954, 3839
|
330, 427
|
6067, 6116
|
2005, 2931
|
6287, 6380
|
1735, 1753
|
4328, 5783
|
5900, 6046
|
3865, 4305
|
6140, 6264
|
1768, 1986
|
252, 292
|
455, 1232
|
1254, 1544
|
1560, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,698
| 101,851
|
20217
|
Discharge summary
|
report
|
Admission Date: [**2169-10-11**] Discharge Date: [**2169-10-21**]
Date of Birth: [**2109-8-8**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Naprosyn / Keflex / Shellfish / Glucophage / Tetracycline /
Penicillins / Erythromycin Base / Ciprofloxacin / Biaxin /
Bactrim / Vancomycin / Latex / Duoderm Cgf / Morphine Sulfate /
Levofloxacin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
This is a 60 year old female with past medical history of
asthma, CAD, AF, and embolic stroke who presented from [**Location (un) 620**]
with respiratory failure. Per report the patient called EMS
today reporting dyspnea. When they arrived she was very short
of breath and appeared cyanotic with diffuse crackles.
Therefore, she was put on NIPPV and transferred to [**Hospital1 **] [**Location (un) 620**]
where she was intubated with succinylcholine etomidate. Given
pink, frothy secretions from the tube and bilateral fluffy
infiltrates presumed etiology was heart failure exacerbation so
the patient received 80 mg of IV furosemide and was transferred
to [**Hospital1 18**]. En route the patient was hypotensive on propofol,
which was discontinued. On arrival she was agitated and
received fentanyl/midazolam for sedation before receiving
linezolid and pipercillin-tazobactam due to concern the
patient's infiltrates were due to pneumonia. Initial ABG here
was 7.23/ 71 / 406 on AC with Tv 450, RR 16, PEEP 5, and 02
100%. The patient was noted to have high peak pressures (>30)
with high plateaus raising concern for auto-PEEP. Therefore, he
received 10 mg IV vercuronium. He also received an unclear
amount of fluid for transient hypotension. With increasing her
minute ventilation pH rose to 7.9 and CO2 dropped to 60. He was
transferred to the MICU. Of note, the patient had a VERY
similar presentation on [**2169-8-5**] in which the patient was
admitted for multifocal pneumonia with concern for volume
overload. During that hospitalization she had very quick
resolution of her chest radiograph and was discharged on a
course of linezolid / piperacillin-tazobactam.
On arrival to the MICU the patient was intubated and sedated.
Paralysis was coming off but patient still not interacting/
reacting in a meaningful way. Some spontaneous movements.
Past Medical History:
Left MCA territory embolic infarct, likely of cardioembolic
etiology in [**2166-5-16**]
Atrial fibrillation on sotalol and coumadin
CAD - MI [**2155**] @ age 44, [**2156**], and NSTEMI in [**2164**] (Trop T 0.06)
Sick sinus syndrome status post dual-chamber pacemaker
MVR
Hyperlipidemia
Diabetes mellitus, type 2
Obesity
Hypertension
Asthma
Ostructive sleep apnea on BIPAP
Mild pulmonary HTN 36/18 on cath in [**8-21**]
Social History:
Significant for the absence of
current tobacco use (quit at age of 22) No heavy alcohol.
Family History:
Per OMR - Her father died of CAD in his 50's, he had his first
MI at age 41. She has multiple younger brothers with "heart
problems."
Physical Exam:
VS: 95.9 Temp: BP:102/62 HR:72 RR 18, and O2sat 93 % on vent
GEN: Intubated, sedated, markedly hirstute, NAD
HEENT: anisocoria (appears old), not following commands,
occasionally aoviding noxiious stimuli or maoning. NO LAD or
masses appreciated.
RESP: Crackles bilaterally with prolonged espiratory phase.
CV: Distant heart sounds, regular, not taychcardic
ABD: Soft, NT, ND, BS+
EXT: cool, large (3-2 cm) round, smooth edged ulcer on right
anterio thigh with erythema and granulation tissue but no acute
pus.
NEURO: intubated and sedating, moving all four extremities
equally.
Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-15.5*# RBC-4.56 Hgb-12.4 Hct-38.7 MCV-85RDW-16.9* Plt Ct-203
PT-23.8* PTT-29.8 INR(PT)-2.3*
Glucose-306* UreaN-25* Creat-1.3* Na-139 K-4.7 Cl-102 HCO3-27
ALT-27 AST-35 LD(LDH)-367* AlkPhos-143* TotBili-0.9
Calcium-8.6 Phos-2.6* Mg-1.8
URINE: Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Color-Straw
Appear-Clear Sp [**Last Name (un) **]-1.006
==============
OTHER RESULTS
==============
Admission EKG: A paced at 80. IVCD. No acute ST changes.
Chest Radiograph [**2169-10-11**]:
IMPRESSION:
1. Hilar prominence with bilateral lung opacities is concerning
for pulmonary congestion/edema with possible pneumonia.
2. Tubes positioned appropriately
Chest Radiograph [**2169-10-13**] 3:31 AM(post extubation):
IMPRESSION:
AP chest compared to [**10-12**]:
The patient has been extubated, lung volumes are normal, and the
lungs are
clear following resolution of heterogeneous opacification in
both lower lungs yesterday. Given the rapid clearance, these
findings were not due to
hemorrhage or pneumonia or noncardiogenic edema. Cardiac edema
and toxic
inhalation or massive aspiration, the likely causes.
Heart size is top normal and unchanged. No pleural abnormality.
Transvenous
right atrial and right ventricular pacer leads in standard
placements.
Chest Radiograph [**2169-10-13**] 6:59 PM (post reintubation)
IMPRESSION:
1. Interval intubation and placement of NG tube.
2. New diffuse bilateral alveolar opacities. Given the time
course, this
most likely represents pulmonary edema.
Transesophageal Echo [**2169-10-14**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
At least mild-moderate mitral regurgitation. Dilated ascending
aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2169-8-7**], an [**Year (4 digits) 34486**] jet of at least
mild-moderate mitral regurgitation is now seen.
Due to the [**Year (4 digits) 34486**] nature of the mitral regurgitation jet, if
clinically indicated a cardiac MRI [**Telephone/Fax (1) 9559**] may be best able
to assess the severity of mitral regurgitation.
CT Chest W/O Contrast [**2169-10-14**]:
IMPRESSION:
1. Multifocal ground-glass opacities, compatible with multifocal
pneumonia.
2. Small bilateral pleural effusions.
3. Unchanged multilobulated right hepatic hypodense lesion,
compatible with
the previously described biliary cystadenoma.
4. 1.3 cm simple left renal cyst.
5. Status post cholecystectomy.
.
CXR [**10-16**]:
1. Significant interval clearing of the lungs. Despite previous
description as multifocal pneumonia, the apparent rapid
resolution of these infiltrates suggest that this more likely
may be due to pulmonary edema.
2. Interval extubation and removal of the NG tube.
.
[**10-19**] Renal CTA:
1. No evidence for renal artery stenosis. No significant
atherosclerotic
disease.
2. Complex hepatic cyst, unchanged in size compared to [**Month (only) 216**]
[**2168**], and also previously characterized by ultrasound. If
further characterization is required, this could be accomplished
by MRI.
3. Status post cholecystectomy.
4. Left parapelvic cysts, with additional exophytic cyst arising
posteriorly from the interpolar region of the left kidney.
.
Brief Hospital Course:
60 y.o. female with [**Hospital 7235**] medical problems and recent
admission for "pneumonia" now readmitted for pneumonia and CHF.
.
1. Acute on Chronic Diastolic CHF: Patient presented with
bilateral infiltrates consistent with multifocal pneumonia vs
CHF. She was empirically treated with antibiotics and
furosemide with improvement but difficulty assessing exactly
what process was predominant. Quick resolution and reappearance
of infiltrates was thought to be more consistent with diastolic
CHF. After her first extubation proceeded uneventfully the
patient rapidly decompensated on arrival to the medical floor
with severe hypoxia and needed to be reintubated urgently. It
is unclear what precipitated these episodes of decompensation
though hypotension was considered possible. Cardiac enzymes
remained negative. Echocardiogram showed MR [**First Name (Titles) 151**] [**Last Name (Titles) 34486**] jet.
Cardiology recommended gentle diuresis and gentle volume
resuscitation as needed to maintain SBP>100. They also
recommended starting an ACE inhibitor or CCB as an outpatient.
Given her predispositoin for flash pulmonary edema, we obtained
a renal CTA to rule out renal artery stenosis, and this was
negative. Pt's blood pressure remained around SBP 100 but we
were able to restart her home lasix dose 20mg (every other day)
prior to discharge with stable pressure. She will have follow up
with cardiology within 1 week.
.
2. Multifocal Pneumonia: Given diffuse infiltrates that waxed
and waned dramatically these were thought less likely to be
multifocal pneumonia so though the patient received linzeolid
and pip-tazo at presentation these were rapidly discontinued.
On [**10-14**] when CT showed clear infiltrate CAP coverage with
ceftriaxone/azithro was restarted. Levo was discontinued when
CXR on [**10-16**] did not show clear consolidation and pt's
oxygenation status improved significantly with diuresis in MICU.
Additionally, pt reported an "allergy" to levo, among multiple
other antibiotic allergies, though reaction seemed to only be
diarrhea.
.
3. Afib w/ RVR: Was well controlled on sotalol. She was
continued on coumadin, had supratherapeutic INR to 4.1 in
setting of levofloxacin use. Coumadin was held and restarted
when INR dropped to 1.6. She was bridged on heparin drip and
discharged on lovenox course with INR of 1.6, instructed to
check INR at home and to adjust coumadin as needed for goal >2.
Discharged on coumadin 5mg daily (home dose 3mg).
.
#. Chest pain - pt had one episode of CP after coming to the
floor, ECG unchanged from previous and no acute findings on
right sided ECG, cardiac markers slightly elevated but stable
over 2 draws. Cardiology was consulted and recommended interval
repeat cathetrization as outpt, last cath a few years ago was
clean and low likelihood of stenosis. Markers likely elevated
due to repeated cardiac stress, not concerning at this time for
ischemia. She was given full dose ASA and high dose statin while
being ruled out, and monitored on tele without any major events.
Pt was chest pain free for the rest of the hospital stay.
Returned to home dose ASA and statin on discharge, cardiology
outpt f/u.
.
5. HTN: Held home lasix and help captopril that was started
during this admission (per cardiology recs) given hypotension to
SBP 90s. Likely in setting of overdiuresis. Gave gentle 250cc
fluid boluses with caution given easy predisposition for flash
pulm edema. Prior to discharge, BP stabilized and we restarted
home lasix dose 20mg qod.
.
6. Hx embolic stroke: continue levetiracetam at home doses
.
7. DM: On large doses at home, on sliding scale in the hospital
with well controlled blood sugars
.
Medications on Admission:
-Albuterol Q4hrs PRN
-Fluticasone 110 mcg/spray 2 puffs [**Hospital1 **]
-Sotalol 80 mg [**Hospital1 **]
-Calcium Carbonate 500 mg PO QID PRN heartburn
-Levetiracetam 250 mg PO BID
-Warfarin 3 mg PO daily
-[**Hospital1 54306**] 2 mg PO BID
-ASA 162 mg PO daily
-Humalog 75-25 15-20 in AM and 15-20 PM
-Humulin N 35-42 QHS PRN
-Atorva 20
-Atroven 17 mcg/actuation Q6hrs PRN
Discharge Medications:
1. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
4. aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-17**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
7. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO four times a day as needed for
heartburn.
8. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: take
5mg today ([**10-21**]), measure INR and take 3mg daily after INR >1.8.
9. [**Month/Day (4) 54306**] 2 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Humalog 100 unit/mL Solution Sig: 75-25 Subcutaneous twice
a day: take 15-20 in AM, 15-20 in PM.
11. Humulin N 100 unit/mL Suspension Sig: Thirty Five (35) u
Subcutaneous at bedtime.
12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-17**]
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
14. Lovenox 100 mg/mL Syringe Sig: 100mg injection Subcutaneous
twice a day for 4 days: please use 1 injection in AM, 1
injection in PM.
Disp:*8 * Refills:*0*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Flash pulmonary edema
.
Secondary:
diastolic CHF
MVR
DM2
HTN
asthma
OSA
Discharge Condition:
Mental Status: Confused - sometimes.
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 at [**Hospital1 18**]. You were admitted
with respiratory distress and found to have flash pulmonary
edema (acute accumulation of fluid in your lungs) and had to be
intubated twice for this. You were extubated and stabilized in
the ICU and then transferred to the medical floor. We did not
see a pneumonia on your last chest x-ray and did not continue
the antibiotics started in the ICU. We diuresed you gently and
started you back on lasix when your blood pressure stabilized.
Your INR was very high (>4) in the beginning of your admission
and we held your coumadin, we restarted it and prior to
discharge your INR was 1.6. We started a heparin drip the day
before you left to cover you while your INR came back to normal.
You will be discharged with Lovenox to bridge your
anticoagulation until your INR is at goal >2, you should take
coumadin 5mg today and remeasure your INR at home. You can
return to your home dose of 3mg daily when your INR is in the
acceptable range. Our cardiologists saw you while you were in
the hospital and recommended that you start a medication called
an ACE inhibitor after you leave the hospital, you should
discuss this with your cardiologist at your appointment. You did
not have a heart attack while you were at the hospital.
.
You should follow up closely your PCP and cardiologist within 1
week of leaving the hospital.
.
We have made the following changes to your medications:
- Take coumadin 5mg tonight ([**10-21**]) and remeasure your INR at
home, you can return to your home dose of 3mg daily after your
INR is >2
- Start lovenox, take 1 injection in the morning and 1 in the
evening (12 hours apart), you are given 4 days of doses, check
your INR daily and continue your coumadin, take lovenox until
your PCP appointment
[**Name Initial (PRE) **] Take lasix 20mg EVERY OTHER day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
We recommended home services for you prior to discharge (PT and
nursing) but you declined these.
Followup Instructions:
Please follow up at your already [**Name8 (MD) 1988**] appointments with
your PCP and your cardiologist.
.
You summarized them as below:
PCP [**Name Initial (PRE) **] [**Name Initial (NameIs) 3816**] @12:15
Electrophysiology/Cardiology - Thursday @2:00
Dr. [**Last Name (STitle) 32878**] - [**10-31**] @2:00
Pleases call Dr. [**Last Name (STitle) **] to schedule an appointment within the
next 2 weeks
Completed by:[**2169-10-21**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,371
| 181,529
|
46099
|
Discharge summary
|
report
|
Admission Date: [**2119-3-3**] Discharge Date: [**2119-3-10**]
Date of Birth: [**2037-7-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
chills, urinary incontinence, confusion.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81M admit from home after developing confusion on the morning of
admission, pt also notes chills. Per his wife, pt awoke at 3AM,
and was found changing his clothes "because they're soaked"
(they were not), however she notes bed was soaked with urine.
she convinced pt to return to bed without difficulty. he awoke
at 6am, not confused, though he did not recall the earlier
events. there is a possible 2nd episode of incontinence. Pt
was then visited by his VNA who checked BP, which was "high",
and recommneded pt [**Last Name (un) 5511**] ED.
.
Upon arrival to ED @11AM, VS=101.7 124 156/100 97%3L.
Initially denied cp, sob, abdominal pain. CXR was suggestive of
PNA (though atypical appearance), elevated WBC (13), 11% bands.
BCx, UCx, and DFA sent. pt started on CTX/levaquin, lactate
4.1->2.3. CK 100s, but +trop (0.20), EKG with ?STE (<0.5mm) II,
avF, creatinine 1.6 (bl ~1.1).
.
pt breathing comfortably, mentating well, BP then dropped to
88/50 @ 3:45PM, code sepsis, pt given 3L IVF, RIJ TLC placed,
and levophed 0.04mcg/hr, BP improved, upon transfer, BP=98.6
118/61 96 22 97%2L.
Past Medical History:
1. Myopathy of unknown etiology
2. Cervical spondylosis status post c3-c6 decompression in [**2110**],
s/p decompression on [**2116-1-29**]
3. Right ulnar neuropathy s/p surgery
4. Hypertension
5. Gout
6. Colon cancer 35 years ago status post colostomy
7. Hypercholesterolemia
Social History:
1 ppw x 3yrs tobbacco, quit 40yrs ago, denies alcohol, IVDU.
married. Lives with wife. [**Name (NI) **] is retired welder. Ambulates with
walker.
Family History:
No family history of neuromuscular disease.
Physical Exam:
VS: 99.0 114/57 95 21 95%2L
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, dry mucous
membranes, no LAD, no carotid bruits. No JVD. no sinus
tenderness.
CV: distant, regular, nl s1, s2, no appreciable m/r/g.
PULM: crackles bilaterally, L>R, up to [**1-5**] lung [**Last Name (un) 8491**], no r/r/w.
decreased air movement on right [**2-4**] habitus.
ABD: soft, NT, ND, + BS, no HSM. well-healed colostomy site
LLQ, colostomy without purulent drainage, healthy appearance.
well healed midline surgical incision. negative [**Doctor Last Name **] sign,
no rebound, gaurding.
EXT: warm, 2+ radial pulses BL, 1+ RLE DP/PT, 2+ LLE DP/PT.
NEURO: alert & oriented x 3, CN II-XII grossly intact. no
asymetry, 5/5 strength symmetric @ triceps, biceps, delts, hip
flexion, dorsoflexion, plantarflexion. sensation grossly
intact. intact finger to nose.
Pertinent Results:
[**2119-3-3**] 11:25AM BLOOD WBC-13.4*# RBC-4.20* Hgb-13.0* Hct-39.6*
MCV-94 MCH-31.0 MCHC-32.9 RDW-16.4* Plt Ct-205
[**2119-3-3**] 11:28AM BLOOD PT-12.8 PTT-25.4 INR(PT)-1.1
[**2119-3-3**] 11:25AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-137
K-6.9* Cl-101 HCO3-22 AnGap-21*
[**2119-3-3**] 11:25AM BLOOD ALT-16 AST-57* CK(CPK)-317* AlkPhos-168*
TotBili-0.5
[**2119-3-3**] 11:25AM BLOOD CK-MB-4 cTropnT-0.20*
[**2119-3-3**] 05:00PM BLOOD CK-MB-4 cTropnT-0.22*
[**2119-3-3**] 08:18PM BLOOD proBNP-3502*
[**2119-3-3**] 11:37PM BLOOD CK-MB-4 cTropnT-0.23* proBNP-2780*
[**2119-3-4**] 05:26AM BLOOD CK-MB-4 cTropnT-0.21*
[**2119-3-3**] 08:18PM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7
[**2119-3-3**] 11:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-3-3**] 11:32AM BLOOD Lactate-4.1*
[**2119-3-4**] 01:02PM BLOOD Lactate-1.0
CHEST, PA & LATERAL: The cardiomediastinal contour appears
stable with tortuosity of the aorta and wall calcifications.
There is new, patchy airspace opacification overlying the left
mid and lower lung zone, which appears to project to the left
upper lobe on the lateral film. Multiple left- sided rib
fractures are again identified. Pulmonary vasculature is within
normal limits.
IMPRESSION: Interval development of patchy airspace opacity
overlying the left mid and lower lung zone projecting to the
left upper lobe on the lateral film, concerning for pneumonia.
.
Micro:
-------
[**2119-3-3**] 11:30 am BLOOD CULTURE 2ND SET.
Blood Culture, Routine (Preliminary):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
Possible penicillin resistance by oxacillin screen.
Penicillin PRESUMPTIVE RESISTANCE NOT CONFIRMED BY MIC.
REFER TO
MIC RESULTS. MEROPENEM = SENSITIVE (<= 0.012 MCG/ML).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >= 2.0 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
LEVOFLOXACIN---------- <=0.5 S
MEROPENEM------------- S
PENICILLIN------------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- 1 I
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2119-3-4**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2119-3-4**] AT 0425.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2119-3-4**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Blood Cx ([**2-/2040**], [**3-5**] x 2) - NGTD
Urine Cx ([**2-/2040**] x 2) - negative
Urine Legionella ([**2-/2040**]) - negative
Influenza DFA ([**2-/2040**]) - negative.
.
CHEST (PORTABLE AP) [**2119-3-4**] 5:06 AM
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2119-3-3**]. Bilateral rib
fractures are again noted. The left hemidiaphragm is elevated.
There are increased ill-defined opacities throughout the left
mid and lower lung. The right lung is grossly clear. Tortuous
calcified thoracic aorta is noted. There is a right paratracheal
opacity likely secondary to tortuous vessels. There is a right
IJ central line in place with its tip within the expected region
of the mid SVC.
IMPRESSION: Increased opacities throughout the left mid and
lower lung likely represent some combination of atelectasis,
edema and/or pneumonia. Recommend continued follow-up
examination.
============
Discharge:
[**2119-3-10**] 05:50AM BLOOD WBC-7.6 RBC-3.39* Hgb-10.5* Hct-32.6*
MCV-96 MCH-31.0 MCHC-32.2 RDW-17.0* Plt Ct-336
[**2119-3-10**] 05:50AM BLOOD Glucose-94 UreaN-22* Creat-1.2 Na-140
K-5.0 Cl-106 HCO3-26 AnGap-13
[**2119-3-9**] 06:10AM BLOOD ALT-93* AST-63* AlkPhos-128* TotBili-0.4
[**2119-3-4**] 05:26AM BLOOD CK-MB-4 cTropnT-0.21*
[**2119-3-3**] 11:37PM BLOOD CK-MB-4 cTropnT-0.23* proBNP-2780*
[**2119-3-8**] 06:20AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.1
[**2119-3-4**] 05:26AM BLOOD calTIBC-200* Ferritn-137 TRF-154*
Surveillance cultures x 5 negative
===========
ECHO TTE Conclusions
The left ventricle is not well seen. The aortic valve is not
well seen. There is no aortic valve stenosis. The mitral valve
leaflets are not well seen. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Extremely poor technical quality. None of the valves
can be well seen. Assessment for endocarditis is impossible.
Cannot assess ventricular function.
(TEE was attempted the following day but the patient did not
tolerate probe placement)
Brief Hospital Course:
81M with PMHx of remote Colon Cancer & complex myopathies
admitted with urinary incontinence, ?confusion, hypotension,
PNA & ARF with mild troponin leak in setting of sepsis, EKGs
unchanged.
.
# Strep Pneumoniae Septicemia - While in the ED, the patient
became hypotensive, code sepsis was activated with elevated WBC,
+bands, +lactate & suspected PNA on CXR. BP and lactate improved
after 3L IVF and levophed gtt. Most likely etiology is septic
shock given that [**2-6**] blood Cx bottles grew strep pneumoniae.
CXR reveals progressive LLL infiltrate suggestive of bacterial
lobar PNA. The patient was started on vancomycin, ctx, and
levofloxacin. The levofloxacin was discontinued after the
return of + blood cultures as it was ordered for atypical
coverage. The patient was quickly weened off pressors, but
required additional IVF for maintainece of adequate blood
pressure. The patient was breathing comfortably on 2-3L
throughout the second day of hospitalization, and blood
pressures have stable. On transfer to the floor from the ICU,
the patient was on CTX/Vanc and receiving PRN nebs. The
sensitivities from the blood cultures showed that the S.
Pneumoniae was sensitive to PCN and Ceftriaxone, so the
Vancomycin was discontinued. He was transitioned to oral
penicillin for discharge.
.
# NSTEMI - The patient did not have chest pain, sob, orthopnea,
or pnd. On admission he had troponin that were
0.20->0.22->0.23->0.21. CK was flat. EKG initially showed
possible ST changes suggestive of demand ischemia in setting of
sepsis, resolved on repeat EKGs in [**Hospital Unit Name 153**] after receiving IVF. CE
flat x 3. Did not have evidence of volume overload. Patient
was continued on ASA. BB and lisinopril were held in the
setting of hypotension, but were subsequently restarted on
transfer to the floor. TTE was ordered, please see results
section.
.
# hyperlipidemia ?????? Though patient has Vytorin written as a
medication, he actually is not on this medicine. He was taking
Simvastatin, but when this was changed to Vytorin he stopped
taking it because of the prohibitive cost. He was maintained on
Simvastatin and will be discharged on this. Given his history
of myopathy, this will have to be monitored and the dose should
be escalated as tolerated.
.
# mental status changes - The patient presented with a single
episode of confusion per wife, [**Name (NI) 98093**] remained AAOx3
without significant neurological eficits. Etiology most likely
secondary to sepsis. TSH, Vit B12 and folate all WNL. RPR
pending.
.
# ARF - Patient presented w/ ARF, with Cr up to 1.6 from
baseline of 1.0. Most likely secondary to volume depletion, as
creatinine trended down from 1.6->1.0 with hydration.
.
# myopathy/cervical spondylosis w/ myelopathy - CK flat, no
muscle pain. Neurontin dose initially decreased and renally
dosed. This was subsequently increased back to his outpatient
dose (900mg tid). He was continued on doxepin
.
# gout - no symptoms, but has chronic knee pain s/p remote
steroid injections. Colchicine was held. Allopurinol was
renally dosed. He was given ultram PRN for pain control.
Colchicine was restarted on discharge and Allopurinol was left
at lower dose (150mg daily instead of 100mg qid).
.
# colon cancer s/p colectomy ?????? remote, not currently receiving
treatment. Ostomy care per patient
Medications on Admission:
allopurinol 100mg po qid
colchicine 0.6mg po qdaily
doxepin 100mg po qhs
gabapentin 900mg po tid
lisinopril 20mg po qdaily
metoprolol succinate 25mg po qdaily
tylenol + codeine 300mg-30mg po q6-8hr prn pain (knee)
vytorin 10-10mg po qdaily
aspirin 325mg po qdaily
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Doxepin 25 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
3. Gabapentin 300 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
9. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every 4-6 hours as needed for knee pain.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Strep Pneumoniae Septicemia
Altered Mental Status
Non-ST Elevation Myocardial Infarction
Acute Renal Failure
Gout
Myopathy
Hyperlipidemia
Peripheral Vascular Disease
Colon Cancer
Hypertension
Anemia
Cervical Spondylosis
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
Complete course of antibiotics as prescribed. You will need to
get a follow up chest x-ray in about 6 weeks.
.
Call your doctor or return to the emergency room if you should
have chest pain, shortness of breath, high fever or increased
confusion.
Followup Instructions:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 7477**]. You have an
appointment on [**2119-3-15**] at 11:45 Am.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2119-4-5**] 1:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2119-5-1**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2119-5-8**] 10:30
|
[
"274.9",
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"443.9",
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"785.52",
"276.51",
"272.0",
"285.29",
"715.36",
"V44.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12418, 12469
|
7683, 11042
|
353, 360
|
12733, 12765
|
2917, 4412
|
13061, 13724
|
1971, 2017
|
11356, 12395
|
12490, 12712
|
11068, 11333
|
12789, 13038
|
2032, 2898
|
4456, 7660
|
273, 315
|
388, 1488
|
1510, 1791
|
1807, 1955
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,190
| 128,563
|
2358
|
Discharge summary
|
report
|
Admission Date: [**2176-3-20**] Discharge Date: [**2176-3-22**]
Date of Birth: [**2129-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
Bilateral Percutaneous Nephrostomy tubes
History of Present Illness:
MR. [**Known lastname 12279**] is a 46 yo male with metastatic bladder cancer s/p
cystectomy and ileal neobladder with disease progression on
chemo who went to a urology clinic appt today for suprapubic
discomfort, had a foley catheter placed and left in, with
minimal urine output. Urology felt that his obstruction was
likely pre-renal in nature [**2-21**] poor PO intake, and not at the
level of the urethra. They ordered labs on him which were
concerning for a K of 7.0 and a Cr of 5.5(baseline 1.2 on
[**2176-3-12**]). Patient's last chemotherapy dose was [**3-12**] and he
feels he has been "the same" since then except that over the
last week he has developed worsening suprapubic/abdominal pain
and over the last day has felt nauseous with "dry heaves". He
vomited 2x upon hitting the ICU floor. Of note, patient had
radiation through his R thigh to bladder on [**2176-3-1**], and since
then has developed cellulitis of the radiation site, written
today for keflex x7 days, of which he has not yet taken a dose.
He reports "ups and downs" of his temp, but not specifically
fevers/chills. Does have some [**3-28**] dull aching pain at the site
of the cellulitis. In addition, pt reports tha this last BM was
8 days ago and he feels very constipated.
In the ED, initial vs were: 96.2 115 128/69 18 100% RA. Patient
was given kayexelate x1 and calcium gluconate. He got vanc and
cefepime for neutropenic hypothermia, and dilaudid for abdominal
pain. EKG done without peaked T-waves. He was refusing A-line,
CVL and "unnecessary blood draws". He was then transferred to
the floor when his repeat labs showed his K was down to 5.9.
On the floor patient appeared very uncomfortable, was dry
heaving every 45 secs, and did vomit x2 after being "moved a
lot".
Review of systems:
(+) Per HPI
(-) Denies night sweats. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies diarrhea. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
# Bladder cancer:
- [**3-/2173**]: diagnosed with bladder cancer with an invasive pT2b
transitional cell carcinoma of mixed histology with
adenocarcinoma and squamous cell cancer components following am
TURBT.
- [**4-/2173**]: underwent radical cystoprostatectomy with bilateral
pelvic lymph node dissection and orthotopic ileal neobladder
placement. Pathology demonstrated negative margins, no
lymphovascular invasion, and 0 of 58 lymph nodes involved.
- [**5-/2174**]: found to have a pelvic mass highly suspicious for
recurrent disease, started on systemic chemotherapy with
gemcitabine and cisplatin at [**Hospital6 **]. He missed
day eight of each cycle due to noncompliance. However, he
experienced symptomatic resolution of his pain following three
cycles of chemotherapy, as well as radiographic improvement in
his disease burden. Due to a resurgence of his pain following
three cycles of gemcitabine and cisplatin, the patient wished to
receive further chemotherapy, but he was unable to receive
chemotherapy at [**Hospital6 **] due to multiple urine
toxicology screens positive for cocaine and other illicit
substances. After going through a detoxification program, he
transferred his care to [**Hospital1 18**].
- [**2175-1-11**]: fourth cycle of gemcitabine 1000 mg/m2 given on days
one and eight and cisplatin at 70 mg/m2 given on day one. He
completed six cycles of chemotherapy on [**2175-3-16**]. Due to renal
insufficiency, his final cycle of chemotherapy consisted of
gemcitabine plus carboplatin.
- [**2175-6-8**] CT scan revealed an increase in the size of his left
pelvic wall mass.
- [**2175-6-14**]: palliative chemotherapy with carboplatin and
gemcitabine was reinitiated.
- [**2175-6-17**]: admitted to the hospital with repeat imaging
demonstrating further progression of his disease.
- [**Date range (1) 12280**]: received palliative radiation therapy to the
left groin
- [**2175-7-27**]: cycle 4 of gemcitabine 1230 mg IV Days 1 and 8. (750
mg/m2), dose reduced for low counts, and carboplatin 435 mg IV
Day 1([**2175-7-27**]) (dose reduced by 20% to 4 AUC). By patient
request, cycle 5 in [**8-/2175**] was held due to him having minimal
symptoms from his disease.
- [**2175-10-18**] CT torso showing significant improvement in left
pelvic wall mass but new L3 mass.
- [**2175-10-30**] MRI of the L-spine: Left pelvic mass, similar in size
to [**2175-10-18**] CT. Posterior paravertebral metastasis at the L3
level on the left, similar to [**2175-10-18**], without extension into
the spinal canal. Rim-enhancing lesion in the posterior
paravertebral muscles at L5, without extension into the spinal
canal.
- [**2175-11-14**]: admitted with severe left groin pain
- [**2175-11-15**] to [**2175-11-23**]: received radiation to L2 from L2-S1,
total dose of [**2165**] cGy in 5 fractions.
- [**2175-12-6**], MRI of the right knee showing two mass-like
abnormalities in the distal femur area.
- [**2175-12-15**], MRI of the thigh showing a lesion in the vastus
intermedius measuring 5.2 x 2.7 x 2.2 cm, and a vastus medialis
lesion measuring 4.3 x 2.6 x 2.2 cm. These are both worrisome
for metastatic cancer.
- [**2175-12-21**], core needle biopsy of thigh mass demonstrating
poorly differentiated carcinoma consistent with known metastatic
bladder cancer.
- [**2176-1-4**]: LENIS: on the left there is occlusive thrombus
identified extending inferiorly from the saphenofemoral junction
into the deep femoral vein. There is flow seen in the proximal
common femoral vein, as well as inferiorly in the left
superficial femoral vein below the deep femoral vein confluence,
and in the popliteal and calf veins. There are flat, non-phasic
waveforms identified, compatible with presence of proximal
thrombus.
- [**2176-1-5**]: CT torso and chest angio showing bilateral pulmonary
emboli in RML, RLL, LLL, disease progression
with increased lymphadenopathy.
- [**2176-1-6**], Cycle 5, day 1 of carboplatin AUC 4 on day 1 and
gemcitabine 1000 mg/m2 on day 1 and day 11. Carboplatin chosen
by inpt attending due to Cr: 1.3.
- [**2176-1-17**]: CT abdomen and pelvis showing no intra-abdominal or
pelvic hematoma. There is interval enlargement of left-sided
pelvic and paraspinal necrotic masses consistent with
metastases.
Left iliac common femoral DVT.
- [**2176-2-1**]: Cycle 7, day 1 (C7 overall, but second cycle of
overall
therapy since restarting chemo) of cisplatin 70 mg/m2 on day 1
and gemcitabine 1000 mg/m2 on day 1. The patient declined to
come in for day eight dose of gemcitabine due to fatigue.
- [**2176-2-11**] CT angio of the chest: no evidence of pulmonary
embolism.
Previous filling defect has resolved. No pathologically
enlarged
lymph nodes were seen.
- [**2176-2-19**] CT torso: No axillary or mediastinal lymphadenopathy.
There are no worrisome nodules in the lungs. There is a stable
1.1 x 1.1 cm right mid polar renal cyst that is complex.
Peritoneal nodules in the right paracolic gutter have increased
in size compared to prior. A hypoattenuating cystic mass in the
left iliac [**Doctor First Name 362**] is increased in size to 2.9 x 5.1 cm from 2.8 x
4.7 cm. Left paraspinal cystic necrotic mass is decreased in
size, measuring 2.7 x 1.9 cm versus 3.2 x 3.7 cm. Prominent
right inguinal and external iliac lymph nodes are increased in
size, with the largest inguinal node measuring 3.0 x 1.4 cm
versus 2.3 x 1.1 cm prior.
- [**Date range (1) 8301**]/11: palliative radiation to right thigh, total
2000cGy
in 5 fractions
- [**2176-3-12**]: cycle 1 day 1 pemetrexed 500mg/m2
.
.
Other Past Medical History:
1. Acute inferolateral myocardial infarction, status post
percutaneous intervention to the right coronary artery in
03/[**2174**]. Related to cocaine use
2. History of tobacco dependence.
3. History of substance abuse including cocaine.
4. Major depressive disorder, recurrent.
5. Posttraumatic stress disorder.
6. History of bladder cancer as noted above.
7. History of scoliosis with back pain
8. Gunshot wound to the head in [**2149**]
9. bilat PEs & DVT in LLE in [**12-28**]
Social History:
The patient is unemployed. He has has been on disability since
[**2165**]. Has been smoking about 3 cigarettes per day. His living
situation is stable at this time, and he is living with his
aunt. His aunt is [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 12281**]). He has no history
of STDs including HIV.
Family History:
Significant for type 2 diabetes and hypertension in his
grandparents. The patient's mother died at age 39 of an MI and
pulmonary failure and question of cancer. Both parents are
alcoholics. His oncologic family history is significant for lung
cancer in his uncle and lymph node cancer in one of his
grandparents, uncle with throat cancer.
Physical Exam:
Vitals: T96.3, 127/83, 111, 13, 97%RA
General: middle aged male appearing much older than stated age,
sitting in bed, cachectic, AAOx3, hiccupping/dry heaving
frequently appears in moderate distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mild scattered wheezes and diminished breath sounds
throuhgout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly tender, moderately distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2176-3-20**] 06:15PM BLOOD WBC-0.5*# RBC-2.91* Hgb-7.9* Hct-23.5*
MCV-81* MCH-27.2 MCHC-33.6 RDW-16.9* Plt Ct-297#
[**2176-3-20**] 06:15PM BLOOD Neuts-84* Bands-0 Lymphs-11* Monos-4
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2176-3-20**] 12:20PM BLOOD Glucose-98 UreaN-143* Creat-5.5*# Na-123*
K-7.0* Cl-92* HCO3-11* AnGap-27*
[**2176-3-20**] 12:20PM BLOOD Mg-3.5*
Interval change:
[**2176-3-21**] 04:35AM BLOOD WBC-0.3* RBC-2.83* Hgb-7.5* Hct-22.8*
MCV-81* MCH-26.4* MCHC-32.8 RDW-17.2* Plt Ct-281
[**2176-3-21**] 04:35AM BLOOD Glucose-108* UreaN-150* Creat-5.2*
Na-127* K-5.4* Cl-91* HCO3-15* AnGap-26*
[**2176-3-21**] 02:46PM BLOOD Glucose-150* UreaN-154* Creat-5.4*
Na-128* K-5.0 Cl-90* HCO3-14* AnGap-29*
Urine:
[**2176-3-20**] 10:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2176-3-20**] 10:40PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2176-3-20**] 10:40PM URINE RBC-24* WBC-6* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
Studies:
RENAL U.S. Study Date of [**2176-3-20**] 7:14 PM
TECHNIQUE AND FINDINGS: Transabdominal son[**Name (NI) 493**] images of the
bilateral kidneys demonstrate moderate bilateral hydronephrosis.
An interpolar right renal lesion seen on CT is not fully
evaluated. Normal main renal arterial and venous waveforms are
seen bilaterally. There are no stones.
IMPRESSION:
1. Moderate bilateral hydronephrosis.
2. Normal main renal arterial and venous waveforms.
Brief Hospital Course:
Mr. [**Known lastname 12279**] is a 46 yo male with metastatic bladder cancer with
disease progression on chemo who went to a urology clinic appt
[**3-20**] for suprapubic discomfort, had a foley catheter placed with
minimal urine output and was found to have hyperkalemia and [**Last Name (un) **]
in the setting of neutropenia.
# [**Last Name (un) **]: Renal function was 1.2 on [**2176-3-12**], and acutely elevated
in the setting of bilateral obstruction. On CT he has bilateral
hydronephrosis which is the likely source of his [**Last Name (un) **]. Urology
was consulted and felt that urological procedure (ie stents) was
not possible and percutaneous nephrostomy tubes were indicated
if this was within pt's goals of care. He felt that he wanted
the procedure as a palliative measure and as a way to help
transition home. On [**2176-3-21**] he had bilateral percutaneous
nephrostomy tubes placed with good urine output after the
procedure. Renal was consulted and felt that the procedure was
indicated for palliation and improvement as a means to a bridge
to home.
# Electrolyte Abnormalities: Likely related to [**Last Name (un) **] (see above).
Potassium, magnesium and phosphorus were all very elevated, HCT
and sodium decreased. His initial EKG showed peaked t-waves. He
was given insulin and calcium gluconate as well as Kayexalate
x2. He did not stool, though his potassium began to trend down
from 7 to 5 within his first day of admission. He was written
for sevelamer and he had repeat ekgs that showed improvement
with his improvement in potassium
# Abdominal pain: He has had constipation without a BM x8 days.
He is on chronic narcotics at home. He is also likely having
discomfort from his obstructive kidney injury and suprapubic
pain. He was writted for an aggressive bowel regimen, and CT
showed partial SBO. He was quite nauseaus, and he was given
compazine, and zofran was avoided for potential compounding of
constipation. His discomfort was largely associated with his
constipation, and in an effort to make him have a BM,
methylnaltrexone was given without effect. After discussion with
Oncology (given his neutropenia) it was felt the benefits
outweighed the risks for using a suppository in an attempt to
make him have a bowel movement, so he was given one still with
no effect. Patient was still passing gas, so we felt it was
safe to send him home with an aggressive bowel regimen of
lactulose, senna, docusate and bisacodyl both PO and PR.
# Neutropenic hypothermia: The likely source is cellulitis on
his righ thigh which has gone untreated since mid-[**Month (only) 956**]. He
was prescribed keflex on the day of admission but did not
receive a dose. He was given vanc and cefepime x1 in ED and was
continued on that regimen while in the MICU and was dosed based
on his renal function.
# Metastatic Bladder Cancer: Disease progressing despite
chemotherapy. Last chemotherapy was [**3-12**], given permetrexed x1,
plan was for repeat dosing every 21 days. No plans for treatment
while in the ICU. Will defer to outpatient oncologist.
Palliative care was consulted for assistance with symptom
management and overall goals of care. While he was nauseaus and
not tolerating oral meds, he was placed on a dilaudid drip to
control his pain.
#Anemia: longstanding per outpatient onc note [**2-21**] chronic dz.
His HCT was stable during his stay in the ICU in the 22-24
range.
# Hx of DVT/PE's: Left DVT and bilateral PE's in [**12-28**]. Per
outpatient onc note, has lifelong risk of clots, will need
lifelong anticoagulation. He takes enoxaparin 60mg [**Hospital1 **] at home.
His dose was held on admission in anticipation of procedure
(perc nephrostomy)with the goal of transitioning back to his
home dose enoxaparin if perc nephrostomy tubes improve kidney
function to baseline.
# Goals of care. With ongoing discussions and involvement of
palliative care team, it was clear that Mr. [**Known lastname 12282**] goals
were to get home. He was transitioned to comfort care with
hospice at home, and discharged directly from the ICU.
Medications on Admission:
# enoxaparin 60 mg/0.6 mL Sub-Q every 12 hours
# cephalexin 500 mg by mouth four times a day
# senna 8.6 mg Tab 2 Tablet(s) by mouth [**Hospital1 **] as needed for
constipation
# morphine ER 30 mg Tab 2 Tablet(s) PO QAM, 2 tabs QPM and 3
tablets QHS
# morphine 15 mg Tab by mouth q3 hours as needed for pain
# nystatin 100,000 unit/mL Oral Susp 5 mL by mouth four times a
day swish and spit; for thrush
# lorazepam 0.5 mg Tab 1 Tablet(s) by mouth every 6 hours as
needed for anxiety, nausea, insomnia ; take before MRI. If
needed, may take 2 pills total before MRI.
# Milk of Magnesia 400 mg/5 mL Oral Susp
# ProAir HFA 90 mcg/Actuation Aerosol Inhaler
# dexamethasone 4 mg Tab 1 Tablet(s) by mouth twice a day ; take
the day before, the day of, and the day after chemotherapy
# omeprazole 20 mg Cap by mouth daily
# prochlorperazine maleate 10 mg Tab 1 Tablet(s) by mouth every
6 hours as needed for nausea ; rarely uses because it gives him
hiccups and doesn't help much
# docusate sodium 100 mg Cap 1 Capsule(s) by mouth [**Hospital1 **] - patient
has not been taking
# fluconazole 200 mg Tab 1 Tablet(s) by mouth daily ; for total
of 14 days (for oral candidiasis)
# folic acid 1 mg Tab by mouth daily
# ondansetron HCl 8 mg Tab 1 Tablet(s) by mouth every eight (8)
Discharge Medications:
1. Cadd pump
1 Cadd pump for dilaudid PCA
2. Dilaudid
Dilaudid infusion and PCA with basal rate of 0.5mg/hr and bolus
1mg q 10 minutes. Dispense 100cc cassette.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
Disp:*1000 ML(s)* Refills:*0*
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation for 1 doses.
Disp:*3 Suppository(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice of [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnoses:
Metastatic Bladder Cancer
Obstructive Uropathy
Hyperkalemia
Acute Kidney Injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname 12279**],
You were seen in the hospital for a blockage of your kidneys and
dangerous levels of potassium in your body. We placed tubes in
your kidneys and helpe dot relieve this blockage. You were
started on pain medication and were sent home on hospice care.
If you have any questions you can call your hospice team at
[**Telephone/Fax (1) 12283**]. It was a pleasure taking care of you on this
hospital admission.
If you have worsening pain or nausea please call your hospice
team on the above number.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2176-3-27**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2176-4-4**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) 10341**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2176-4-4**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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18038, 18038
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,283
| 182,571
|
1080
|
Discharge summary
|
report
|
Admission Date: [**2133-3-25**] Discharge Date: [**2133-4-2**]
Date of Birth: [**2063-8-13**] Sex: F
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Lower Extremity Weakness
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
Ms. [**Known lastname 7053**] is a 69 year old woman with metastatic HCC who was
transferred from [**Hospital1 **] ED to [**Hospital1 18**] with slowly progressive
weakness. She was found to have acute renal failure and
hyponatremia. She was transferred to the ICU for hypotension in
the ED. She has failed several chemotherapy trials and is
currently on Avastin/erlotinib (although obtaining erlotinib has
been problem[**Name (NI) 115**] due to insurance issues). She has known
metastatic disease throughout the chest, abdomen and pelvis with
extensive adenopathy and pulmonary metastases. She has
significant ascites, last para was 2 weeks ago. The patient
reports feeling progressively more weak, particularly in her
legs for the past several weeks. She started off using a cane,
then walker, and now is even having trouble with that. Initially
she thought her arm strength was normal, then thought that she
was having some trouble with her handwriting. She denies
incontinence of urine or stool. Her appetite has been poor and
she has been hopeful to try an appetite stimulant. She has felt
queasy on occasion but no persistent nausea and no emesis. No
diarrhea. She reports a "tickle" cough for the past couple of
days but no fever, chills, sweats, or sputum production.
.
In the ED her VS were T 97.4 BP 113/69 HR 97 RR 18 O2 100%
on 2L. She had back pain (chronic) and was given 4mg IV morphine
and SBP dropped to high 80s. She was given a total of 3L of
IVFs which maintained SBPs in 90s-100s. Given concern for
possible pneumonia, she received Levaquin 750mg IV, and cefepime
2g IV x 1.
Past Medical History:
ONCOLOGIC HISTORY:
- This 69-year-old female was initially diagnosed with
hepatocellular carcinoma in 09/[**2130**]. At that time, she had pain
in her right upper quadrant and underwent an ultrasound to
evaluate for potential gallstones. The ultrasound showed a mass.
She went on to have a CT scan, which also showed a very
suspicious looking mass concerning for HCC. She had an AFP of
112,000.
- She was started on sorafenib, which she was on from [**10/2131**]
until 05/[**2131**].
- She had progression by AFP and imaging and was changed over to
a clinical trial on RAD001 in 06/[**2131**].
- She continued on RAD001 for some time; however, developed a
rising AFP and worsening disease on CT scan on [**2132-12-5**] and
was taken off of the study.
- She was started on trial 08-243 on [**2133-1-12**] of GC33. She had a
CT scan [**2133-2-3**] which showed progressive disease so she was taken
off of the trial.
- [**2133-2-23**] She was started on Avastin and Tarceva.
.
PAST MEDICAL HISTORY:
1. Nonalcoholic steatohepatitis (NASH) with subsequent
cirrhosis.
2. Type 2 diabetes for 16 years.
3. Status post total right hip replacement in [**2124**].
4. Status post total knee replacement in [**2126**].
5. Status post D&C in [**2128**].
6. Hypertension.
7. Hidradenitis of the labia.
8. Arthritis.
Social History:
Married with 4 children. Worked as a bookkeeper for [**University/College 7054**]. No alcohol. Quit cigarette smoking 39 years ago. 15
pack year history.
Family History:
Not contributory
Physical Exam:
-- on admission --
Vitals: T 96.6 HR 98 BP 108/59 RR 16 O2 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Distant breath sounds. No wheezes or crackles
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM > RUSB, no
rubs, gallops
Abdomen: Distended but soft, nontender, no guarding or rebound
tenderness, normoactive BS
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, trace pedal
edema.
Neuro: A+Ox3, CNII-XII intact, strength in upper extrem [**4-8**],
lower extrem: [**3-9**] (R), 4-/5 (L), sensation intact throughout.
Pertinent Results:
[**2133-3-26**] 03:12AM BLOOD WBC-4.4 RBC-3.90* Hgb-10.7* Hct-32.9*
MCV-85 MCH-27.3 MCHC-32.3 RDW-15.5 Plt Ct-161
[**2133-3-25**] 12:39PM BLOOD Neuts-87.2* Lymphs-6.6* Monos-4.9 Eos-0.9
Baso-0.4
[**2133-3-26**] 03:12AM BLOOD PT-13.6* PTT-27.6 INR(PT)-1.2*
[**2133-3-25**] 12:39PM BLOOD Glucose-94 UreaN-49* Creat-1.5* Na-128*
K-5.6* Cl-93* HCO3-22 AnGap-19
[**2133-3-26**] 03:12AM BLOOD Glucose-86 UreaN-43* Creat-1.3* Na-129*
K-4.8 Cl-99 HCO3-17* AnGap-18
[**2133-3-26**] 04:12PM BLOOD Glucose-77 UreaN-38* Creat-1.2* Na-134
K-4.3 Cl-101 HCO3-21* AnGap-16
[**2133-3-25**] 12:39PM BLOOD ALT-27 AST-92* AlkPhos-171* TotBili-0.7
[**2133-3-25**] 12:39PM BLOOD Albumin-3.3* Calcium-9.3 Phos-4.2 Mg-2.4
[**2133-3-26**] 03:12AM BLOOD Triglyc-115
[**2133-3-25**] 04:49PM BLOOD Lactate-1.4
[**2133-3-25**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2133-3-25**] 02:00PM URINE Hours-RANDOM Creat-116 Na-LESS THAN
[**2133-3-25**] 02:00PM URINE Osmolal-515
[**2133-3-26**] 03:46PM ASCITES WBC-367* RBC-8250* Polys-PND Lymphs-PND
Monos-PND
[**2133-3-26**] 03:46PM ASCITES TotPro-2.1 Creat-1.1 LD(LDH)-75
Amylase-22 Albumin-1.4 Triglyc-275
[**2133-4-1**] 08:06AM BLOOD WBC-8.9 RBC-4.56 Hgb-12.6 Hct-38.3 MCV-84
MCH-27.7 MCHC-33.0 RDW-15.6* Plt Ct-137*
[**2133-3-30**] 07:55AM BLOOD Glucose-207* UreaN-38* Creat-1.0 Na-129*
K-5.4* Cl-97 HCO3-25 AnGap-12
[**2133-3-30**] 03:10PM BLOOD Creat-0.9 Na-129* K-5.9* Cl-98
[**2133-4-1**] 08:06AM BLOOD Glucose-222* UreaN-62* Creat-1.2* Na-131*
K-5.4* Cl-97 HCO3-21* AnGap-18
[**2133-3-25**] 12:39PM BLOOD ALT-27 AST-92* AlkPhos-171* TotBili-0.7
[**2133-4-1**] 08:06AM BLOOD ALT-43* AST-67* LD(LDH)-221 AlkPhos-166*
TotBili-0.8
[**2133-4-1**] 08:06AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.2
[**2133-3-26**] 03:46PM ASCITES WBC-367* RBC-8250* Polys-12* Lymphs-63*
Monos-9* Macroph-16*
[**2133-3-26**] 03:46PM ASCITES TotPro-2.1 Creat-1.1 LD(LDH)-75
Amylase-22 Albumin-1.4 Triglyc-275
.
Microbiology
[**3-25**] Blood Cultures Negative
[**3-26**] Ascites Fluid Negative
.
Imaging
[**2133-3-25**] LLE U/S
No evidence of left lower extremity DVT.
.
[**2133-3-25**] CXR:
1. Bilateral right greater than left pleural effusions,
essentially unchanged in cross-modality comparison to the CT
from [**2133-2-3**].
2. Opacity at the right lung base likely represent atelectasis,
however,
early pneumonic infiltrate cannot be ruled out.
.
[**2133-3-27**] Ascites Fluid
NEGATIVE FOR MALIGNANT CELLS.
.
[**2133-3-27**]
IMPRESSION: Small acute infarcts as described above. Left
parietal 1.5cm
lesion suspicious for metastasis. Gadolinium enhanced study
recoomeded
.
[**2133-3-28**] MR [**Name13 (STitle) **]
IMPRESSION:
1. Technically limited study. No intravenous contrast given,
precluding
evaluation for leptomeningeal metastatic disease.
2. No obvious change in extensive multilevel spondylosis. Severe
spinal
canal stenosis with compression of the cauda equina at L2-3.
Moderate spinal canal stenosis at L1-2 and L3-4.
.
[**2133-3-30**] ECHO
The left atrium is mildly dilated. 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
normal (LVEF>55%). The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. Significant
aortic stenosis is present (not quantified). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. There is probably mild aortic
stenosis but the severity cannot be accurately determined.
.
[**2133-3-30**] CXR
1. Decrease in bilateral pleural effusions with improved lung
aeration
bilaterally. No new opacities in the lung parenchyma.
2. Stable bilateral hilar and mediastinal masses
Brief Hospital Course:
Ms. [**Known lastname 7053**] is a 69 year old woman with metastatic hepatocellular
carcinoma. She was initially admitted to [**Hospital Unit Name 153**] with hypotension,
hyponatremia and acute renal failure. She was called out to the
floor, but had progressive weakness from severe spinal stenosis,
agitation, and respiratory difficulties. Extensive family
discussions were held regarding goals of care given extensive
tumor involvement. She died [**2133-4-2**].
# ARF - Ms. [**Known lastname 7053**] presented with an acute elevation in Cr (1.5
on arrival, ~1.0 at baseline). FeNa < 0.1%. Given history of
decreased PO intake and physical exam, thought to be consistent
with hypovolemia and prerenal failure. She was given IVF +
albumin challenge to attempt to improve renal function, as well
as rule-out/treat HRS. She showed improvement by discharge from
the ICU to the floor. On the floor, she was given another
challenge of albumin and her creatinine normalized. Her
creatinine again worsened when she had severely decreased PO
intake. She was given several boluses of normal saline.
# Weakness - Ms. [**Known lastname 7053**] initially had some focal weakness in her
lower extremities, left greater than right. This was initially
thought to be secondary to a metabolic processes. After
stabilization of those processes the patient was called out to
the floor. On the floor, initial exam showed marked weakness.
Neurology was consulted and an MRI of the spine was attempted,
which was complicated by the patient`s inability to lay flat.
Scout films that were obtained were able to demonstrate severe
spinal stenosis but no evidence of malignancy causing cord
compression. The patient was started on Decadron 4mg q6h. She
was not a surgical candidate. She was continued on Decadron, but
her weakness progressed.
# Hyponatremia - Ms. [**Known lastname 7053**] has chronic hyponatremia in low 130s
and presented with a sodium of 128. This improved with fluid
and albumin challenges and was likely hypervolemic hyponatremia
secondary to the patient`s known cirrhosis and NASH.
.
# Hypotension - Resolved after initial fluid challenge in the
ICU. Likely in the setting of receiving morphine.
.
# Cirrhosis - Liver enzymes at baseline on admission. On review
of old medical records, patient noted to have 2 cords of grade 1
varices. Significant ascites with recent, rapid accumulation.
No history of encephalopathy. Given symptoms and patient
presentation, patient was tapped in the ICU for 3L to rule out
SBP, as well as provide some comfort from symptoms. Volume on
initial tap was limited given possibility of SBP as well as
ongoing ARF. Ascites labs were consistent with a portal
hypertensive etiology. Of note, triglycerides were elevated in
the ascitic fluid, consistent with chylous ascites; this is
strongly associated with malignancy, consistent with patient's
h/o HCC.
.
# HCC: Ms. [**Known lastname 7053**] and her family had extensive discussions about
treatment for her HCC. Her disease had progressed to include new
met to the brain and significant disease burden in the
mediastinum and lungs. She and her family met extensively with
the primary oncology team to discuss the rapid decline and the
role of cancer directed therapy. Further chemotherapy was not
considered to be beneficial given her overall rapid decline and
poor performance status.
.
# Hypoxia: Ms. [**Known lastname 7053**] developed a new oxygen requirement of 4 L
while in the hospital. She was initially started on antibiotics
for concern of pneumonia. However, these were eventually stopped
when there was no evidence to suggest pneumonia. Her oxygen
requirement was thought related to her extensive disease.
.
# Goals of Care: Palliative Care, chaplains, and the primary
team had extensive conversations with Ms. [**Known lastname 7053**] and her family
regarding her goals of care. On admission, she was a full code.
However, as her prognosis worsened, her code status was changed
to DNR/DNI. She developed significant agitation and pain. As her
status declined, the treatment focus changed to maximize comfort
measures. Her pain regimen was changed to include IV morphine.
She was initially given ativan for anxiety, but became more
agitated. She had a good response to Zyprexa. Her family was at
her bedside when she died.
Medications on Admission:
Avastin
Fentanyl 25 mcg/hour patch Q72H +
Fentanyl 100 mcg/hr patch Q72H
Metformin 500 mg po bid
Omeprazole 40 mg po bid
Oxycodone 5 mg tabs, 1-2 tabs Q3-4H prn
Pravastatin 80 mg daily
Vitamin C - not taking
Ca-Vit D - not taking
Colace
Iron - not taking
MVI
OM3FA - not taking
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis
1. Hepatocellular Carcinoma
2. Spinal Stenosis
3. Cauda Equina Compression
4. Cirrhosis
5. Acute Renal Failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
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[
[
[]
]
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[
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icd9pcs
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,031
| 100,416
|
38482
|
Discharge summary
|
report
|
Admission Date: [**2162-6-23**] Discharge Date: [**2162-7-14**]
Date of Birth: [**2109-7-26**] Sex: M
Service: SURGERY
Allergies:
Aloe
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal compartment syndrome [**3-16**] pancreatitis
Major Surgical or Invasive Procedure:
1. Exploratory decompressive laparotomy. [**6-24**]
2. Application of open abdominal dressing. [**6-28**]
3. Repair of perforated cecum. [**7-1**]
3. Closure of open abdomen
History of Present Illness:
60M +EtOH + seizures who presented to OSH [**6-23**] afternoon with
altered ms, abdominal pain, SOB. High DDimer, high bandemia and
SOB was concerning for PE presentation -> CT chest obtained,
negative. Seized at OSH CT scan, found to be in status
epilepticus, intubated and xferred to [**Hospital1 18**] ER. Patient became
hypotensive in ED, given 5L of IVF, started on pressors with
benzodiazpine gtt. Patient has received 19L of crystalloid
total, and he has had worsening renal failure (rapid rise in cr
from 1.4 to 2.1, marked oliguria, rising CK's despite seizure
history, and concerning abdominal exam). Non-contrast CT scan
in ED demonstrated pancreatic tail inflammation, no free air,
min fluid in the pelvis. We were initially consulted for
management of pancreatitis, but concern grew for abdominal
Compartment syndrome.
Past Medical History:
* Alcoholism - multiple withdrawal episodes, unclear if DTs or
alcohol-related seizures
* Chronic back pain
* Rib fracture ~1 year ago?
* Seizure - Pt was not drinking and had a witnessed seizure. Got
admitted to [**Hospital1 2025**] and was started on Keppra aproximately ~3 years
ago.
* PFO
" Cyst in the brain"
* Hyperlipidemia
* GERD
* Psoriasis
PAST SURGICAL HISTORY:
* Lumbas spine surgery
* Knee surgery
Social History:
He lives by himself in [**Location (un) **], MA. He works driving his own
18-wheel truck. He has history of chronic alcoholism; it is
unclear if he has history of DTs or alcohol-related seizures. He
smokes 1 pack-per-day and has been doing so for 20-30 years.
Family denies that he uses drugs.
Family History:
No family history of seizures, no DM (maybe uncle), no stroke,
mother with heart attack and father with heart attack. No early
MI. Father's side with prostate and lung cancer and breast
cancer.
Physical Exam:
99.4 98.4 85 145/90 18 97% RA
AOX3 NAD
RRR
CTAB
Abd soft non tender non distended
inc: CDI
ext: no edema
Pertinent Results:
[**2162-7-14**] 06:50AM BLOOD WBC-11.6* RBC-2.62* Hgb-8.7* Hct-26.8*
MCV-103* MCH-33.3* MCHC-32.4 RDW-14.1 Plt Ct-346
[**2162-7-13**] 06:50AM BLOOD WBC-13.0* RBC-2.42* Hgb-8.5* Hct-25.3*
MCV-105* MCH-35.3* MCHC-33.7 RDW-14.6 Plt Ct-286
[**2162-7-12**] 08:05AM BLOOD WBC-15.6* RBC-2.72*# Hgb-9.2*# Hct-28.0*
MCV-103* MCH-33.9* MCHC-32.9 RDW-14.1 Plt Ct-354#
[**2162-7-11**] 08:19AM BLOOD Hct-26.4*
[**2162-7-11**] 05:55AM BLOOD WBC-12.7* RBC-2.03* Hgb-7.2* Hct-21.5*
MCV-106* MCH-35.4* MCHC-33.4 RDW-14.8 Plt Ct-183
[**2162-7-10**] 06:32AM BLOOD WBC-16.1* RBC-2.50* Hgb-8.8* Hct-26.7*
MCV-107* MCH-35.1* MCHC-32.9 RDW-14.8 Plt Ct-229
[**2162-7-9**] 07:00AM BLOOD WBC-14.5* RBC-2.70* Hgb-9.1* Hct-28.2*
MCV-105* MCH-33.7* MCHC-32.2 RDW-14.5 Plt Ct-408
[**2162-6-28**] 09:52PM BLOOD Hct-33.5*
[**2162-6-27**] 11:51AM BLOOD WBC-12.6* RBC-3.18* Hgb-11.3* Hct-35.3*
MCV-111* MCH-35.6* MCHC-32.1 RDW-14.2 Plt Ct-121*
[**2162-6-27**] 12:23AM BLOOD WBC-11.2* RBC-3.04* Hgb-11.4* Hct-33.6*
MCV-110* MCH-37.5* MCHC-33.9 RDW-15.0 Plt Ct-104*
[**2162-6-26**] 11:27AM BLOOD WBC-10.1 RBC-3.03* Hgb-10.9* Hct-33.5*
MCV-111* MCH-36.1* MCHC-32.6 RDW-14.2 Plt Ct-130*
[**2162-6-26**] 03:28AM BLOOD WBC-11.0 RBC-3.06* Hgb-11.2* Hct-33.9*
MCV-111* MCH-36.5* MCHC-33.0 RDW-15.0 Plt Ct-109*
[**2162-6-25**] 02:04AM BLOOD WBC-11.4* RBC-3.37* Hgb-12.4* Hct-36.8*
MCV-109* MCH-36.8* MCHC-33.6 RDW-14.9 Plt Ct-106*
[**2162-6-24**] 10:15PM BLOOD WBC-10.3 RBC-3.26* Hgb-12.0* Hct-35.6*
MCV-109* MCH-36.9* MCHC-33.8 RDW-15.0 Plt Ct-99*
[**2162-6-24**] 05:38PM BLOOD WBC-14.6* RBC-3.77* Hgb-13.8* Hct-41.2
MCV-109* MCH-36.5* MCHC-33.4 RDW-14.7 Plt Ct-122*
[**2162-6-24**] 11:40AM BLOOD WBC-14.0* RBC-3.68* Hgb-13.5* Hct-39.7*
MCV-108* MCH-36.6* MCHC-33.9 RDW-14.9 Plt Ct-122*
[**2162-6-24**] 02:08AM BLOOD WBC-17.5* RBC-4.22* Hgb-15.9 Hct-44.5
MCV-105* MCH-37.5* MCHC-35.7* RDW-14.5 Plt Ct-126*
[**2162-6-23**] 06:00PM BLOOD WBC-19.3* RBC-3.94* Hgb-14.1 Hct-42.0
MCV-107* MCH-35.7* MCHC-33.5 RDW-13.6 Plt Ct-153
[**2162-6-24**] 05:38PM BLOOD Neuts-84* Bands-8* Lymphs-3* Monos-4
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2162-7-6**] 10:17AM BLOOD PT-16.0* PTT-38.7* INR(PT)-1.4*
[**2162-7-14**] 06:50AM BLOOD Glucose-94 UreaN-33* Creat-2.4* Na-138
K-3.4 Cl-103 HCO3-25 AnGap-13
[**2162-7-13**] 06:50AM BLOOD Glucose-98 UreaN-42* Creat-3.3* Na-135
K-3.2* Cl-99 HCO3-24 AnGap-15
[**2162-7-12**] 08:05AM BLOOD Glucose-163* UreaN-49* Creat-4.3* Na-136
K-3.2* Cl-98 HCO3-23 AnGap-18
[**2162-7-11**] 05:55AM BLOOD Glucose-109* UreaN-46* Creat-4.8* Na-133
K-3.3 Cl-96 HCO3-24 AnGap-16
[**2162-7-10**] 06:32AM BLOOD Glucose-101* UreaN-39* Creat-5.0*# Na-136
K-3.3 Cl-99 HCO3-25 AnGap-15
[**2162-7-9**] 07:00AM BLOOD Glucose-130* UreaN-62* Creat-7.4*# Na-136
K-3.5 Cl-97 HCO3-23 AnGap-20
[**2162-7-8**] 01:04AM BLOOD Glucose-120* UreaN-47* Creat-6.2*# Na-139
K-3.8 Cl-99 HCO3-24 AnGap-20
[**2162-7-7**] 02:28AM BLOOD Glucose-117* UreaN-78* Creat-9.8* Na-138
K-4.4 Cl-101 HCO3-18* AnGap-23*
[**2162-7-6**] 01:45AM BLOOD Glucose-112* UreaN-73* Creat-9.4*# Na-140
K-4.2 Cl-104 HCO3-21* AnGap-19
[**2162-7-5**] 01:33AM BLOOD Glucose-94 UreaN-58* Creat-7.9*# Na-140
K-4.5 Cl-102 HCO3-23 AnGap-20
[**2162-7-4**] 02:04AM BLOOD Glucose-118* UreaN-42* Creat-6.0*# Na-141
K-4.1 Cl-103 HCO3-28 AnGap-14
[**2162-7-3**] 03:10PM BLOOD Glucose-164* UreaN-31* Creat-4.8*# Na-140
K-3.9 Cl-102 HCO3-29 AnGap-13
[**2162-7-3**] 01:09AM BLOOD Glucose-136* UreaN-57* Creat-8.0*# Na-138
K-4.4 Cl-101 HCO3-24 AnGap-17
[**2162-6-24**] 10:15PM BLOOD Glucose-144* UreaN-33* Creat-3.7* Na-138
K-3.4 Cl-108 HCO3-20* AnGap-13
[**2162-6-24**] 05:38PM BLOOD Glucose-182* UreaN-32* Creat-3.5* Na-135
K-3.6 Cl-106 HCO3-17* AnGap-16
[**2162-6-24**] 11:40AM BLOOD Glucose-180* UreaN-30* Creat-3.1* Na-136
K-3.0* Cl-102 HCO3-22 AnGap-15
[**2162-6-24**] 02:08AM BLOOD Glucose-248* UreaN-28* Creat-2.1* Na-133
K-3.6 Cl-100 HCO3-20* AnGap-17
[**2162-6-23**] 06:00PM BLOOD Glucose-69* UreaN-21* Creat-1.8* Na-138
K-3.1* Cl-103 HCO3-21* AnGap-17
[**2162-7-2**] 02:04AM BLOOD ALT-28 AST-35 AlkPhos-210* Amylase-29
TotBili-0.4
[**2162-6-30**] 01:19AM BLOOD ALT-45* AST-48* AlkPhos-314* Amylase-31
TotBili-0.3
[**2162-6-29**] 02:22AM BLOOD Amylase-40
[**2162-6-28**] 01:16AM BLOOD Amylase-56
[**2162-6-27**] 05:24AM BLOOD CK(CPK)-1345* Amylase-62
[**2162-6-27**] 12:23AM BLOOD ALT-72* AST-173* AlkPhos-156* TotBili-0.7
[**2162-6-26**] 11:27AM BLOOD ALT-74* AST-183* CK(CPK)-2663*
AlkPhos-136* TotBili-0.7
[**2162-6-26**] 03:28AM BLOOD ALT-73* AST-225* CK(CPK)-3718*
AlkPhos-116 Amylase-65 TotBili-0.8
[**2162-6-25**] 10:12AM BLOOD CK(CPK)-6058*
[**2162-6-25**] 02:04AM BLOOD ALT-71* AST-275* CK(CPK)-7772* AlkPhos-72
Amylase-85 TotBili-0.6
[**2162-6-24**] 10:15PM BLOOD CK(CPK)-8790*
[**2162-6-23**] 06:00PM BLOOD ALT-33 AST-69* LD(LDH)-459* CK(CPK)-364*
AlkPhos-64 Amylase-152* TotBili-1.2
[**2162-7-2**] 02:04AM BLOOD Lipase-34
[**2162-6-29**] 02:22AM BLOOD Lipase-57
[**2162-6-27**] 05:24AM BLOOD Lipase-91*
[**2162-6-26**] 03:28AM BLOOD Lipase-65*
[**2162-6-25**] 02:04AM BLOOD Lipase-64*
[**2162-6-24**] 05:38PM BLOOD Lipase-96*
[**2162-7-14**] 06:50AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.4*
[**2162-7-13**] 06:50AM BLOOD Calcium-7.6* Phos-4.5 Mg-1.7
[**2162-7-12**] 08:05AM BLOOD Calcium-7.8* Phos-5.8* Mg-2.4
[**2162-7-1**] 09:30AM BLOOD Calcium-8.3* Phos-2.4*
[**2162-6-30**] 01:19AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.3
[**2162-6-29**] 02:50PM BLOOD Calcium-8.0* Phos-1.6* Mg-2.2
[**2162-6-24**] 02:08AM BLOOD Albumin-2.5* Calcium-6.7* Phos-3.4
Mg-5.4*
[**2162-6-23**] 06:00PM BLOOD Albumin-2.1* Calcium-6.0* Phos-2.9
Mg-4.0* Iron-65 Cholest-80
[**2162-6-23**] 06:00PM BLOOD calTIBC-148* VitB12-337 Folate-7.5
Ferritn-1849* TRF-114*
[**2162-7-8**] 06:58AM BLOOD Vanco-19.2
[**2162-6-26**] 07:32AM BLOOD Vanco-25.3*
[**2162-7-1**] 09:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2162-7-6**] 09:13PM BLOOD Type-ART pO2-120* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
[**2162-7-6**] 07:38PM BLOOD Type-ART pO2-113* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2162-6-24**] 02:25AM BLOOD Type-MIX pO2-59* pCO2-37 pH-7.37
calTCO2-22 Base XS--3 Comment-GREEN TOP
[**2162-6-24**] 02:09AM BLOOD Type-ART pO2-89 pCO2-32* pH-7.42
calTCO2-21 Base XS--2
[**2162-6-23**] 07:34PM BLOOD Type-ART Temp-36.7 Rates-/16 Tidal V-500
PEEP-5 FiO2-100 pO2-122* pCO2-23* pH-7.32* calTCO2-12* Base
XS--12 AADO2-591 REQ O2-94 Intubat-INTUBATED Vent-CONTROLLED
[**2162-7-6**] 01:59AM BLOOD Lactate-1.0
[**2162-7-5**] 01:37AM BLOOD Glucose-95 Lactate-1.0
[**2162-7-4**] 02:17AM BLOOD Glucose-108* Lactate-0.8
-
-
IMAGING:
[**6-23**] CXR: ETT in place. NGT to be advanced
[**6-23**] NC Head CT: No intracranial process
[**6-23**]: Abd/ Pelvis CT w/o contrast: Fat stranding surrounding the
tail of the pancreas, with thickening and stranding of the left
anterior pararenal fascia, most compatible with pancreatitis.
Bilateral nephograms, concerning for acute renal failure,
although there is some continued excretion into the ureters.
Trace free fluid within the abdomen. No loculated collections
seen. NGT coiled within the stomach. Further assessment limited
due to lack of IV contrast.
[**6-23**] CXR: Low lung volumes, ETT 1.2 cm above carina, RIJ tip in
RA
[**6-24**] TTE: mild symmetric LVH. LV cavity unusually small. Focal
wall motion abnormality cannot be fully excluded. LVEF
low-normal(50-55%). Trace AI. Trivial MR.
[**6-25**]: EEG =No ictal activity, background activity was slow and
suppressed suggesting moderate to severe encephalopathy
[**6-28**] CXR= ETT 7cm above carina
[**6-28**] AXR= Configuration of Dobbhoff feeding tube compatible with
positioning in the distal duodenum. Nasogastric tube terminates
in the stomach. Bilateral pleural effusions are noted.
[**6-30**] CT A/P: Diffuse inflammatory stranding, trace fluid w/o
drainable collections. Areas of necrosis in panc head and tail.
[**7-1**] CXR: No evidence of interval changes.
[**7-2**] KUB: Gastric and Dobbhoff tubes in appropriate positions
[**7-4**] CXR: There is no new infiltrate
[**7-5**]: Unchanged, ? retrocardiac atelectasis.
[**7-6**] IR: Uncomplicated placement of a double-lumen tunneled
hemodialysis catheter through the left internal jugular venous
approach
.
Brief Hospital Course:
The patient was admitted to ICU on [**6-23**]: Overall pt was admitted
for sepsis secondary to pancreaitits with renal failure,
seizures and abdominal compartment syndrome. Seizures EEk--
treated with Keppra. Renal failurelast HD [**4-10**]. Electrolytes
stable wnl, BUN, Creatin normalizing, thought to be secondary to
sepsis and ATN which ultimately resolved (followed by
nephrology) and surgery for abdominal syndrome. Pancreatitis
also resolved (amylase lipse wnl, liver enzymes also trending to
wnl).
ICU events:
EVENTS:
[**6-24**]: Decompressive laparotomy,Transferred to TICU
[**6-25**]: Seen by renal, plan dialysis tomorrow. Access planned
first thing in AM pre-dialysis.
[**6-26**]: CVVH started. Hemodynamically stable. HIT sent. Vanc
dosing adjusted.
[**6-27**]: Vanc/Zosyn d/c'd, increased CVHHD rate to remove 150
cc/hour
[**6-28**]: To OR for partial closure/DHT in duodenum. Postop bladder
P 22. ETT advanced 2cm. TFs Nutren 2.0@15 per trauma. PIPs
improved 40s->35. CVVHD circuit clot per Nsg->estimate patient
lost up to 200cc blood. Renal CVVHD goal neg 150cc/h. Tachy
100s, metop IV. Brief desat w/coughing, thick ETT sputum
suctioned, improved.
[**6-29**]: Vanc/Levo/Flagyl resumed for WBC 24.6. CVVHD stopped, line
removed. Will start HD in AM.
[**6-30**]: HD line placed, CT A/P, intermittant dialysis c/ 2.5 L
removed
[**7-1**]: IHD neg 3L. Keppra dosed for IHD. Vanc trough 19.4. Aline
replaced. To OR for abdominal closure, peaks 31. Midaz/Fent gtts
weaned to prn.
[**7-2**]: TF still held. HD planned for Saturday. Insulin gtt off,
NPH 10'' and RISS started.
[**7-3**]: Dialysis with 3L neg. Versed off. On dex. Weaned to [**11-19**].
Fluconazole added. Mucus plugging episode c/ tachypnea and
hypoxia, back on CMV.
[**7-4**]: Bronched/BAL with removal of mucus plugs. No TFs. Needs
tunneled line monday then ?SBT/extubation. ?pulling on ETT ON,
CXR to reconfirm position.
[**7-5**]: fever pan cultureed, tunneled line for tomorrow, extuabte
then. Nephro tf started.
[**7-6**]: Fluc dcd, extubated
[**7-7**]: vanco, levo, flagyl d/c;d per ID. Passed S/S- clears.
Creon started for diarrhea. -2L dialysis. Standing PO lopressor.
[**7-8**]: Last HD, pt was transfered to floor
[**7-9**]: Pt on regular renal diet, worked with PT
[**7-10**]: diarrhea (likely [**3-16**] pancreatitis) c-dff neg, WBC 16
[**7-11**]: retal tube removed
[**7-13**]: remove HD catheter, WBC 11.6, pt afebrile, workign with PT,
reg diet
6:2 discharge in stable condition to rehab
MICRO:
[**6-23**] LP - 2+ PMNs, 2900 RBCs (in 4th tube, +xanthochromia),
Final neg organ
Urine - NG
[**6-23**] cdiff neg
[**6-23**] blood cx - neg
[**6-24**] blood cx - neg
[**6-24**] Stool - pan-negative
[**6-24**] peritoneal fluid NG
[**6-28**] blood cx -neg
[**6-28**] blood cx -neg
[**6-29**] sputum: neg
[**6-28**] rectal swab grew VANCOMYCIN RESISTANT ENTEROCOCCUS
[**6-29**] stool: neg
[**6-29**] sputum: ng
[**6-29**] catheter tip: NG
[**6-29**] stool: Cdiff neg
[**7-4**] BAL,cx: NG
[**7-5**] Sputum: NGF
[**7-5**] Ucx:NGF
[**7-5**] MRSA screen negative
[**7-6**] Bl Cx: P
[**7-6**] CVL tip: NG
-
Neuro: Pt has history of one prior seiure 3 yrs ago, known area
of encephalomalacia and possibly arachnoid cyst L superior
frontal involving the cortex, HTN. Seizure at OSH was
prolonged GTC but duration not clear (through ativan 12mg
andfosphenytoin 1g) then persistent rythmic chewing on arrival
to our ED. He remained on EEG for > 48hrs with no seizure
activity. Etiology or seizures unclear ([**Name2 (NI) **] withdrawl vs
other). Pt was placed on Keppra 1g/day and extra 500mg after
each HD. Neurology recommends MRI of head when feasible given
the presentation with
prolonged seizure and follow up.
-
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary:
GI/GU/FEN: initialy patient was made NPO with IV fluids. Pt
abdmon was closed on [**7-1**]. 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. pt had signigicant diarrhea thought to be secondary
to pancreatitis, c- diff negative.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Pt was treated with
antibiotics Vanc and Zosyn which were d/c on [**6-27**]. no clear
organism was identified as source of infection. Pt WBC trended
down off of antibiotcs and pt was afebrile at discharge.
Skin: pt had significant erythema especially on the buttox
bilaterally. Intially thought to be secondary to diarrhea.
creams were applied, rectal tube was placed for dirrhea.
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, working with physical therapy, voiding, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
CURRENT MEDICATIONS:
Keppra
Atenolol
Chlorthalidone
Prilosec
Methadone 40 mg Tab
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 31006**] of [**Location (un) **]
Discharge Diagnosis:
sepsis secondary to pancreatitis, urosepsis, seizures
Discharge Condition:
alert and oriented, tolerating regular diet, making good urine,
electrolytes stable, no seizures since early admision, working
with physical therapy.
Discharge Instructions:
You are recovering from pancreatitis, severe systemic infection,
seizures and renal failure. You need to have your labs drawn
every day or every other day at rehab and electrolytes followed
to be sure that your kidney function continues to improve.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*Any new signs of seizure activity, including lip smaking,
twitching, change in mental status, fainting, shaking.
*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 have decrease in urination. You experience burning when you
urinate, have blood in your urine, or experience a discharge.
*Your pain in not improving. Call or return immediately if your
pain is getting worse or changes location or moving to your
chest or back.
*You have shaking chills, or fever greater than 101.5 degrees.
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-21**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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:
Call Dr. [**First Name (STitle) **] in neurology or your local neurologist for follow
up for seizures in [**2-13**] weeks
PCP for history of renal failure or local nephrologist or Dr.
[**Last Name (STitle) 9125**] ad [**Hospital1 18**] if your electrolytes are not improving or you
are not making urine.
General surgeon Dr. [**Last Name (STitle) **] to follow your abdmoninal incision.
Follow up in [**2-13**] weeks. Call [**Telephone/Fax (1) 600**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"745.5",
"112.0",
"599.0",
"728.88",
"303.90",
"729.73",
"272.4",
"305.1",
"287.5",
"696.1",
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"577.0",
"348.39",
"289.89",
"530.81",
"584.5",
"276.4",
"278.00",
"345.3",
"038.9",
"785.52",
"V85.38",
"995.92",
"348.0",
"518.81",
"276.8",
"401.9",
"285.29",
"E878.1",
"996.73",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"03.31",
"96.6",
"33.24",
"54.62",
"96.72",
"46.75",
"54.11",
"38.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16080, 16152
|
10640, 15948
|
318, 493
|
16250, 16402
|
2460, 9043
|
18763, 19345
|
2124, 2320
|
16173, 16229
|
15974, 15974
|
16426, 18231
|
18247, 18740
|
1756, 1796
|
2335, 2441
|
224, 280
|
15995, 16057
|
521, 1360
|
9052, 10617
|
1382, 1733
|
1812, 2108
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,511
| 141,297
|
43282
|
Discharge summary
|
report
|
Admission Date: [**2146-8-20**] Discharge Date: [**2146-8-24**]
Service: MEDICINE
Allergies:
Morphine / Mirtazapine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 85 year old man with hx of CAD s/p MI and
CABG, biV-ICD, blindness, presents from [**Hospital1 100**] Senior Life after
developing chest pain and ICD shocks over the past week. The
history was obtained with the assistance of a Russian
translator. The patient states that he first felt the shock
about a week ago. Of note, per EMS, his potassium on the day
prior to admission was 2.8 and treated with 60 mEq of KCl.
According to the referred information from the [**Hospital1 100**] Senior
Life, a cardiology consult was requested on [**2146-8-1**] for
defibrillator charge. Currently the patient feels well. He has
no active chest pain or shortness of breath. He has no abd pain
or dysuria.
.
Upon arrival to the ED his initial vital signs were 98 74 112/74
16 92%RA. He was noted to be in VT and was paced out of it. A
second episode of VT was terminated with ICD discharge. His
potassium was noted to be low and was repleted. He was bolused
with amiodarone and transfered to the CCU.
.
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:
Coronary artery disease s/p CABG, biV ICD done in [**2142**]
(previously followed at [**Hospital3 **])
atrial fibrillation (not anticoagulated)
legally blind secondary to glaucoma
s/p left BKA (traumatic from WWII)
liver cysts
osteoarthritis
depression/anxiety
BPH s/p prostatectomy
hx of PPD+
chronic low back pain (DJD)
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. unknown family
history. The patient is a former oncology surgeon. 1 daughter
and grand-daughter in [**Name (NI) 86**].
Family History:
none
Physical Exam:
VS: T 98.1, BP 106/76, HR 92, RR 18-37, O2 98% on 2L
Gen: elderly male in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant but speaking in loud full Russian
sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6cm with patient flat.
CV: PMI located in 5th intercostal space, midclavicular line. LV
heave. RR, normal S1, S2. No S4, no S3.
Chest: sternotomy scar, No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: mild Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. s/p left BKA.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit
Pertinent Results:
[**2146-8-20**] 11:30AM BLOOD Glucose-141* UreaN-30* Creat-1.2 Na-136
K-3.0* Cl-95* HCO3-28 AnGap-16
[**2146-8-20**] 06:22PM BLOOD Calcium-9.8 Phos-1.5*# Mg-2.1
[**2146-8-20**] 11:30AM BLOOD WBC-12.0* RBC-5.29 Hgb-15.5 Hct-44.7
MCV-85 MCH-29.3 MCHC-34.6 RDW-15.1 Plt Ct-200
.
[**2146-8-24**] 05:30AM BLOOD Glucose-127* UreaN-32* Creat-1.1 Na-136
K-4.1 Cl-100 HCO3-27 AnGap-13
[**2146-8-24**] 05:30AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.4
[**2146-8-24**] 05:30AM BLOOD WBC-10.6 RBC-5.19 Hgb-15.1 Hct-44.1
MCV-85 MCH-29.2 MCHC-34.3 RDW-15.1 Plt Ct-190
.
[**2146-8-20**] 11:30AM BLOOD cTropnT-0.03*
[**2146-8-20**] 06:22PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2146-8-21**] 03:48AM BLOOD CK-MB-5 cTropnT-0.04*
.
[**2146-8-23**] 05:15AM BLOOD TSH-0.39
[**2146-8-23**] 05:15AM BLOOD Free T4-1.6
.
[**2146-8-23**] 05:15AM BLOOD ALT-23 AST-21 AlkPhos-85 TotBili-3.8*
.
Transthoracic Echo [**2146-8-22**]: The left atrium is markedly dilated.
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with severe hypokinesis of nearly all
segments. The estimated cardiac index is depressed
(<2.0L/min/m2). No intraventricular thrombus is seen. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be quantified. There is no
pericardial effusion.
IMPRESSION: Moderate left ventricular cavity enlargement with
extensive regional systolic dysfunction and depressed cardiac
index c/w multivessel CAD or other diffuse process (LVEF 20%).
Right ventricular cavity enlargement with free wall hypokinesis.
Moderate mitral regurgitation. Dilated thoracic aorta.
Brief Hospital Course:
In brief, the patient is an 85 year old man with history of
ischemic cardiomyopathy s/p CABG and [**Hospital1 **]-v ICD implantation
presenting for evaluation of ICD discharges.
.
Ventricular tachycardia: Mr. [**Known lastname **] is a 85 year old man with hx
of CAD s/p MI and CABG, biV-ICD, blindness, who presented from
[**Hospital1 100**] Senior Life after experiencing chest pain and ICD shocks
over the past week. After interrogating the pacer it was found
that the patient was having appropriate ICD ATP activity
followed by appropriate shocks since mid-[**Month (only) **]. According to the
rehab center, the patient had been experiencing diarrha which
was likely contributing to his electrolyte abnormalities
(hypokalemia). The patient was ruled out for MI by negative
cardiac enzymes. The care team attempted to suppress VT to
prevent future shocks and initiated medical therapy first with
Amiodarone. The patient continued to have episodes of
antitachycardial pacing with the ICD firing, and required two
additional doses of an amiodarone bolus of 150 mg in order to
control the rhythm. He was monitored on telemetry to rule out
any additional dysrrhythmic episodes. After day 1 of admission
the patient did not have any additional rhythm abnormalities
causing the ICD to fire. Pt will need to have potassium < 4 and
magnesium < 2 repleted to prevent dysrrhythmia. Baseline TFTs
were nl, LFTs were significant for elevated total bilirubin, and
full PFTs will be checked within 1-2 weeks at Rehab.
.
CAD: The patient was continued on aspirin, a statin, and a
beta-blocker for their cardioprotective effects and had no
evidence of pump failure on exam. The patient was started on a
low-dose ACE-I for systolic heart failure (EF 20%) on echo with
the added benefit of potassium retention. The patient was also
continued on lasix and spironolactone, the latter for its
potassium-sparing effects. His potassium and renal function on
his new medication regimen will be followed over the next 8
days.
.
Anxiety: The patient appears markedly anxious about being in the
hospital likely due to the language barrier, hearing
impairments, and visual impairments. His home doses of
psychotropic medications (ativan/effexor) were continued and
frequent telephone calls were made to facilitate Russian
interpretation. His family was also [**Name (NI) 653**], but unable to
visit the hospital as they were out of town.
.
Hyperbilirubinemia: LFTs were drawn to evaluate for amiodarone
toxicity. Total bili was elevated at 3.8 with no prior labs
available for comparison. Fractionated bilis were pending on
discharge. All other labs were wnl and patient without
abdominal pain. Patient will have LFTs redrawn on [**8-25**]; to be
followed up by [**Hospital 100**] Rehab physician.
.
Code Status: DNR/DNI
Medications on Admission:
Colace 100 mg [**Hospital1 **]
Miralax 1pkt daily prn
Ativan 0.5 mg q4prn
Ativan 0.5 mg [**Hospital1 **]
Nitroglycerin 0.4 mg prn
Metoprolol 12.5 mg [**Hospital1 **]
Lasix 80 mg daily
Trazodone 25 mg qhs:prn
Benadryl 25mg qhs
Metolazone 2.5 mg qWed/Sat
Acetaminophen 325 mg TID
Imdur 120 mg daily
Lidoderm patch daily
Aspirin 81 mg daily
Brimodine drops [**Hospital1 **]
Trusopt [**Hospital1 **]
Eucerin qhs
Xalatan 1 drop qhs
Milk of magnesium 30 cc daily:prn
Zocor 20 mg qhs
Effexor 75 mg daily
Discharge Medications:
1. PFT
Please schedule patient for full PFTs within 1-2 weeks. Forward
result to [**Hospital 100**] Rehab staff physician.
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
11. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days.
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times
a day for 3 weeks: to start after completing 400 mg twice daily
for week.
19. Amiodarone 300 mg Tablet Sig: One (1) Tablet PO once a day:
to start after completing 3 weeks of 3x/day dosing.
20. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
22. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day as needed for K < 4.
23. Outpatient Lab Work
Please draw the following lab test every 2 days for 8 days:
Potassium, Cr. Forward the results to the rehab staff
physicians.
24. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Ventricular tachycardia s/p ICD discharge
Hypokalemia
Ischemic cardiomyopathy
.
Secondary:
Chronic systolic congestive heart failure (EF 20%)
Discharge Condition:
Stable. Tolerating oral medication and nutrition.
Discharge Instructions:
You have been evaluated and treated for a heart arrhythmia.
This was likely worsened by low potassium in your blood. You
were started on a new medication to keep the heart rhythm
normal. The pacemaker was working appropriately.
Please take your medication as prescribed.
New medications include:
Amiodarone - please take according to recommended schedule
Spironolactone - please take daily
Lisinopril - please take daily
Potassium
Please attend recomended follow-up appointments. Please weigh
daily and report increase of > 3 pounds in 1 day or 6 pounds in
3 days to PCP
If you experience any new or concerning symptoms such as chest
pain, shortness of breath, or bleeding; please seek medical
attention.
Followup Instructions:
Primary Care Physician: [**Name10 (NameIs) 357**] have the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab
evaluate you within 1 week.
.
Cardiology Device Clinic: [**Hospital Ward Name 23**] [**Location (un) **] Date/Time:[**2146-9-2**]
10:00 Phone:[**Telephone/Fax (1) 59**]
.
Cardiology Clinic: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital Ward Name 23**] [**Location (un) **]
Date/Time:[**2146-9-2**] 10:20 Phone:[**Telephone/Fax (1) 285**]
|
[
"715.90",
"573.8",
"414.00",
"276.8",
"787.91",
"428.22",
"427.31",
"441.2",
"V49.75",
"300.4",
"428.0",
"V45.81",
"412",
"424.0",
"V45.02",
"365.9",
"414.8",
"427.1",
"782.4",
"369.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10934, 11000
|
5326, 8141
|
240, 247
|
11195, 11247
|
3026, 5303
|
12005, 12511
|
2073, 2079
|
8688, 10911
|
11021, 11174
|
8167, 8665
|
11271, 11982
|
2094, 3007
|
190, 202
|
275, 1466
|
1488, 1812
|
1828, 2057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,999
| 189,252
|
51353
|
Discharge summary
|
report
|
Admission Date: [**2180-7-24**] Discharge Date: [**2180-7-29**]
Date of Birth: [**2107-5-20**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
[**Doctor First Name **]
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
HPI: 73 female with CAD s/p LAD stent [**72**], DM2, hyperlipidemia,
CRI, metastatic liposarcoma of thigh who presented with L sided
CP constant nonradiating and s/p fall out of bed landing on R
side. Pt EKG in EW showed STE in leads I, AVL, V2-V5. Pt sent to
cath which revealed right dominant, LMCA-mild distal taper; LAD
- previous stent widely patent; Mid LAD 90% lesion involving
proximal portion of the bifuracation with the D2, distal LAD
diffusely diseased. Proximal LCX-discreate 60% lesion. RCA
without lesion. LAD and LCX treated with balloon PTCA and
stenting (Cypher). Final LAD residual was 10% with normal flow
and LCX no residual with normal flow. Pt left cath CP free,
stable. Pt hemodynamics revealed RA=8, RV=42/10, PAP=42/20(27),
PCPW=21, LV=123/23, Ao=123/68(87) PAsat 55%, CI=3. Previous echo
on [**5-2**] showed EF>55%
Past Medical History:
Coronary artery disease s/p MI, PCI to LAD ([**2172**])
L thigh liposarcoma s/p radiation, metastases to lungs
DM
hypercholesterolemia
CRI
Chest/Back pain from metastases
colonic polyp s/p partial colectomy
GERD
s/p CCY, partial TAH
Social History:
Married with one son. former librarian. no tobacco, EtOH, IVDU.
+ sexually active. Lives at home with her husband.
Family History:
Mother with DM, HTN
Brother with [**Name2 (NI) 499**] CA
Physical Exam:
T: afebrile HR 90 BP 118/65
Gen: Pt in discomfort due to pain in leg
Heent: PERRLA, EOMI, oral mucosa clear
Neck: no JVD
Lungs: CTA B/L
CV: RRR, S1/S2 no murmur, no carotid bruits
Abd: NABS NTND
Groin: R femoral cath site, no bruit or hematoma
Ext: no edema
Pertinent Results:
[**2180-7-25**] 12:00AM CK(CPK)-265*
[**2180-7-25**] 12:00AM CK-MB-25* MB INDX-9.4* cTropnT-3.55*
[**2180-7-25**] 12:00AM WBC-7.0 RBC-3.94* HGB-9.3* HCT-30.9* MCV-79*
MCH-23.7* MCHC-30.2* RDW-15.7*
[**2180-7-25**] 12:00AM PLT COUNT-234
[**2180-7-24**] 03:40PM POTASSIUM-4.9
[**2180-7-24**] 03:40PM CK(CPK)-548*
[**2180-7-24**] 03:40PM CK-MB-59* MB INDX-10.8*
[**2180-7-24**] 03:40PM PLT COUNT-213
[**2180-7-24**] 10:11AM PLT COUNT-202
[**2180-7-24**] 08:28AM TYPE-ART O2 FLOW-3 PO2-75* PCO2-40 PH-7.37
TOTAL CO2-24 BASE XS--1 INTUBATED-INTUBATED COMMENTS-NASAL [**Last Name (un) 154**]
[**2180-7-24**] 08:28AM HGB-8.1* calcHCT-24 O2 SAT-95
[**2180-7-24**] 07:11AM PT-12.5 PTT-22.5 INR(PT)-1.0
[**2180-7-24**] 06:50AM GLUCOSE-172* UREA N-36* CREAT-1.1 SODIUM-139
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2180-7-24**] 06:50AM CK(CPK)-20*
[**2180-7-24**] 06:50AM CK-MB-NotDone
[**2180-7-24**] 06:50AM WBC-7.2# RBC-3.67* HGB-8.5* HCT-28.2* MCV-77*
MCH-23.3* MCHC-30.4* RDW-15.5
[**2180-7-24**] 06:50AM CALCIUM-9.7 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2180-7-24**] 06:50AM NEUTS-60.5 LYMPHS-26.0 MONOS-5.7 EOS-6.8*
BASOS-1.1
[**2180-7-24**] 06:50AM HYPOCHROM-3+ MICROCYT-1+
[**2180-7-24**] 06:50AM PLT COUNT-176
Echo [**2180-7-24**]
1.The left atrium is normal in size.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
severely
depressed. Resting regional wall motion abnormalities include
apical, septal,
anterior and mid and distal lateral akinesis.
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 5.The mitral valve
leaflets are
structurally normal. Trivial mitral regurgitation is seen.
6.There is no pericardial effusion.
CAth [**2180-7-24**] Cardiology Report C.CATH Study Date of [**2180-7-24**]
BRIEF HISTORY: Patient is a 73 year old woman with metastatic
liposarcoma, type 2 DM, HTN and high cholesterol. She has known
CAD and
had an LAD stent placed on [**2173-10-31**]. The patient presented
today with
chest and shoulder pain and was found to have ST elevations in
leads I
and AVL.
INDICATIONS FOR CATHETERIZATION:
STEMI
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter,
advanced
to the left ventricle through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Percutaneous coronary revascularization of an additional vessel
was
performed using placement of drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.71 m2
HEMOGLOBIN: 8.5 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 10/8/7
RIGHT VENTRICLE {s/ed} 42/10
PULMONARY ARTERY {s/d/m} 42/20/27
PULMONARY WEDGE {a/v/m} 23/25/21
LEFT VENTRICLE {s/ed} 123/23
AORTA {s/d/m} 123/68/87
**CARDIAC OUTPUT
HEART RATE {beats/min} 90
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 41
CARD. OP/IND FICK {l/mn/m2} 5.2/3.1
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1231
PULMONARY VASC. RESISTANCE 92
**% SATURATION DATA (NL)
PA MAIN 55
AO 91
**ARTERIAL BLOOD GAS
pO2 75
pCO2 40
pH 7.37
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 90
8) DISTAL LAD DIFFUSELY DISEASED
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 DIFFUSELY DISEASED
12) PROXIMAL CX DISCRETE 60
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
**PTCA RESULTS
LAD CX
**BASELINE
STENOSIS PRE-PTCA [**65**] 60
**TECHNIQUE
PTCA SEQUENCE 1 1
GUIDING CATH 8FXB3.5 8FXB3.5
GUIDEWIRES FORTE FORTE
INITIAL BALLOON (mm) 2.0 3.0
FINAL BALLOON (mm) 2.75 3.75
# INFLATIONS 3 2
MAX PRESSURE (PSI) 310 310
**RESULT
STENOSIS POST-PTCA [**85**] 10
SUCCESS? (Y/N) Y Y
PTCA COMMENTS: Initial angiography revealed a 90% mid LAD
stenosis
involving the proximal portion with the bifurcation to the D2
and a hazy
lesion of the proximal LXC. We decided to treat both these
lesions with
baloon PTCA and stenting. The patient was already on integrilin.
A 8
French XB 3.5 guide provided good support. A PT [**Name (NI) 9165**] wire was
advanced to the the Diagonal and a Forte wire in the distal LAD
without
difficulty. The lesion was predilated with a 2.0x15mm Voyager
baloon
inflated at 14 atms. Then a 2.5x18 Cypher DES was deployed at 16
atms.
The stent was postdilated with a 2.75x15mm Maverixk baloon
inflated at
22 atms. Final angiography revealed 10% residual stenosis, no
dissection
and TIMI III flow.
We then turned our attention to the proximal LCX. The lesion
was
crossed with a Fortte wire without difficulty. A 3.0x13mm Cypher
DES was
deployed at 16 atms. The stent was then postdilated with a
3.75xx8mm
Quanrum Maverick baloon inflated at 22 atms. Final angiography
revealed
no resdiual stenosis, no dissection and TIMI III flow.
The patient left the lab chest pain free and in stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 53 minutes.
Arterial time = 49 minutes.
Fluoro time = 12.4 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 225 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 4000 units IV
Other medication:
Fentanyl 125mcg IV
Midazolam 1.5mg IV
Integrilin 6.2cc IV
Integrilin 11cc/h IV
TNG 100mcg IC
Plavix 600mg PO
Cardiac Cath Supplies Used:
.014 [**Company **], FORTE MS
.014 [**Name (NI) **], PT [**Name (NI) **], 300CM
2.0 GUIDANT, VOYAGER 15
2.75 [**Company **], QUANTUM MAVERICK, 15
3.75 [**Company **], QUANTUM MAVERICK, 8
8F CORDIS, XBLAD 3.5
200CC MALLINCRODT, OPTIRAY 200CC
2.5 CORDIS, CYPHER RX, 18
3.5 CORDIS, CYPHER RX, 13
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
two vessel CAD. The LMCA had a mild distal tapering but was
without
critical lesions. The previously placed LAD stent was widely
patent.
Beyond the stent there was a 90% mid LAD lesion. The remaining
LAD had
mild diffuse disease. The LCx had a 60% hazy proximal lesion.
The RCA
had no angiographically apparent disease.
2. Resting hemodynamics revealed elevated left sided filling
pressures,
pulmonaryy hypertension and a preserved cardiac output.
3. Left ventriculography was not performed.
4. Successful stenting of the mid LAD with a 2.5x18mm Cypher DES
postdilated to 2.75mm (See PTCA comments).
5. Successful stenting of the proximal LCX with a 3.0x13mm
Cypher [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7930**] to 3.75mm (See PTCA comments).-
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate to severe diastolic dysfunction.
3. Acute anterolateral MI treated with PCI/stenting of the mid
LAD using
Drug Eluting Stent.
4. Successful stenting of the proximal LCX using Drug Eluting
Stent.
Brief Hospital Course:
1) CAD - Pt sent to cath lab and had stent placed in LAD and
LCX. Started pt on ASA, Plavix, BB, ACEI, Lipitor, and
Integrillin. Integrillin stopped after 18 hours. Pt [**Name (NI) 30474**]
and ACEI were held after her blood pressure became low.
2) Poor EF - Pt had echo after cath which revealed ejection
fraction of 25-30%. Pt was started on [**Name (NI) 30474**] and ACEI, but
medication was held after pt became hypotensive.
3) Pain - Pt continued to have pain to her right hip, buttock
area throughout hospitalization. Pain service was consulted and
pt was first given oxycontin and IV morphine which was switched
to oxycontin and MSIR for breakthrough pain. Pt pain improved
somewhat while in hospital. Xray of right hip was done to r/o
fracture, xray came back negative.
4) Acute Renal Failure - Pt has h/o of chronic renal
insufficiency and after hospital day #4 pt Cre bumped up from
1.0 to 2.3 to 3.0. Pt ARF may have been contributed to dye load
as well as poor fluid intake. Pt was given fluids and Cre and
urine output monitored. Cr has decreased to 1.5 on the day of
discharge.
Medications on Admission:
Oxycontin 30 [**Hospital1 **]; MS-IR 15mg 1-2prn; ASA 325mg;
atenolol/chlorthalidone 100/25, Lipitor 10, Celebrex 100mg,
glipizide 5mg, lisinopril 40mg, protonix 40mg
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).
Disp:*30 Tablet(s)* Refills:*2*
3. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q2-3H
(every 2-3 hours) as needed for for breakthrough pain: Please
call your primary care physician for refill.
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO BID (2 times a day): Please
call your PCP for refill. .
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5 minutes x 3 prn as needed for chest pain: please
take one pill under your tongue [**Doctor First Name **] 5 minutes, do not exceed 3
pills. If continue to have chest pain call 911 or go to the
emergency room. .
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Anterior Myocardial Infarction
2. Diabetes type II
3. Hyperlipidemia
4. Dye nephrophathy
5. Liposarcoma
Discharge Condition:
Fair
Discharge Instructions:
Please follow up with PCP and Heme/Onc appointments. Please
follow up with cardiology appointment at scheduled date.
You are being treated with medications after your heart attack.
It is important that you continue to take Plavix and Asprin
everyday until you are told to stop by your cardiologist. Please
do not take Celebrex with Aspirin and Plavix.
Please take all medications as prescribed. Please consult your
primary care physician [**Last Name (NamePattern4) **] [**2180-8-1**] regarding whether you need to
resume your blood pressure medicines.
Please call your primary care physcian if you have increased
pain.
Please call 911 and go to the emergency room if you develop
persistent chest pain, difficulty breathing or other worrisome
symtpoms.
Followup Instructions:
Please call [**Telephone/Fax (1) 62**] to verify your appointment with
cardiology, Dr. [**Last Name (STitle) 1445**] on Septemeber 1, [**2179**] at 10 am. [**Hospital Ward Name 23**]
Center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2180-8-1**] 11:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-8-3**] 9:30
|
[
"197.0",
"410.01",
"272.4",
"V10.89",
"250.00",
"E947.8",
"414.01",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.05",
"37.23",
"36.07",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
12937, 12995
|
10085, 11190
|
316, 339
|
13146, 13152
|
1966, 4238
|
13957, 14532
|
1614, 1672
|
11407, 12914
|
13016, 13125
|
11216, 11384
|
9814, 10062
|
13176, 13934
|
1687, 1947
|
8030, 9797
|
4271, 8011
|
266, 278
|
367, 1210
|
1232, 1466
|
1482, 1598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,228
| 175,122
|
6730
|
Discharge summary
|
report
|
Admission Date: [**2161-12-24**] Discharge Date: [**2161-12-25**]
Date of Birth: [**2101-9-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Elective admission for R carotid stent/angioplasty
Major Surgical or Invasive Procedure:
R carotid angioplasty/stent
History of Present Illness:
60 yo male with hx of CAD s/p CABG in [**2159**], and hx of bilateral
carotid disease initially found during the pre-op workup for
CABG. Pt had [**Doctor First Name 3098**] stent in [**2159**] prior to CABG. He hever had a
TIA or any neurological symptoms. No weakness, numbness,
transient blindness, word finding difficulty, or gait
instability. Pt has not had any anginal like sx since CABG. Pt
had follow up carotid U/S in [**2161-5-16**] which showed right sided
stenosis of 80-99%, and left sided stenosis of 70-79% distal to
the stent. Pt has been followed by his neurologist and was
decided to pursue conservative measure at that time. He had
another carotid u/s on [**2161-12-1**] which showed again 80-89% [**Country **]
stenosis and 70-79% [**Doctor First Name 3098**] stenosis. CTA of the head and neck was
done which showed high grade stenosis at the [**Country **], and high
grade stenosis of the [**Doctor First Name 3098**] with concordant narrowing of the
stent. He denies ever having any neurological symtoms. Pt was
electively admitted for [**Country **] stent/angioplasty.
[**Last Name (NamePattern4) **]dical History:
HTN
Hyperlipidemia
CAD s/p CABG [**6-17**] (LIMA to LAD, SVG to OM1, SVG to ramus, SVG to
PDA) by Dr. [**Last Name (Prefixes) **]
Hernia repair
L thumb repair after laceration
Carotid dz s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent in [**6-17**]
Anxiety disorder
Social History:
Pt lives with hs wife and their dog. Has one adult daughter.
[**Name (NI) **] works as an insurance broker. He smokes socially (4
packs/month x 35 yrs), and drinks 1-2 drinks daily. Denies
illicit drug use.
Family History:
Father with stroke in 60's
Physical Exam:
VS: T 97.0 BP 139/79 HR 67 RR 16 O2sat 96% RA
GEN: Pleasant, well nourished, male lying in bed in NAD
HEENT: NC/AT, PERRL (3->2mm bilaterally), nl OP, neck supple, no
carotid bruits bilaterally, no JVD.
COR: RRR S1, S2, no murmurs/rubs/gallops
LUNGS: CTA anteriorly
ABD: +BS, soft, NTND, no guarding
EXT: no edema, R groin with no hematoma, no bruit. 2+ DP
bilaterally
NEURO: A+Ox3, CN III-XII intact, [**5-20**] strengths inall major
muscle groups. Quad not tested since pt post-cath. No obvious
higher cognitive fxn deficits.
Pertinent Results:
Cath:
Angiography demonstrated normal RCCA, the [**Country **] had a tubular 90%
lesion. The [**Country **] filled the ipsilateral ACA and MCA. The LCCA
was normal. The [**Doctor First Name 3098**] stent is patent with 50% stenosis. The [**Doctor First Name 3098**]
filled the ipsilateral ACA and MCA without evidence of cross
filling. Successful stenting of the [**Country **] with a [**6-23**] x 30 mm
tapered Acculink stent post dilated with a 4.5 x 20 mm highsail
balloon at 10 atms with no residual stenosis, no dissection and
normal flow.
Brief Hospital Course:
1)Carotid dz: Pt underwent successful [**Country **] stent with 6-8 taper
Acculink stent. [**Country **] [**Male First Name (un) **] a 90% tubular lesion. ICA filled the
ipsilateral ACA and MCA. LCCA was normal. The [**Doctor First Name 3098**] stent was
patent with 50% restenosis. Pt was continued on Plavix 75 mg po
qd. His BP was controlled with nitro gtt overnight. He resumed
his home meds of atenolol 100 mg po qd and Lisinopril 2.5 mg po
qd with adequate BP control post-stent.
2)CAD: Pt was continued on Atenolol 100 mg po qd, lisinopril 2.5
mg po qd, Lipitor 40 mg po [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg po qd.
3)HTN: Pt was temporarily BP controlled with nitro gtt. He was
continued on atenolol 100 mg po qd and lisinopril 2.5 mg po qd
with good BP control.
4)Hyperlipidemia: He was continued on Lipitor 40 mg po qd.
Medications on Admission:
[**First Name3 (LF) **] 325 mg po qd
Lisinopril 2.5 mg po qd
Plavix 75 mg po qd
Lipitor 40 mg po qd
Atenolol 100 mg po qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral carotid disease s/p [**Country **] stent
Discharge Condition:
Stable.
Discharge Instructions:
Patient was instructed to take all of the medications as
directed. Pt was instructed to seek medical attention if he
were to develop dizziness, headache, visual changes, weakness,
numbness, and any other concerning neurological symptoms. Pt
needs to follow up with Dr. [**First Name (STitle) **] with follow-up Doppler
Ultrasound. Pt should resume all of the home meds he did
before.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-2-23**] 10:30
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-2-23**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2162-2-23**] 1:00
Completed by:[**2161-12-25**]
|
[
"V45.81",
"274.9",
"433.10",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
4624, 4630
|
3231, 4088
|
325, 354
|
4725, 4734
|
2661, 3208
|
5169, 5679
|
2067, 2095
|
4260, 4601
|
4651, 4704
|
4114, 4237
|
4758, 5146
|
2110, 2642
|
235, 287
|
382, 1824
|
1840, 2051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,864
| 111,825
|
479
|
Discharge summary
|
report
|
Admission Date: [**2195-3-7**] Discharge Date: [**2195-3-11**]
Date of Birth: [**2148-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Abdominal pain, hypothermia
Major Surgical or Invasive Procedure:
1) Arterial line
2) Central venous line /femoral line
3) Patient continued his usual peritoneal dialysis sessions
History of Present Illness:
Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hepatitis B/C, ESRD
on peritoneal dialysis who presented to the ED with abdominal
pain, constipation and also feeling dizzy with lightheadedness.
Called the ambulance for these symptoms. Initial VS 91.1F
orally, HR 72, BP initially unmeasurable, RR 20 and 100% oxygen
saturation on room air. Exam with clear lungs, RRR, distended
abdomen which was soft and full. He refused a rectal exam. CT
was obtained given abdominal pain and preliminary read was
negative for any acute intrabdominal processes. Right femoral
line was placed with some difficulty due to scar tissue. BP
remained difficult to assess given severe vascular disease.
Repeat VS soon after presentation revealed temperature 96.1F,
75HR, BPs of 59/25-105/47, RR 12, and oxygen saturation was 100%
room air. Fingerstick glucose was 123. Patient had potassium
repleted with 40 mEq K in 1L NS, with 3 additional L NS. His
peritoneal dialysate was sampled and did not reveal evidence of
infection. Denies ever having abdominal pain, but more a sense
of constipation and "fullness". Systolic blood pressures in ED
ranged 74--> 68 --> 90 --> 105. By time of transfer from ED to
inpatient setting he was saturating well on RA, eating and
requesting more food. Given patient's initial presentation of
appearing very unwell, was sent to the ICU for closer
monitoring.
Upon arrival in the ICU, denied any complaints except a sense of
constipation in his abdomen. Upon ROS, patient denied associated
nausea, vomiting, fevers, chills, dizziness,dysuria, rash,
dyspnea. Confirms he had decreased oral intake for 4 days in the
setting of his constipation and has taken an unknown medication
for his constipation in the past. Also with partial blindness
which is his baseline. States he had one episode of chest pain
on day before admission but this improved with sugar as provided
in the ED. Denies any exertional component or pain radiation.
Past Medical History:
HIV
Hepatitis B
Venous capillary sepsis
Venous thromboembolism
Depressive disorder & nervousness
CMV infection
History of tuberculosis
ESRD [**1-12**] HIV - on peritoneal dialysis, followed at [**Last Name (un) 4029**] in
[**Location (un) **] on [**State **] St.
Chronic constipation - on senna PRN
h/o XRT at MEEI for SCC in his left ear
Hypertension
Syphilis in [**Month (only) **] l993. CSF showed lymphocytosis. The
patient was treated with intravenous penicillin for ten days.
Hepatitis C antibody positive
SURGICAL HISTORY:
PD catheter placement [**2190**], numerous HD catheters and AV
fistulas; all failed
Social History:
Tobacco [**12-12**] PPDx 20 years, no ETOH, unemployed and lives alone
in an apartment and he has CMA nursing help at home.
Family History:
Noncontributory
Physical Exam:
T: unable to obtain initially, BP: 89/64, PR: 67, RR: 13, O2:
100/RA
General: Alert, oriented, no acute distress; able to relay
history in a coherent fashion
HEENT: Sclera anicteric, MM mildly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds but no
appreciable murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding; bandaged PD wound in
LLQ
Ext: Warm, nonpalpable distal pulses, no edema; R femoral groin
wound noted
Neuro: CN II-XII grossly intact; A&O x 3
Skin: Multiple excoriated lesions over entire body, slight
crusting; including arms, back
Pertinent Results:
ADMISSION LABS
[**2195-3-7**] 07:15PM LACTATE-0.9 K+-3.0*
[**2195-3-7**] 03:45PM ASCITES WBC-2* RBC-0 POLYS-8* LYMPHS-17*
MONOS-72* MESOTHELI-4*
[**2195-3-7**] 01:42PM LACTATE-3.0* K+-2.4*
[**2195-3-7**] 01:30PM GLUCOSE-93 UREA N-28* CREAT-10.0* SODIUM-137
POTASSIUM-2.3* CHLORIDE-94* TOTAL CO2-27 ANION GAP-18
[**2195-3-7**] 01:30PM estGFR-Using this
[**2195-3-7**] 01:30PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9
[**2195-3-7**] 01:30PM WBC-2.3* RBC-4.44* HGB-13.3* HCT-40.0 MCV-90
MCH-30.1 MCHC-33.3 RDW-17.8*
[**2195-3-7**] 01:30PM NEUTS-65 BANDS-0 LYMPHS-29 MONOS-3 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2195-3-7**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2195-3-7**] 01:30PM PLT SMR-LOW PLT COUNT-92*
[**2195-3-7**] 01:30PM PT-13.2 PTT-31.1 INR(PT)-1.1
[**2195-3-9**] BLOOD LABS /HIV CD COUNTS:
-WBC: 3.0
Lymph: 26
Abs-[**Last Name (un) **]: 780
CD3%: 78
Abs-CD3: 612
CD4%: 35
Abs-CD4: 273
CD8%: 42
Abs-CD8: 328
CD4/CD8: 0.8
ENDOCRINE STUDIES:
[**2195-3-8**] 06:04PM BLOOD Free T4-1.3
[**2195-3-9**] 04:32AM BLOOD TSH-3.6
[**2195-3-8**] 06:04PM BLOOD Cortsol-19.2
[**2195-3-11**] 05:29AM BLOOD Cortsol-17.5
.
IMAGING:
[**3-8**] CXR: IMPRESSION: AP chest reviewed in the absence of prior
chest radiographs: The patient has had resection of the medial
left clavicle, and a vascular graft follows the course of the
left subclavian and brachiocephalic veins to the SVC.
Mediastinal widening extends to the apices of the chest with
thickening of the pleura and may represent treated adenopathy.
Heart is mildly enlarged. Lower lungs clear. No pleural
effusion.
.
CT ABDOMEN /PELVIS:
IMPRESSION:
1. Cirrhosis with ascites.
2. Atrophic native kidneys wuth hyperdense cystic lesions in the
left kidney which do not qualify as simple cysts. These lesions
should be watched closly on follow-up exams.
3. PD catheter in place.
4. Probable emphysema at the lung bases.
[**3-11**] -CT HEAD WITHOUT CONTRAST:
1. No definite acute intracranial process.
2. Relatively symmetric, confluent low-attenuation in
bihemispheric
periventricular white matter, most likely representing chronic
microvascular
infarction, in a patient with these predisposing conditions;
there is no
evidence of acute vascular territorial infarction.
3. Extensive fluid-opacification involving the left mastoid air
cells, of
uncertain duration and clinical significance; this should be
closely
correlated clinically.
4. Prosthetic right globe with abnormal appearance to the left
globe, as
detailed above.
EKG: Sinus rhythm. P-R interval prolongation. Lateral ST-T wave
changes. Modest QTc interval prolongation.
MICROBIOLOGY:
Blood Cultures 3/28, [**3-8**] and [**3-9**], [**3-10**] all negative to date at
time of discharge
Peritoneal Fluid:
[**2195-3-7**] 3:45 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2195-3-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2195-3-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
DISCHARGE LABS:
[**2195-3-11**] 05:29AM BLOOD WBC-3.5* RBC-3.17* Hgb-9.7* Hct-28.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-18.8* Plt Ct-85*
[**2195-3-11**] 05:29AM BLOOD Neuts-68.3 Bands-0 Lymphs-25.6 Monos-3.6
Eos-2.2 Baso-0.4
[**2195-3-11**] 05:29AM BLOOD Plt Ct-85*
[**2195-3-11**] 05:29AM BLOOD Glucose-65* UreaN-29* Creat-9.5* Na-142
K-3.0* Cl-104 HCO3-28 AnGap-13
[**2195-3-11**] 05:29AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hep B/C, ESRD on
peritoneal dialysis who presented with abdominal pain x 1 day,
hypothermia, and hypotension which resolved status-post IVFs.
Brief MICU Course:
The patient was admitted to the MICU for close observation,
although his symptoms of abdominal pain had resolved. His blood
pressure did drop to as low as 60s systolic, and he received 2 L
NS, and was started on Levophed. He was cultured and covered
empirically with Vanco/Zosyn given the hypotension and this was
later narrowed to Zosyn alone. He was hypothermic to 92 degrees
rectally, and a Bair Hugger was applied. Peritoneal Dialysis was
attempted but terminated early given the hypotension. Blood
pressure readings were inconsistent so an a-line was placed.
Over the course of hospital day 1, the patient's hemodynamics
improved and the Levophed was weaned off. TSH and cortisol
levels were normal. Throughout this, the patient mentated well
and was A&Ox3. On Hospital Day 2 he was called out to the
regular medical floor from the ICU for ongoing monitoring.
Please see below for problem based summary after transfer to
general medical wards.
Continued course after transfer out of ICU to medical floor:
# Abdominal Discomfort: Continued to deny any active abdominal
pain after hospital day 2. Bloated from constipation on
admission but he had multiple bowel movements with relief of his
sense of "fullness" soon after admission. Oral intake improved
daily. Exam revealed a soft, NT abdomen. No noted organisms in
peritoneal culture; all cultures NTD thus far, finals pending.
Initially had elevated lactate, but this resolved. CT abdomen
essentially clear with exception of cirrhosis and ascites and
some kidney findings as [**Known lastname 4030**] below. Probably dehydration
from admitted poor PO intake promoted constipation. He was
monitored with serial abdominal exams. Aggressive bowel regimen
with Senna and lactulose given for regularity of bowel
movements.
.
# Hypothermia / Hypotension: Low blood pressures have
stabilized. Still unclear etiology, although likely from his
poor PO intake and some mild dehydration. Changes in body
temperature unlikely endocrinologic in nature as initial
cortisol and TSH were within normal limits, repeat a.m. cortisol
added on [**3-11**] and was also WNL. Some of his borderline low blood
pressure shifts may be due to small amount of volume changes
with dialysis treatments as well (although PD not HD). Initial
infectious workup labs/studies for concerns over looming
SIRS/sepsis picture have all been unremarkable to date. History
of HIV, HepC, HepB. Latest CD-4 count=273. Leukopenias initially
concerning for an acute infection but as he appeared markedly
more stable after IVFs and all culture data was unrevealing it
was felt hat his low blood cell counts were more likely due to
his HIV. Anuric so no urine studies collected. Trended
temperatures, improved after he was transferred to the medical
floor from the ICU. However, he is still having some more
intermittent low temperatures in the 93F range with oral
measures. He had a CT head without contrast on the morning of
[**3-11**] to rule out of any hypothamalmic masses/CVAs that may have
impacted his ability to self regulate body temperature. Head CT
showed no definite acute intracranial process, and relatively
symmetric, confluent low-attenuation in bihemispheric
periventricular white matter, most likely representing chronic
microvascular infarction. Otherwise, it is quite possible that
his body temperature is having fluctuations in the setting of
his 2L exchanges during peritoneal dialysis with resultant
cooling of underlying mesenteric venous bed. Patient's rectal
temperature taken on [**2195-3-11**] but was too low to register on
rectal thermometer which had a cut-off of 96F. Vitals today at
time of discharge included BPs 98-110/60-80s range, HR 70-100,
RR 18 and oxygen saturations at 100% room air. CXR unremarkable
for any acute new infiltrates or PNAs although some subtle
perihilar area changes should be followed up on a repeat CT/CXR
over the next 1-2 weeks time. At time of discharge several
cultures were also pending, will plan to follow-up final reports
and notify [**Hospital1 **] staff of any organisms/infections
identified.
.
# Leukopenia: Likely from his HIV history, appears to be a
chronic issue. Initial WBC with slight drop from baseline
however to 2.3; PMN 65%, now WBCs up to 3 range. Not
neutropenic currently. CD4 is 273. Trended daily CBC with
differential/ANC levels, remained stable. Continue Zosyn for
now; will complete 7 day course on [**2195-3-14**].
# ESRD: Continued peritoneal dialysate regimen with daily
exchanges. Euvolemic on exam now. Renal team followed while
inpatient. Anuric with his ESRD. Continued on Calcitriol 0.25mcg
daily, Sensipar 90mg daily, PhosLo TID, and Epogen. He will
resume his ongoing PD sessions on transfer. Last BUN/Cr was
29/9.5 respectively at time of discharge.
.
#Labile affect: Please note that Mr. [**Known lastname 122**] was refusing
multiple medications during his stay and missed a few doses of
his antibiotics and a few of his usual daily medications on
[**3-10**]. Also refused a P.M. peritoneal dialysis session on night
of [**3-10**] as well. Patient is alert and oriented x3 and seems to
have capacity so team felt he had right to refuse treatment but
made repeated efforts to discourage this behavior by reviewing
risks/benefits. Team was considering a psychiatry consult near
time of discharge as patient's refusal to collect vitals and
accept medications was counter to his effective management. He
has a noted PMH of depression and anxiety per records. He seemed
to perseverate on going back to [**Hospital1 **] and expressed that he
feels less anxious at [**Hospital1 **] as he has been cared for there in
past. He may benefit from formal psychiatric evaluation upon
return to [**Hospital1 **] if this behavior continues.
.
# Kidney cysts/masses: Please note that routine CT abdomen for
workup of abdominal pain showed atrophic native kidneys wuth
hyperdense cystic lesions in the left kidney which do not
qualify as simple cysts. These lesions should be watched closly
on follow-up exams and repeat CT recommended in 2 months.
.
# HIV: CD4 in [**2192-3-10**] was 27, now current CD4 count is up to
273. He was continued on outpatient Tenofovir 300mg once weekly.
Bactrim DS 1 tab MWF continued. As above, no new acute
infections identified. Will plan to follow-up on outstanding
final blood culture reports.
.
# Fluids, Electrolytes & Nutrition: Continued on his peritoneal
dialysis; hypokalemia trend noted so he was repleted as needed.
Given some magnesium repletion as well prior to discharge. Renal
diet provided, good appetite.
#Access: Femoral line was placed. Patient with very difficult
upper extremity access so team left access with femoral line in
place so that he could complete the additional 3 days of his
antibiotics. Line appears clean /dry/ intact. Also has left
abdominal catheter/peritoneal port for his ongoing peritoneal
dialysis sessions.
#Prophylaxis: He was continued on a PPI / Pneumoboots / bowel
regimen PRN
.
#Code Status: DNR/DNI confirmed on admission with patient.
.
.
Medications on Admission:
(per CMA service 1-[**Telephone/Fax (1) 4031**])
Bactrim DS 1 tab MWF
Epivir 25mg daily
Phoslo 667mg 3 tabs TID with meals
Tenofovir 300mg (qWeek per CMA service)
Zerit 15mg daily
Zyprexa 5mg QHS
Epogen 10000u SC Qweek
Omeprazole 20mg Qday
Calcitriol 0.25mcg daily
Sensipar 90mg daily
Senna 2 tabs QHS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
2. Lamivudine 100 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 3 days: please
complete on [**2195-3-14**] .
5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 1X/WEEK ([**Doctor First Name **]).
6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
11. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once
a week.
12. Stavudine 15 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
13. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day: with meals.
14. peritoneal dialysis instructions
Peritoneal Dialysis Orders:
4 exchanges/24hrs; 2.5% solution; 2L volume; 4 hr dwell time.
Please record daily weights, I/Os, effluent appearance daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Hypotension
Hypothermia
Constipation
.
Secondary:
HIV
Hepatitis B/C
End Stage Renal Disease
Discharge Condition:
Good. At time of discharge the patient had stable blood
pressures, and he had no residual complaints of abdominal pain.
Constipation had resolved and he was having regular bowel
movements.
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted with complaints of
lightheadedness, low blood pressures, low body temperatures
(hypothermia)and abdominal pains. A CT scan imaging study of
your abdomen showed no acute new abdominal issues to explain
this abdominal pain and your symptoms were likely due to your
constipation as you had not had a bowel movement in several
days. Once you had medication to help you have a bowel movement
you felt better. Multiple lab studies were done and there were
no infections found to explain your symptoms. The renal team was
called and helped to continue your usual peritoneal dialysis
sessions while you were here in the hospital.
.
Please follow-up with your primary doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
If you have any additional abdominal pains, fevers, low blood
pressures, feelings of dizziness, diarrhea, more constipation,
or any additional health concerns please call your primary
doctor or notify your covering medical staff at the [**Hospital **]
Hospital.
.
Medication Instructions:
Antibiotics for broad coverage were added to your daily regimen
for a planned 7 days of therapy. Please continue daily Zosyn as
prescribed up until [**2195-3-14**].
-Otherwise you can continue taking all of your usual medications
as previously prescribed.
-
Additional Notes/Instructions:
Please follow-up with your doctor for a repeat CT abdomen in 2
months to assess a left sided kidney cystic region that was
found on CT. This should be evaluated for any increase in size
or signs or concerning features with repeat imaging.
Followup Instructions:
Please call the infectious disease clinic and your primary care
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 4032**] to make a follow-up
appointment over the next 1-2 weeks time.
Completed by:[**2195-3-11**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,946
| 103,018
|
49738
|
Discharge summary
|
report
|
Admission Date: [**2184-1-29**] Discharge Date: [**2184-2-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
History was obtained from a friend who talks with her a few
times a week, but the last time he saw her was 4 years ago
(history was not obtained from her neighbor who found her), and
also from ED records.
.
84 F with unknown medical history, was found down tonight on her
kitchen floor by her neighbor. [**Name (NI) **] neighbor noticed that she had
been SOB and panting over the past few days, and he kept telling
her she had to go to a physician, [**Name10 (NameIs) 6643**] she refused. He was
walking by her [**Last Name (un) **] this afternoon and heard moaning. He
unlocked the door to her [**Last Name (un) **] and found her lying on the
kitchen floor, no blood or apparent trauma. She states that she
fell off the couch due to sudden weakness, no CP, no abd pain.
+back pain due to position in bed. Neighbor called 911 and
patient was brought to [**Hospital1 18**] ED.
.
In the ED, SBP was 60s, received 2L with BP still in 70s,
received 2 more L with little SBP improvement. Sats started
dropping to 85, so she was intubated for airway protection and
had LIJ central line placed. Norepinephrine was started and SBP
improved to 110s. T102 rectally. NGT put out 250 ml coffee
ground fluid, received 1 U RBC. UO 230 ml after 4 L IVF.
.
UA was positive, CXR shows LLL infiltrate. WBC 21, Bands 5. Hct
35.5. Lactate 4.1. INR 1.9. CK 1677, MB 21, Trop 0.03. CT chest
shows LLL infiltrate, aorta is mildly dilated but nonaneurysmal
with no dissection, large goiter, RML centrilobular nodules
suggestive of atypical Mycobacterial infection, large hiatal
hernia with intrathoracic stomach.
.
At baseline, the patient is independent, lives alone, walks with
a cane, pays a woman who does her shopping for her.
Past Medical History:
Goiter on R side of neck
L hip replacement
Hypertension
Social History:
Has no close relatives, is a private person. Never been married,
has no children. Used to work at [**Location 17448**] in unknown job.
Likes brandy before bed but unknown if has ETOH problem, doesn't
smoke, no illicit drugs. Lives alone in [**Last Name (un) **] [**Location (un) **]. Has a siamese cat, Frank, for the last 10 years.
Family History:
Unknown
Physical Exam:
VS: 100.8 / 116/65 / 103
99% on AC 550 pulling in 600 / 15 breathing 7 over vent at RR 22
/ 5 / 0.5
.
GEN: Sedated, arousable to voice and holding hand, looks
comfortable
HEENT: JVD 7 cm, no LAD, intubated, PERRL. 6x6 cm goiter, soft
and mobile in R central neck.
LUNGS: Coarse breath sounds, clear anteriorly
CHEST: Petechiae on upper chest, upper arms, in axillary areas
bl
HEART: 2/6 systolic flow murmur, no r/g
ABD: Soft, +BS, surgical scar RUQ, ND, NT
EXTR: No c/c/e, 2+ DP bl
NEURO: Withdraws from painful stimuli
SKIN: Petechiae as noted on chest/back
Pertinent Results:
CT chest:
IMPRESSION:
1. Within the limitations of a non-IV contrast examination, the
aorta is mildly dilated but non-aneurysmal with no secondary
evidence of dissection.
2. There is a large goiter. Correlate with physical exam and
thyroid
biochemical profile. If indicated, consider thyroid ultrasound
for further evaluation.
3. Likely small focus of evolving pneumonia or aspiration in the
lateral basal segment of the left lower lobe.
4. Centrilobular nodules in the right middle lobe suggestive of
atypical Mycobacterium infection (indolent and chronic).
5. Large hiatal hernia with resultant intrathoracic stomach.
.
CT C spine:
FINDINGS: There is no fracture. There is exaggeration of the
lordotic
curvature otherwise no malalignment noted. There is disc space
narrowing at C5-C6 and C6-C7 with small marginal osteophytes.
The _____ osteophytes favor the right lateral recess resulting
in bony neural foraminal encroachment. Endotracheal and
nasogastric tubes are evident. There is a large heterogeneous
thyroid, likely goiter. Otherwise, the prevertebral and other
soft tissues of the neck are unremarkable.
IMPRESSION: Degenerative disc disease as detailed above. No
acute traumatic findings.
.
CXR:
FINDINGS: There has been interval withdrawal of a left internal
jugular central venous catheter with tip now in the left
brachiocephalic vein. The remainder of the lines and tubes are
in unchanged position. Again seen is a large hiatal hernia with
an intrathoracic stomach. There is mild airspace opacity
adjacent to the left heart border. The remainder of the
examination remains unchanged.
IMPRESSION:
1. Interval withdrawal of left internal jugular central venous
catheter with
2. Mild airspace opacity adjacent to the left heart border.
.
[**2184-1-30**] Abdominal U/S:
.
[**2184-1-30**] CT abdomen/pelvia:
[**2184-1-29**] 03:10PM PLT SMR-LOW PLT COUNT-92*
[**2184-1-29**] 03:10PM NEUTS-94* BANDS-5 LYMPHS-1* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2184-1-29**] 03:10PM WBC-21.3* RBC-4.07* HGB-12.3 HCT-35.5* MCV-87
MCH-30.3 MCHC-34.8 RDW-15.6*
[**2184-1-29**] 03:10PM ETHANOL-NEG
[**2184-1-29**] 03:10PM CK-MB-21* MB INDX-1.3
[**2184-1-29**] 03:10PM cTropnT-0.03*
[**2184-1-29**] 03:10PM CK(CPK)-1677*
[**2184-1-30**] 12:25AM BLOOD CK-MB-32* MB Indx-0.9 cTropnT-0.05*
[**2184-1-30**] 11:33AM BLOOD CK-MB-16* MB Indx-0.8 cTropnT-0.03*
[**2184-1-30**] 12:25AM BLOOD ALT-65* AST-165* LD(LDH)-542*
CK(CPK)-3747* AlkPhos-221* Amylase-33 TotBili-0.9
[**2184-1-30**] 06:09AM BLOOD CK(CPK)-2938* TotBili-0.6
[**2184-1-30**] 11:33AM BLOOD ALT-63* AST-139* CK(CPK)-1894*
AlkPhos-132* TotBili-0.5
[**2184-1-29**] 03:10PM BLOOD Glucose-78 UreaN-47* Creat-2.3* Na-137
K-3.8 Cl-99 HCO3-19* AnGap-23*
[**2184-1-30**] 06:09AM BLOOD FDP-[**Telephone/Fax (1) 14007**]*
[**2184-1-30**] 11:33AM BLOOD Fibrino-353 D-Dimer-[**Numeric Identifier 961**]*
[**2184-1-30**] 12:25AM BLOOD Fibrino-261
[**2184-1-29**] 05:10PM BLOOD PT-19.5* PTT-40.3* INR(PT)-1.9*
[**2184-1-30**] 12:25AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.6*
[**2184-1-30**] 11:33AM BLOOD PT-15.6* PTT-35.2* INR(PT)-1.4*
.
CT abdomen/pelvis IMPRESSION:
1. Left lower lobe consolidation, probably representing
pneumonia. Small bilateral pleural effusions.
2. Very large hiatal hernia containing contrast. NG tube in
place.
3. Stranding in the mesentery and perirenal spaces, consistent
with history of recent percussive resuscitation.
4. Bilateral staghorn calculi.
5. Enlargement of left adrenal gland, which is not specific for
adenoma as there is no definite mass. Dedicated imaging with
adrenal CT or MRI is recommended for further evaluation.
.
ABDOMINAL ULTRASOUND: The gallbladder is unremarkable without
evidence of stones or wall edema. The common bile duct is not
dilated. The liver is coarsened in echotexture. There are
multiple echogenic portal triads. There are no focal lesions.
The portal vein is patent with appropriate directional flow. The
right kidney measures 13.5 cm. The left kidney measures 12.6 cm.
There are no stones or hydronephrosis bilaterally. The spleen
and visualized portions of the pancreas are unremarkable
Brief Hospital Course:
84 F found down, temperature of 102 and significant leukocytosis
admitted with severe sepsis from GU source.
.
# Severe sepsis:
Initially required levophed in order to maintain MAPs. There
was question.- On Ceftriaxone and Azithro for CAP and UTI,
Flagyl for possible aspiration pna, start [**1-29**]. No growth from
cultures (urine or blood). Eventually found to have staghorn
calculus in kidneys and believed most likely to be urinary
source of infection. Later also question of aspiration
pneumonia. Received 10 day course of flagyl and finishing 14
day course CAP/urinary antibiotic (one more day of
levofloxacin). Initially had element of DIC as well, resolved.
Patient transferred to floor with stable blood pressure.
.
# Respiratory insufficiency:
Was intubated for airway protection after sats dropped to 85%
after receiving 2 L NS. Hypoxemia may have been from element
pulmonary fluid overload, although also treated for aspiration
pneumonia.
.
# UTI: Urine cultures remained no growth but received broad
spectrum coverage. Has staghorn calculi which puts her at
increased risk of recurrence. Has follow up appointment with
urology to address.
.
# Leukocytosis: Patient had wbc count peak at [**Numeric Identifier 7670**], down to
[**Numeric Identifier 20476**] on day of discharge. Given flagyl empirically for c diff,
although stools negative here. [**Month (only) 116**] have been all reactive to
infection but will follow up with hematology as an outpatient.
.
# UGIB:
Coffee ground fluid from NGT. Received 1 U RBC in ED. Has a
large hiatal hernia with resultant intrathoracic stomach. [**Month (only) 116**]
predispose to UGIB and gastritis. Cont PPI. H. pylori serology
was negative.
.
# Goiter on R side of neck: TSH and rest of TFTs wnl in
12/[**2183**]. Mild airway involvement. Should get ultrasound as
outpatient and endocrine follow up arranged. Repeat TFTs in 6
weeks.
.
# Adrenal gland: Enlargement of left adrenal gland, which is not
specific for adenoma as there is no definite mass. Dedicated
imaging with adrenal CT or MRI is
recommended for further evaluation as an outpatient.
.
# Anxiety: Patient reports longstanding anxiety. Started on
SSRI and given lorazepam prn, as well as trazodone to help with
sleep. Reports some increased symptom control with combination.
Should be reviewed in outpatient setting.
.
# Dispo: Patient deconditioned after MICU admission. Will be
discharged to [**Hospital 100**] Rehab today for STR with plan for eventual
discharge home.
Medications on Admission:
Given lorazepam previously by PCP.
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Severe sepsis from urinary tract infection
Staghorn calculi
Leukocytosis, most likely from infection
Acute renal failure (pre renal and infection)
Goiter
Gastritis
Anxiety/Depression
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as prescribed.
You will need to follow up with multiple physicians after
discharge. Please see the appointments below.
You have been found to have a large stone in your kidneys that
needs to be reevaluated by the urologists after discharge.
You also have been found to have a goiter that needs to be
followed up as an outpatient. Your primary care doctor (Dr.
[**First Name (STitle) **] will arrange this.
Your white blood cell count got very high here. Most likely
this was from infection and has now resolved, but you will need
to follow up with hematology as an outpatient as well.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-2-18**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2184-2-18**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2184-2-24**] 11:30 (general medicine/geriatrics)
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] (urology) [**2184-2-25**] @ 10:15am phone:([**Telephone/Fax (1) 93948**]
|
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"592.0",
"038.9",
"599.0",
"300.4",
"451.82",
"584.9",
"241.0",
"995.92",
"518.81",
"286.6",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10437, 10522
|
7218, 9735
|
273, 286
|
10749, 10756
|
3076, 7195
|
11425, 12048
|
2471, 2480
|
9820, 10414
|
10543, 10728
|
9761, 9797
|
10780, 11402
|
2495, 3057
|
223, 235
|
314, 2024
|
2046, 2103
|
2119, 2455
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,659
| 133,827
|
38836
|
Discharge summary
|
report
|
Admission Date: [**2194-4-23**] Discharge Date: [**2194-5-2**]
Date of Birth: [**2121-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p Coronary artery Bypass Grafting /Aortic Valve
Replacement(Left internal mammary artery grafted to left
anterior descending artery. Saphenous vein grafted to Obtuse
Marginal/Right coronary artery)/ (#21mm [**Doctor Last Name **] tissue Aortic
valave)-[**4-24**]
History of Present Illness:
73 year old man with past medical history of hypertension,
hyperlipidemia, chronic atrial fibrillation, referred for
cardiac catherization for evaluation
of coronary artery disease and aortic stenosis. The patient
presented with chest pain in the setting of rapid atrial
fibrillation, and was found to have positive cardiac biomarkers
at OSH as well as severe atrial stenosis on echocardiography
with estimated valve area of 0.5 cm2 and EF 60%. Transferred to
[**Hospital1 18**] for cardiac cath which revealed CAD. Csurg was consulted
for evaluation for AVR/CABG. He underwent dental extractions
[**2194-3-6**] in preparation for
surgery. He was then transferred to rehab for antibiotic
therapy for lower leg cellulitis. He was treated with
Vancomycin and Cipro and was eventually discharged to home. He
was home for 9 days and then was found to have a UTI by his PCP
and was admitted to [**Hospital6 33**] on [**4-14**] and was treated
with Imipenem. His foley was changed and he was sent back to
rehab on [**4-18**] and
was transferred here today for surgery in the morning. He had a
power PICC placed last week. He had a negative urine culture
on[**4-21**].
Past Medical History:
- Hypertension
- Chronic atrial fibrillation, on aspirin and not anticoagulated
[**1-7**] recurrent epistaxis on warfarin
- Diastolic congestive heart failure (EF 60%)
- Aortic stenosis
- H/o cervical fracture age 29 s/p C3-5 laminectomy, resulting
in mild atony of LE muscles and neurogenic bladder, with
indwelling Foley catheter x5 years
- Gastroesophageal reflux disease
- Benign prostatic hyperplasia
- Multiple UTIs
- CKD stage I-II
- S/p skin cancer resection left shoulder 6 years ago
- BLE draining cellulitis x 3-4 weeks
Social History:
Lives in [**Hospital1 1474**] alone, [**Last Name (un) **] lives in the area and helps with
care. Married 30 years. No children. was a truck driver for some
time and then did consulting at [**Hospital6 33**]. School
through 8th grade. Smoked until [**2149**] (3 pack daily). No illicit
drugs. EtOH: Pt endorses drinking whiskey in the past, but not
so far this century.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with Peripheral vascular disease leading
to bilateral amputation at 71, CVA at 72. Mother with HTN died
at 84 secondary to complication of CVA.
Physical Exam:
Pulse: 86 Resp: 18 O2 sat: 98% RA
B/P Right: 93/62 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []bilat. redness on calves
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: dop Left: dop
PT [**Name (NI) 167**]: dop Left: dop
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Admission:
[**2194-4-23**] 06:05PM BLOOD WBC-10.0 RBC-5.16 Hgb-10.9* Hct-36.2*
MCV-70* MCH-21.1* MCHC-30.1* RDW-18.6* Plt Ct-211
[**2194-4-23**] 06:05PM BLOOD PT-14.1* PTT-34.8 INR(PT)-1.2*
[**2194-4-23**] 06:05PM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-141
K-4.4 Cl-104 HCO3-28 AnGap-13
[**2194-4-23**] 06:05PM BLOOD ALT-27 AST-27 LD(LDH)-224 AlkPhos-178*
TotBili-0.5
Discharge
[**2194-5-2**] 08:50AM BLOOD WBC-13.1* RBC-4.71 Hgb-11.3* Hct-36.7*
MCV-78* MCH-24.0* MCHC-30.8* RDW-20.6* Plt Ct-169
[**2194-5-2**] 08:50AM BLOOD Plt Ct-169
[**2194-4-28**] 03:13AM BLOOD PT-14.8* PTT-41.0* INR(PT)-1.3*
[**2194-5-2**] 08:50AM BLOOD UreaN-23* Creat-0.9 K-4.1
[**2194-5-1**] 04:13AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-142
K-4.6 Cl-106 HCO3-25 AnGap-16
ECHOCARDIOGRAPHY REPORT
Date/Time: [**2194-4-24**] at 08:33 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: [**Doctor Last Name 11422**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aortic Valve - Peak Gradient: *61 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. Mild spontaneous echo contrast in the LAA. No thrombus in
the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate (2+) MR.
TRICUSPID VALVE: Mild to moderate [[**12-7**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
Mild spontaneous echo contrast is seen in the body of the left
atrium.
Mild spontaneous echo contrast is present in the left atrial
appendage.
No thrombus is seen in the left atrial appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %), with moderate global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Patient is AV-Paced, on low dose Phenylephrine.
Good biventricular systolic fxn. EF now 45 - 50%.
Prosthetic aortic valve is in place with no leak and no AI. Mean
residual gradient = 9 mmHg.
MR is 1+ - 2+.
Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2194-4-24**] 12:39
CHEST (PORTABLE AP) Study Date of [**2194-4-29**] 4:45 PM
Final Report CHEST RADIOGRAPH
INDICATION: Status post CABG and thoracocentesis.
FINDINGS: As compared to the previous examination, the signs of
pulmonary
edema have decreased. Nonetheless, small bilateral pleural
effusions are
still seen. In almost unchanged manner, a retrocardiac
atelectasis is shown.
Moderate cardiomegaly.
The Swan-Ganz catheter has been removed, the venous introduction
sheath is in unchanged position.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**]
Brief Hospital Course:
On [**4-24**] Mr.[**Known lastname **] went to the operating room and underwent
Coronary artery bypass grafting x3 with a left internal mammary
artery to left anterior descending artery andreverse saphenous
vein graft to the distal right coronary artery and the obtuse
marginal artery. And Aortic valve replacement with a 21-mm
[**Doctor Last Name **] Magna Ease
pericardial valve, size 21 mm, model number 3300CFX with Dr.[**Last Name (STitle) **].
Please see operative report for further details. He tolerated
the procedure well and was transferred to the CVICU in critical
but stable condition. He was sedated, intubated and required
inotropes and pressors to augment his cardiac function. He awoke
neurologically intact and on POD#1 he was extubated without
difficulty. All lines and drains were discontinued in a timely
fashion. Postoperatively he went back into his chronic atrial
fibrillation. He was treated medically to rate control him. No
anticoagulation per Dr.[**Last Name (STitle) **] as he has a history of recurrent
epistaxis while on Coumadin in the past as well as being a high
fall risk. He remainded in the CVICU while weaning off drips and
maintaining hemodynamic stability. Postoperative Ciprofloxacin
was started prophylactically for the UTI treated preop. While in
the CVICU, Mr.[**Known lastname **] became delusional and was having visual
hallucinations. All narcotics were discontinued and he was
treated with Haldol and Seroquel with good response. POD#6 he
was transferred to the step down unit for further monitoring.
Physical therapy was consulted for evaluation of strength and
mobility. He remaind hemodynamically stable in rate controlled
AFib. POD#8 he was cleared for discharge to [**Location (un) **] at [**Hospital 701**]
rehab. All follow up appointments were advised.
Medications on Admission:
Imipenem 500 mg IV q 8 hours
ASA 325 mg PO daily
Lovenox
Lipitor 80 mg PO daily
Lopressor 75 mg PO daily
Finasteride 5 mg PO daily
Lasix 40 mg PO daily
Diltiazem 30 mg PO QID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for itching.
13. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED): AC&QHS.
14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
CAD
s/p Coronary artery Bypass Grafting /Aortic Valve
Replacement(Left internal mammary artery grafted to left
anterior descending artery. Saphenous vein grafted to Obtuse
Marginal/Right coronary artery)/ (#21mm [**Doctor Last Name **] tissue Aortic
valave)-[**4-24**]
-hypertension, hyperlipidemia, chronic
atrial fibrillation (on
ASA, no coumadin [**1-7**] recurrent epistaxis on warfarin) diastolic
CHF (EF 60%) AS, h/o cervical fx age 29 s/p C3-C5 laminectomy,
resulting in mild atony of LE muscles and neurogenic bladder,
indwelling Foley x 5 years, GERD, BPH, multiple urinary tract
infections, CKD stage I-II, skin cancer resection left shoulder
6
years ago, BLE draining cellulitis x 3-4 weeks, h/o MRSA
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with assistive device at baseline/wheelchair
Foley->gravity(neurogenic bladder)
Incisional pain managed with Tylenol only
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema:[**12-7**]+ (B)
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] #[**Telephone/Fax (1) 170**], appointment arranged for Wed,
[**5-28**], at 2pm
Please call to schedule appointments with your
Primary Care: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6699**] in [**12-7**]
weeks
Cardiologist: Dr [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-7**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? indication
Goal INR:
First draw:
Results to: phone:
fax:
Completed by:[**2194-5-2**]
|
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icd9cm
|
[
[
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] |
[
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] |
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|
[
[
[]
]
] |
11551, 11625
|
7998, 9809
|
340, 607
|
12381, 12687
|
3664, 7975
|
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|
2764, 2997
|
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9835, 10013
|
12711, 13611
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|
281, 302
|
635, 1806
|
1828, 2360
|
2376, 2748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,240
| 121,373
|
33768
|
Discharge summary
|
report
|
Admission Date: [**2121-9-10**] Discharge Date: [**2121-9-29**]
Date of Birth: [**2060-1-23**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Demerol
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
[**2121-9-11**]: anterior corpectomy of C6 and C7 with cage
reconstruction/fusion C5-T1 for C6-C7 epidural abscess.
[**2121-9-17**]: C5-T1 instrumented posterior spinal fusion with iliac
crest bone graft and laminectomies.
History of Present Illness:
61yo male psychiatrist with h/o bladder cancer (TCC) s/p radical
cystoprostatectomy ([**4-23**]), now with increasing atraumatic neck
pain for 1 week, has had 2 similar episodes but less severe.
pain not controlled with aleve or percocet at home, so came to
ER on [**9-10**] and was admitted to Medicine Service. some
pain/tingling in both arms and both posterior thighs, especially
with neck ROM and palpation around C7. some difficulty in past
2days with writing.
motor on initial exam: [**4-20**] right elbow extension and right wrist
extension. this progressed until preop to ~[**3-20**] right EE/WE had
min BLE movement just prior to surgery.
Past Medical History:
PMH: Bladder cancer s/p radical cystoprostatectomy with ileal
loop urostomy, Meniere, Lumbar laminectomy, Cervical myelopathy,
Knee arthroscopy.
Social History:
He is divorced. He rarely smokes. He works as
a psychiatrist. His descent is eastern European Jew and he
rarely drinks alcohol.
Family History:
In [**2104**], his father died of bladder cancer after
undergoing a cystectomy. His mother died at 53 of renal cell
carcinoma. She, of note, had a hypertrophied right kidney, and
he has a grandfather with prostate cancer.
Physical Exam:
pleasantly conversant, NAD.
c-collar on. ant/post incisions intact.
about 3/5 strength at right elbow extension/wrist extension.
otherwise [**5-20**] in BUE/BLE.
Pertinent Results:
[**2121-9-10**] 04:30PM BLOOD WBC-10.3# RBC-3.78* Hgb-11.4* Hct-34.9*
MCV-92 MCH-30.1 MCHC-32.6 RDW-13.7 Plt Ct-262
[**2121-9-10**] 04:30PM BLOOD Neuts-75.9* Lymphs-15.7* Monos-6.1
Eos-1.9 Baso-0.5
[**2121-9-10**] 04:30PM BLOOD PT-12.9 PTT-29.4 INR(PT)-1.1
[**2121-9-11**] 06:08PM BLOOD ESR-90*
[**2121-9-21**] 08:10AM BLOOD ESR-85*
[**2121-9-21**] 08:10AM BLOOD Plt Ct-1014*
[**2121-9-21**] 08:10AM BLOOD PT-14.3* PTT-32.5 INR(PT)-1.2*
[**2121-9-21**] 08:10AM BLOOD WBC-11.7* RBC-3.13* Hgb-9.1* Hct-28.6*#
MCV-91 MCH-29.0 MCHC-31.8 RDW-14.1 Plt Ct-1014*
[**2121-9-21**] 08:10AM BLOOD Neuts-79.9* Lymphs-12.8* Monos-4.2
Eos-2.4 Baso-0.6
[**2121-9-10**] 04:30PM BLOOD Glucose-149* UreaN-24* Creat-1.0 Na-136
K-4.3 Cl-98 HCO3-27 AnGap-15
[**2121-9-21**] 08:10AM BLOOD Glucose-111* UreaN-17 Creat-0.7 Na-136
K-4.6 Cl-98 HCO3-30 AnGap-13
[**2121-9-11**] 06:08PM BLOOD CRP-GREATER TH
[**2121-9-21**] 08:10AM BLOOD CRP-152.8*
Brief Hospital Course:
[**9-10**] C-spine CT scan: significant DJD throughout with loss of
lordosis and disc spaces at C4-C7 with ant/post osteophytes. no
mets. severe neuroforaminal stenosis bilat at C7/T1. no
enhancement.
[**9-11**] C-spine MRI scan: epidural abscess at C6/C7 with severe
stenosis. prevertebral swelling/abscess.
admitted to medicine service on [**9-10**] for neck pain. needed to be
intubated to tolerate MRI on [**9-11**]. taken urgently to OR on [**9-11**]
for anterior decompression and fusion. blood cx's done before
starting vanco/zosyn preop: GNR=> e.coli. [**9-11**] OR cx's
tissue/swab after starting abx: GNR=> e.coli. initial urine cx:
min presumed enterococcus. cipro started [**9-12**]. stopped
zosyn/cipro and started ceftazidime. ID consulted. transferred
to ortho spine team and sent to TICU intubated after surgery.
LLE weakness postop on [**9-12**]. STAT C/T/L spine on [**9-12**]. some
increased signal change in cord at C6. lumbar spine stenosis. No
infectious source on [**9-13**] C/A/P CT scan. transferred to TSICU
for monitoring postop. TTF on [**9-15**]. [**9-16**] TTE: no vegetations. Had
PICC placed.
fever to 102 on [**9-18**], blood cx from PICC with coag neg staph (no
growth from peripheral cx's on [**9-4**]). PICC removed on [**9-19**] and
tip cx with no growth. vanco started on [**9-18**] and dosing titrated
based upon trough values. clean urine cx on [**9-18**].
switched from ceftazidime to cefepime on [**9-18**] for concern of RUL
PNA on CXR. [**9-19**] chest CT: no PE or PNA. PCA was stopped on [**9-19**]
but patient asked for it to be restarted on [**9-21**] to supplement PO
analgesia. his PO regimen has been titrated up and PCA was
stopped. he has been afebrile since [**9-21**] and beginning to advance
his activity with PT/OT. there has been serosanguinous drainage
from his posterior incision, but this has continued to decrease
and is being treated with daily DSD changes. TEDs/SCDs for DVT
prophylaxis. PICC was replaced on [**9-23**] after blood cx's have been
negative for >48h.
during his stay he also had the following consults: urology (no
interventions needed), psychiatry (resume home meds), neurology
(no further recommendations). he has had high platelet levels
postop. this was thought to be purely a reactive thrombocytosis
by the Medicine Consult team and not requiring any intervention.
he was transfused 2u pRBCs on [**9-20**] for HCT of 22.6 and now his
HCT has been stable with a normalizing WBC.
on [**9-24**] there was a trigger activation for Acute mental status
changes and O2 desat, Labs, Blood Gas, CXR, CT were all wihtin
normal/postop limits. he was transferred to the TICU for
monitoring and transferred back to the floor on [**9-25**]. he
continued to do well after this and there is no drainage from
his incisions. he is ready for discharge at this time.
Medications on Admission:
Adderall 30 mg po daily
Aleve prn
Claritin prn
Clonazepam 3 mg qhs
Fish Oil
Nystatin (for stoma site)
Prozac
acyclovir
Vitamin B-50
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*120 Capsule(s)* Refills:*2*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for pressure spots on ears from
hearing aids.
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
13. Heparin Flush 10 unit/mL Kit Sig: One (1) ml Intravenous prn
PICC care.
14. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q24H (every 24 hours): continue through
[**2121-10-29**].
Disp:*60 gm* Refills:*0*
15. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Disp:*40 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
C6-C7 epidural abscess and cervical spinal stenosis.
Discharge Condition:
stable
Discharge Instructions:
You have undergone the following operation: Anterior and
Posterior Cervical Decompression and Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry you may take a shower. Do not soak
the incision in a bath or pool. If the incision starts draining
at anytime after surgery, do not get the incision wet. Call the
office at that time. If you have an incision on your hip please
follow the same instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
WBAT BUE/BLE. c-collar on at all times except for hygiene. no
heavy lifting.
Treatments Frequency:
daily dry, sterile dressing changes to ant/post neck incisions
until fully healed.
Followup Instructions:
follow-up with dr. [**Last Name (STitle) **] about 7-10 days after discharge. call
[**Telephone/Fax (1) 3736**] for appt.
call ([**Telephone/Fax (1) 4170**] to schedule follow-up appt with Infectious
Disease clinic on [**10-14**].
weekly labs with results to [**Hospital 18**] [**Hospital **] clinic.
Completed by:[**2121-9-29**]
|
[
"389.9",
"041.4",
"V44.6",
"386.00",
"V10.51",
"324.1",
"337.1",
"285.1",
"041.04",
"238.71",
"599.0",
"722.71",
"790.7",
"730.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21",
"81.03",
"02.94",
"77.79",
"03.4",
"38.93",
"81.62",
"81.02",
"80.99",
"77.49",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
7564, 7616
|
2885, 5722
|
282, 507
|
7713, 7722
|
1941, 2862
|
10491, 10825
|
1518, 1744
|
5905, 7541
|
7637, 7692
|
5748, 5882
|
7746, 7848
|
1759, 1922
|
10285, 10362
|
10384, 10468
|
9706, 10267
|
7881, 8104
|
233, 244
|
8675, 9694
|
535, 1185
|
1207, 1353
|
1369, 1502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,670
| 165,163
|
33034
|
Discharge summary
|
report
|
Admission Date: [**2112-5-9**] Discharge Date: [**2112-5-16**]
Date of Birth: [**2058-6-22**] Sex: M
Service: SURGERY
Allergies:
Prednisone
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Chronic ulcerative colitis with
multiple pseudopolyps
Major Surgical or Invasive Procedure:
total abdominal colectomy with ileostomy creation,
cardiac catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 53 year old gentleman with a past medical
history of ulcerative colitis diagnosed in [**2085**], who presents
for a total abdominal colectomy, ileostomy for multiple polyps
throughout the colon.
Past Medical History:
UC dx [**2085**], DM2, CAD s/p MI [**2109**], stents x4
Social History:
The patient is married, and works for an engineering firm.
Family History:
Physical Exam:
99.2 84 114/60 13 982L
gen: NAD
CV: RR, occasionally tachycardic
Pertinent Results:
[**2112-5-9**] 12:16PM BLOOD WBC-10.5 RBC-4.28* Hgb-14.8 Hct-41.5
MCV-97 MCH-34.5* MCHC-35.6* RDW-14.0 Plt Ct-294
[**2112-5-10**] 04:16AM BLOOD WBC-9.3 RBC-3.96* Hgb-13.8* Hct-38.7*
MCV-98 MCH-34.8* MCHC-35.7* RDW-14.1 Plt Ct-249
[**2112-5-10**] 07:14PM BLOOD WBC-12.7* RBC-3.56* Hgb-12.3* Hct-34.4*
MCV-97 MCH-34.5* MCHC-35.7* RDW-14.5 Plt Ct-233
[**2112-5-12**] 06:30AM BLOOD WBC-15.8* RBC-3.48* Hgb-12.0* Hct-34.8*
MCV-100* MCH-34.6* MCHC-34.6 RDW-13.6 Plt Ct-253
[**2112-5-13**] 06:45AM BLOOD WBC-11.7* RBC-3.22* Hgb-10.8* Hct-32.0*
MCV-99* MCH-33.6* MCHC-33.9 RDW-13.6 Plt Ct-344
[**2112-5-9**] 12:16PM BLOOD CK(CPK)-191*
[**2112-5-9**] 02:18PM BLOOD CK(CPK)-303*
[**2112-5-9**] 10:15PM BLOOD CK(CPK)-1225*
[**2112-5-10**] 04:16AM BLOOD CK(CPK)-1038*
[**2112-5-10**] 11:53AM BLOOD CK(CPK)-794*
[**2112-5-10**] 07:14PM BLOOD CK(CPK)-652*
[**2112-5-11**] 04:23AM BLOOD CK(CPK)-482*
[**2112-5-9**] 12:16PM BLOOD CK-MB-3 cTropnT-<0.01
[**2112-5-9**] 02:18PM BLOOD CK-MB-13* MB Indx-4.3 cTropnT-0.12*
[**2112-5-9**] 10:15PM BLOOD CK-MB-171* MB Indx-14.0* cTropnT-2.68*
[**2112-5-10**] 04:16AM BLOOD CK-MB-120* MB Indx-11.6* cTropnT-3.85*
[**2112-5-10**] 11:53AM BLOOD CK-MB-73* MB Indx-9.2* cTropnT-3.24*
[**2112-5-10**] 07:14PM BLOOD CK-MB-31* MB Indx-4.8 cTropnT-2.37*
[**2112-5-11**] 04:23AM BLOOD CK-MB-12* MB Indx-2.5 cTropnT-1.65*
[**5-9**] Path: Ileocolectomy:
1) Ulcerative colitis, chronic focally active:
a) Diffuse disease from ascending colon to distal margin, more
prominent in the distal part.
b) Inflammatory pseudopolyps in distal two-thirds, most
prominent in the sigmoid.
c) No sinus tracts or granulomas.
d) No dysplasia.
2) Ileal segment and appendix: Within normal limits.
[**5-9**] Echo: Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal to mid inferior
segments. Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion/position. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. The pulmonary artery systolic pressure
could not be determined.
IMPRESSION: Suboptimal image quality. The inferior segments are
probably hypokinetic. Overall LVEF is normal as the other
segments are hyperdynamic. RV function appears preserved.
3) Omentum, within normal limits.
[**5-10**] cardiac catheterization: . Coronary angiography in this
right-dominant system revealed:
--the LMCA had no angiographically apparent disease.
--the LAD had no angiographically apparent disease, with patent
stents
both proximally and distally.
--the LCx had no angiographically apparent disease.
--the RCA had patent stents with serial moderate stenoses
including 50%
proximal, 60% mid, and 50% distal.
2. Limited resting hemodynamics revealed normal systemic
arterial
systolic pressures, with SBP 113 mmHg; normal left-sided filling
pressures with LVEDP 11 mmHg. There was no gradient across the
aortic
valve upon pullback of the angled pigtail catheter from LV to
ascending
aorta.
3. Left ventriculography revealed normal LV wall motion, LVEF
60%, and
no significant mitral regurgitation.
FINAL DIAGNOSIS:
1. No tight coronary stenoses. Continue with medical therapy.
[**5-11**] CTA: 1. No filling defect within the pulmonary arteries to
suggest pulmonary embolus.
2. Bilateral dependent atelectasis. Small right pleural
effusion.
3. Small amount of perihepatic ascites. Tiny locule of air is
seen anterior to the liver which likely relates to recent
surgery.
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment post operatively. The patient underwent a total
abdominal colectomy, ileostomy ([**5-9**]); for details, please see
operative note. The patient initially recovered in the PACU
where the patient was observed to have ventricular tachycardia;
he had no complaints of chest pain or shortness of breath at
that time.
Neuro: The patient received a diluadid PCA with good effect and
satisfactory pain control initially. When tolerating oral
intake, the patient was transitioned to oral pain medications.
His PCA was held immediately post operatively, as the patient
was noted to have a respiratory acidosis, which promptly
resolved. The patient continued to experience significant post
operative pain, not entirely controlled with the PCA, and
Toradol was ordered with good effect.
CV: The patient initially recovered in the PACU where the
patient was observed to have ventricular tachycardia; he had no
complaints of chest pain or shortness of breath at that time.
The patient received amiodarone and magnesium, and his vital
signs were closely monitored. The patient was then given
aspirin with the possibility of coronary ischemia, and also
received calcium and lipitor. An ABG at that time showed
acidosis. Cardiac enzymes were cycled, the patient was
transferred to the ICU, and cardiology was [**Month/Day (4) 4221**]. The
patient was also put on IV metoprolol for beta blockade. An
echo was performed; for details, please see reports section.
Serial EKGS and cardiac enzymes were sent; the patient had
suffered an NSTEMI. A heparin drip was subsequently started;
levels were adjusted according to his coagulation profile. On
[**5-10**], the patient was taken for cardiac catheterization, which
revealed patent stents proximally and distally in the LAD, and
moderate stenoses in the RCA; he was transferred to the CCU for
initial recovery. The amiodarone was stopped without
recurrence.
The patient's heart rate was closely monitored, and his beta
blockade dosage was adjusted accordingly.
On [**5-10**]-2, the patient complained of pleuritic chest pain, with
tachycardia and hypoxia at 92% on room air. A CTA was performed
to rule out a PE; for details, please see results section.
Pulmonary: The patient was initially stable from a respiratory
standpoint. During the episode of ventricular tachycardia
postoperatively, an ABG revealed respiratory acidosis, for which
narcotics were temporarily held. On [**5-10**]-2, the patient
complained of pleuritic chest pain, with tachycardia and hypoxia
at 92% on room air. A CTA was performed to rule out a PE; for
details, please see results section.
The patient was stable from a pulmonary standpoint afterwards;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well (clears on [**5-12**], and diet as tolerated on [**5-13**]).
The ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for post operative care and
ostomy teaching; the patient will be discharged home with ostomy
nursing visits
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
On [**5-14**], the patient was noted to have high ostomy output, and
was put on loperamide with good result; he was discharged home
on loperamide.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly. His Lantus
dose was also increased gradually with increasing PO intake.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. He was put on a heparin drip initially, which was
stopped by [**5-11**]. The patient was also put on aspirin, which was
increased from 81 to 325 mg on [**5-13**] on the recommendation of our
cardiology collegues.
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.
Medications on Admission:
lantus 30QPM, humalog SS, MVI 1', caltrate 600', 6-MP 50'',
metoprolol 12.5'', lipitor 40', ASA 81', celexa 20', lialda
1200'
.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) U
Subcutaneous at bedtime.
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
chronic ulcerative colitis with pseudopolyps,
NSTEMI
Discharge Condition:
stable, tolerating usual oral diet, able to tolerate pain well
on oral pain regimen, able to ambulate independently without
difficulty, appropriate teaching with regard to self-care
post-operatively
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites
Monitoring Ostomy Output / Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 500mL to 1000mL per day.
*If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool. Do not exceed 16mg in 24
hours.
You are to continue working with the ostomy nursing care team to
ensure proper functionality of your ostomy.
Followup Instructions:
You are to call Dr. [**Last Name (STitle) **] [**Name (STitle) 2678**] at [**Telephone/Fax (1) 76822**] for a
follow-up appointment.
You are to call your primary care physician [**Name9 (PRE) 2678**] for [**Name Initial (PRE) **]
post-hospitalization appointment.
|
[
"412",
"E878.6",
"414.01",
"250.00",
"V45.82",
"556.9",
"427.1",
"556.4",
"276.2",
"518.81",
"410.71",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.55",
"46.23",
"37.22",
"45.8"
] |
icd9pcs
|
[
[
[]
]
] |
10019, 10123
|
4606, 9232
|
320, 396
|
10219, 10419
|
937, 4206
|
12151, 12419
|
825, 825
|
9411, 9996
|
10144, 10198
|
9258, 9388
|
4223, 4583
|
10443, 11273
|
11288, 12128
|
840, 918
|
227, 282
|
424, 651
|
673, 731
|
747, 807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,790
| 159,801
|
36781
|
Discharge summary
|
report
|
Admission Date: [**2150-8-4**] Discharge Date: [**2150-8-7**]
Date of Birth: [**2076-4-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Trach Obstruction
Major Surgical or Invasive Procedure:
[**2150-8-4**] Flexible bronchoscopy through the tracheostomy tube.
[**2150-8-4**] 1. Rigid bronchoscopy using the Dumon yellow
tracheoscope.
2. Flexible bronchoscopy.
3. Tracheostomy tube change from [**Location (un) 17122**] #7 to [**Last Name (un) 295**] #8
adjustable placed at 12 cm.
History of Present Illness:
Pt is a 74 y/o morbidly obese male s/p Hypercapnic resp failure
s/p trach now complicated by granulation tissue at distal end of
the trach. Admitted to [**Hospital6 3622**] on [**2150-6-24**] with respiratory distress and AMS,
found to be in renal failure and CHF with increased troponin
question leak vs NSTEMI. Transfered to [**Hospital3 **] on
[**2150-7-5**]. Developed respiratory distress, emergently intubated on
[**2150-7-9**] with suction of purulent secretions. On vanc and
cefepime for possible PNA until [**7-11**]. Transfered to [**Hospital 7301**] Medical
Center ICU for management of airway. Underwent tracheostomy on
[**2150-7-13**], PEG placement [**2150-7-14**]. Transfered back to [**Hospital1 **] on
[**2150-7-15**] for weaning of mechanical ventilation and further
management. On [**2150-8-3**], patient had increased respiratory
distress, patient had bronch and 2 trach changes, now with #7
[**Doctor Last Name 83140**] in place. Found to have granulation tissue obstructing
the distal end of his trach. He is now transfered to [**Hospital1 18**] for
further management of his airway and operative management of
trach obstruction.
Past Medical History:
Morbid obesity
hypoventilation syndrome with OSA
CPAP/O2 at home, hx of non-compliance
HTN
IDDM
CHF EF 45% ([**2150-6-27**])
Hypothyroidism
Social History:
Exsmoker quit 10 years ago
Family History:
non-contributory
Physical Exam:
VS: T: 99.3 HR: 83 BP: 97/39 Sas: 100% CPAP 50% 16/618/10
General: no apparent distress
Neck: trach in place
Pertinent Results:
[**2150-8-6**] WBC-12.9* RBC-2.87* Hgb-8.3* Hct-26.1* Plt Ct-303
[**2150-8-5**] WBC-20.4* RBC-3.43* Hgb-9.7* Hct-31.3* Plt Ct-429
[**2150-8-4**] WBC-19.1* RBC-3.50* Hgb-9.8* Hct-32.2* Plt Ct-354
[**2150-8-4**] Neuts-89.2* Lymphs-6.0* Monos-3.8 Eos-0.7 Baso-0.2
[**2150-8-6**] Glucose-218* UreaN-79* Creat-1.6* Na-135 K-4.5 Cl-91*
HCO3-37
[**2150-8-4**] Glucose-173* UreaN-77* Creat-1.7* Na-137 K-5.2* Cl-84*
HCO3-43*
[**2150-8-6**] Type-ART pO2-77* pCO2-73* pH-7.38 calTCO2-45* Base
XS-13
Cultures: [**2150-8-5**] BAL 4+ PMN normal flora
Urine Cx pending
Blood Cultures: no growth to date
CXR:
[**2150-8-6**] FINDINGS: In comparison with the study of [**8-5**], there
is progressive clearing of the right base. Some persistent
atelectatic changes or effusion at the left base. Stable
enlargement of the cardiac silhouette.
[**2150-8-5**] Right lower lobe collapse is new. Left upper lobe
collapse has resolved. Moderate left basal atelectasis present
but improved. Tracheostomy tube is in standard placement.
Partial opacification of the entire tracheobronchial tree
suggests considerable retention of secretions. Heart is probably
large but difficult to assess given the low lung volumes.
[**2150-8-4**] Left lung is almost entirely collapsed, reflected in a
uniform opacification and ipsilateral mediastinal shift.
Heterogeneous opacification in the right upper lung could
represent incipient collapse or pneumonia. Heart size is
obscured.
Brief Hospital Course:
Mr. [**Known lastname 83141**] was transferred for further trach management. On
[**2150-8-4**] a flexible bronchoscopy showed granulation tissue that
was completely occluding the lumen of the trachea. He was
immediately taken to the operating room for Rigid and Flexible
bronchoscopy; Tracheostomy tube change from [**Location (un) 17122**] #7 to [**Last Name (un) 295**]
#8 adjustable placed at 12 cm.
Of note: the previously-placed Shiley #7 at an outside hospital
tracheostomy tube and
introduced our flexible bronchoscope through the stoma and were
able to visualize the subcutaneous tissue which was previously
thought to be central airway obstruction. The tube was passed
into the trachea. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] #8 adjustable tracheostomy tube was
then introduced via the stoma. Repeat flexible bronchoscopy
revealed granulation tissue in the subglottic region, vocal cord
edema, and supraglottic edema. The patient was receiving
adequate volume through the ventilator and maintaining his
oxygen saturation very well. He was transferred back to the
surgical intensive care unit in stable condition.
Pulmonary: His oxygen saturations remained in the high 90's on
CPAP 50%. Aggressive pulmonary toilet and nebs were continued.
His trach was changed to a #7 [**Last Name (un) **]. Attempted to wean from
ventilator patient became tachypnic, saturation 90-92% .50% FiO2
but the patient complained of shortness of breath (high anxiety)
on T-tube.
ID: his WBC was elevated. He was pan cultured. UA was positive
he was started on Vanco and Zosyn empirically then converted to
Cipro 500 mg [**Hospital1 **] x 3 days. He WBC on [**2150-8-6**] was 12.9. He
remained afebrile throughout his stay. Miconazole powder to
groin region.
Cardiac: Immediately postoperatively he required small amount of
Neo for blood pressure support. He was immediately wean off
with SBP 100's. He remained in Sinus Rhythm.
GI: Benign. PEG in place.
Renal: Cre 1.6 with gentle diuresis. On admission 1.7. Urine
output Good.
Endocrine: was maintained on a sliding scale insulin
Nutrition: Tube feeds were resumed Replete with Fiber at 50
mL/hr
Disposition: He returned to [**Hospital1 **].
Medications on Admission:
ASA 325mg PO daily
Lasix 20mg PO daily
Amlodipine 7.5mg PO daily
Lopressor 50mg PO q8h
RISS
Flunisolide INH 2 puffs [**Hospital1 **]
Colace 100mg PO BID
Miconazole powder
Nexium 40mg PO daily
Tube feeds: Jevity 1.2 goal 70cc/hr plus 210cc free water q6h
Discharge Medications:
1. Insulin Sliding Scale
Glucose Insulin Dose
0-50 mg/dL 1 amp D50
51-150 mg/dL 0 Units
151-200 mg/dL 4 Units
201-250 mg/dL 6 Units
251-300 mg/dL 8 Units
> 300 mg/dL Notify M.D.
2. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
6. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 doses.
9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for fungal rash.
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**12-26**]
Puffs Inhalation Q6H (every 6 hours).
11. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) mL PO twice
a day: via PEG.
12. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Trach mislplaced/trach obstruction
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] with any questions or concerns
[**Telephone/Fax (1) 7769**].
Call with fevers greater than 101.5
Call lwith increased cough secretions or shortness of breath.
Followup Instructions:
Patient needs to follow up with his PCP in the next few weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2150-8-7**]
|
[
"327.26",
"327.23",
"276.2",
"250.00",
"401.9",
"V44.1",
"278.01",
"428.0",
"E878.3",
"518.83",
"244.9",
"519.09",
"V46.11",
"458.29",
"599.0",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.23",
"33.24",
"96.6",
"97.23",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
7656, 7727
|
3677, 5903
|
337, 632
|
7806, 7815
|
2204, 3654
|
8064, 8269
|
2038, 2056
|
6208, 7633
|
7748, 7785
|
5929, 6185
|
7839, 8041
|
2071, 2185
|
279, 299
|
660, 1814
|
1836, 1978
|
1994, 2022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,949
| 138,433
|
3710+3711
|
Discharge summary
|
report+report
|
Admission Date: [**2185-8-3**] Discharge Date: [**2185-8-21**]
Date of Birth: [**2120-9-24**] Sex: M
Service: CSU
CONTINUATION:
PAST MEDICAL HISTORY: Hypercholesterolemia, hypertension,
diabetes mellitus type 2, type B aortic dissection as
described above, chronic renal insufficiency with creatinine
ranging from 1.7 to 2.5, obesity, spinal stenosis, anemia,
rheumatic fever, retinopathy and left hydronephrosis in the
past.
PAST SURGICAL HISTORY: Failed intrathecal catheter.
MEDICATIONS: Labetalol 800 t.i.d., Avandia 2 mg b.i.d.,
Lipitor 10 mg daily, nifedipine 90 mg daily, iron sulfate 325
mg daily, Imdur 30 mg daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
with all vital signs within normal limits. Blood pressure was
noted to be approximately 140/75. He was normocephalic and
atraumatic. Neck was without masses and there were no signs
of bruits. The oropharynx was clear. Lungs were clear to
auscultation bilaterally with no wheezes, rales or rhonchi.
Heart was regular rate and rhythm, with a II/VI holosystolic
murmur, normal S1 and S2 otherwise. Abdomen was obese, but
soft and nondistended and nontender throughout with positive
bowel sounds. Extremities were warm and well perfused and
without edema. Others, there is a small area of swelling over
the lumbar region where an attempt was made for an
intrathecal catheter. Neurologic: The patient was alert and
oriented x3. Strength was [**5-26**] throughout. Sensation was
intact throughout, and his gait was steady and pulse exam was
2+ distally in both lower extremities.
HOSPITAL COURSE: At this time, the patient was admitted with
an enlarging and penetrating ulcer within the aneurysm of his
thoracic aorta. Labs were sent. Chest x-ray was also sent but
did not reveal any acute cardiopulmonary process and a
consent was signed for surgical intervention. Thus on [**2185-8-3**], hospital day 1, the patient was brought to the
operating room for an aneurysm repair. This was done through
a left posterolateral thoracotomy incision. The aneurysm was
noted to be thinning from the level of the left subclavian
artery to the level of the pulmonary veins. There was no
obvious hematoma surrounding the aneurysm and it was noted to
be well contained. The patient was noted to tolerate the
procedure well and good hemostasis was achieved afterwards
and transesophageal echo at the end of the case revealed the
heart function to be normal. The patient had basilar and
apical chest tubes placed at this time and Marcaine was
injected for anesthesia for the postoperative period. The
patient was noted to progress well and was initially admitted
to the intensive care unit at this time and his pain was
noted to be well controlled as well. However, shortly
thereafter, the patient began to have increasing shortness of
breath in the postoperative period. Films revealed a likely
loculated effusion on the left and thoracic surgery was
consulted for possible left VATS evacuation with possible
decortication and, on [**2185-8-15**], the patient was brought
to the operating room by the thoracic surgery service and Dr.
________ performed a left VATS procedure where the patient
received a left thoracotomy and evacuation of hemothorax.
Chest tubes were placed at this time on the left, 1 apically
and 1 in the middle fields. The patient, however, was noted
to have lost his airway at the time the case was ending and
the patient was being repositioned. There was also noted to
be a brief episode of pulseless arrest. The patient was given
external compressions and Atropine and Epi boluses. The
patient promptly returned back to sinus rhythm and a LMA was
placed following then by the endotracheal tube. His oxygen
saturations normalized at this time and end tidal CO2 was
normalized and the patient was brought to the PACU and then
shortly thereafter to the CSRU.
The patient was examined serially in the postoperative period
and there were noted to be no neurologic deficits upon
lessening of propofol sedation. From this point on, the
patient continued to progress well. The patient was continued
as well on vancomycin for suspected pulmonary source that was
located by the thoracic staff and was continued as well on
ciprofloxacin for a positive urinalysis. During this
postoperative time, the patient continued to progress well
and on postoperative day #3, his chest tubes were able to be
removed. The patient was now taking a regular diet, was
walking with physical therapy, who found him able to be
discharged to home when he was medically cleared and he had
been extubated the prior day. His epidural was able to be
removed. His Foley catheter was removed as well. He was noted
to be voiding on his own and on postoperative day #6, he was
deemed fit for discharge to home with visiting nurse
assistance and this was done accordingly.
DISCHARGE INSTRUCTIONS: The patient to take medications as
directed per the discharge instructions. The patient not to
drive for 4 weeks. The patient not to lift more than 10
pounds for 3 months. The patient not to use powders, lotions
or creams on the wounds. The patient to shower but to pat dry
with a towel. To call office for incisional drainage,
temperature greater than 101.5 degrees Fahrenheit.
MEDICATIONS ON DISCHARGE: Potassium chloride 20 mEq p.o.
b.i.d., Colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. daily,
acetaminophen 325 mg p.o. q.4-6hours as needed for pain,
hydromorphone 2 mg p.o. q.2hours as needed for pain,
atorvastatin calcium 10 mg p.o. daily, rosiglitazone maleate
8 mg p.o. daily, ferrous gluconate 300 mg p.o. daily,
pantoprazole sodium 40 mg p.o. daily, furosemide 20 mg p.o.
b.i.d., metoprolol tartrate 25 mg p.o. b.i.d., nystatin 5 ml
p.o. q.i.d. as needed for 7 days.
DISPOSITION: The patient to be discharged to home with
visiting nurse assistance for vital sign checks, wound checks
and medication compliance and to be placed on a diabetic
consisting of carbohydrate and cardiac heart healthy diet.
The patient to follow-up according to discharge instructions.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2185-8-21**] 12:02:28
T: [**2185-8-21**] 13:41:59
Job#: [**Job Number 16728**]
Unit No: [**Numeric Identifier 16726**]
Admission Date: [**2185-8-3**]
Discharge Date: [**2185-8-21**]
Date of Birth: [**2120-9-24**]
Sex: M
Service: CSU
</
HISTORY OF PRESENT ILLNESS: This is a 64 year old male with
past medical history of hypertension and hypercholesterolemia
as well as a history of type B aortic dissection in [**2184-8-22**], with recent CAT scan that revealed interval enlargement
of a penetrating ulcer within the thoracic aorta that went
from 2.3 cm to 3.2 cm. This has been followed by serial CT
scans during this time. His aneurysm measures 6.2 cm in
maximum diameter. He was initially going to have this
repaired in early [**Month (only) **] of this year, however, this was not
able to be done due to failed placement of a cerebrospinal
fluid drain for anesthesia as well as a failed intrathecal
catheter. He had a follow-up MRI after this that was deemed
to be normal. Also of note, his cardiac catheterization in
[**Month (only) 116**] of this year revealed no significant coronary artery
disease with an ejection fraction of 56% and normal left
sided filling pressures with the thoracic aortic aneurysm as
described above. His echocardiogram last [**Month (only) 216**] revealed no
aortic regurgitation with mild thickening of the mitral and
aortic leaflets.
DICTATION ENDED
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2185-8-21**] 11:48:31
T: [**2185-8-21**] 13:51:07
Job#: [**Job Number 16729**]
|
[
"593.9",
"441.01",
"599.0",
"427.5",
"997.3",
"518.0",
"272.0",
"401.9",
"511.8",
"250.00",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.45",
"57.32",
"33.22",
"39.61",
"88.72",
"34.09",
"99.60",
"38.93",
"96.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5326, 6518
|
1647, 4894
|
4919, 5299
|
475, 692
|
715, 1629
|
6547, 7931
|
174, 451
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,801
| 144,188
|
33669
|
Discharge summary
|
report
|
Admission Date: [**2173-1-30**] Discharge Date: [**2173-4-2**]
Date of Birth: [**2112-10-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
WBC of 185K
Major Surgical or Invasive Procedure:
Bone marrow biopsy
Endotracheal Intubation
PICC line placement and removal
PEG tube placement
History of Present Illness:
Ms. [**Known lastname **] is a 60yo F w/ a PMH of hypothyroidism, hypertension,
fibromyalgia and hyperlipidemia who presented to an OSH today
for evaluation of a month of night sweats, worsening back pain,
frequent and easy bruising, and fatigue. She had been to her PCP
[**Name Initial (PRE) **] 1 week ago for evaluation of these symptoms and had her
thyroid checked (which was normal per her report). She continued
to feel poorly so presented to [**Hospital6 8972**] today
for evaluation and her CBC revealed a WBC of 185K, with 90%
peripheral blasts. Her platelets were also found to be ~35K and
her fibrinogen was undetectable. She was reportedly given
cryoprecipitate and antibiotics (but there is no documentation
of this) and was then transferred to [**Hospital1 18**] for further
evaluation.
.
On arrival here, her VS were T 100.0, BP 148/80, HR 100, RR 20,
sats of 98% on RA. Initial labs showed a WBC of 185k with a
predominance of blasts and some promyelocytes. Her transaminases
were elevated, her uric acid was 7.8, LDH 897, INR 1.4, K 3.2,
Cr 1.0 and fibrinogen 197. She remained afebrile in ER (T
99.3-100.0), BP 111-137/61-83, HR 70s. She was seen by the
heme-onc team who looked at her peripheral smear and felt that
it was most consistent with the microgranular variant of APML.
She was given 3gm hydrea PO x1, D5W + 3amps bicarb at 150/hr,
and 300mg allopurinol x1. A CVL was placed and she received 1u
plts post CVL placement. She was then transferred to 7F for
further management.
.
On arrival to 7F, she states that she overall is feeling OK. She
has a [**3-25**] headache, bandlike, across her forehead and behind
her eyes, c/w her sinus headaches. She's had this same headache
for about 2 weeks. Not associated with any vision changes,
weakness, numbness or tingling. She usually takes tylenol for
this but her last dose of tylenol was this AM. She otherwise
feels fatigued and a little nauseated, but otherwise is doing
well.
.
ROS:
+ NS, as well as "sweats" during the day
no frank fever, chills
no weight changes but + anorexia x1 week
+ easy bruising (several wks) and bleeding from her gums (1 day)
denies any visual changes
+ headaches as noted above, along with increased fatigue
denies ST, nasal congestion, ear pain, + rhinorrhea
denies CP, SOB, CP
+ palpitations/tachycardia - HR as high as 117 in last few weeks
denies any emesis, but + nausea
denies abdominal pain, diarrhea, constipation, BRBPR
denies any dysuria, hematuria, frequency or urgency
denies epistaxis
denies rashes, + dry skin
+ worsening back pain over last 24 hrs
Past Medical History:
# Hypothyroidism
# Hyperlipidemia
# HTN
# Fibromyalgia
# GERD
# Migraines
Social History:
Lives in [**Location 6134**] with her husband. Disabled by fibromyalgia so
is not currently working. Used to work making clothing. Has 3
sons and 6 grandchildren. Never smoked, does not drink EtOH.
Family History:
No family history of bleeding or cancers; father's cousin
recently died of leukemia.
Physical Exam:
Vitals - T: 98.6 BP: 126/72 HR: 78 RR: 16 02 sat: 96% on RA wt
135.1 lbs
GENERAL: WDWN middle aged female in NAD. Skin pink. Pleasant and
cooperative.
SKIN: Multiple scattered ecchymoses over body including
bilateral LE, bilateral UE, sole of L foot, forehead. Skin dry,
cool.
HEENT: Sclera anicteric. PERRL, EOMI. OP clear but has evidence
of bleeding on her buccal mucosa bilaterally. No LAD. R IJ in
place. Has soft swelling at site of line insertion. Line with
minimal oozing. No palpable hematoma, but line is slightly
tender to palpation.
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNG: CTAB, no crackles or wheezes.
ABDOMEN: Soft, ND, ttp in RUQ, no palpable liver edge, no
appreciable splenomegaly. No masses. + BS.
EXT: No edema. 2+ DP, radial pulses bilaterally. Ecchymoses as
noted above.
NEURO: CN II-XII intact. Strength 5/5 in UE and LE bilaterally,
both distally and proximally. Sensation to LT intact. 2+ DTR at
[**Name2 (NI) 15219**] bilaterally. [**Last Name (LF) 43945**], [**First Name3 (LF) **] intact. No pronator drift. Toes
downgoing bilaterally.
Pertinent Results:
CXR PA/LAT [**2173-1-30**] No evidence of pneumonia/edema.
.
CVR PA/LAT [**2173-1-31**] Cardiac size is top normal. Right internal
jugular catheter tip is in the SVC with no pneumothorax or
pleural effusion. Ill-defined bibasilar reticular opacities are
new and of uncertain etiology, for which, if clinically
indicated, further evaluation with CT for further
characterization could be performed.
.
CXR Port [**2173-2-1**] Cardiomediastinal contour is unchanged with
cardiac size top normal. Right IJ line tip is in the SVC.
Small left pleural effusion has increased. Bibasilar
atelectases has increased, worse in the right side. There is
engorgement of the pulmonary and mediastinal vasculature without
overt CHF. No radiologic
findings of ARDS.
.
[**2-1**] Liver US- No evidence of hepatic mass or gallbladder
pathology and otherwise unremarkable ultrasound.
.
[**2-2**] TTE- Left ventricular systolic function is hyperdynamic
(EF>75%). The estimated cardiac index is high (>4.0L/min/m2).
The right ventricular cavity is borderline dilated with normal
free wall contractility. No structural valvular disease. Resting
tachycardia.
.
[**2-2**] CXR Portable- New moderate pulmonary edema. Small
bilateral pleural effusions and bibasilar atelectasis.
.
[**2-3**] CXR Portable- Worsening moderate pulmonary edema with small
bilateral pleural effusions. Increased left basilar
atelectasis.
.
[**2-3**] Lower extremity arterial non-invasives at rest- Normal
resting arterial study
.
[**2-3**] CXR portable- Worsening moderately severe pulmonary edema
with increasing confluent areas of opacification in the right
upper and left mid lung zones representing asymmetric edema or
evolving infectious process.
Brief Hospital Course:
Initial BMT floor course:
After admission to the BMT floor, pt was started on treatment
with cytarabine. She was also given hydroxyurea, allopurinol,
and hydration. Patient was noted to have hypoxia to 86% on RA on
[**1-31**], and was placed on 3L NC, and decision was made to start
leukopheresis in preparation for starting ATRA. She received one
round of leukopheresis on [**1-31**] and one on [**2-1**]. Over the course
of the next two days, patient received 2u pRBC, 5u
cryoprecipitate, 2u FFP, and 2u platelets for DIC. She was 6L
positive and on [**2-1**], she again had a desaturation to 87% on 2L
NC and was febrile to 101.1. She was diuresed with lasix with
some response, and was also started on aztreonam. She remained
persistently febrile to 103.8 and vancomycin was started as
well. On [**2-2**] she desat'd again in the setting of SBP 170 and
was put on a NRB. Blood gas showed hypoxemia. She was started on
10mg IV decadron. She was transferred to MICU for hypoxic
respiratory failure. Potential etiologies of her respiratory
failure considered were pulmonary edema in the setting of fluid
overload, pulmonary hemorrhage, TRALI, leukostasis, or
pneumonia.
ICU course:
Initially placed on BIPAP 2 hours on, 1 hour off for 2 days and
then was weaned off to 3LO2 NC. She was diuresed aggressively
due to concern for volume overload, but this was hindered by her
continued need for blood products. It was felt her respiratory
failure was due to a combination of volume overload and
capillary leak. She was started on ATRA and given 3 doses
initially, then held due ot concern over ATRA syndrome. Her DIC
was resolving with stable fibrinogen. She was continued on
vanc/aztreonam and levoflox was added for atypical coverage. She
also developed acute renal failure and therefore her cytarabine
and hydrea were held. Nephrology was consulted and felt this to
be a tubular toxic effect from cytarabin/hydrea (she had
granular casts on sediment) verses (less likely) thrombotic
microangiopathy from DIC. Her Cr has been stable at 1.8 and she
has been hydrated with IVFs w/bicarb. She has been off BIPAP for
>36hours and was transferred to the BMT floor for further
management. She was received 3 more doses of ARA-c and 3 days of
idarubicin and continued on ATRA to day #11. Steroids were
weaned, creatinine return to near baselin levels, and O2
requirement resolved. On [**2-9**] patient developed necrotic oral
lesions that were swabbed and treatment dose of acyclovir was
initiated. On [**2-11**], oral swab showed evidence of HSV-like
cytopathic effect and acyclovir was changed to IV. Overnight
into [**2-13**], patient developed a new oxygen requirement and
developed massive hemoptysis with progression of oral and
esophageal pain. Patient was transferred to the [**Hospital Unit Name 153**] for
management of her hemoptysis and respiratory failure.
[**Hospital Unit Name 153**] course:
#) Respiratory Failure: Pt was transferred to [**Hospital Unit Name 153**] with
hemopytsis and worsening respiratory distress, intubated on
[**2173-2-15**] & bronchoscopy was performed on [**2-15**] & [**2-16**]. Imaging was
consistent with ARDS of unknown etiology & bronch showed some
bloody clots in large airways thought due to mucositis, but no
evidence of diffuse alveolar hemorrhage. Pt had some evidence
of low grade DIC that improved over ICU course, and
oropharyngeal bleeding improved with plt tranfusion threshold
>50. The BAL cultures were + for GPCs & final culture was
consistent with oral flora, thought not to be cause of her
primary pulm process. Blood Cx on [**2-15**] was + MSSA (2/4 bottles).
BAL from [**2-16**] was lost in transit. Pt was treated with empiric
Abx while neutropenic & febrile with Vanc/Aztreonam/Fluconazole
& Acyclovir with plan to continue abx until [**3-7**] to complete 7
day course post resolution of neutropenia. Pt was weaned from
the vent with aggressive diuresis & was extubated on [**2-24**].
Initially, pt was noted to have ongoing tachypnea, respiratory
alkalosis, mucositis causing significant upper airway
secretions. Fungal & Viral sputum cultures have otherwise been
negative, blood Cx NGTD. Acyclovir was switched to prophylactic
dose after pt had received 14 days of treatment dose and is no
longer neutrapenic. Pt also completed 5/5 days of levofloxacin
for atypical coverage. Fluconazole was switched to Caspofungin
on [**2-22**] due to positive glucan, will need to f/u on repeat
fungal studies. Pt has been doing better with clearing
secretions as counts have recovered and mucositis is resolving.
Currently, pt is maintaining sats with 2L NC but has not been
able to take significant po, started TPN on [**3-1**].
.
#) Respiratory alkalosis??????Pt was noted during & s/p extubation,
pt was noted to have a persistent respiratory alkalosis due to
hyperventilation. It is unclear if this was a central response
to pain or agitation. During diuresis, there was an additional
component of contraction alkalosis with elevated bicarbonate
suggest a mixed metabolic & respiratory alkalosis. Pt was
continued on viscous lidocaine, magic mouthwash, ativan,
morphine for pain/anxiety.
.
#) Abn LFTs: On [**2-26**], pt was noted to have mild elevation in
LDH/Alk Phos & Tbili. Pt had no RUQ tenderness on exam & repeat
labs showed T.bili was trending down with a stable haptoglobin
& no schistocytes on smear. Etiology unclear, possibly med
effect, continue to trend LFTs.
.
#) Acute systolic heart failure: Pt presented to ICU with
significant pulm edema & initial ECHO showed an EF drop from 70%
to 10%, believed to be [**1-16**] acute chemo toxicity as pre chemo
ECHO had a normal LVEF. Cardiology was consulted and pt was
started on afterload reduction with nitrates & lasix diuresis.
Pt had a follow up TTE within 1wk that showed significantly
improved EF of 50%. Per cards, pt was started on coreg,
valsartan and isordil. BP was well controlled & pt diuresed
well. However, after extubation BP has been difficult to
control due to inability to take po meds, currently on IV
Labetalol, Hydralazine, Lasix & started Clonidine patch on [**3-2**].
Once pt can tolerate PO, would restart coreg/valsartan per
cardiology.
.
#) APML: Day 25 s/p induction with 7+3 and Atra. Pt was
intermittently febrile & neutropenic throughout ICU course on
broad spectrum ABx including Vanc, Aztreonam, Acyclovir,
Caspofungin & completed a 5 day course of Levo for atypical
coverage. Counts recovering, ANC >500 as of [**2-28**] and pt has not
had any fevers in last 24 hrs. Pt is still having some mild
bleeding from oropharynx likely due to resolving mucositis,
trauma & possible reactivation of HSV mucositis. Per ID, there
is no need to restart treatment dose Acyclovir unless mucosa
fails to improve over next few days. Pt has not been getting PCP
[**Name9 (PRE) **] while NPO, d/w BMT and presumably safe in the short term.
.
#) HTN: BP was well controlled while intubated on Carvedilol,
Valsartan, Sotalol & IV lasix diuresis. However, pt has been
unable to take po & pressures became persistently elevated since
extubation requiring max dose IV meds including Hydralazine,
Labetalol, Lasix & on [**3-2**], pt was started on a Clonidine patch.
Pt has hx of lifelong hypertension that has been difficult to
control. Renal US showed no evidence of renal artery stenosis.
BP has not been particularly responsive to diuresis. Continue
current regimen & anticipate >24hrs before onset of action for
Clonidine patch.
.
#) HSV: Pt had hard palate swabs positive for HSV, Acyclovir
was increased to treatment dose and pt completed a 14day course.
Pt still unable to take significant po due to mucositis,
Acyclovir was decreased to ppx dose on [**2-28**] and pt was continued
on viscous lidocaine, Magic Mouthwash, Morphine & Ativan prn. Pt
was noted to have significant skin breakdown on hard palate with
e/o bleeding on [**3-2**] thought to be secondary to trauma &
suctionning. D/w ID who recommended continuing ppx dose
Acyclovir, monitor for interval worsening, and consider
reswabbing HSV DFA is no improvement.
.
#) Constipation ?????? Since extubation on [**2-24**], pt has not had a BM.
Pt has not been able to take PO stool softeners due to mucositis
and nothing per rectum while she continues to be neutropenic.
Abd is mildly distended with BS, pt is having flatus.
BMT floor course after return:
.
# APML (15-17) s/p cytarbine, idarubicin followed by ATRA,
intra-thecal ara-c on [**3-5**]
- Had LP and per hemepath there were no definite blasts in CSF
from [**3-5**]; did have myeloid precursors but likely contamination
from peripheral blood
- pt was continued on ATRA, along with Bactrim for PCP
prophylaxis
[**Name Initial (PRE) **] leukocytosis initially which was thought to be [**1-16**] ATRA
maturation of cells and recovery of marrow which was consistent
with normalization after a few days.
- continued to have early cells in peripheral blood including
bands, myelos, promyelos; somewhat worrisome and another
incentive to cont therapy soon especially considering the fact
that the cure rate for patients with this disease is about 70%
and the normal treatment for this disease is 3 rounds of
anthracyclines + ATRA --> therefore risks and benefits were
discussed with patient regarding further anthracyclines and it
was decided to continue with mitoxantrine for a second round on
[**3-15**] given that there is often an acute non-cumulative dose
related cardiac toxicity in patients that receive
anthracyclines. Prior to therapy cards were consulted who
agreed pt had not received an amount of anthracycline that would
put her at risk for a cumulative effect and could not say
definitively that the first event was due to idarubacin although
it was the most likely cause. Prophylaxis with Dexrazoxane 500mg
IV given 30 minutes prior to each dose of mitoxantrone was used
for prevention of cardiac toxicity. Her counts reached an
appropriate nadir without complication with intermittent
transfusions for low platelets and hematocrits and subsequently
recovered. She continued to received prophylactic acyclovir,
fluconazole, and Bactrim. She received a repeat bone marrow
biopsy on day +16 s/p mitoxantrine. The results of this are
pending at the time of discharge. She will follow up at the
outpatient clinic in several days for count checks and with Dr.
[**First Name (STitle) **] in approximately 1 week.
.
# Acute systolic HF, resolved
Pt had acute systolic heart failure likely [**1-16**] to idarubicin
related cardiac tox although it is also possible this was septic
induced (but no definite culutres positive). Pt had global
hypokinesis and was on diuretic therapy when I came on the
service with metoprolol. Some time before that ACEi and
carvedilol had been d/c'd. EF at this time was 50%. The BB was
continued and titrated to better HR control ( was on metoprolol
37.5mg po bid by the time I signed off). She was diuresed until
appeared euvolemic and LFTs which almost certainly were due to
hepatic congestion and not med related trended down with
diuresis. At the time of euvolemia she still had significant
dependant edema ([**12-16**]+) but given euvolemic we held further
diuresis and allowed pt to equilibrate and eventually
autodiurese (as EF has recovered). A repeat echo showed EF
55-60% (although not completely back to baseline). Prophylaxis
with Dexrazoxane 500mg IV given 30 minutes prior to each dose of
mitoxantrone was used for prevention of cardiac toxicity for the
second round of anthracyclines. No s/s of toxicity were
apparent during the rest of her admission.
.
# LUE DVT: The patient was noted to have LUE swelling on [**3-23**]. An
ultrasound confirmed a DVT associated with the PICC in that arm.
The PICC was removed and she was begun on Lovenox for
anticoagulation. As her platelets decreased below 70, her
Lovenox was held and then restarted after they increased again.
A repeat u/s on [**3-29**] confirmed the presence of continued clot in
the subclavian vein. She was continued on Lovenox on discharge
for another 2 weeks.
.
# Aspiration pneumonia
- completed 10 days of flagyl and levofloxacin today on [**3-13**] and
remained afebrile thorugh entire course and afterwards
.
# Profound Dysphagia, weakness
- failed swallow eval and then had video swallow demonstarting
pt may take nectar pre-thickened fluids but given that pt would
not be able to take enough PO a PEG was placed by GI and TFs
started. Pt had some difficulty with high residuals and this
was thought to be related to slow GI transit (large amount of
contrast from barium swallow was seen on the KUB, no
obstruction). She was initially started on Reglan with
improvement in her residuals. A re-evaluation by speech and
swallow showed that she was able to take thin liquids and a soft
diet. Her PO intake was monitored for several days and was found
to be sufficient. Her tube feeds were stopped approximately 1
week prior to discharge. In discussion with GI, they felt her
PEG tract was not mature enough for removal at the time of
discharge. She will follow up with Dr. [**Last Name (STitle) 6880**] on [**4-13**] for
removal in the GI suite but his office may contact her with an
earlier appointment.
- Pt was evaluated by neurology who agreed this was most likely
ICU polyneuropathy, given the long ICU course. An EMG/NCS was
done which was consistent with this dx. MRI was negative for
CSN involvement of tumor. No APML blast on CSF and CSF cultures
negative. Pt received agressive PT/OT for this and made
tremendous progress. She was cleared for discharge home with
only minimal PT at home. She was able to ambulate easily with
braces and minimal assistance from a walker.
.
# HTN
- metoprolol as above
.
# Hypothyrmoidism
- Continued levothyroxine, home dose 112mcg po daily
- TSH elevated but in setting of illness difficult to interpret;
may need to increase dose
.
# Fibromyalgia: continued to have good relief with PRN morphine.
Discharged with morphine PO
.
# GERD: continued on lansoprazole with good effect
.
# Hyperlipidemia
- lipitor held for elevated LFTs, not restarted on discharge,
will address at follow up appointment.
# Code: FULL
Medications on Admission:
Excedrin prn
Amitryptyline 20mg PO QHS
Levothyroxine 112mcg PO QD
ranitidine 150mg PO BID
Klor-con 8mEq PO QD
Lisinopril 20mg/HCTZ 25mg PO QD
Lipitor 20mg PO QD
Metoprol ER 25mg PO QD
Tramdol 100mg PO TID prn
Discharge Medications:
1. Lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*300 ML(s)* Refills:*0*
2. Tretinoin (Chemotherapy) 10 mg Capsule Sig: Four (4) Capsule
PO DAILY (Daily).
Disp:*120 Capsule(s)* Refills:*0*
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
[**Hospital1 **] (2 times a day) as needed for hemorrhoidal pain.
Disp:*1 tube* Refills:*0*
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
Disp:*300 mL* Refills:*0*
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*180 Capsule(s)* Refills:*2*
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
10. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 14 days.
Disp:*20 syringes* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
twice a day for 4 days.
Disp:*8 syringes* Refills:*0*
17. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Acute Promyelocytic Leukemia
ICU polyneuropathy
HSV Mucositis
Resolved acute systolic heart failure
Febrile Neutropenia
Disseminated Intravascular Coagulation
Capillary Leak syndrome
Left upper extremity DVT
Hypothyroidism
Hypertension
Fibromyalgia
Discharge Condition:
All vital signs stable, afebrile, ambulatory
Discharge Instructions:
You were admitted for treatment of your leukemia called APML.
You have experienced a number of complications but most have
resolved. You still have some weakness associated with your long
hospital stay for which you will receive physical therapy at
home. You will also continue to take a blood thinner called
Lovenox by injection to treat a blood clot in your left arm. We
have started many medications for treament of your cancer and
it's associated conditions. We will review all of these with you
prior to discharge.
Please take all your medications as prescribed and attend all of
your follow up appointments.
Please call your doctor or return to the emergency room if you
experience fevers >100.5, chills, worsening headache, visual
changes, sore throat, cough, shortness of breath, worsening pain
anywhere, nausea, vomitting, diarrhea, painful urination,
numbness, tingling, increased weakness, or any other symptom
that concerns you.
Followup Instructions:
You have an appointment at the outpatient clinic on 7 [**Hospital Ward Name 1826**]
on [**Last Name (LF) 766**], [**4-5**] at 11am for a check up and labs.
You have an appointment with Dr. [**First Name (STitle) **] on [**4-9**] at 2pm,
located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building. ([**Telephone/Fax (1) 3936**]
You have an appointment to have your PEG tube removed by the GI
doctors [**First Name (Titles) **] [**4-13**] at 10am, at the Gastroenterology Center on
the [**Location (un) **] with Dr. [**Last Name (STitle) **]. Please do not eat anything
the morning prior to this appointment.
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,055
| 149,163
|
8039+8040+55902+55906
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2141-6-13**] Discharge Date: [**2141-6-22**]
Date of Birth: [**2072-9-8**] Sex: M
Service: CARDIAC SURGERY
Date of discharge pending, awaiting rehabilitation bed.
CHIEF COMPLAINT: Asymptomatic.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male who underwent an echocardiogram in preparation for
replacement of left total hip replacement. The
echocardiogram revealed three vessel disease. A stress
echocardiogram was done in advance of his surgery where the
patient had no symptoms.
PAST MEDICAL HISTORY:
1. Asbestosis.
2. Myocardial infarction.
3. Noninsulin dependent diabetes mellitus.
4. Gastrointestinal bleed in [**2139-6-1**], with Indocin use.
5. Benign prostatic hypertrophy.
6. Peripheral vascular disease with intermittent right leg
claudication.
7. Bilateral carotid disease.
8. Status post inferior vena cava [**Location (un) 260**] filter.
9. Right hip osteomyelitis.
10. Abdominal umbilical hernia repair.
11. Obesity.
PAST SURGICAL HISTORY:
1. In 08/97, fractured pelvis and left hip with total hip
replacement.
2. In [**2136**], reversal of total hip replacement with infection
and osteomyelitis.
3. In [**1-31**], removal of total hip replacement with
antibiotics for fourteen months.
4. Right total knee replacement in [**2137**], plus bilateral knee
arthroscopy.
MEDICATIONS ON ADMISSION:
1. Glyburide 10 mg b.i.d.
2. Prevacid 30 mg q.d.
3. Pravachol 20 mg q.d.
4. Proscar 5 mg q.d.
5. Pericolace 100 mg q.d.
6. Actos 15 mg q.p.m.
7. Neurontin 600 mg p.o. b.i.d.
8. Toprol XL 25 mg q.d.
9. Enteric Coated Aspirin 81 mg q.d.
10. Senna C two tablets q.p.m.
11. Pletal 100 mg b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Quit tobacco twenty-five years ago. ETOH
occasional.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three on [**2141-6-14**]. His intraoperative
course was uneventful. He was transferred to the CSRU
postoperatively in stable condition. He was extubated on
postoperative day one. His drips were weaned off and he was
transferred to the floor on postoperative day one. He was
stable on postoperative day two. His chest tubes were
discontinued no postoperative day two. The rest of his
hospital course was fairly not significant. He has not been
able to ambulate as he has only a left girdle stone hip and
cannot weight-bear on bilateral arms on his walker as he was
doing prior to surgery because of the sternal incision. He
has been currently being assisted out of bed to chair. He
continues to remain stable at this point and is deemed ready
for discharge to a rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Proscar 5 mg q.d.
2. Actos 15 mg q.p.m.
3. Heparin 5000 units subcutaneous b.i.d.
4. Lopressor 100 mg b.i.d.
5. Lasix 20 mg q.d. times five days.
6. Tylenol 650 mg q4-6hours p.r.n.
7. Potassium Chloride 20 meq q.d. times five days.
8. Colace 100 mg b.i.d.
9. Zantac 150 mg b.i.d.
10. Aspirin Enteric Coated 325 mg q.d.
11. Glyburide 10 mg b.i.d.
12. Regular insulin sliding scale.
13. Albuterol nebulizers q6hours p.r.n.
14. Pravachol 20 mg q.d.
15. Neurontin 600 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To a rehabilitation facility.
FOLLOW-UP: Dr. [**Last Name (STitle) 28745**], primary care physician, [**Name10 (NameIs) **] two
weeks, and with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2141-6-22**] 19:24
T: [**2141-6-22**] 19:40
JOB#: [**Job Number 28746**]
Admission Date: [**2141-6-13**] Discharge Date:
Date of Birth: [**2072-9-8**] Sex: M
Service: CARDIAC SURGERY
Date of discharge pending, awaiting rehabilitation bed.
CHIEF COMPLAINT: Asymptomatic.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male who underwent an echocardiogram in preparation for
replacement of left total hip replacement. The
echocardiogram revealed three vessel disease. A stress
echocardiogram was done in advance of his surgery where the
patient had no symptoms.
PAST MEDICAL HISTORY:
1. Asbestosis.
2. Myocardial infarction.
3. Noninsulin dependent diabetes mellitus.
4. Gastrointestinal bleed in [**2139-6-1**], with Indocin use.
5. Benign prostatic hypertrophy.
6. Peripheral vascular disease with intermittent right leg
claudication.
7. Bilateral carotid disease.
8. Status post inferior vena cava [**Location (un) 260**] filter.
9. Right hip osteomyelitis.
10. Abdominal umbilical hernia repair.
11. Obesity.
PAST SURGICAL HISTORY:
1. In 08/97, fractured pelvis and left hip with total hip
replacement.
2. In [**2136**], reversal of total hip replacement with infection
and osteomyelitis.
3. In [**1-31**], removal of total hip replacement with
antibiotics for fourteen months.
4. Right total knee replacement in [**2137**], plus bilateral knee
arthroscopy.
MEDICATIONS ON ADMISSION:
1. Glyburide 10 mg b.i.d.
2. Prevacid 30 mg q.d.
3. Pravachol 20 mg q.d.
4. Proscar 5 mg q.d.
5. Pericolace 100 mg q.d.
6. Actos 15 mg q.p.m.
7. Neurontin 600 mg p.o. b.i.d.
8. Toprol XL 25 mg q.d.
9. Enteric Coated Aspirin 81 mg q.d.
10. Senna C two tablets q.p.m.
11. Pletal 100 mg b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Quit tobacco twenty-five years ago. ETOH
occasional.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three on [**2141-6-14**]. His intraoperative
course was uneventful. He was transferred to the CSRU
postoperatively in stable condition. He was extubated on
postoperative day one. His drips were weaned off and he was
transferred to the floor on postoperative day one. He was
stable on postoperative day two. His chest tubes were
discontinued no postoperative day two. The rest of his
hospital course was fairly not significant. He has not been
able to ambulate as he has only a left girdle stone hip and
cannot weight-bear on bilateral arms on his walker as he was
doing prior to surgery because of the sternal incision. He
has been currently being assisted out of bed to chair. He
continues to remain stable at this point and is deemed ready
for discharge to a rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Proscar 5 mg q.d.
2. Actos 15 mg q.p.m.
3. Heparin 5000 units subcutaneous b.i.d.
4. Lopressor 100 mg b.i.d.
5. Lasix 20 mg q.d. times five days.
6. Tylenol 650 mg q4-6hours p.r.n.
7. Potassium Chloride 20 meq q.d. times five days.
8. Colace 100 mg b.i.d.
9. Zantac 150 mg b.i.d.
10. Aspirin Enteric Coated 325 mg q.d.
11. Glyburide 10 mg b.i.d.
12. Regular insulin sliding scale.
13. Albuterol nebulizers q6hours p.r.n.
14. Pravachol 20 mg q.d.
15. Neurontin 600 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To a rehabilitation facility.
FOLLOW-UP: Dr. [**Last Name (STitle) 28745**], primary care physician, [**Name10 (NameIs) **] two
weeks, and with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2141-6-22**] 19:24
T: [**2141-6-22**] 19:40
JOB#: [**Job Number 10489**]
Name: [**Known lastname 5026**], [**Known firstname 1340**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 5027**]
Admission Date: [**2141-6-13**] Discharge Date: [**2141-6-29**]
Date of Birth: [**2072-9-8**] Sex: M
Service: CARDIAC [**Doctor First Name **]
DISCHARGE SUMMARY ADDENDUM:
ADDENDUM TO MEDICATIONS ON DISCHARGE:
1. Flovent 110 micrograms two puffs [**Hospital1 **].
2. Atrovent nebulizer q four hours prn.
3. Diltiazem 60 mg qid.
4. Amiodarone 400 mg q day.
5. Lopressor discontinued.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 5028**]
MEDQUIST36
D: [**2141-6-29**] 10:01
T: [**2141-6-30**] 10:04
JOB#: [**Job Number 5029**]
Name: [**Known lastname 5026**], [**Known firstname 1340**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 5027**]
Admission Date: [**2141-6-13**] Discharge Date: [**2141-6-29**]
Date of Birth: [**2072-9-8**] Sex: M
Service: CARDIAC [**Doctor First Name **]
DISCHARGE SUMMARY ADDENDUM: The patient's discharge to
rehabilitation was postponed by a few days because of
respiratory issues. He needed chest physiotherapy for
secretions. His pulmonary status improved with chest
physiotherapy.
On postoperative day nine the patient had an episode of rapid
atrial fibrillation. He was treated and started on Diltiazem
infusion. He continued to have an irregular heart rate over
the next day. Subsequently he converted to a sinus rhythm
though he had occasional very brief bursts of atrial
fibrillation. His Diltiazem infusion was discontinued on
postoperative day 14.
Mr. [**Known lastname **] also had an episode of coughing and spluttering
while taking po liquids. Because of a question of aspiration
he was made NPO and a swallowing study was obtained. He
underwent bedside swallowing study on [**2141-6-27**] and had a
normal mechanism. On recommendation of swallow therapy, a
modified barium swallow was obtained on [**2141-6-27**]. He did not
aspirate on the modified barium swallow and was cleared to
start regular po diet. He is currently taking regular po, his
chest is much improved. He also started ambulation on
postoperative day 14 and is doing well with that. He has been
started on Coumadin for atrial fibrillation and appeared to
be therapeutic. He will be discharged to rehabilitation as
soon as a bed is available.
ADDITIONAL DISCHARGE MEDICATIONS:
1. Coumadin 5 mg q day. INR to be checked by M.D. at
rehabilitation q day and then twice q week after INR is
therapeutic.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 5028**]
MEDQUIST36
D: [**2141-6-29**] 09:55
T: [**2141-6-30**] 09:56
JOB#: [**Job Number 5043**]
|
[
"427.31",
"787.2",
"905.5",
"440.21",
"250.80",
"414.01",
"518.5",
"E878.1",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"88.72",
"42.23",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10048, 10451
|
7828, 10025
|
5076, 5415
|
5505, 6361
|
4719, 5050
|
3916, 3931
|
3960, 4235
|
4257, 4696
|
5432, 5487
|
6899, 7802
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,382
| 185,465
|
49440+59178
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-1-18**] Discharge Date: [**2190-1-22**]
Date of Birth: [**2138-6-4**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Roxicet / Penicillins / Aspirin
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
bleeding from trach site
Major Surgical or Invasive Procedure:
s/p revision of tracheostomy with resection of granulation
tissue and oropharyngeal biopsies
History of Present Illness:
51 M h/o SCCa vallecula and tonsil treated with chemo/XRT,
s/p trach in [**2187**], presents to ED with tracheostomal bleeding
since last night. Wife noted bright red blood oozing around
trach last night, about 2 table spoons total, no clots coughed
from trach. [**Year (4 digits) 269**] saw patient this AM and noted continued
bleeding
so referred to ED.
Denies recent fevers/chills, increased sputum production. Has
not had bleeding from trach since [**2189-4-21**], which is also the
last time the trach was changed. Patient is g-tube depedent.
Past Medical History:
PAST ONCOLOGIC HISTORY: He was initially diagnosed with SCC of
the vallecula, treated with radiotherapy alone. He presented
with a new right tonsillar mass in [**10/2188**] consistent with a new
primary head and neck cancer. He underwent tracheostomy and PEG
tube placement, and was subsequently treated with concurrent
hyperfractionated every other week XRT for weeks 1,3,5 and 7
with Cisplatinum and Taxol chemotherapy according to protocol
99-11 (not actually on protocol, but treated as such). Combined
therapy completed [**2-/2189**], awaiting follow-up PET in 4 weeks.
*
PAST MEDICAL HISTORY:
1. Squamous cell cancer vallecula/tonsillar as detailed above.
2. Liver cirrhosis secondary to EtOH, complicated by
splenomegaly, esophageal varices (last EGD [**11/2188**] with grade 1
varices) with prior bleeding. Prior hepatic encephalopathy.
3. Reported history of portal vein thrombosis, though I can not
find when this happened. Most recent CT abdomen [**1-/2189**] without
thrombosis, MRI in [**7-/2188**] with normal flow.
4. Seizure disorder, last siezure >2 years ago.
5. Chronic pancreatitis secondary to EtOH.
6. Status post G-tube placement [**10-28**]
7. Status post tracheostomy
8. History of multidrug resistant Klebsiella
9. Psoriasis
Social History:
He lives at home with his wife. [**Name (NI) **] is ambulatory.
Family History:
brother died of MI at 34
Physical Exam:
PE:
Afebrile, VSS (98% on RA)
Gen: NAD, breathing comfortably
Lungs CTAB, heart RRR, Abd: benign, Neuro: awake, alert
NC/NP: patent anterior, no erythema or edema
OC/OP: no erythema or edema
Fiberoptic: supraglottis with post radiation changes, large
amounts of secretions, airway patent
fiberoptic trach shows trach in good position above carina with
no bleeding source below, trachea with smooth contour, no
pulsations
Trach removed revealing suprastomal granuloma actively oozing,
trach replaced with difficulty and cuff inflated. No active
bleeding after trach replaced.
Neck: post-radiation changes, no LAD
Pertinent Results:
[**2190-1-18**] 02:30PM PT-14.9* PTT-32.1 INR(PT)-1.3*
[**2190-1-18**] 02:30PM PLT COUNT-118*
[**2190-1-18**] 02:30PM NEUTS-85.6* LYMPHS-8.0* MONOS-5.3 EOS-1.0
BASOS-0.1
[**2190-1-18**] 02:30PM WBC-5.0 RBC-3.45* HGB-11.6* HCT-32.2* MCV-94
MCH-33.7* MCHC-36.1* RDW-13.7
[**2190-1-18**] 02:30PM estGFR-Using this
[**2190-1-18**] 02:30PM GLUCOSE-95 UREA N-6 CREAT-0.6 SODIUM-133
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-32 ANION GAP-12
Brief Hospital Course:
Patient was admitted to the hospital for observation secondary
to his bleeding trach site. He was taken the next day to the
operating room where granulation tissue was resected and the
bleeding controlled. Oropharyngeal biopsies were taken at this
time as well. Post-op he had some pain issue and his dilaudid
dose was increased which worked well. His tube feeds were
restarted. He did have some bleeding from his mouth secondary
to the biopsies and some bloody secretions from his trach. Both
of these steadily improved over the next few days. On the day
of discharge his pain was controlled, he was tolerating his tube
feeds, and the bleeding had almost completely resolved. He was
to be sent home and resume his usual trach care, tube feeds, and
medications and would follow up with Dr. [**Last Name (STitle) **] in 1 week
Medications on Admission:
ATIVAN 0.5 mg--1 tablet(s) by mouth every 4 to 6 hours as needed
for anxiety/insomnia
Albuterol-Ipratropium 2.5 mg-0.5 mg/3 mL--1 vial inhaled via
nebulizaiton every six (6) hours as needed for shortness of
breath or wheezing
Clobetasol 0.05 %--use on affected areas as directed twice a day
DILAUDID-5 1 mg/mL--4 ml by mouth every 4 hours as needed for
pain no substitution
KEPPRA 100 mg/mL--15 ml by mouth twice daily via peg tube -
LACTULOSE 10 gram/15 mL--30 milliliters by mouth three times a
day
Metoclopramide 5 mg/5 mL--10ml solution(s) by mouth every 6
hours
NADOLOL 20 mg--1 (one) tablet(s) by mouth once a day crushed
NEURONTIN 250 mg/5 mL--6 (six) ml by mouth twice a day also 12
ml at bedtime
NYSTATIN 100,000 unit/mL--1 ml suspension(s) by mouth rinse four
times a day
PREVACID 30 mg--1 tablet(s) by mouth once a day
ZOFRAN 4 mg--2 tablet(s) by mouth three times a day quick
dissolve tablets
ducolax --use suppository as directed as needed for constipation
Discharge Medications:
1. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours) as needed for wheeze.
3. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
4. Clobetasol 0.05 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
5. Levetiracetam 500 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
6. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
7. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours).
8. Nadolol 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
10. Gabapentin 300 mg Capsule [**Hospital1 **]: Two (2) Capsule PO HS (at
bedtime).
11. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q3H
(every 3 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
velacular squamous cell carcinoma
Discharge Condition:
bleeding resolved, pain better controlled, facial edema
improved, tolerating Gtube feeds
Discharge Instructions:
Please resume your normal Tracheostomy care as well as your
regular tube feeding regimens.
Please resume your previous medications regimen.
Please seek immediate medical attention if you experience:
increased bleeding from your tracheostomy, from around the
trach, or from your mouth. It is normal to have some mild
secretions with blood for the next day, but if things become
concerning please call the clinic or come to the ER.
Please leave the trach cuff inflated until your follow up visit
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2190-1-27**] 3:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2190-2-2**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2190-1-26**] 10:45
Name: [**Known lastname 3786**],[**Known firstname **] Unit No: [**Numeric Identifier 16769**]
Admission Date: [**2190-1-18**] Discharge Date: [**2190-1-22**]
Date of Birth: [**2138-6-4**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Roxicet / Penicillins / Aspirin
Attending:[**First Name3 (LF) 16770**]
Addendum:
Just prior to discharge the patient felt lightheaded when
standing. His blood pressure was found to be 100/60 laying
down, and was orthostatic with a pressue around 64/30 standing
up. His heart rate remained normal, but likely due to his beta
blockade. It was believed he was orthostatic secondary to
hypovolemia. He was NPO for days, and did not receive much IVFs
or Gtube boluses the day prior. We bolused him 2 liters NS, ran
MFs overnight, and started Gtube fluid and gatorade boluses. A
set of electrolytes showed some mild hypokalemia and
hypomagnesemia. These were replaced. The next morning his lytes
were normal other than a mild hypophosphatemia, which was
replaced. His blood pressure had normalized and he was no
longer symptomatic. We felt at this time that he was adequately
fluid resuscitated and would be ok to discharge home.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 16771**] MD [**MD Number(1) 16772**]
Completed by:[**2190-1-22**]
|
[
"303.90",
"300.00",
"571.2",
"V10.01",
"V44.1",
"519.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"29.12",
"33.21",
"31.74"
] |
icd9pcs
|
[
[
[]
]
] |
9255, 9468
|
3513, 4347
|
323, 418
|
6931, 7022
|
3048, 3490
|
7565, 9232
|
2373, 2400
|
5368, 6778
|
6874, 6910
|
4373, 5345
|
7046, 7542
|
2415, 3029
|
259, 285
|
446, 1000
|
1621, 2275
|
2291, 2357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,777
| 169,328
|
31110
|
Discharge summary
|
report
|
Admission Date: [**2190-4-20**] Discharge Date: [**2190-4-25**]
Date of Birth: [**2124-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Abdominal distension, lower extremity swelling and poor appetite
Major Surgical or Invasive Procedure:
EGD with intubation
History of Present Illness:
Mr. [**Known lastname **] is a 66 year-old man with known hepatitis B cirrhosis
and recently-diagnosed hepatocellular carcinoma who presented to
the [**Hospital1 18**] ED with approximately one week of progressive
abdominal distension and bilateral leg swelling as well as a new
anemia. He has become progressively fatigued as his leg swelling
and abdominal distension have progressed. His abdomen has felt
uncomfortable due to the distention, but he denies any actual
abdominal pain, constipation, or diarrhea. He also denies any
hematemasis, hematochezia but may have had some melena. He
denies any frank fevers but has "felt warm" with some chills as
well. Aside from him being fatigued, his family has not noticed
his mental status to be altered; his daughter denies him being
confused or disoriented. He has noted a decreaed appetite and
has had a poor PO intake. Due to the poor intake, his family
brought him into the ED.
.
Review of Systems:
Negative for fevers, melena, hematochezia. Positive for
abdominal distension, leg edema, chills, fatigue, and anorexia.
.
.
Past Medical History:
- chronic hepatitis B infection (precore mutation positive,
HBeAb positive, HBeAg negative) with cirrhosis with known grade
II varices on EGD in [**11/2188**]
- chronic thrombocytopenia, presumably from cirrhosis
- recent hepatocellular carcinoma diagnosis with "innumerable
nodules" on liver MRI with elevated alpha-fetoprotein
- positive PPD
Social History:
Smoked less than one pack of cigarettes per day. Recent alcohol
use, several drinks per week but has stopped drinking over the
past month. From [**Country 3992**]. Lives with his wife.
Family History:
His wife has a history of hepatitis B infection; otherwise
noncontributory.
Physical Exam:
On admission
General: fatigued-appearing man, uncomfortable appearing
HEENT: marked scleral icterus, dry mucous membranes
Neck: supple, JVD to earlobe
Chest: bibasliar rales
CV: regular rate/rhythm, 3/6 systolic murmur
Abdomen: tense ascites, nontender, hypoactive bowel sounds, no
palpable masses
Extremities: 3+ pitting edema to buttocks bilaterally with 2+ PT
pulses
Neuro: alert, oriented x3 per family, CN 2-12 intact, no
asterixis
Skin: markedly jaundiced with no rashes
Pertinent Results:
On Admission
[**2190-4-20**] 04:05PM BLOOD WBC-18.7*# RBC-2.72*# Hgb-10.1*#
Hct-29.9*# MCV-110* MCH-37.1* MCHC-33.8 RDW-20.7* Plt Ct-107*
[**2190-4-20**] 04:05PM BLOOD Neuts-73* Bands-0 Lymphs-7* Monos-16*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-3* Promyel-1*
[**2190-4-20**] 04:05PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2190-4-20**] 04:05PM BLOOD PT-31.0* PTT-58.6* INR(PT)-3.2*
[**2190-4-20**] 04:05PM BLOOD Glucose-137* UreaN-43* Creat-1.8*#
Na-128* K-4.9 Cl-97 HCO3-23 AnGap-13
[**2190-4-20**] 04:05PM BLOOD ALT-243* AST-235* AlkPhos-129*
TotBili-30.5* DirBili-18.6* IndBili-11.9
[**2190-4-20**] 04:05PM BLOOD Albumin-2.5* Calcium-8.2* Phos-4.5
Mg-3.0*
[**2190-4-21**] 03:19AM BLOOD Type-ART pO2-101 pCO2-30* pH-7.48*
calTCO2-23 Base XS-0
[**2190-4-20**] 06:15PM BLOOD Lactate-3.8*
[**2190-4-22**] 05:27AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-80* pCO2-36
pH-7.45 calTCO2-26 Base XS-1 Intubat-INTUBATED Vent-SPONTANEOU
[**2190-4-21**] 03:19AM BLOOD Lactate-3.6*
.
Hepatitis B viral load PCR ([**2190-4-7**]): 23,400 IU/mL
Alpha-fetoprotein ([**2190-4-7**]): 760.7
EBV serologies ([**2190-4-7**]): negative IgG and IgM
CMV serologies ([**2190-4-7**]): positive IgG, negative IgM
.
Studies:
CXR AP ([**2190-4-20**]):
There is elevation of the right hemidiaphragm, which appears new
when compared to the prior study. Findings may be due to
increased perihepatic fluid, but a subpulmonic effusion cannot
be completely excluded. Cardiac, mediastinal, and hilar contours
otherwise are unchanged, with unfolding of the aorta again
noted. The left lung is clear. No pneumothorax is identified.
Osseous structures are unremarkable.
.
CXR [**4-21**]: interval development of edema
.
MRI Abdomen ([**2190-4-7**]):
There is decrease in signal intensity of the liver diffusely on
the
in-phase images, compatible with presence of siderotic nodules.
The liver is diffusely heterogeneous in signal intensity. There
is nodularity of the liver contour compatible with chronic liver
disease. There are several nodules within the liver, which have
increased signal intensity on the T1-weighted images,
pre-contrast and decreased signal intensity on the T2-weighted
images. On the arterial phase images, there is no definite
enhancement, however, minimal peripheral enhancement of the
lesions is identified post-contrast and there also appears to be
new wash-out of contrast from many of the lesions. The liver
appears to have innumerable nodules throughout, which appear
bigger and more discrete compared to the previous study and also
show new wash-out and increased heterogeneity in the later
phases post-contrast compared with the previous study. These
findings are concerning for diffuse hepatoma (HCC). The largest
discrete lesions are as follows measuring 1.2 x 1.3 cm in the
dome of the liver. This lesion was present on the previous
study, but currently has a more round shape. Previously, it
measured approximately 1.5 x 0.9 cm. Just medial to this, there
is another lesion, which measures 1.9 x 1.4 cm and appears more
prominent than on the previous study, although this area is
difficult to evaluate as it is at the dome of the liver. In
segment V of the liver, there is a 1.8 x 1.6 cm nodule, on
series 200, image 68, which previously was approximately 1.5 x
1.3 cm. There are also tiny cysts within the liver such as an
8-mm cyst in segment VIII and a tiny cyst in the dome. There is
a linear area of increased enhancement seen in segment VI of the
liver subcapsularly. This region shows minimal increased signal
intensity on the T2-weighted images and probably represents
fibrosis with also some shunting between the portal vein and
hepatic vein without significant change. There is minimal
ascites. There is a tiny cyst in the mid left kidney. The
adrenals, spleen, and visualized pancreas appear unremarkable,
as is the gallbladder.
.
.
Brief Hospital Course:
Upon arrival to the [**Hospital1 18**] ED, T 97.8, BP 99/64, HR 100, RR 18,
Sat 95% on room air. His labs were notable for a Hct of 29.9
(down from 44.7 on [**2190-4-8**]), a WBC of 18.7 with 73% PMNs, 3%
myelos, and 1% promyelos (no bands), and an INR of 3.2 (up from
2.7 on [**2190-4-8**]). He was given two units of FFP and a diagnostic
paracentesis was performed to rule out SBP; prior to the ascitic
fluid cell count results returning, he received 1000 mg of IV
vancomycin (he was also written for 4.5 grams of
piperacillin/tazobactam but did not receive this). Of note, he
had Guaiac positive brown stool on rectal exam.
.
First night in the hospital, he became dyspneic after IVF fluids
and albumin; a chest xray: mod fluid overload. Pt developed a
new O2 requirment. Serial Hct trending down to 22 and then, the
following morning, he had a maroon, jelly-consistency stool.
Gave 2 units of pRBC's with lasix in between. BP drifted down to
SBP 80s-90s, with mild tachycardia 80s-> 105. Pt received 2 more
units of pRBCs and was transferred to the MICU for urgent EGD
with intubation.
.
In the MICU, EGD showed blood in stomach, stigmata of variceal
bleeding, one varices banded, duodenal ulcers one of which
looked ulcerated and suspicious for malignancy. Pt was continued
on ocreotide gtt, protonix gtt and antibiotics. He was given 2
more units FFP, one bag PLT and two more pRBC's. Pt was
extubated post-EGD and maintained on non-rebreather.
Paracentesis attempted but not successful. CXR c/w bowel gas,
NGT to suction. Pt's renal function deteriorated, consistent
with hepatorenal syndrome, despite volume challenge with
albumin, normal saline and blood products.
Pt's dire prognosis was discussed at length with patient and
patient's family. Ultimately the decision was made to change his
status to Comfort Measures Only, and the patient was transferred
to the floor. Pt was kept comfortable with supplemental oxygen
and morphine prn. Pt expired on [**2190-4-25**].
Medications on Admission:
tenofovir 300 mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary Edema
hep B Cirrhosis
HCC
Discharge Condition:
Expired
Discharge Instructions:
NA
Completed by:[**2190-4-26**]
|
[
"276.1",
"288.60",
"584.9",
"456.20",
"789.59",
"572.4",
"599.71",
"285.1",
"532.40",
"287.4",
"518.81",
"V66.7",
"070.30",
"155.0",
"514",
"795.5",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"42.33",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8710, 8719
|
6628, 8608
|
380, 401
|
8799, 8809
|
2683, 6605
|
2093, 2170
|
8682, 8687
|
8740, 8778
|
8634, 8659
|
8833, 8866
|
2185, 2664
|
1379, 1506
|
276, 342
|
429, 1360
|
1528, 1874
|
1890, 2077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,058
| 168,170
|
53203
|
Discharge summary
|
report
|
Admission Date: [**2193-7-22**] Discharge Date: [**2193-8-12**]
Date of Birth: [**2132-3-19**] Sex: M
Service: MEDICINE
Allergies:
albuterol
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
high dose melphalan and auto stem cell transplant
Major Surgical or Invasive Procedure:
Left subclavian line insertion
History of Present Illness:
61-year-old man with a history of kappa light chain multiple
myeloma. He is status post four cycles of Velcade and
dexamethasone.
Patient was originally diagnosed with a plasmacytoma that was
found incidentally on a CXR and was treated and had a cage
placed. A couple of years later he developed left shoulder pain
and further testing indicated he had MM and he was started on
treatment with Velcade and completed four cycles. The only
complication he developed from this treatment was lower
extremity neuropathy which he feels as pins and needles and
numbness with some tnederenss of the feet. He was then found to
have a lesion on a rib on a cxr following his velcade regimens.
He has completed XRT for this lesion. He completed a 21 day
course of relmicade on [**7-18**] and is currently off all
medications.
His last BM showed no morphological evidence of a plasma cell
myeloma and his last protein electrophoresis performed on [**Month (only) 116**]
29was negative for an M spike. On that same day, his kappa
lambda ratio was normal at 1.52 with a free kappa of 10.5 and a
free lambda of 6.9. His last IgG was 434, IgA 75 and IgM 48
Today he was directly admitted for autologus stemcell
transplant. Today he denies any fevers, chills, nausea,
vomiting. He reports that he has a heat rash on his chest afer
all of the heat recently. He denies any associated puritis. He
also reports some dry skin, but no other skin changes or skin
breakdown or lesions on his feet.
Past Medical History:
#Multiple myeloma, s/p XRT to left shoulder and 4 cycles
bortezomib and dexamethasone.
#Atrial fibrillation s/p catheter ablation (not on
anticoagulation since).
Social History:
He works at the high school in [**Hospital1 8**], previously has worked
[**Hospital1 18**] and the [**Last Name (un) **]. He lives alone and has two adult daughters
who live in [**State 350**]. He smoked >1 pack per day up until
age 35. He drinks socially.
Family History:
His mother had lung cancer but died of cardiovascular disease.
His father is still living. He has two grown children.
Otherwise, no known family history of malignancy.
Physical Exam:
Admission Exam:
VS 98.2, 122/82, 92, 20, 99RA height:67.25in, Wt 216lbs
GEN: AAOx3, NAD, sitting up in a chair
HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
CVS: RRR, no m/r/g
LUNGS: CTAB
ABD: soft, NT, ND, NABS
ext: 2+ pulses, no c/c/e
Skin: erythematous plaques scattered on the chest bilaterally.
No exudates, pustules or associated crusting.
neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat.
Discharge Exam:
VS 99.1, 98.9, 118/70, 20, 95% RA
GEN: AAOx3, NAD
HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
CVS: RRR, NS1S2,no m/r/g
LUNGS: CTAB with slightly decreased breath sounds
ABD: soft, NT, ND, +BS
ext: 2+ pulses, 2+ peripheral edema
Skin: no lesion
neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat,
decreased sensation on soles of both feet
Psych: calm, appropriate
Pertinent Results:
Admission labs:
[**2193-7-22**] 10:45AM BLOOD WBC-3.3* RBC-4.39* Hgb-13.7* Hct-42.9
MCV-98 MCH-31.3 MCHC-32.0 RDW-13.9 Plt Ct-210
[**2193-7-22**] 10:45AM BLOOD Neuts-56 Bands-0 Lymphs-17* Monos-17*
Eos-4 Baso-4* Atyps-1* Metas-0 Myelos-0 Hyperse-1*
[**2193-7-22**] 10:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2193-7-22**] 10:45AM BLOOD PT-9.8 PTT-29.4 INR(PT)-0.9
[**2193-7-22**] 10:45AM BLOOD UreaN-12 Creat-0.7 Na-143 K-5.0 Cl-107
HCO3-32 AnGap-9
[**2193-7-22**] 10:45AM BLOOD ALT-18 AST-13 LD(LDH)-150 AlkPhos-55
TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2193-7-22**] 10:45AM BLOOD TotProt-5.9* Albumin-4.0 Globuln-1.9*
Calcium-9.2 Phos-2.9 Mg-2.2
[**2193-7-22**] 06:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2193-7-22**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
[**2193-7-22**] 06:20PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2193-7-22**] 06:20PM URINE Mucous-RARE
Micro:
[**2193-7-29**] Stool- CDIFF negative
[**2193-7-30**] Blood cutlure
7/3/12/ Urine culture
Imaging:
CXR [**2193-7-22**]: IMPRESSION: Satisfactory position of left
subclavian catheter.
CXR [**2193-8-1**]: As compared to the previous radiograph, there is no
relevant
change. No evidence of pneumonia or other acute lung disease.
Unchanged
moderate cardiomegaly without pulmonary edema. No pneumothorax.
Constant
position of the vertebral fixation devices and the left
subclavian catheter.
CT chest [**2193-8-2**]: 1. No evidence of acute infectious or
inflammatory process. 2. Radiation fibrosis from T6 and right
eighth rib radiation therapy. 3. Expansile right eighth rib
lesion, surgical repair of pathological fracture within T6 and
severe compression fracture of L1, consistent with patient's
history of multiple myeloma.
CT Sinus [**2193-8-2**]: Sinus disease as noted above with hyperdense
material within the right frontal and right maxillary sinus
which may represent inspissated secretions versus fungal
colonization. No bony dehiscence.
Brief Hospital Course:
Mr. [**Known lastname 1968**] is a 61 yo M w/ PMH of multiple myeloma s/p velcade
treatment who was admitted for high dose melphalan and auto stem
cell transplant complicated by neutropenic fever and atrial
tachycardia requiring ICU stay.
#Multiple myeloma- patient underwent high dose melphalan and
then auto stem cell treatment for his multiple myeloma. He
developed high grade mucositis and required TPN for nutrition
during this time and IV pain medication. The muscositis improved
and pt was transitioned to PO medications with slow advancement
of diet as tolerated. The patient tolerated auto transplant well
and engrafted, white blood cell count on discharge 7.8 with 76%
PMN. Patient will follow up as directed with Dr. [**Last Name (STitle) 410**].
#Neutropenic fever- patient developed neutropenic fevers on Day
+4 with fevers to 104 despite broad spectrum antibiotics. He had
imaging of his sinuses and chest given cough and sinus symptoms
and was found to have a sinusitis. There was no [**Last Name (un) 2043**]
inovlvement and ID was consulted and recommended ENT to scope.
ENt saw no evidence of necrosis and no biospy was obtain and
swabs were sent which showed no evidence of fungus. Pt was
changed from ambisone to micafungin per ID recs. The patient's
white count recovered and antibiotics were discontinued. The
patient remained afebrile and will not require antibiotics on
discharge. He will continue acylovir prophylaxis.
#Tachycardia- on Day +8 patient had been febrile x 4 days and
went into a supraventricular tachycardia to teh 200s. This was
unresponsive to adenosine given on the floor. Cardiology was
consulted and recommened amiodarone drip so the patient was
transferred to the [**Hospital Unit Name 153**]. He remained hemodynamically stable and
chest pain free despite the tachycardia. In the ICU, pt was on
an amiodarone drip and diltiazem drip with good control of
tachycardia. He was transitioned from the drips to PO amiodarone
and diltiazem without recurrence of the tachycardia. Of note,
he had a few episodes of asymptomatic atrial fibrillation while
in the ICU (pt has known h/o Afib status post ablation). The
patient was transferred to the floor and placed on telemetry.
He had no recurrence of the tachycardia on the oral medications.
The patient will complete an amiodarone taper as directed and
follow up with cardiology.
#Neuropathy- patient has peripheral neuropathy following his
velcade treatment. This was stable during this admission and
began to improve somewhat towards the end.
#Mucositis-Patient had significant mucositis, which was treated
with morphine as needed, caphasol and gelcair. This resolved and
the patient was able to tolerate food and drink.
# Diarrhea: Thought to be due to melphalan. Cdiff negative [**7-29**]
and [**8-6**]. Patient was treated with Loperamide PRN. Bowel
movements decreased from 10/day to baseline of [**3-1**] per day.
Transitional issues:
-cardiology follow up
-heme onc follow up
Medications on Admission:
None
Discharge Medications:
1. diltiazem HCl 90 mg tablet Sig: One (1) tablet PO QID (4
times a day).
Disp:*120 tablet(s)* Refills:*2*
2. acyclovir 400 mg tablet Sig: One (1) tablet PO Q8H (every 8
hours).
Disp:*90 tablet(s)* Refills:*2*
3. amiodarone 200 mg tablet Sig: please take 400 mg twice daily
until Friday [**2193-8-16**], then on [**2193-8-17**] start taking 200 mg twice
daily until Friday [**2193-8-23**], then starting on [**2193-8-24**] take 200 mg
daily until you are told to stop by your cardiologist. tablet PO
BID Disp:*50 tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple myeloma- autologous stem cell transplant
Sinusitis
Atrial tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1968**]
It was a pleasure taking care of you while you were here at
[**Hospital1 18**]. You were admitted for chemotherpay and an auto stem cell
transplant. You underwent this and had some fevers and were
found to have a sinus infection while you were here and treated
with IV antibiotics while your counts were low. During your
stay your heart rate went into a fast rhythm and you were
temporarily in the ICU while you were on medications to slow the
heart rate. You are now safe to go home.
**Please see below for follow up appointment with Hematology and
Cardiology
Medications started:
Diltiazem 90 mg by mouth 4 times per day
Amiodarone- please take 400 mg twice daily until Friday [**2193-8-16**],
then on [**2193-8-17**] start taking 200 mg twice daily until Friday
[**2193-8-23**], then starting on [**2193-8-24**] take 200 mg daily until you
are told to stop by your cardiologist.
Acyclovir- 400 mg PO every 8 hours
Medications changed/stopped: None
Followup Instructions:
Cardiology- Eletrophysiology
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]
[**2193-9-16**]
Time: 10:20 AM
Where: Shapior [**Location (un) **]
Department: HEMATOLOGY/BMT
When: TUESDAY [**2193-8-13**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2193-8-13**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2193-8-13**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"787.91",
"427.31",
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"780.61",
"427.89",
"288.00",
"276.8",
"528.00",
"473.9",
"203.00",
"E849.7",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93",
"99.15",
"41.04"
] |
icd9pcs
|
[
[
[]
]
] |
9141, 9147
|
5535, 8461
|
320, 352
|
9270, 9270
|
3413, 3413
|
10438, 11573
|
2329, 2498
|
8580, 9118
|
9168, 9249
|
8551, 8557
|
9421, 10415
|
2513, 2962
|
2978, 3394
|
8482, 8525
|
231, 282
|
380, 1852
|
3429, 5512
|
9285, 9397
|
1874, 2038
|
2054, 2313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,407
| 153,355
|
10318
|
Discharge summary
|
report
|
Admission Date: [**2186-3-28**] Discharge Date: [**2186-4-17**]
Date of Birth: [**2113-5-5**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
LE edema and syncope 4 days ago
Major Surgical or Invasive Procedure:
Cardiac catheterization
PD catheter replacement
History of Present Illness:
72 yo M who presented with LE and scrotal edema x 4 days and
syncopal episode 4 days ago. Patient states that his PD
catheter has not been working properly during the same time; he
reports putting in 2L dialysate and only getting 1L fluid out.
This occurred in [**12-5**] requiring laparascopic repositioning of
PD catheter on [**2186-1-5**].
.
Patient also reports 2 syncopal episodes in the past week. He
denies feeling lightheaded, palpitations, pain, or SOB prior to
episodes. He denies post-ictal confusion or incontinence. He
denies head trauma, but reports falling on his elbow and back.
He complains of left elbow pain along with some low back pain.
He reports a prior episode of syncope in [**9-/2184**], resulting in
CABG and AICD placement. In [**2-6**] he had a p-MIBI showing
mod-severe partially reversible perfusion defect in the inferior
wall. He had frequent episodes of AFib and was restarted on
amiodarone. He had his AICD interrogated by Dr. [**Last Name (STitle) **] on
[**2186-3-10**]. He denies any chest pain/pressure, SOB, N/V/D, or F/C.
.
In the [**Name (NI) **], pt had positive troponin. Dr [**Last Name (STitle) 34293**] talked to the
on-call cardiology fellow, and in the setting of ARF he did not
feel that this was due to an acute coronary event.
.
ROS: Pt reports having a URI with cough last week. He also
admits to 2 pillow orthopnea, no PND. He is able to walk up one
flight of stairs; no change in his exercise tolerance.
Past Medical History:
CABG x 3: LIMA-LAD, SVG-OM, SVG-Diag in [**9-4**] at [**Location (un) 7349**] [**Hospital1 **] after
presenting with loss of consciousness. Followed by Dr. [**First Name (STitle) **]
[**Name (STitle) **].
MV repair: [**9-4**] (#28 Physio ring)
AICD implant: [**9-4**] for VT
ESRD: [**2-2**] IgA nephropathy
Peritoneal dialysis
HTN
s/p Left-sided CVA
dyslipidemia
Atrial fibrillation
Gout
Social History:
He lives alone, has family in [**Location (un) **]. He emigrated from [**Location (un) 30926**] in [**2172**]. He denies cigarette, alcohol or drug use. He
does occasionally take Chinese herbal medicines.
Family History:
His parents are both deceased of unclear cause.
He has two siblings, both deceased of unclear cause. He has
three children ranging in age from 40-47. He is not able to
specify what medical problems they have but says they do have
medical problems.
Physical Exam:
T 95.6 HR 70 BP 169/89 RR 10 O2Sat 100% RA
Gen: NAD, lying in bed comfortable
Heent: PERRL, EOMI, MMM
Neck: supple
Lungs/Chest: CTA b/L
Cardiac: RRR S1/S2 no murmurs
Abdomen: Increased distension, soft, NT, PD cath in place. +BS
Ext: +2 pitting edema upto knee and + scrotal edema
Neuro: AAOx3, no wrist flap
Pertinent Results:
CXR [**3-28**]: 1. Markedly tortuous aorta. 2. Patchy opacity in left
lower lobe, which may represent atelectasis; however, pneumonia
cannot be excluded. 3. Prominent gas below the right
hemidiaphragm, probably representing air fluid level in the
colon; however, clinical correlation recommended. 4. Small left
effusion.
.
Xray L-S spine [**3-28**]: Marked degenerative changes. No definite
evidence of fracture. Gallstones. Spinous processes are not
well visualized on this study.
.
Xray elbow [**3-28**]: Well-corticated bone fragment at medial
epicondyle, which may represent avulsion fracture; however, the
finding is unlikely to be acute.
.
PD fluid [**3-29**]: 588 WBC, 93 RBC, 50% PMN, 45% lymph
PD fluid gram stain [**3-29**]: 1+ PMN, no organisms
PD fluid cx [**3-29**]: negative
PD fluid [**3-30**]: 490 WBC, 400 RBC, 42% PMN, 17% lymph
PD fluid gram stain [**3-30**]: 1+ PMN, no organisms
PD fluid cx [**3-30**]: negative
PD fluid [**4-1**]: 240 WBC, 1145 RBC, 80% PMN
.
KUB [**3-30**]: Free intra-abdominal air under the right
hemidiaphragm.
Peritoneal dialysis catheter in the left lower quadrant. Unable
to determine if it is occluded on these plain film radiographs.
.
Abd CT [**4-2**]: 1. Bilateral moderately sized pleural effusions and
associated basilar atelectasis.
2. Large amount of abdominal and pelvic ascites. The fluid
measures density values of approximately 10 Hounsfield units or
less, which is consistent with ascites, rather than hemorrhage.
There is no sentinel clot sign seen. However, it is difficult
to exclude that an intraperitoneal hemorrhage has mixed with
pre-existing ascites and therefore has low-density values. The
ascites is mostly intra-abdominal with sparing of the
retroperitoneum.
3. Small umbilical hernia.
4. Diverticulosis, without evidence of diverticulitis.
.
Cath [**4-3**]: 1. Three vessel coronary artery disease.
2. Patent SVG --> OM2.
3. Patent SVG --> diagonal.
4. Patent LIMA --> LAD.
5. Mildly elevated left ventricular filling pressures.
6. Systemic hypertension.
7. Small left to right shunt at the level of the right atrium.
.
Echo [**3-29**]: LA is mildly dilated. Mild symmetric LVH. Mild
global LV hypokinesis; lateral wall moves best. Overall LV
systolic function is mildly depressed (45%). E/e' is elevated
(>15) suggesting increased LV filling pressure (PCWP >18mmHg).
RV systolic function is borderline normal. Aortic root is
moderately dilated. Ascending aorta is moderately dilated.
Aortic arch is mildly dilated. Aortic valve leaflets are mildly
thickened. Mild to moderate ([**1-2**]+) AR is seen. Mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-2**]+) MR is
seen. [the severity of MR may be significantly UNDERestimated.]
Moderate [2+] TR is seen. Severe PA systolic hypertension.
Significant pulmonic regurgitation is seen. Compared with prior
[**2185-8-15**], LV systolic function is now less vigorous and MR is
more prominent. Estimated PA systolic pressure is much higher.
.
CXR [**4-1**]: The lung volumes are low, but the lungs are clear.
Deviation of the trachea to the right is partly attributable to
the tortuous aorta. No effusion. No significant interval
change.
.
KUB [**4-5**]: The peritoneal dialysis catheter is seen coiled in the
left mid abdomen. It has not changed in position or appearance
since the prior exam.
.
CXR [**2186-4-12**] - Slight increase in left pleural effusion, now
moderate in size. Persistent small right pleural effusion.
U/S LUE [**2186-4-14**]-No evidence of DVT.
Brief Hospital Course:
72 yo M with ESRD on PD, s/p CABG, and AICD who presented with
LE and scrotal edema, syncopal episode, elevated troponin, and
ARF. Patient's edema is likely related to PD catheter
dysfunction, either from clot, fibrin blockage, catheter
displacement, or infection. Syncope may be explained by drop
attack from decreased venous return. However, patient's prior
history of cardiogenic syncope is concerning for AICD
malfunction, arrhythmia, or ACS.
.
## Syncope: Unclear etiology. [**Month (only) 116**] be explained by drop attack
from decreased venous return. EP consulted to interrogate AICD:
working well with no episodes of AFib. Neuro consultants felt
that peripheral neuropathy causing poor proprioception, cervical
spondylosis and nighttime dialysis causing increased tiredness
(no seizures). Echo with PA HTN and decr EF, thought to be from
volume overload. TSH elev with nl T4 (may be due to amiodarone,
reassess in [**1-2**] mos), nl B12 and folate, nl HbA1c, nl SPEP.
UPEP with multiple protein bands but no monoclonal Ig.
.
## CAD: On admission, Trop was likely elevated in setting of ARF
and CK elevated [**2-2**] to fall; troponin trended down twice. Cards
felt that EKG changes were minimal. He was ruled out for MI.
He underwent Cardiac Cath on [**4-3**] which showed patent stents. He
was continued on ASA, lipitor, BBlocker. ACEI deffered
initially given Renal Insufficiency. Given his history of CAD,
Plavix was started on discharge.
.
## Acute on chronic renal failure: Acute renal insufficiency on
admission thought secondary to PD catheter malfunctioning and
underdialysis. PD catheter dysfunction, either from clot,
fibrin blockage, displacement, or infection. Renal service
followed patient while he was admitted along with transplant
surgery. He underwent PD catheter replacement [**2186-4-7**]. Course
complicated by intrabdominal hematoma. PD catheter exchange
fluid was blood tinged and hct was monitored closely. PD fluid
cleared and hct remained stable. He was also contiued on Epo.
.
.
## Fever: Patient had fever to 101.1 on [**4-13**]. PD fluid culture
grew Enterobacter and he was started on Ceftaz IP.
Sensitivities later returned and patient was changed over to PO
Bactrim on discharge.
.
## HTN: Poorly controlled. He was continued on BBlocker at TID
dosing, ACEI was restarted at a lower dose, tamsulosin and
amlodipine.
.
## A. fib: Was continued on Amiodarone. Coumadin was not
started as patient has been unreliable in follow up per OMR
notes.
Medications on Admission:
aspirin 81mg once daily
lisinopril 20 mg b.i.d.
allopurinol 150 mg every other day
metoprolol 100 mg b.i.d.
paroxetine 10 mg daily
pantoprazole 40 mg daily
tamsulosin 0.4 mg daily
amiodarone 200 mg daily
Lipitor 20mg daily
Calciferol 2.5mcg daily
Dyazide [**Hospital1 **]
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
14. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a
day for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO once a day.
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Chronic Kidney disease
intrabdominal bleed
Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all your medications as directed and
follow up with your appointments as below.
.
If you notice difficulty with peritoneal dialysis, blood in the
peritoneal fluid, fevers, chills please return to emergency
room.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 34294**] and [**Doctor First Name 3040**] (dialysis nurse)
tomorrrow [**4-18**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2186-4-27**] 1:20
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2186-5-4**] 11:00
Completed by:[**2186-4-18**]
|
[
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"286.7",
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"780.2",
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"996.56",
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"427.31",
"719.42",
"V53.32",
"998.12",
"553.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"97.82",
"54.93",
"53.49",
"54.95",
"37.23",
"88.56",
"54.98",
"88.57",
"96.71",
"99.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10922, 10989
|
6655, 9164
|
301, 350
|
11100, 11109
|
3100, 6632
|
11393, 11834
|
2504, 2756
|
9486, 10899
|
11010, 11079
|
9190, 9463
|
11133, 11370
|
2771, 3081
|
230, 263
|
378, 1851
|
1873, 2263
|
2279, 2488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,528
| 169,102
|
45124
|
Discharge summary
|
report
|
Admission Date: [**2117-10-21**] Discharge Date: [**2117-11-5**]
Service: MEDICINE/[**Hospital1 **]
HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old
man who is a nursing home resident and has a past medical
history significant for progressive neurologic decline over
the last year who was transferred from the nursing home for
feeding tube placement. The patient had recently been
discharged from [**Hospital1 69**] after
admission for aspiration pneumonia, sepsis. At that time the
family was informed that the patient had failed swallowing
evaluation and was at risk for recurrent aspiration if fed
orally, however, the family refused feeding tube stating the
patient would not want invasive measures. Nevertheless, a
couple of days prior to admission, the patient began to
develop increased cough during oral feeding and the family
decided to accept invasive measures including feeding tube.
Since the patient could not receive feeding via nasogastric
tube at nursing home the patient was transferred to [**Hospital1 1444**] for nasogastric tube feeding
and eventual percutaneous feeding tube placement. At time of
presentation the patient was nonverbal, responsive only to
painful stimuli, as a result, the patient could not provide
additional history. No other family members were present for
further history. Of note, the patient has a history of
previous gastrostomy tube placement, which was discontinued
secondary to bleeding.
PAST MEDICAL HISTORY:
1. Progressive neurological decline.
2. Dementia.
3. History of left parietal cerebrovascular accident.
4. Recurrent aspiration pneumonia.
5. MRSA colonization.
6. Coronary artery disease status post coronary artery
bypass graft.
7. Cerebellar pontine meningioma.
8. Benign prostatic hypertrophy status post transurethral
resection of the prostate.
9. Hypothyroidism.
10. Recurrent urinary tract infection.
11. Mild pulmonary hypertension.
12. AV block.
13. Cervical spondylitis.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Nursing home resident.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Megestrol 40 mg po q.i.d.
3. Levothyroxine 75 micrograms q.d.
4. Atorvastatin 10 mg q.d.
5. Lansoprazole 30 mg q.d.
6. Metoprolol 50 mg b.i.d.
7. Colace.
8. Senna two tablets b.i.d.
9. Captopril 12.5 mg t.i.d.
ALLERGIES: Diamox, Hydrochlorothiazide.
PHYSICAL EXAMINATION: On presentation the patient was found
to have vital signs as follows, temperature 99.8, heart rate
76, blood pressure 187/90. Respiratory rate 16, 02 sat 100%
on room air. The patient was nonverbal with minimal response
to voice, minimal response to touch and some response to
painful stimuli. The patient was markedly contracted. Heart
sounds and lung sounds were difficult to appreciate.
LABORATORY STUDIES: Hematocrit significant at 32.8, SMA 7
unremarkable. Chest x-ray some interval improvement in left
basilar atelectasis, pleural effusion.
HOSPITAL COURSE: 1. Fluid, electrolytes and nutrition:
Nutrition, nasogastric tube was placed in the Emergency
Department for tube feeding. Gastrointestinal was consulted
and evaluated the patient on hospital day number three and
recommended the patient be given percutaneous jejunostomy
tube by interventional radiology to decrease the risk of
aspiration. Interventional radiology attempted tube
placement on hospital day number six, but was unable to place
tube secondary to anatomy. As a result the patient was
evaluated by General Surgery on hospital day number seven and
was taken to the Operating Room on [**2117-10-28**] hospital day
number eight. There was no intraoperative complications, but
immediate postoperative course was complicated by respiratory
decompensation most likely secondary to an aspiration event.
the patient was admitted to the MICU. The patient was
started on free water drip through the jejunostomy tube from
discharge from the MICU on hospital day nine. These were
temporarily held when the patient was briefly transferred
back to the MICU care secondary to likely mucous plug later
that evening. On hospital day number ten the patient was
stable on the general wards and was started on tube feeds at
half strength. Feeds were again held on hospital day 11 for
evaluation of abdominal tenderness and increased bilious
nasogastric tube output. Tenderness was found to be
secondary to hematoma around tube site with no evidence of
ileus/obstruction, so feeds were restarted again at half
strength on hospital day number 12. Surgery recommended the
patient be advanced to and kept at 3/4 strength feeds to
decrease risk of bowel necrosis. As a result the patient's
goal rate was determined to be 75 cc an hour at 3/4 strength.
Surgery also recommended 50 cc free water boluses q 6 hours.
This goal was reached on hospital day number 14. An
nasogastric tube was discontinued. The patient continued to
tolerate feeds well through the jejunostomy tube. The
patient was followed by Nutrition Service as well during
admission. At discharge the patient was on Probalance feeds
as recommended by the Nutrition Service.
Electrolytes, the patient received electrolytes replacement
prn.
Fluids, the patient received fluid resuscitation prn.
2. Respiratory: The patient's respiratory status was stable
until the patient experienced episode of desaturation about
30 minutes after admission to the PACU following jejunostomy
tube placement. The patient was intubated and transferred to
the MICU. Event determined to be most likely secondary to
aspiration. The patient did well and was extubated on
hospital day number nine, the day following intubation and
was discharged to the floor. Later that evening the patient
desaturated again and was transferred back to MICU care, but
secondary to bed shortage remained in the MICU care, but on
the general [**Hospital1 **]. The patient did well after nasal
suctioning and was transferred back to care of the general
medicine team on the morning of hospital day number 10.
During the remaining admission the patient received
Guaifenesin around the clock and q.i.d. nasal suctioning to
decrease risk of further desaturation from retained
secretions. The patient was also given a course of
Levofloxacin for likely aspiration pneumonia.
3. Cardiovascular: Rhythm, at admission the patient had a
history of first degree AV block. The patient was also noted
to have episodes of atrial fibrillation during this
admission. The patient was rate controlled with beta blocker
and anticoagulated, but was felt to be a poor candidate for
further intervention.
Pump, the patient has a history of regurgitation and has had
prophylaxis for dental procedures.
Ischemia, the patient has a history of coronary artery
disease. During this admission found to have
electrocardiogram changes and elevated troponin in the
setting of respiratory decompensation. These normalized.
The patient was maintained on Lovenox, aspirin, beta blocker,
ace inhibitor and statin. The patient was felt to be a poor
candidate for further interventions secondary to general
medical condition.
4. Neurology: The patient has a history of rapid onset of
neurologic decline that has led to abrupt decline over the
last year to the point that the patient has become
contracted, bed bound and almost mute. The patient had an
MRI during this admission, which showed old left hemisphere
infarct, increased size of meningioma and atrophy.
Parkinsonian syndrome was considered in the differential and
neurology felt a trial of Sinemet would be reasonable,
however, they cautioned that the patient's history is not
typical of classic Parkinson's disease and that Sinemet has
much less benefit in other Parkinsonian syndromes. They
recommended that if a trial of Sinemet be pursued it should
be delayed until after the immediate postoperative period.
This was not started during this admission. Of note, over
the course of the admission the patient had rare
verbalization, which was always logical. There was also rare
incidence in which the patient responded to commands. I
suspect that the patient may have significant comprehension,
but limited ability to verbalize. As a result please keep
this in mind when speaking in front of the patient.
5. Hematology: The patient required transfusion of 2 units
of packed red blood cells after hematoma development around
the jejunostomy site. Hematocrit was stable following
transfusion.
6. Vascular: Deep venous thrombosis identified in the left
brachial artery on hospital day number two. The patient was
initially maintained on Lovenox in preoperative period. This
was switched to Heparin in the postoperative period to
decrease injections and improve patient comfort. The patient
was also started on Coumadin. At the time of discharge
Coumadin had been held for three previous nights secondary to
supratherapeutic INR. After discharge the patient should
receive daily INRs and dosed with 2.5 mg of Coumadin q.h.s.
only when INR falls below 2.5.
7. Endocrine: The patient was maintained on Synthroid for
hypothyroidism during admission.
DISCHARGE MEDICATIONS: As admission except:
1. Levothyroxine increased from 75 to 100 mg q.d.
2. Coumadin for atrial fibrillation as well as deep venous
thrombosis. Of note, as stated above, the patient became
supratherapeutic on low doses of Coumadin. Coumadin should
be carefully dosed and INR should be followed closely.
3. Tylenol and Oxycodone for pain as the patient's rare
verbalizations usually reflected expressions of pain.
4. Guaifenesin to decrease retention of respiratory
secretions.
5. Albuterol and Atrovent nebulizers.
6. The patient is to complete a ten day course of
Levofloxacin.
DISPOSITION: To nursing facility.
DISCHARGE STATUS: Bed bound, significantly contracted, in
significant pain, minimally verbal, stable respiratory
status, on stable jejunostomy feedings.
DISCHARGE DIAGNOSES:
1. Failure to thrive.
2. Dysphagia.
3. Dementia.
4. History of stroke.
5. Deep venous thrombosis.
6. Aspiration pneumonia.
7. Atrial fibrillation.
8. Hypertension.
9. Anemia secondary to blood loss.
10. Hypothyroidism.
CODE STATUS: Full.
DISCHARGE FOLLOW UP: None necessary.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 47939**]
MEDQUIST36
D: [**2117-11-27**] 07:43
T: [**2117-11-29**] 08:27
JOB#: [**Job Number 96441**]
|
[
"787.2",
"507.0",
"285.1",
"569.69",
"783.7",
"263.9",
"427.31",
"453.8",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"96.71",
"38.93",
"03.31",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1996, 2014
|
9913, 10174
|
9115, 9892
|
2081, 2358
|
2954, 9091
|
10186, 10474
|
2381, 2936
|
139, 1463
|
1485, 1979
|
2031, 2055
|
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