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58,135
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41435
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Discharge summary
|
report
|
Admission Date: [**2160-2-3**] Discharge Date: [**2160-2-17**]
Date of Birth: [**2108-2-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2160-2-6**] Transesophageal echocardiogram
[**2160-2-7**] Cardiac catheterization with Placement of IABP
[**2160-2-8**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] mechanical) and
Mitral Valve Replacement(31mm St. [**Male First Name (un) 923**] mechanical).
History of Present Illness:
This is a 51 year old male who presented on [**2160-1-23**] to Cape Code
Hospital with worsening shortness of breath.
.
He was in his usual state of health until 23 days prior to
admission when he developed dyspnea and cough. He saw a
cardiologist, Dr. [**Last Name (STitle) 83602**] and was started on Torsemide for
heart failure. A few days prior to admission, he saw a Dr.
[**First Name (STitle) 65453**] (pulmonologist), who prescribed Symbicort. The day prior
to admission, he had a CT chest that yielded bilateral
parenchymal disease, pleural effusions and adenopathy. He was
referred to the ED. He was given nebs and Doxycylcine and sent
home. Thereafter he developed SOB with the slightest exertion,
[**3-14**] pillow orthopnea, pink frothy sputum and difficulty
sleeping. He returned to [**Hospital3 **] the following morning.
.
In [**Hospital **] [**Hospital **] Hospital, [**Doctor Last Name **] underwent bronchoscopy which
revealed only "reactive bronchial cells and mixed inflammatory
cells". Gram stain negative and there were no malignant cells. A
PPD was planted, negative. On [**2160-1-30**] he had a wedge biopsy by
Dr. [**Last Name (STitle) 30119**]. On direct visualization there were "antracotic
changes and some interstitial changes with mainly noncompliant
lung". A chest tube was placed. The biopsy read was
"desquamative interstial pneumonitis". This biopsy was sent to
[**Hospital1 2177**] for a second opinion from Dr.[**Last Name (un) 90142**]. The patient,
frustrated by poor doctor communication and staffing, requested
transfer to the [**Hospital1 18**].
Past Medical History:
Hypertension
Prior Back and Knee Surgery
Social History:
Married, no children.
Tobacco: Admits to 1.0 - 1.5 ppd until the day the sxs started.
ETOH: 12 beers vs quart of vodka every other day, but again not
since sxs started.
Other: Industrial chemical exposure at a golf course where he
worked as a superintedant for 13 years, 5 years ago.
Family History:
Father died at 69 from MI.
Mother still alive, had CVA at 82.
One brother has CAD.
Physical Exam:
ON ADMISSION:
Vitals: 97.4, 131/94, 102, 24, 96 on 4L
General: Alert, oriented, no acute distress. Speaks in long,
complete sentences with some tachypnea
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to jawline, no LAD
Lungs: Bronchial breath sounds in bilateral mid fields, occ.
wheezes r > L, dullness to percussion at base
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
heard best at apex with radiation to axilla; no rubs, gallops
CHEST WALL: ostomy bag with fruit-punch serosanguinous fluid
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses. MARKED clubbing of all
digits. No cyanosis. 2+ pitting edema to knees bilaterally
Neuro: oriented x3, CNII-XII intact, no gross sensory or motor
deficits, negative pronator drift, gait not assessed
Psych: verbose expositions for answers but redirectable.
Pertinent Results:
ADMISSION LABS:
[**2160-2-4**] WBC-17.3* RBC-4.14* Hgb-12.8* Hct-38.2* Plt Ct-207
[**2160-2-4**] PT-13.4 PTT-26.4 INR(PT)-1.1
[**2160-2-4**] Glucose-144* UreaN-24* Creat-0.9 Na-135 K-4.5 Cl-103
HCO3-23
[**2160-2-4**] ALT-135* AST-59* AlkPhos-61
[**2160-2-4**] cTropnT-0.02*
[**2160-2-4**] CK-MB-3 cTropnT-0.03*
[**2160-2-5**] proBNP-3087*
[**2160-2-4**] Calcium-9.4 Phos-3.1 Mg-2.1
[**2160-2-5**] ANCA-NEGATIVE B
[**2160-2-5**] [**Doctor First Name **]-NEGATIVE
[**2160-2-5**] RheuFac-15*
.
[**2160-2-4**] CHEST CT: 1. Progression of the underlying ground-glass
and consolidative abnormality, predominantly in the right lung
relative to [**1-22**]. Much of this is probably pulmonary
edema. The remainder, including the more nodular consolidative
lesions is a pulmonary process, particularly hemorrhage, since
some of it resolved, and some worsened. If there is some primary
lung disease, vasculitis could explain the presumed hemorrhage,
but I do not see why it should have resolved so clearly in one
area (LLL) and worsened so considerably in most of the right
lung.
2. Stable relatively small layering nonhemorrhagic pleural
effusions. No
other intrathoracic or chest wall collections.
3. Probable calcific aortic stenosis. Mitral valve function
should also be
assessed. New mild-to-moderate cardiomegaly.
4. Central adenopathy, probably related to pulmonary
abnormality, could be
reactive, and at least the AP window node has less edema.
.
[**2160-2-6**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic function may
be depressed given the severity of mitral regurgitation.] There
with moderate global right ventricular free wall hypokinesis.
Extensive simple atherosclerotic plaque in the descending
thoracic aorta down to 48 cm from the incisors. There aortic
valve leaflets (?#) are moderately thickened with reduced
excursion consistent with aortic stenosis. No aortic valve
vegetation or abscess is seen. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is a
large vegetation involving both leaflets with perforation/hole
in the anterior mitral leaflet. No mitral valve abscess. Severe
(4+) mitral regurgitation is seen. Tricuspid valve is normal
with trivial tricuspid regurgitation. Pulmonic valve is normal.
There is no pericardial effusion.
.
[**2160-2-7**] Cardiac Catheterization: Coronary angiography in this
right dominant system revealed no angiographically apparrent
CAD. The LMCA, LAD, Cx and RCA were angiographically normal.
Severe Mitral Stenosis. Moderate Aortic Stenosis. Successfull
placement of IABP.
.
[**2160-2-16**] 06:00AM BLOOD WBC-5.2 RBC-3.15* Hgb-9.9* Hct-29.3*
MCV-93 MCH-31.4 MCHC-33.8 RDW-14.3 Plt Ct-378
[**2160-2-17**] 04:45AM BLOOD PT-38.6* PTT-36.8* INR(PT)-4.0* coumadini
0mg
[**2160-2-16**] 06:00AM BLOOD PT-50.3* INR(PT)-5.5* coumadin 0mg
[**2160-2-15**] 05:10AM BLOOD PT-35.1* INR(PT)-3.6* coumadin 2.5mg
[**2160-2-14**] 04:50AM BLOOD PT-25.8* PTT-95.4* INR(PT)-2.5* coumadin
5mg
[**2160-2-13**] 05:47AM BLOOD PT-15.2* PTT-62.0* INR(PT)-1.3* coumadin
5mg
[**2160-2-12**] 01:22AM BLOOD PT-13.6* PTT-33.8 INR(PT)-1.2* coumadin
5mg
[**2160-2-11**] 03:00AM BLOOD PT-13.6* PTT-26.8 INR(PT)-1.2* coumadin
5mg
[**2160-2-10**] 04:11AM BLOOD PT-16.1* PTT-31.8 INR(PT)-1.4*
[**2160-2-9**] 03:10AM BLOOD PT-15.4* PTT-29.0 INR(PT)-1.3*
[**2160-2-8**] 01:32PM BLOOD PT-15.1* PTT-33.5 INR(PT)-1.3*
[**2160-2-8**] 12:00PM BLOOD PT-16.3* PTT-36.7* INR(PT)-1.4*
[**2160-2-16**] 06:00AM BLOOD Glucose-122* UreaN-17 Creat-0.8 Na-133
K-4.2 Cl-99 HCO3-27 AnGap-11
Brief Hospital Course:
Initially admitted with the presumed diagnosis of desquamative
interstial pneumonitis per [**Hospital3 **] Hospital based on pathology
from wedge biopsy. Pulmonary was consulted who advised repeat CT
scan and review of the outside slides. Repeat CT scan showed
progression of the ground glass opacities and consolidative
process concerning for pulmonary edema. Review of the pathology
slides from OSH showed bland hemorrhage that was not entirely
consistent with a primary pulmonary process. Patient was tapered
off steroids and cardiac evaluation was pursued to explain
pulmonary hemorrhage. He underwent TTE which did not show signs
of systolic failure, but did show functional mitral stenosis,
some mitral regurgitation, and mild aortic stenosis. Cardiology
was consulted and in collaboration with pulmonary advised TEE
which revealed thickened mitral leaflets with large vegetation
and perforation/hole of anterior mitral leaflet and severe
mitral regurgitation. The aortic valve leaflets were moderately
thickened with reduced excursion consistent with aortic
stenosis. No aortic valve vegetation or abscess was seen. No
aortic regurgitation was seen. Given the above findings, cardiac
surgery was consulted and cardiac catheterization was performed
which revealed normal coronary arteries. Given his severe mitral
regurgitation and decompensated heart failure, an IABP was
placed for hemodynamic support.
.
On [**2-8**], he was urgently brought to the operating room
where Dr. [**Last Name (STitle) **] performed mechanical aortic and mitral valve
replacments. For surgical details, please see operative note.
Following surgery, he was brought to the CVICU for invasive
monitoring. On postoperative day zero, the IABP was removed
without complication. He remained intubated and sedated for
several days due to decompensated heart failure, pulmonary edema
and non-compliant lungs. He required aggressive mechanical
ventilation, along with therapeutic bronchoscopy and esophageal
balloon. Prcedex was used for mild postoperative agitation.
Following several days of diuresis, he was eventually extubated
on postoperative 4. He gradually weaned from inotropic support.
Operative mitral valve pathology showed no microorganisms and
revealed no growth. Coumadin with a heparin bridge was started
for antiocagulation with a goal INR of 3.0-3.5. Dr. [**Last Name (STitle) **] will
manage his coumadin as an outpatient. The physical therapy
service was consulted to assist him with his strength, mobility
and physical recovery. On postoperative day five, he was
transferred to the step down unit for further recovery. Heparin
was continued until his INR was therapeutic. After several doses
of 5mg the INR quickly rose to 5.5. This did delay discharge by
a day. INR trended down and coumadin was adjusted accordingly.
The patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33733**] for cardiology
by his PCP and an appointment has been made with her for
follow-up. By the time of discharge on POD 9 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He remains edematous, and will be
prescribed Lasix for 10 days. All follow up instructions are
advised.
Medications on Admission:
Transfer Medications:
Albuterol Nebs PRN
Benzonatate 100mg PO TID
Guaifenesin 5-10ml P Q6hrs
Ipratropim Bromide
Morphine Sulfate 2-4mg IV Q4hrs PRN
Oxycodone-Acetaminophen 1 tab PO Q6hrs
Pantoprazole 40mg PO Q24hrs
Miralax 17g daily PRN
Prednisone 60mg PO daily
Bactrim 1 DS tab daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr.
[**Last Name (STitle) **] to dose daily for goal INR 2.5-3.5 for mechanical aortic
and mitral valves.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication double mechanical
valves(Aortic/Mitral Valve)
Goal INR 3.0 - 3.5
First draw Monday, [**2160-2-18**]
Results to phone fax Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 90143**] Fax: [**Telephone/Fax (1) 90144**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**]
Discharge Diagnosis:
Chronic Diastolic Congestive Heart Failure
Aortic Stenosis, Mitral Regurgitation/Stenosis
Hypertension
Atrial Fibrillation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) 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.
5) No lifting more than 10 pounds for 10 weeks
6) Coumadin for double mechanical valve. Goal INR 3.0-3.5. Take
coumadin daily as instructed by Dr. [**Last Name (STitle) **]. Please note your dose
will change based on your lab results. Needs PT/INR day
following discharge. Please contact Dr.[**Name2 (NI) 2056**] office with
results. ([**Telephone/Fax (1) 90145**] Fax: [**Telephone/Fax (1) 90144**]
7) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**3-5**], 1:00PM ([**Telephone/Fax (1) 1504**]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33733**] on Wednesday at 2:15 on [**2-28**]
(referred to you by your PCP)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] on Thursday [**3-13**] at 1:30([**Telephone/Fax (1) 90143**]
**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 double mechanical
valves(Aortic/Mitral Valve)
Goal INR 3.0 - 3.5
First draw day after discharge from [**Hospital3 **]
Results to phone fax Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 90143**] Fax: [**Telephone/Fax (1) 90144**]
Plan confirmed with [**Doctor Last Name 402**]
Completed by:[**2160-2-17**]
|
[
"288.60",
"786.39",
"511.9",
"274.9",
"428.33",
"428.0",
"396.8",
"515",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"96.71",
"39.61",
"33.24",
"37.61",
"97.44",
"88.56",
"35.24",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
12509, 12560
|
7489, 10739
|
329, 613
|
12727, 12950
|
3685, 3685
|
14162, 15124
|
2610, 2694
|
11075, 12486
|
12581, 12706
|
10765, 10765
|
12974, 14139
|
2709, 2709
|
270, 291
|
10787, 11052
|
641, 2229
|
3701, 7466
|
2723, 3666
|
2251, 2293
|
2309, 2594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,946
| 130,590
|
29582
|
Discharge summary
|
report
|
Admission Date: [**2183-2-3**] Discharge Date: [**2183-2-20**]
Date of Birth: [**2119-2-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Toradol / Neurontin
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Tracheal stenosis
Major Surgical or Invasive Procedure:
[**2183-2-5**] Rigid bronchoscopy, flexible bronchoscopy, balloon
dilatation x2.
[**2183-2-7**] Cervical tracheal resection and reconstruction,
suprahyoid release.
[**2183-2-14**] Flexible bronchoscopy
History of Present Illness:
The patient is a 63 y/o male who is transferred from OSH for
treatment of tracheal stenosis revealed on CT scan. The patient
was originally admitted to the OSH in [**2182-9-27**] with
obesity hypoventilation syndrome. During that admission, he had
a tracheostomy secondary to ventilator dependence. He was
discharged to rehab where he was weaned off the vent and was
eventually decannulated and discharged to home shortly prior to
[**2183-1-20**]. Over the previous week, he has had increasing
shortness of breath and has been complaining of saliva getting
stuck in his upper airway. He represented to the OSH where he
was started on steroids with improvement of his symptoms. The
patient has had cough productive of clear sputum. The patient
otherwise denies fever, chills, nausea/vomiting, chest pain, or
hemoptysis.
Past Medical History:
1. Obesity
2. IDDM
3. HTN
4. Obstructive sleep apnea
5. restrictive lung disease
6. chronic venous stasis
7. rectal abscess
8. nasal polyposis
9. elevated R hemidiaphragm due to MVA
10. PFO
Social History:
The patient is married, lives with his wife. [**Name (NI) **] has two
children. He owns five restaurants. He is half Greek half
Albanian. He smoked for several years and admittedly denies
alcohol use. He quit smoking in [**2182-8-27**].
Family History:
Father had a pacemaker and irregular heart rate and question of
diabetes, mother history of kidney cancer and had one kidney
removed. There is no history of premature coronary artery
disease in the family.
Physical Exam:
T 98.2 P 118 BP 148/90 R 24 SaO2 91% RA
Gen - alert and oriented x3, no acute distress, pupils equal
round and reactive to light, extraocular muscles intact
Heent - neck supple, no cervical lymphadenopathy, no carotid
bruits
Lungs - diminished breath sounds bilaterally, no wheezes
Heart - regular rate and rhythm, I/VI systolic ejection murmur
Abd - obese, soft, nontender, nondistended, bowel sounds
auscultated
Extrem - chronic venous stasis with hyperpigmentation in
bilateral lower extremities
Pertinent Results:
[**2183-2-3**] 09:20PM BLOOD WBC-18.9* RBC-4.73 Hgb-13.9* Hct-42.3
MCV-89 MCH-29.3 MCHC-32.8 RDW-16.0* Plt Ct-225
[**2183-2-3**] 09:20PM BLOOD PT-11.6 PTT-20.5* INR(PT)-1.0
[**2183-2-3**] 09:20PM BLOOD Glucose-419* UreaN-35* Creat-1.2 Na-137
K-5.2* Cl-96 HCO3-30 AnGap-16
[**2183-2-3**] 09:20PM BLOOD Phos-3.9 Mg-2.0
[**2183-2-3**] 09:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2183-2-3**] 09:03PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.026
[**2183-2-10**] 8:19 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2183-2-15**]**
GRAM STAIN (Final [**2183-2-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2183-2-15**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SERRATIA MARCESCENS. MODERATE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| SERRATIA MARCESCENS
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- R <=1 S
CEFUROXIME------------ R
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- =>8 R <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- R <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 4 S
Brief Hospital Course:
The patient was admitted and had an airway CT which showed
high-grade focal tracheal stenosis at level of the
cervicothoracic junction, corresponding to a site of prior
tracheostomy tube insertion. Coronal narrowing to 6 mm at end
inspiration, with component of airway malacia at end expiration,
with further narrowing to 3 mm. The patient was continued on
steroids because it had helped with his respiratory distress.
The patient also had an echocardiogram which was negative for
patent foramen ovale or atrial septal defect and showed
preserved left ventricular systolic function.
The patient went to the OR [**2183-2-5**] for a rigid bronchoscopy and
balloon dilatation, however the stenosis was unable to be
dilated. The patient went to the OR [**2183-2-7**] for trachel
reconstruction which he tolerated well. The patient was kept
sedated and intubated to allow the tracheal reconstruction to
heal. Broad spectrum antibiotics were started for empiric
therapy. A dobhoff tube was placed for tube feeds. Lovenox was
started because the patient was considered high risk for DVT.
The patient also developed brief runs of atrial fibrillation
which was well rate controlled with beta blockers. The patient
had bilateral patchy infiltrates on chest x-ray, grew E. coli
and Serratia from his sputum cultures, and received a
bronchoscopy for therapeutic aspiration on [**2183-2-12**] and [**2183-2-14**].
The patient was able to be extubated on [**2183-2-14**]. The patient
self d/c'd his dobhoff tube and was started on TPN.
Fortunately, he was able to pass his swallow evaluation and his
diet was gradually advanced. The patient was transferred to the
floor on [**2183-2-18**]. Physical therapy was consulted to assist the
patient with his ambulation. At discharge, the patient was able
to tolerate a regular diet and his pain was well controlled. He
will continue with a steroid taper. From a respiratory
standpoint, the patient had good oxygen saturations with
supplemental oxygen via 4 liters nasal canula.
Medications on Admission:
1. Prednisone 30''
2. ativan
3. trazadone
4. lisinopril
5. combivent
6. flonase
7. metoprolol 25''
8. protonix 40
9. tamsulosin 0.4
10.lantus 35U [**Hospital1 **]
11. pregabalin 50'''
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Furosemide 20 mg IV BID
3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q4H (every 4 hours) as needed.
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-28**]
Drops Ophthalmic PRN (as needed).
10. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q12H (every 12 hours).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO three times
a day.
14. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
15. regular insulin
sliding scale per finger stick
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Tracheal stenosis
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor or seek immediate medical attention if you
experience fever, chills, lightheadedness, dizziness, chest
pain, shortness of breath, wheezing, palpitations, abdominal
pain, nausea/vomiting, or increased drainage, redness, or
bleeding from surgical wound.
No driving while taking pain medications.
No tub baths or swimming.
No heavy lifting for one month.
Diet as tolerated.
You may use dry dressing to cover wound.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 952**] on [**3-4**] 10am
[**Telephone/Fax (1) 170**] on [**Hospital Ward Name 23**] clinical center [**Location (un) **].
This d/c summary was completed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] and signed by
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 54929**] NP
Completed by:[**2183-2-20**]
|
[
"250.00",
"519.4",
"327.23",
"482.83",
"V58.65",
"278.00",
"519.19",
"518.5",
"459.81",
"482.82",
"600.00",
"255.4",
"V58.67",
"496",
"427.31",
"458.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.99",
"33.24",
"99.15",
"96.05",
"83.14",
"96.72",
"31.79",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8957, 9038
|
5365, 7393
|
320, 524
|
9100, 9109
|
2616, 5342
|
9587, 10002
|
1868, 2077
|
7627, 8934
|
9059, 9079
|
7419, 7604
|
9133, 9564
|
2092, 2597
|
263, 282
|
552, 1379
|
1401, 1593
|
1609, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,484
| 199,803
|
42383
|
Discharge summary
|
report
|
Admission Date: [**2160-2-7**] Discharge Date: [**2160-2-23**]
Date of Birth: [**2079-2-11**] Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Difficulty breathing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 80-year-old woman with DM, HTN, COPD, and obesity
recently discharged from [**Hospital6 4620**] on [**2160-1-30**]
for hypercarbic respiratory failure and sepsis (from ?skin
source) who is admitted from [**Hospital3 2558**] with fatigue and
shortness of breath.
Ms. [**Known lastname **] was initially admitted to NWH on [**2160-1-15**] after being
found down at home and unresponsive. She was admitted to the
MICU at NWH and intubated for hypercarbic respiratory failure.
There was concern for sepsis given elevated WBC and chance in
mental status, and patient was started on broad spectrum
antibiotics. A throrough infectious work-up at NWH was
unrevealing, and the cause of sepsis was thought to be skin
breakdown sustained during fall at home. She was treated with
broad spectrum antibiotics and eventually extubated. Developed
ARF and was temporarily on HD, but recovered and was not
discharged with RRT. Hospital course was also significant for
afib with RVR, for which patient was started on amiodarone. She
also suffered a hct drop while on a heparin gtt, attributed to
peptic ulcer and as such was not discharged on anticoagulation.
.
At rehab on date of admission, patient was found to have labored
breathing, hypoxia, and difficulty clearing secretions. She was
transferred to [**Hospital1 18**] for further evaluation. In the ED, initial
vitals were: 98.5, 78, 100/50, 28. An ABG was significant for:
7.30/74/153. Hct was 24.8 (down from a hct of 28 on discharge
from OSH), bicarb 35, and creatinine 1.8. Patient was
transferred to the MICU for respiratory distress.
Past Medical History:
--Hypertension
--Obesity
--Lumbar spinal stenosis
--Paroxysmal afib
--COPD (though no PFTs)
--Former tobacco use
--Chronic renal insufficiency
Social History:
Used to live by herself before recent hospitalization, long
smoking history.
Family History:
NC
Physical Exam:
Admission exam
Vitals: T: 98 BP: 121/51 P: 67 R: 35 SPO2: 70% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
NECK: JVD difficult to appreciate though not obviously elevated
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: Rhonchorous bilaterally, bronchial breath sounds, some
crackles at left lower base
ABDOMEN: Soft, non-tender, non-distended
GU: Foley in place
EXT: Warm, well perfused, 1+ edema bilaterally
NEURO: Alert and oriented x3
Discharge exam
Pertinent Results:
Admission labs
[**2160-2-7**] 04:55PM BLOOD WBC-5.5 RBC-2.78* Hgb-7.9* Hct-24.8*
MCV-89 MCH-28.4 MCHC-32.0 RDW-18.4* Plt Ct-159
[**2160-2-7**] 04:55PM BLOOD Neuts-61.2 Bands-0 Lymphs-29.3 Monos-8.0
Eos-1.0 Baso-0.5
[**2160-2-7**] 04:55PM BLOOD Plt Ct-159
[**2160-2-7**] 04:55PM BLOOD Glucose-119* UreaN-32* Creat-1.8* Na-139
K-4.7 Cl-99 HCO3-35* AnGap-10
[**2160-2-7**] 10:09PM BLOOD CK(CPK)-23*
[**2160-2-7**] 10:09PM BLOOD CK-MB-3 cTropnT-0.03* proBNP-5920*
[**2160-2-7**] 10:09PM BLOOD Calcium-9.1 Phos-4.8* Mg-1.7
[**2160-2-8**] 03:12AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.9* Iron-25*
[**2160-2-8**] 03:12AM BLOOD calTIBC-335 Ferritn-55 TRF-258
[**2160-2-7**] 04:34PM BLOOD Type-ART pO2-153* pCO2-74* pH-7.30*
calTCO2-38* Base XS-7 Intubat-NOT INTUBA
[**2160-2-7**] 04:34PM BLOOD Lactate-1.3
.
MICROBIOLOGY:
[**2160-2-7**] Blood culture- no growth
[**2160-2-8**] Nasopharyngeal swab- negative Influenza A/B
[**2160-2-10**] Stool culture-
Norovirus Antigen: POSITIVE
FECAL CULTURE (Final [**2160-2-12**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2160-2-12**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2160-2-11**]): NO OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO (Final [**2160-2-12**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2160-2-12**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7: NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: negative
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2160-2-11**] Stool culture- NO OVA AND PARASITES SEEN.
[**2160-2-12**] Blood culture- no growth
[**2160-2-13**] Stool culture- negative for C.difficile toxin A&B
.
Discharge labs
###########################
IMAGING:
CXR [**2160-2-7**] Moderate cardiomegaly is noted. Flattening of
diaphragms is suggestive of hyperinflation likely representing
chronic obstructive lung disease. There is no evidence of focal
consolidation, pulmonary edema, pleural effusion or
pneumothorax. IMPRESSION: Moderate cardiomegaly but no acute
cardiopulmonary process.
.
Transthoracic echocardiogram [**2160-2-9**]: Dilated and hypokinetic
right ventricle with moderate tricuspid regurgitation and severe
pulmonary hypertension. Normal regional and global left
ventricular systolic function. Indeterminate diastolic function.
Mild mitral regurgitation. There is a mobile echodensity seen on
the supra-sternal notch views (66-70). It is unclear which blood
vessel this is in - if in PA, it could be a thrombus. If in
aorta, suspect a mobile atheroma.
.
Bilateral lower extremity venous dopplers [**2160-2-9**]- negative for
DVT
.
Unilateral upper extremity venous dopple [**2160-2-10**]- negative for
DVT
.
CTA [**2160-2-16**]-
1. Evaluation of distal segmental and subsegmental pulmonary
arteries is limited by motion; however, no central pulmonary
embolism identified.
2. Bilateral pleural effusions and bibasilar atelectasis, left
greater than right.
3. Emphysematous changes with bilateral upper lobe predominance.
4. 6 mm right upper lobe pulmonary nodule. Follow up CT in [**7-15**]
months is
recommended.
.
Transthoracic echocardiogram [**2160-2-21**]: The left atrium is
elongated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. 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. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate to severe
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Moderate to severe pulmonary hypertension.
Hypertrophied and dilated right ventricle with mild systolic
dysfunction. Normal global and regional left ventricular
systolic function. Mild mitral regurgitation. Moderate tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2160-2-9**],
estimated pulmonary pressures are slightly lower. The other
findings are similar.
Brief Hospital Course:
Ms. [**Known lastname **] is an 80-year-old woman with a pmhx. significant for
COPD, HTN, paroxysmal afib, obesity, and former tobacco abuse
who presented with shortness of breath.
.
# Respiratory distress- Patient admitted to MICU with hypoxia
and shortness of breath. This was initially attributed to COPD
exacerbation, though patient does not carry a diagnosis of COPD.
She was placed on azithromycin/prednisone and Bipap. On HD1,
she developed acute hypoxia and dyspnea, with CXR evidence of
flash pulmonary edema. She was diuresed and weaned off of
bipap. Prior to transfer to the floor, TTE showed evidence of
RV overload and severe pulmonary hypertension, new in comparison
to TTE done during OSH admission in mid-[**Month (only) 1096**]. Concern was
high for PE, so patient was started on heparin gtt, however CTA
was deferred in the setting of decreased renal function and V/Q
would not have been informative given abnormalities on CXR.
There was no evidence of upper or lower extremity venous
thrombosis. Once creatinine improved, CTA showed no central
embolism, but motion artifact prevented evaluation for
segmental/subsegmental PE. However, patient was not continued
on heparin. Patient was diuresed aggressively throughout
admission, but continued to have a 3L O2 requirement.
Bicarbonate levels rose, and patient developed a metabolic
alkalosis, at which time diuresis was slowed to goals of
-500cc/day with 60mg oral lasix. She was also started on
acetazolamide which brought down the bicarbonate level.
Pulmonary was consulted and agreed that patient likely had
multiple issues contributing to her respiratory issues. First,
they felt she had underlying COPD, GOLD Stage IV. She was
continued on albuterol/ipratropium nebs and started on
fluticasone-salmeterol. She will likely need PFTs which can be
done as outpatient. She will also need oxygen supplementation
and nebulizers in rehab and likely at home.
In addition, patient had evidence of LV diastolic
dysfunction contributing to volume overload. She was diuresed
throughout admission, as above, and was discharged on lasix 60mg
po daily.
Patient had an inpatient sleep study, as there was concern
that given her body habitus, OSA/OHS may be contributing to
pulmonary hypertension, creating a restrictive process. Sleep
study showed obstructive process with desaturations while
sleeping. Patient was started on CPAP at night on autoset [**6-12**]
with 2L/min oxygen. She was discharged on these settings. She
does not like the CPAP machine, but should be encouraged to use
it as much as possible at night. If she cannot become
habituated, the mask can be adjusted as an outpatient.
Repeat TTE prior to discharge showed continued moderate
right ventricle overload and pulmonary hypertension. Given
findings of COPD, OSA, these are likely contributing to her
pulmonary hypertension and driving the right ventricular
overload.
.
# Blood pressure lability- Initially, patient's blood pressure
was elevated, and she was placed on labetolol 100mg TID per
outpatient regimen. On HD4, patient became acutely bradycardic
with hypotension. EKG showed sinus bradycardia, and patient was
transferred back to the MICU on dopamine drip. Dopamine was
weaned, and bradycardia/hypotension was attributed to labetolol.
Following this episode, patient had no further episodes of
bradycardia. Her blood pressure trended up again, and she was
titrated up on hydralazine. She was discharged on hydralazine
25mg po QID. Her blood pressure ranged from 140-160/50-70 at
the time of discharge.
.
# Acute renal failure- Patient's renal function was poor at the
time of admission, following her prior hospitalization at OSH
where she had acute renal failure requiring hemodialysis. At
the time of discharge from OSH her creatinine was 2.6, and at
the time of admission, creatinine was 1.8 Creatinine trended up
to 2.4, likely related to diuretics and blood pressure lability.
Creatinine improved with time and at the time of discharge was
1.3.
.
# Atrial fibrillation- Patient had new onset atrial fibrillation
during OSH admission. She was placed on amiodarone prior to
discharge, and was in sinus rhythm on discharge. Patient was
monitored on telemetry throughout this admission, and was in
sinus rhythm. She was taken off of amiodarone, but restarted
after she had several episodes of non-sustained ventricular
tachycardia. Once amiodarone was resumed, patient had no
ongoing ventricular tachycardia.
.
# Anemia- Patient's hematocrit was low at the time of admission,
but was at her baseline. Hematocrit was watched closely
throughout admission, given GI bleed during OSH admission with
heparin administration. She had no guaiac positive stools
during this admission, and hematocrit remained stable.
.
# Anxiety/insomnia- Mirtazapine and trazodone were held
initially in setting of hypercarbic respiratory distress, but
restarted once patient was stabilized.
.
# Goals of care- During admission, patient determined that she
wanted to change her code status to DNR/DNI. This was discussed
at length with the patient and her HCP, her son [**Name (NI) 2259**], and they
continued to express this wish. A family meeting took place
during this admission to determine goals of care and the patient
and her son expressed that her goal was to get back to her home.
.
# Transitional issues-
- outpatient PFTs
- f/u with pulmonary
- RUL pulmonary nodule noted on CTA, will need f/u scan in [**7-15**]
months
- room air sat on the day of discharge was 92-96% on 2LNC
- weight on the day of discharge was 173.3 lbs by bed weight
Medications on Admission:
--Insulin sliding scale
--Remeron 15mg by outh at bedtime
--Hydralazine 75mg po QID (need to confirm dose)
--Nystatin
--Oxycodone IR 5mg PO q6 hours prn pain
--Trazodone 50mg Qhs
--Prilosec 40mg QD
--Fragmin 5,000 IV subcu qday
--Acetaminophen
--Albuterol
--Ipratropium
--Amiodarone 200mg QD
--Fluticasone 220mcg 2 puffs [**Hospital1 **]
--Labetalol 200mg [**Hospital1 **]
--Nicotine patch
--Milk of magnesia
--Bisacodyl
--Furosemide 20mg QD (not taking at CH)
--Lovastatin 10mg QD (not taking at CH)
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-4**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
11. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous four times a day: Please take per sliding scale
prior to meals and bed.
15. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Chronic obstructive pulmonary disease
2. Obstructive sleep apnea
3. Diastolic cardiomyopathy
SECONDARY DIAGNOSIS:
1. Hypertension
2. Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound- but working to get to chair
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 69**].
You were admitted because of difficulty breathing. This was
likely due to several issues, including problems with your lungs
and with your heart. You were started on several new
medications to help with your breathing, and you were given
medication to help decrease excess fluid building up in your
lungs. In addition, you were started on a machine to help you
breathe while you sleep at night. You should use this machine
every night after leaving the hospital.
Several changes were made to your medication regimen:
- START albuterol nebulizer every 6 hours to help with breathing
- START fluticasone-salmeterol inhaler twice daily
- START tramadol three times a day for pain
- START Tylenol three times a day for pain
- DECREASE hydralazine dose, but continue four times a day for
your blood pressure
- START normal saline nasal spray
Followup Instructions:
When you are ready to leave [**Hospital3 2558**], please call your
primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69482**], at [**Telephone/Fax (1) 69483**], to arrange an
appointment.
You also have an appointment with a pulmonologist, Dr. [**Last Name (STitle) **], on
[**3-17**] at 3:00pm
|
[
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"V66.7",
"416.8",
"428.33",
"276.51",
"276.8",
"458.29",
"V15.82",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14578, 14648
|
7025, 12642
|
290, 296
|
14885, 14885
|
2785, 7002
|
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|
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|
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|
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12668, 13170
|
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|
2222, 2766
|
230, 252
|
324, 1927
|
14809, 14864
|
14688, 14788
|
14900, 15027
|
1949, 2093
|
2109, 2187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,361
| 183,166
|
42403
|
Discharge summary
|
report
|
Admission Date: [**2174-3-1**] Discharge Date: [**2174-3-6**]
Date of Birth: [**2115-8-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Rectal exam under anesthesia, oversewing of rectal bleeding
Fiberoptic intubation
History of Present Illness:
This is a 58 year old male with PMH of adenomatous polyps,
diverticulosis, hemorrhoids s/p recent banding times 2 in [**12-6**]
and [**2-6**], gastritis, GERD, microcytic anemia, obstructive sleep
apnea, erectile dysfunction, h/o vasovagal syncope, vertiginous
migraine, and anxiety presenting for further evaluation of
painless BRBPR. He has been having intermittent GI bleeding for
about a year, ranging from dark blood to dark emesis and BRBPR
per outpatient notes. He had a colonoscopy in [**11-6**] which
showed adenomatous polyps, internal/external hemmorhoids, and
descending/sigmoid diverticulosis. He has had his hemorrhoids
banded twice as an outpatient ([**12-6**] and [**2-6**]) by Dr. [**Last Name (STitle) **] and
completed the subsequent regimen of hydrocortisone
suppositories/cream for 2 weeks s/p banding. He also had an
endoscopy for hematemesis in [**2-6**] which showed gastritis and
esophageal stenosis (? early Schatzki's ring).
This most recent episode of BRBPR started around [**2-25**] with blood
in his stool. He was seen by his PCP [**Last Name (NamePattern4) **] [**2-28**] at which point his
HCT was 35.6 compared to his baseline of 37.9 in [**Month (only) 404**] and
43.2 in [**Month (only) 956**]. At his PCP visit, he reported having the
sudden urge to move his bowels on [**2-27**]. He was incontinent of a
small amount of stool and then had explosive bloody diarrhea.
He flushed the toilet 5 times as more and more blood kept coming
out. He began to feel lightheaded but did not lose
consiousness. The bleeding eventually stopped on its own. He
did receive 2L of NS at his PCP's office which relieved his
orthostatic vital signs. Of note, he is tachycardic to
100s-110s at baseline over the last 8 years in clinic. He came
in today because he had painless bleeding spontaneously down his
leg during a meeting at work this morning.
Per his PCP's note, he's had episodes of BRBPR like this over
the past year, though usually the bleeding is mainly when he's
on the toilet moving his bowels, rather than the explosive
unexpected event that he reported. The bleeding on Sunday night
was much more than his usual. He's especially concerned because
he's a lawyer and has a trial in 2 days. His main concern is
that the bleeding might suddenly start while in the courtroom.
.
In the ED, initial VS were: 97.3, HR=118, BP=134/66, RR=18,
POx=100% RA. At first he was noted to have a small amount of
BRBPR. GI and colorectal surgery was consulted given his recent
hemorrhoidal banding as an outpatient and a CTA of his abdomen
was recommended given his active bleeding. 16 and 18 gauge
peripherals were obtained in addition to a type and screen. He
was given 3L NS, 2 units of pRBCs, 80mg of IV Protonix bolus,
and he was started on a drip at 8mg/hr. Blood and urine
cultures were sent. His initial Hct was 31.8 and his PTT was
slightly elevated at 23.4. He was noted to be tachycardic and
felt the need to pass stool so went to the bathroom where he
passed a large amount of clot. He then became lightheaded and
passed out. He did hit his head. The fall was witnessed by his
nurse. [**First Name (Titles) **] [**Last Name (Titles) 5058**] on his own and just returned to his ED room on a
stretcher. He was boarded and collared and a CT head and
C-spine was obtained in addition to his CTA abdomen. The head
and spine imaging was negative so his neck was cleared and the
collar was removed prior to transfer. CTA abdomen was also
negative. Upon transfer, he was tachycardic to the 110s but his
blood pressures had remained stable in the 130s systolic.
.
On arrival to the MICU, he was having continuous liquid and
jelly consistency bright red blood per rectum. He was initially
alert and oriented, but soon developed chills and appeared
extremely pale. Additional peripheral IV access was obtained.
His blood pressure dipped to the 40s systolic and massive
transfusion protocol was initiated. A repeat Hct was 25.6. He
received 8L of NS, 12 units of pRBCs, 6 units of FFP, and 2 unit
of platelets. He developed a transfusion reaction which
manifested itself with neck swelling which did not resolve after
25mg of IV benadryl requiring emergent intubation. He had a
difficult airway related to the swelling from the transfusion
reaction and required fiberoptic intubation by anesthesia.
Past Medical History:
-Adenomatous polyps on colonoscopy [**11-6**]
-Diverticulosis
-Hemorrhoids s/p recent banding times 2 in [**12-6**] and [**2-6**]
-Gastritis on [**2-6**] EGD for hematemesis, but no stigmata of
recent bleed
-GERD
-Microcytic anemia
-Obstructive sleep apnea
-Erectile dysfunction
-h/o vasovagal syncope
-Vertiginous migraine
-Lumbosacral radiculopathy
-Anxiety
Social History:
He is married and lives with his wife, [**Name (NI) **] [**Name (NI) 91830**], and his
son in [**Location **], MA. He works as an attorney. He has never
smoked and drinks alcohol rarely.
Family History:
Brother Alive and well
Father Deceased at 80s CAD/PVD; Hypertension
Maternal Grandfather Deceased
Maternal Grandmother Deceased
Mother Deceased at 80s CAD/PVD; Hyperlipidemia; Osteoporosis;
Rheumatoid Arthritis; Stroke
Paternal Grandfather Deceased CAD/PVD; Cancer; Hypertension
Paternal Grandmother Deceased
Physical Exam:
Vitals: T: 97.8, BP: 90s/60s, P: 100s R: 13 O2: 98% RA
General: Alert, oriented, extremely pale, chills noted, anxious
appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple
CV: Tachycardic, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: no clubbing, cyanosis or edema
Neuro: Non-focal, alert, oriented, anxious
Pertinent Results:
Admission labs:
[**2174-3-1**] 02:55PM GLUCOSE-123* UREA N-16 CREAT-1.1 SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10
[**2174-3-1**] 02:55PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-56 TOT
BILI-0.2
[**2174-3-1**] 02:55PM cTropnT-<0.01
[**2174-3-1**] 02:55PM ALBUMIN-3.8
[**2174-3-1**] 02:55PM WBC-8.1 RBC-3.81* HGB-11.0* HCT-31.8* MCV-83
MCH-28.9 MCHC-34.6 RDW-14.4
[**2174-3-1**] 02:55PM NEUTS-75.7* LYMPHS-19.0 MONOS-3.2 EOS-1.5
BASOS-0.6
[**2174-3-1**] 02:55PM PLT COUNT-186
[**2174-3-1**] 02:55PM PT-10.7 PTT-23.4* INR(PT)-1.0
[**2174-3-1**] 04:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2174-3-1**] 04:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Brief Hospital Course:
58 year old male with PMH of adenomatous polyps, diverticulosis,
hemorrhoids s/p recent banding times 2 in [**12-6**] and [**2-6**],
gastritis, and anxiety presenting with massive lower GI bleed
requiring massive transfusion protocol.
.
# Lower GI bleed. Upon admission, patient was noted to have a
massive continuous lower GI bleed consisting of BRBPR both
liquid and jelly consistency. He has known diverticulosis and
recently banded hemorrhoids times two. He required massive
transfusion protocol and received a total of 8L of NS, 15 units
of pRBCs, 7 units of FFP, and 2 units of platelets. EGD was
negative upon arrival, but flex [**Month/Year (2) 65**] was positive for an arterial
bleed in the rectum at 5cm above his hemorrhoidal bed. GI was
unable to stop the bleeding and colorectal surgery consultation
was required. He was taken to the OR and the colorectal
surgeons were able to oversew and pack the area with Surgicel to
achieve hemostasis. No colon resection was required. Hematocrit
subsequently stable. Held ASA 81mg daily given active bleed, and
this discontinued permanently given no clear indication for its
use and pts hx gib and gastritis.
.
# Respiratory failure: Patietn was intubated in the setting of
possible transfusion reaction and airway swelling, (required
fiberoptic intubation). Ventilated easily and was extubated
without difficulty the next day.
.
# Aspiration pneumonia - pt. developed bibasilar consolidations
and cough concerning for aspiration pneumonia subsequent to
difficult intubation and mech ventillation following transfusion
reaction/respiratory failure. Cx revealed moraxella. He was
given unasyn and ultimately augementin with clinical
improvement.
.
# ? Bacteremia - admit blood cultures only with 2/4 bottles CNS.
Most c/w contamination. Surveillance cultures negative. No
clinical evidence of true bacteremia.
.
# Blood transfusion reaction: Patient had neck swelling and
hives in setting of receiving massive transfusion protocol. This
resolved with Benadryl and he did not get steroids. He received
so many blood products it was difficult to know culprit unit of
blood - although statistically, FFP (plasma) would be most
likely to have been the culprit in causing a reaction.
.
# Reported dysuria subsequent to foley catheter removal - UA
clean, culture pending. Will follow result as outpatient.
.
# Syncope: The patient had a syncopal event in the ED after
having a large bloody bowel movement. He fell and hit his head.
He was initially boarded and collared. CT imaging of his spine
and head was obtained and his C-spine was cleared before
transfer to ICU.
.
# GERD/gastritis: continued home PPI, ASA d/c'd.
# Depression/anxiety: Continued home bupropion/benzodiazepine.
Medications on Admission:
-ZOMIG ZMT 2.5 mg prn migraine, may repeat in [**4-1**] hours, max
#2/24 hours
-Tadalafil 20 mg one hour before sex
-Albuterol Sulfate HFA [**12-27**] inhalations every 4-6 hours as
needed.
-Lorazepam 0.5 mg Oral Tablet prn
-PSYLLIUM HUSK
-Flaxseed Oil
-Lansoprazole 30 mg PO BID (1/2 hr before meals)
-KLONOPIN 0.5 MG TID
-MULTIVITAMIN daily
-VITAMIN B-12 daily
-ASPIRIN 81mg daily
-BUDEPRION SR 150 MG three times daily
-STOOL SOFTENER OTC
Discharge Medications:
1. Zomig 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO daily prn () as
needed for migraine.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Month/Day (2) **]:
[**12-27**] puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. fluticasone 50 mcg/actuation Spray, Suspension [**Month/Day (2) **]: Two (2)
spray Nasal once a day.
4. lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day as
needed for anxiety, insomnia: do not combine with clonazepam as
we discussed (you are transitioning to lorazepam from
clonazepam), or alcohol, or other sedating medications.
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. Budeprion SR 150 mg Tablet Extended Release [**Last Name (STitle) **]: One (1)
Tablet Extended Release PO twice a day.
7. polyethylene glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*30 Powder in Packet(s)* Refills:*0*
8. amoxicillin-pot clavulanate 875-125 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
11. Vitamin B-12 Oral
12. clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times
a day as needed for anxiety: do not combine with lorazepam,
alcohol, or other sedating meds.
13. psyllium husk Oral
14. sildenafil Oral
15. tadalafil Oral
16. flaxseed oil Oral
17. scopolamine base Transdermal
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleeding (hemorrhoidal) requiring massive blood
transfusion protocol complicated by: transfusion reaction
requiring emergent intubation, complicated by difficult
intubation requiring fiberoptic intubation technique complicated
by aspiration event resulting in aspiration pneumonia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
see below.
Do not take aspirin any more as we discussed
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Location: [**Hospital1 641**]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 86789**]
When: Tuesday, [**3-8**], 9:40 AM
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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|
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|
310, 393
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6228, 6992
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5166, 5356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,921
| 178,042
|
9287
|
Discharge summary
|
report
|
Admission Date: [**2128-11-14**] Discharge Date: [**2128-11-30**]
Date of Birth: [**2051-9-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
thorocentesis
History of Present Illness:
77 y/o male w/ h/o rheumatic heart dz s/p mechanical mvr/avr,
afib (s/p VVI PPM); CAD s/p stenting; h/o CHF with preserved EF
55%; s/p recent admit to [**Hospital1 18**] for 7 wks (work up for valve
leakage included TTE, TEE, MRI showing 2+ MR [**First Name (Titles) 31820**] [**Last Name (Titles) 31821**]e; s/p cath x 2 with stenting of RCA and LAD; s/p VVI
pacemaker for chronic afib) who was discharged and then
readmitted with SOB and resp failure, aggressively diuresed with
natrecor and laxis and DC to rehab on [**11-9**]. Now readmitted with
increased SOB and weight gain (148 on [**11-13**], 153 on [**11-14**], goal
is 132). Unable to diurese at rehab despite increasing Bumex to
3mg [**Hospital1 **] on [**11-13**]. Increaed edema, decreased sats.
In ED: Decreased BP to 60s systolic (usually 90s) and somnolent.
Recieved 250 bolus and dopamine gtt. ABP 7.19/82/94 placed on
bipap. had temp to 101 in ED and recieve 1gm vanco. K was 6.2
and recieved 10 units of insulin/D50/2gm cal glu. Rt fem CVL
placed. CXR showed worse right pleural effusion aas compared to
previous. Pt transferred to floor, ABG 7.16/87/61 and decided to
intubate after extensive discussion with family about code
status.
Past Medical History:
1. CAD - s/p cath [**2128-7-30**]:stenting of the RCA with 3
overlapping cypher [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] [**2128-8-11**]: rotational atherectomy,
PTCA and stenting of the LAD/LCX.
2. MVR/AVR
3. CHF - EF >55% 2+MR [**Month/Day/Year 31820**], RV dysfunction, moderate
pulmonary HTN
4. PAF s/p VVI pacemaker
5. CRI
6. MDS
7. Chronic mechanical hemolysis
8. Hx. of perirectal abscess s/p surgery
Social History:
no hx of etoh or tobacco, lives at home alone, widower.
Children are very involved in his care.
Family History:
non-contributory
Physical Exam:
Vitals: T= 99.8, HR = 60-89, BP = 82/45 on dopa of 5, RR = 20 ,
SaO2 = 100% on AC 500, rate 18, Peep 8. FiO2 50%. weight 153 lbs
General: uncomfortable, mild distress, intubated
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: chest rose and fell with equal size, shape and symmetry,
lungs with decreased breath sounds, left greater than right.
CV: PMI appreciated in the fifth ICS in the midclavicular line-
hyperdymanic, afib, mechanical S1 and S2. III/VI systolic
murmur, II/IV diastolic murmur
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing. 2+ symetric edema with 2+
dorsalis pedis by doppler pulses bilaterally
Integument: no rash
Neuro: Solmnmelent but answer questions yes, no. communicates
with family. CN II-XII symmetrically intact, PERRLA.
Pertinent Results:
CXR:
FINDINGS: A single AP supine image. Comparison study taken 3
hours earlier. The ETT has been withdrawn slightly and its tip
is now 3 cm above the carina in good position. The NG line is
well positioned in the lower portion of the stomach. The heart
shows fairly marked enlargement, predominantly left ventricular.
There is evidence of prior cardiac surgery but the prosthetic
valves are not clearly defined. There is also evidence of CABG
procedure with some cardiovascular clips and sternal sutures
noted. The aorta is slightly calcified and unfolded. The
pulmonary vessels show fairly marked upper zone redistribution.
There is a moderate sized right sided pleural effusion. These
findings are consistent with left heart failure. The severity of
the cardiac decompensation is not significantly changed since
the prior study. An external electrode overlies the inferior
aspect of the cardiac silhouette. A pacemaker overlies the left
shoulder region with a single electrode extending into the apex
of the right ventricle.
IMPRESSION: 1) Evidence of prior surgery. There is now left
ventricular decompensation of moderate severity associated with
a right sided effusion. The ETT is now in good position.
Brief Hospital Course:
1. Respiratory failure: When the aptient was admitted, he was
placed on BiPap, however continued to have decreased PaO2 and
was acidotic and hypercarbic. Therefore he was intubated and
remained intubated until [**11-18**] when he was successfully
extubated/ The patient's respitary failure was though to be due
to a combination of CHF, a large pleural effusion and possibly a
PNA. He was aggressively diuresed, and his plueral effusion was
tapped and found to be transudative, and he was placed on broad
spectrum antibiotics. The IV antiobiotics were switched to PO
levofloxacin. Repeat CXR showed increased right pleural
effusion compared to the CXR after the thoracentesis. However,
pt continued to breath comfortably on room air. Pt also got Flu
vaccine during his stay.
2. Decompensated CHF: The patient came in with a weight of
69.4kg and his dry weight is 60kg. The patient later admitted to
drinking a large amount of water in rehab and being constantly
thirsty. Historically the patient responds best to natrecor with
dopamine. He was started on dopamine and natrecor for diuresis
and Lasix IV bolsues were added as needed. As his urine output
fell, he was started on a Lasix drip. Once he was close to his
dry weight, Natrecor was stopped and he was switched to PO
Zaroxyln and Lasix prn. He was eventually switched converted to
standing po Bumex 2 mg po bid and achieved his ideal wt of 60 kg
and remained stable. Once pt was off dopamine tolerating BP,
Toprol XL was started. Lisinopril was re-started as well.
These medications were administered at bedtime since his SBP
drops to 80's with these meds. Standing po Bumex was started (2
mg [**Hospital1 **]). Pt achieved his ideal dry weight of 60.5 kg at one
point, but wt returned to 63.5 kg which was thought to be
secondary to sodium retention from the prednisone he took for
gout flare. His discharge weight was 62.8 kg. He was
discharged with Toprol 12.5 mg po qhs, Lisinopril 1.25 mg po
qhs, Bumex 2 mg po bid. Pt is very sensitive to ACEI and drops
his BP in 80's, so it is given at bedtime. It is emphasized
that his baseline BP is in the 80's-low 100's, and no
medications should be held for SBP of high 80's or 90's. Toprol
and Lisinopril should be spaced 2 hr apart. Pt will be followed
at [**Hospital 1902**] clinic.
3. CAD: The paitent is s/p RCA stenting on [**2128-7-30**] for reversible
inferior wall defect. His ASA and plavix were continued and
carvediol and lisinopril were initially held for low SBP. As
above, after diuresis and improved cardiac output, pt was
started on Toprol and lisinopril.
4. Rhythm: Chronic afib s/p VVI pacer [**2128-8-12**]. Pt was initially
started on digoxin for rate control while he was hypotensive and
on dopamine gtt. But it was switched to Toprol later for rate
control. Coumadin was held for thoracentesis but re-started.
5. Chronic anemia [**1-26**] mechanical hemolysis MDS, and anemia of
chronic disease. He was initially continued on iron and folate,
but the EPO was given 10,000 units qMWF which is half of what he
was getting on last admission to keep his Hct stable. His Hct
slowly drifted down, so the EPO was increased to 20,000 units
qMWF with good response. His Hct remained stable at 29-30. Pt
will be discharged with EPO 20,000 qMWF and Iron supplement.
8.CRI: The paitent's baseline is 1.2. He had a bump up to 3.0 on
admission. His creatinine improved to his near baseline after
aggressive diuresis to improved the cardiac output.
9.Mechanical valve: Pt was on Coumadin which was held initiallya
and bridged with Heparin gtt for procedures. Coumadin was
re-started with goal of INR 2.5-3.5. INR was 3.5 on discharge.
10. Gout: Pt developed a severe left foot pain localized at
tarsal area. The area appeared erythematous and tender to
palpation. Pt responded well to prednisone 30 mg x 3 days. Pt
was given additional 15 mg x 3 days. He will be followed by
outpatient [**Hospital 2225**] clinic and decide whether he needs to be
on long term prophylaxis. Pt's uric acid was 10.6. Gout flare
may have been triggered by chronic mechanical hemolysis, chronic
diuresis, and CRI.
11. FEN: Pt needs to be on 2gm sodium diet, cardiac diet, and
fluid restriction of 1.5 L. Pt needs to be weighed daily and be
reported to MD if he has more than 1 kg of weight gain, so his
medications could be adjusted.
Medications on Admission:
Plavix 75, folic acid 1, atrovent, lipitor 20, asa 81, remeron
15, no aldactone (was not supposed to start this in rehab given
labile K), ranitidine 150, epogen [**Numeric Identifier 389**] qMWF, cravediolol 3.125
[**Hospital1 **], lisinopril 5 (was supposed to be taking 3.75), Bumex 2 [**Hospital1 **]
increased to 3 [**Hospital1 **] on [**11-13**], Coumadin 13mg.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime).
13. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO HS (at bedtime):
Please give 2 hrs before lisinopril
Hold for SBP<90, HR<55.
16. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Please have INR checked frequently.
18. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO once a
day: Please base the dosing on INR level. Goal 2.5-3.5.
19. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
for 2 days.
20. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
Take 2 hrs after Toprol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CHF exacerbation
Pneumonia
Gout
A-fib
CAD
Discharge Condition:
Stable, pt near his ideal weight, breathing on room air.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
Patient was instructed to take all of the medications as
instructed. Pt needs to be weighed daily and needs to report to
MD (Dr. [**Last Name (STitle) 73**] or MD at the rehab and have his medications
be adjusted accordingly. Pt needs to restrict the fluid intake
to 1.5 L/day. Pt should have his INR checked until it is at a
stable level between 2.5-3.5, and have the coumadin dose
adjusted accordingly.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2128-12-6**] 3:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2128-12-15**] 10:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2128-12-29**] 11:30
Completed by:[**2128-11-30**]
|
[
"486",
"518.81",
"V43.3",
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"584.9",
"276.7",
"427.31",
"458.9",
"428.0",
"593.9",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"34.91",
"93.90",
"96.04",
"00.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11048, 11120
|
4390, 8756
|
320, 335
|
11206, 11264
|
3155, 4367
|
11845, 12411
|
2150, 2168
|
9174, 11025
|
11141, 11185
|
8782, 9151
|
11288, 11822
|
2183, 3136
|
277, 282
|
363, 1571
|
1593, 2021
|
2037, 2134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,398
| 141,582
|
8195
|
Discharge summary
|
report
|
Admission Date: [**2118-6-13**] Discharge Date: [**2118-6-17**]
Date of Birth: [**2049-8-11**] Sex: M
Service: NME
CHIEF COMPLAINT: Headache, nausea, vomiting, and dizziness.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old right-
handed man with multiple vascular risk factors who presents
with the acute onset of dizziness followed by nausea,
vomiting, and a headache.
Two days prior to admission, he was having lunch with his
wife when he suddenly felt dizzy - like things were moving
around here. He got up and tried to walk 10 feet, and he
then fell to the right against a wall. He then walked to his
care but was veering to the right. When he got to the car,
he noticed that dizziness was worse with head movement. 911
was called, and he was taken to [**Hospital3 **].
At the outside hospital, he had a noncontrast head computer
tomography that was negative. He was then admitted for rule
out for myocardial infarction. On Sunday morning he noticed
that his right arm was clumsy and that his speech was clumsy.
He denied any language difficulties such as comprehension or
thinking of words to say. He then became nauseous with a
headache and vomited. A repeat noncontrast head computer
tomography showed a right 4-cm X 3-cm cerebellar infarction.
The patient was then put on intravenous heparin without bolus
and transferred to the Intensive Care Unit on a nitroglycerin
drip due to a blood pressure of 220/80.
REVIEW OF SYSTEMS: The patient denies any fevers, chills,
weakness, numbness, visual changes, hearing changes, chest
pain, shortness of breath, abdominal pain, dysuria,
hematuria, dysphagia, diarrhea, bright red blood per rectum,
or bowel or bladder problems.
PAST MEDICAL HISTORY: Coronary artery disease.
Hypertension.
Diabetes.
Hypercholesterolemia.
Chronic renal insufficiency.
Hypothyroidism.
MEDICATIONS AT HOME:
1. Aspirin 81 mg by mouth once per day.
2. Atenolol 50 mg by mouth once per day.
3. Lisinopril 40 mg by mouth once per day.
4. Synthroid 150 mcg by mouth every day.
5. Glucophage 500 mg by mouth twice per day.
6. Glucotrol-XL 10 mg by mouth once per day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No strokes.
SOCIAL HISTORY: He is a retired carpenter who lives with his
wife. [**Name (NI) **] quit smoking in [**2078**]. He drinks occasional
alcohol, but he uses no drugs.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.3
degrees Fahrenheit, his blood pressure was 166/63, his pulse
was 51, his respiratory rate was 20, and oxygen saturation
was 96 percent on room air. Generally, a pleasant male in
no acute distress. There were no carotid bruits. His heart
had a regular rate and rhythm. The lungs were clear to
auscultation bilaterally. Extremities had no clubbing,
cyanosis, or edema. On neurologic examination, he was awake
and alert. He was cooperative with examination. He was
oriented to person, place, and date. He was able to do
months of the year backwards. His recall was [**3-9**] at five
minutes. He was fluent with good comprehension and
repetition. His naming was intact. There was no dysarthria
or paraphasic errors. There was apraxia or neglect. On
cranial nerve examination, the pupils were equal, round, and
reactive to light at 4 mm to 3 mm bilaterally. The visual
fields were full to confrontation. The extraocular movements
were intact and without nystagmus. There was limited
abduction of the eyes bilaterally. His facial strength and
sensation were intact and symmetric. Hearing was intact to
finger rub bilaterally. Palatal elevation was symmetric.
Sternocleidomastoid and trapezius were normal bilaterally.
The tongue was midline and without fasciculations. On motor
examination, he had normal bulk and tone bilaterally. There
was no tremor. He had full power at 5/5 throughout. There
was no pronator drift. On sensory examination, he was intact
to light touch, pinprick, and proprioception. On reflex
testing, he was [**3-10**] in the upper extremities and [**2-9**] in the
lower extremities. The toes were downgoing bilaterally. On
coordination examination, he had dysmetria on the right
finger-to-nose and heel-to-shin test. On gait testing, he
could not perform examination due to dizziness.
OUTSIDE LABORATORY VALUES ON PRESENTATION: White blood cell
count was 6.2, his hematocrit was 40.5, and his platelets
were 235. Sodium was 140, potassium was 5.5, chloride was
105, bicarbonate was 24, blood urea nitrogen was 47,
creatinine was 1, and blood glucose was 333. His creatine
kinase was 134. His MB was 3.5. Troponin was less than
0.15.
PERTINENT RADIOLOGY-IMAGING: A magnetic resonance imaging of
the head with magnetic resonance angiography of the head and
neck at the outside hospital showed a right PICA and SCA
infarction of the right cerebellum. Scans reviewed with Dr [**Last Name (STitle) 1693**]
who felt it appeared embolic. There was little flow in the
right vertebral artery in the neck. Both intracranial/vertebral
arteries were difficult to visualize. The left intracranial
vertebral seemed to have no flow at the junction with the
basilar, and there was some flow in the right intracranial
vertebral artery.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Intensive Care Unit given that he was on nitroglycerin and
heparin drips. His goal blood pressures were 150s to 170s,
and he was able to be weaned off of the nitroglycerin drip.
Once his blood pressure was manageable off any drips, he was
transferred to the floor.
He was kept on heparin with a goal partial thromboplastin
time of 50 to 60 until a transthoracic
echocardiogram/transesophageal echocardiogram were performed.
Information from these echocardiograms revealed that he had a
small patent foramen ovale and nonmobile atheroma in his
aortic arch. Given the amount of right vertebral occlusion
in the neck, he was kept on heparin and Coumadin was started.
The heparin can be discontinued once he reaches an INR level
between 2 and 3. He will be anticoagulated for three to six
months, and then that will be discontinued.
He was ruled out for a myocardial infarction. He was
continued on his statin and his lipid panel was checked. His
cholesterol was normal at 186, his triglycerides were 155,
his high-density lipoprotein was 60, and his low-density
lipoprotein was 95. His homocystine was checked and found to
be normal at 11.7.
A noncontrast head computer tomography was performed and
showed no interval change in the right cerebellar infarction.
One day prior to discharge, a magnetic resonance
imaging/magnetic resonance angiography of the head was
repeated and found to show no changes except for some small
susceptibility signaling in the right cerebellum. Given that
the amount of blood was quite small in the cerebellum, it was
felt that it was safe to continue his anticoagulation.
DISCHARGE DIAGNOSES: Right cerebellar infarction.
Right vertebral occlusion.
Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg by mouth once per day.
2. Heparin drip.
3. Protonix 40 mg by mouth once per day.
4. Colace.
5. Synthroid 150 mcg by mouth every day.
6. Pravastatin 40 mg by mouth once per day.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE FOLLOW UP: The patient was instructed to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital 878**] Clinic within two to
four weeks of being discharged from the rehabilitation
center. The patient was instructed to call for an
appointment at telephone number [**Telephone/Fax (1) 29128**].
The patient was instructed to follow up with his primary care
doctor within one week of discharge from the rehabilitation
center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6600**], [**MD Number(1) 6601**]
Dictated By:[**Last Name (NamePattern1) 11265**]
MEDQUIST36
D: [**2118-6-16**] 18:01:02
T: [**2118-6-16**] 18:47:52
Job#: [**Job Number **]
|
[
"401.9",
"414.00",
"V45.81",
"434.11",
"250.00",
"244.9",
"433.20",
"272.0",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
2193, 2206
|
6904, 6985
|
7011, 7207
|
1881, 2176
|
7302, 8032
|
5239, 6882
|
1473, 1715
|
154, 198
|
227, 1453
|
1738, 1860
|
2223, 5210
|
7232, 7290
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,734
| 157,829
|
36795
|
Discharge summary
|
report
|
Admission Date: [**2125-9-9**] Discharge Date: [**2125-10-1**]
Date of Birth: [**2058-6-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
New onset of jaw and shoulder pain.
Major Surgical or Invasive Procedure:
[**2125-9-12**] - CABGx3(Left internal mammary artery->Left anterior
descending artery, Saphenous vein graft->Obtuse marginal artery,
Saphenous vein graft->Posterior descending artery)/Aortic Valve
Replacement(25mm [**Doctor Last Name **] Pericardial)/MV Repair(St. [**Male First Name (un) 923**] 32mm
saddle ring)
Cardioversion
[**2125-9-19**] PEG placement
[**2125-9-19**] Bronchoscopy
[**2125-9-26**] Tracheostomy #8 Portex
Cardioversion
History of Present Illness:
67 year old male previously healthy until 5days ago when he
developed new onset bilateral jaw pain radiating to his arms,
lasting the the entire day. The following day he went to see his
PCP who sent him to the emergency room at MWMC. He ruled in for
NSTEMI. Trop 1.5. Cardiac catherization revealed coronary artery
disease and was transferred for surgical evaluation.
Past Medical History:
Tobacco
Social History:
Occupation: stock portfolio manager
Lives with sister
[**Name (NI) 1139**]: [**2-17**] PPD X 50 years - current smoker on admission
ETOH: none
Family History:
None
Physical Exam:
Pulse: 74 Resp: 18 O2 sat: 99% on RA
B/P Right: 127/66 Left:
Height: 74" Weight: 103.6 kg
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
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left: +2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
[**2125-9-12**] ECHO
Pre-CPB:
Patient had originally been planned as an off-pump CABG.
However, valve disorders were seen as significant enough to
warrant intervention.
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50 %), with mild global free wall hypokinesis.
The aortic valve leaflets (3) are mildly thickened. Moderate
(2+) aortic regurgitation is seen.
There are non-mobile complex atheroma of the ascending and
descending aorta.
The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post- CPB:
The patient is AV-Paced and on low-dose NTG.
There is a mitral ring in placed with no MR. Residual mean
gradient = 3.
There is a prosthetic aortic valve with no leak and no AI.
Residual mean gradient = 13.
Good biventricular systolic fxn.
Aorta intact. Other parameters as pre-bypass.
[**2125-9-13**] Head CT
[**2125-9-20**] 02:41AM BLOOD WBC-20.6*# RBC-3.03* Hgb-9.6* Hct-29.8*
MCV-98 MCH-31.7 MCHC-32.3 RDW-13.7 Plt Ct-203
[**2125-9-9**] 03:26PM BLOOD WBC-9.7 RBC-3.95* Hgb-12.5* Hct-38.3*
MCV-97 MCH-31.5 MCHC-32.5 RDW-13.9 Plt Ct-140*
[**2125-9-20**] 02:41AM BLOOD PT-16.2* PTT-42.4* INR(PT)-1.4*
[**2125-9-9**] 03:26PM BLOOD PT-14.4* PTT-26.6 INR(PT)-1.2*
[**2125-9-20**] 02:41AM BLOOD Glucose-122* UreaN-32* Creat-1.2 Na-138
K-3.9 Cl-100 HCO3-26 AnGap-16
[**2125-9-9**] 03:26PM BLOOD Glucose-120* UreaN-22* Creat-0.9 Na-137
K-4.1 Cl-106 HCO3-21* AnGap-14
[**2125-9-30**] 03:19AM BLOOD WBC-14.3* RBC-2.51* Hgb-7.7* Hct-24.8*
MCV-99* MCH-30.5 MCHC-30.9* RDW-15.7* Plt Ct-201
[**2125-9-30**] 03:19AM BLOOD PT-21.5* PTT-33.6 INR(PT)-2.0*
[**2125-9-30**] 03:19AM BLOOD Glucose-120* UreaN-40* Creat-1.1 Na-148*
K-4.8 Cl-112* HCO3-29 AnGap-12
Brief Hospital Course:
He was admitted to the [**Hospital1 18**] for surgical management of his
coronary artery disease. He was worked-up in the usual
preoperative manner. As there was a positive Heparin Induced
Thrombocytopenia assay from [**Hospital6 1109**], a repeat
assay was obtained which was negative. A hematology consult was
obtained and he was cleared for surgery. On [**2125-9-12**], he taken to
the operating room were he underwent coronary artery bypass
grafting, aortic valve replacement, and a mitral valve repair.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. He received
vancomycin for perioperative antibiotics because he was in the
hospital preoperatively. On postoperative day one, left sided
weakness was noted, a CT scan was obtained which revealed a
right sided infarct. Neurology was consulted for assistance in
his care. He was extubated on post operative day two. dobhoff
was placed for nutrition due to loss of gaga and inability to
control secretions, speech therapy was consulted. He had
episodes of atrial flutter that was treated with beta blockade,
amiodarone, calcium channel blockers and digoxin but unable to
control rate. EP was consulted for further management of atrial
flutter. He was then cardioverted but within twenty four hours
returned to atrial flutter. Reintubated electively for peg
placement at bedside and bronchoscopy was performed due to
secretions on post operative day seven, and he was extubated
after procedures complete. He continued to be followed by
electrophysiology and medications were adjusted but he remained
in atrial flutter. Repeat DCCV was performed on [**9-18**] with
conversion to NSR, in which he has remained. Anticoagulation
was maintained for cardiac rhythm with heparin and coumadin.
His pulmonary status remained tenuous with his difficulty in
mobilizing thick, moderate to large amounts of secretions. On
[**9-25**] he was reintubated due to increased work of breathing and
the next day he had tracheostomy. Empiric antibiotics were
started for due to leukocytosis and secretions, and Infectious
disease was consulted. All cultures negative except for sputum
which grew out rare growth Staph Aureus, coag +, gram negative
rods which is preliminary and urine with gram negative rods
~7000. He received 8 days course of vancomycin and zosyn per
infections disease recommendations stopped [**10-1**]. He was started
on trach collar trials but requiring ventilator at night.
Physical therapy was consulted for strength and mobility.
Occupational therapy for work with left arm and leg. On [**10-1**]
his tube feeds were adjusted due to free water deficit and water
added to tube feeds. He was ready for discharge to rehab on
[**2125-10-1**].
Sternal incision healing no drainage no erythema, sternum stable
Left Leg EVH healing no erythema no drainage
Edema +1 lower extremity
Weight preoperative 103.8 kg [**10-1**] - 97.2 kg
Neurologically alert, follows commands except left lower
extremity able to lift and hold off bed, left upper extremitiy
no movement when asked but has sponateously moved at times
Respiratory trach collar as tolerated but returns to ventilator
CPAP
Medications on Admission:
Aspirin 325mg daily
plavix 300 mg (dose 7/23 only)
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and PRN as needed for line flush.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY
(Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day): while mechanically
ventilated.
13. Regular insulin Sliding Scale
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL 4 oz. Juice
61-109 mg/dL 0 Units
110-130 mg/dL 3 Units
131-150 mg/dL 5 Units
151-180 mg/dL 7 Units
181-210 mg/dL 9 Units
211-240 mg/dL 11 Units
> 240 mg/dL Notify M.D.
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please check INR monday, wednesday, and friday until on stable
dose - goal INR 2.0-2.5, medication adjustment with amidarone
and antibiotics in last few days that would effect INR level .
15. Outpatient Lab Work
please check CBC and Chem 7 weekly while in rehab
Please check sodium wednesday and friday this week to evaluate
free water deficit
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Mitral Regurgitation s/p mitral valve repair
Aortic Insufficiency s/p AVR
right frontal infarction - acute stroke
Atrial fibrillation/flutter
Failed swallow with signs aspiration s/p PEG
Inability to manage secretions s/p tracheostomy
Acute renal failure
Non ST elevation myocardial infarction
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. 5) 5) Please bathe daily and wash incisions with mild
soap and water, rinse with water and gently pat the wound dry.
6) 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 until cleared by PCP and cardiac [**Telephone/Fax (1) 5059**]
7) Call with any questions or concerns. [**Telephone/Fax (1) 170**]
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **](for Dr. [**First Name (STitle) **] in 1 month at
[**Hospital1 **] [**Telephone/Fax (1) 6256**]
Please follow-up with Dr. [**First Name (STitle) **] in [**2-16**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 14334**] in [**3-20**] weeks.
Please follow up with Dr [**Last Name (STitle) **] (neurology) 3-4 weeks
Coumadin for atrial fibrillation with goal INR 2.0-2.5 - please
check INR monday - wednesday - friday until on stable dose and
with changes in amiodarone and discontinuation of antibiotics
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-10-1**]
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29,509
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3911
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Discharge summary
|
report
|
Admission Date: [**2120-3-13**] Discharge Date: [**2120-3-19**]
Date of Birth: [**2052-5-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 year old male with CAD s/p CABG in [**2100**] and recent
catherization with BMS to SVG-RCA admitted from PCP's office's
for hypotension. He went to [**Hospital1 2025**] on [**2-28**] with chest pain and
shortness of breath. He had a stress test that showed reversible
inferior ischemia and was cathed on [**3-4**]. BMS was placed to
SVG-RCA. He was discharged on [**3-7**]. On [**3-11**] he went to PCP with
complaints of right groin pain. His INR was noted to be 3.8 and
he was told to stop coumadin and levonox which were started at
[**Hospital1 2025**] for afib. On [**3-13**], he followed up with his PCP and reported
worsening right groin pain and was found to be hypotensive and
pale with BP in the 70's. He was transferred to [**Hospital1 18**] ED.
.
In the ED, initial vitals were: 100.0, 100, 74/42, 19, 96% on
RA. Hct was 26.8, baseline about 30. He was started on 1unit of
PRBC. Central line was placed. He was given 4L of NS and was on
levophed. His INR was 3.1 and was given vitamin K and 2U FFP. He
was given asa and plavix. He was given vanc and ceftriaxone. His
mental status was never comprimised and he made some urine
during his ED course. Cards consult was called and bedside echo
did not show new WMA and no pericardial effusion. His cardiac
marker was not dramatically elevated. EKG had RBBB which is old.
Abd CT ruled out retroperitoneal hematoma but revealed a right
groin intramuscular hematoma. Vascular consult was called and
there are no plans for surgery. He was admitted to the CCU for
further care.
.
On review of symptoms, he denies any deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
CAD s/p CABG (5-vessel at [**Hospital1 2025**] in [**2098**])
-- CABG: LIMA --> LAD, SVG --> distal RCA, and SVG --> D1, OM1,
OM3
-- Cath: [**2120-3-4**]:
1. Short LM with minimial luminal irregularities.
2. Mid LAD chronic total occlusion. Diag with diffuse disease
and proximal 75% focal stenosis.
3. Native LCX with 80% mid stenosis.
4. Chronically occluded RCA.
5. Patent LIMA to LAD.
6. SVG to D1 to OM1/OM2 occluded.
7. SVG to PDA 80% proximal and distal stenosis, stented
successfully
CHF, systolic and diastolic dysfunction
Atrial fibrillation
Stroke
Carotid stenosis
Chronic renal insufficiency, baseline cr 1.5
Hypercholesterolemia
Subclavian stenosis
Anemia (B12 deficiency)
Alcoholism
Hypogonadism
Osteoarthritis
Myeolodysplastic syndrome
Social History:
25 pack year tobacco, quit 24 years ago.
Quit alcohol 26 years ago.
Lives with girlfriend in [**Name (NI) **]. Divorced with three children
with ex-wife.
Family History:
Family history non-contributory.
Physical Exam:
VITALS: 97.6, 110/56, 83, 18, 100%2LNC
GEN: A+Ox3, NAD, pleasant, follows commands, poor memory
HEENT: PERRLA, EOMI, MMM, OP clear
NECK: Thick neck; cannot assess JVP
CV: RRR, no M/G/R
PULM: Mild crackles at left base, no wheezing, rhonchi
ABD: Soft, NT, ND, +BS, no HSM, guaiac negative in ED
EXT: Large legs with pitting edema in lower extremities. Right
groin with palpable induration along inguinal line (hematoma?).
Legs and feet warm to palpation with good capillary refill.
NEURO: CN II-XII intact, mobilizes all extremities
PULSES: Fem 2+ bilaterally, DP 1+ bilaterally, PT pulses not
palpable.
Pertinent Results:
[**2120-3-13**] 02:40PM BLOOD WBC-11.7*# RBC-2.59* Hgb-8.8* Hct-26.8*
MCV-103* MCH-34.1* MCHC-33.0 RDW-17.0* Plt Ct-296
[**2120-3-13**] 11:31PM BLOOD WBC-7.9 RBC-2.13* Hgb-7.2* Hct-21.9*
MCV-103* MCH-33.9* MCHC-33.1 RDW-17.4* Plt Ct-205
[**2120-3-17**] 06:16AM BLOOD WBC-5.7 RBC-3.33* Hgb-10.6* Hct-31.3*
MCV-94 MCH-31.7 MCHC-33.8 RDW-17.4* Plt Ct-175
[**2120-3-13**] 02:40PM BLOOD PT-30.6* PTT-48.2* INR(PT)-3.1*
[**2120-3-17**] 06:16AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.3*
[**2120-3-13**] 02:40PM BLOOD Glucose-161* UreaN-31* Creat-1.9* Na-137
K-4.8 Cl-101 HCO3-24 AnGap-17
[**2120-3-17**] 06:16AM BLOOD Glucose-95 UreaN-19 Creat-1.1 Na-139
K-4.3 Cl-102 HCO3-28 AnGap-13
[**2120-3-13**] 02:40PM BLOOD CK(CPK)-568*
[**2120-3-13**] 10:00PM BLOOD CK(CPK)-484*
[**2120-3-14**] 04:55AM BLOOD CK(CPK)-486*
[**2120-3-15**] 05:11AM BLOOD CK(CPK)-181*
[**2120-3-13**] 02:40PM BLOOD cTropnT-0.24*
[**2120-3-15**] 05:11AM BLOOD CK-MB-3 cTropnT-0.27*
[**2120-3-13**] 11:31PM BLOOD Albumin-2.9* Calcium-7.7* Phos-3.2 Mg-2.1
[**2120-3-17**] 06:16AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
.
[**2120-3-13**] 3:29 pm BLOOD CULTURE R IJ.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2120-3-14**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 17441**] [**Last Name (NamePattern1) 394**] AT 2040 ON [**3-14**]..
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2120-3-13**] 3:35 pm BLOOD CULTURE R AC.
Blood Culture, Routine (Pending):
.
[**2120-3-16**] 3:38 pm CATHETER TIP-IV Source: IJ.
WOUND CULTURE (Preliminary): No significant growth.
.
FEMORAL VASCULAR US RIGHT [**2120-3-13**] 8:04 PM
FEMORAL VASCULAR US RIGHT
Reason: RT FEM ART. S/P HEART CATH, HYPOTENSIVE, HEMATOMA ON CT
[**Hospital 93**] MEDICAL CONDITION:
67 year old man w/R fem hematoma ?active bleed; s/p R groin
entry for cardiac cath 2 wks ago; now hypotensive
REASON FOR THIS EXAMINATION:
duplex ultrasound of R fem art
RIGHT FEMORAL VASCULAR ULTRASOUND
INDICATION: 67-year-old with right groin hematoma, question
active extravasation, rule out pseudoaneurysm.
COMPARISON: CT and ultrasound performed earlier today.
FINDINGS: Redemonstrated is a large heterogeneous focus in the
right inguinal area deep to the femoral vessels. This
corresponds with intramuscular hematoma noted on CT. No
significant vascular flow or connection to the femoral vessels
is demonstrated. Normal waveforms are demonstrated in the right
common femoral artery and vein.
IMPRESSION: No evidence of pseudoaneurysm. Hematoma noted
.
CT PELVIS W/O CONTRAST [**2120-3-13**] 3:16 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval for RP bleed
[**Hospital 93**] MEDICAL CONDITION:
67 year old s/p recent cardiac cath in R groin at [**Hospital1 **], now with
R groin pain, "lump", and hypotension, gen fatigue. BP 70s.
REASON FOR THIS EXAMINATION:
eval for RP bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST
INDICATION: 67-year-old man post-recent cardiac catheterization,
presenting with groin pain, mass, and hypotension. Evaluate for
retroperitoneal hematoma.
COMPARISON: Not available.
TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained
without administration of oral or intravenous contrast. Coronal
and sagittal reformatted images were obtained.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is dependent
atelectasis at lung bases bilaterally. Thoracic and abdominal
aorta contain extensive calcification. Eventration of the left
hemidiaphragm is noted. Non-contrast evaluation of the liver,
gallbladder, spleen, right adrenal gland, pancreas is
unremarkable. There is nodular thickening of the left adrenal
gland. There is fusiform aneurysmal dilatation of the infrarenal
aorta, measuring up to 3.4 cm in AP diameter. There is no free
air and no free fluid in the abdomen. There are no
pathologically enlarged retroperitoneal or mesenteric lymph
nodes. There is diverticulosis of the descending colon without
evidence of acute diverticulitis. Normal appendix is seen. Small
bowel loops are normal, given lack of oral contrast. There is no
retroperitoneal hematoma.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: There is extensive
diverticulosis of the sigmoid colon without evidence of acute
diverticulitis. There is Foley catheter within urinary bladder.
The air in the bladder is presumably related to recent
instrumentation. There is no free fluid and no pathologically
enlarged pelvic or inguinal lymph nodes. There is no pelvic
hematoma.
Within the adductor muscle compartment of the right medial
thigh, there is a 8.7 x 5.4 cm high attenuation collection,
consistent with an intramuscular hematoma. Active extravasation
cannot be excluded on the basis of non-contrast study.
BONE WINDOWS: Demonstrate no concerning lytic or sclerotic
lesions. Degenerative changes are noted in the lumbar spine.
IMPRESSION:
1. Large intramuscular hematoma within right adductor
compartment; active extravasation cannot be excluded. No
retroperitoneal hematoma.
2. Diverticulosis without evidence of acute diverticulitis.
3. Atherosclerotic calcification of the aorta with fusiform
dilatation up to 3.4 cm.
.
FEMORAL VASCULAR US RIGHT [**2120-3-15**] 12:52 PM
FEMORAL VASCULAR US RIGHT
Reason: please assess for right cath site hematoma,
pseudoaneurysm,
[**Hospital 93**] MEDICAL CONDITION:
67 year old man s/p heart cath through right groin with thigh
hematoma and unstable HCT.
REASON FOR THIS EXAMINATION:
please assess for right cath site hematoma, pseudoaneurysm,
interval change of thigh hematoma
INDICATION: 67-year-old man with recent right groin
catheterization, assess right groin for pseudoaneurysm or
hematoma.
COMPARISON: Groin ultrasound, [**2120-3-13**].
FINDINGS: Again seen in the right groin is a heterogeneous mass
consistent with a hematoma. Today, it measures 5.5 x 6.8 x 3.9
cm. Color Doppler and pulse wave Doppler images of the common
femoral artery and vein in the right groin demonstrate
appropriate flow in those vessels. A benign-appearing lymph node
is also identified in the right groin, which measures 1.8 x 0.7
x 1.2 cm.
IMPRESSION: Stable appearing 6.8 cm hematoma in the right
groin/upper thigh. Appropriate vasculature with no evidence of a
pseudoaneurysm or an AV fistula.
.
Echo:
There is mild regional left ventricular systolic dysfunction
with inferior, inferolateral and basal inferoseptal severe
hypokinesis/akinesis. The remaining segments contract normally
(LVEF = 40-45%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
borderline normal free wall function. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation secondary to tethering and restricted
leaflet motion is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild aortic regurgitation. Moderate mitral
regurgitation. Moderate pulmonary hypertension.
.
ECG:
Baseline artifact. Regular rhythm. P waves are inverted in the
inferior
leads and there is probability of 2:1 block. At this rate,
probable atrial
tachycardia with 2:1 block versus slow atrial flutter. There is
low limb
lead voltage. Leftward axis. The presence of inferior myocardial
infarction cannot be ruled out. Right bundle-branch block. Other
ST-T wave
abnormalities. On the previous tracing of [**2110-6-16**] inferior
myocardial
infarction was noted. However, the atrial tachycardia with 2:1
block and
right bundle-branch block are new. Clinical correlation is
suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 [**Telephone/Fax (3) 17442**]/[**Medical Record Number 17443**] -141
Brief Hospital Course:
67 year old male with CAD s/p CABG and recent stent to SVG-PDA
10 days ago admitted from PCP's office with right leg pain and
hypotension.
.
# Hypotension. The source of his hypotension was a right femoral
hematoma, as he just had a cardiac catheterization done the week
before, and radiographic imaging revealed a right femoral
hematoma without fistula or pseudoaneurysm. The patient
presented with a supratherapeutic INR of 3.5. He initially
presented with SBP in 80's, improved overnight to 100/60 after
aggressive resuscitation with IVF and packed red blood cells. He
was also placed on levophed. His levophed was weaned off by
HD#2, and his blood pressure remained stable throughout his
hospital course. Other etoiologies of hypotension, including
cardiogenic shock from stent thrombosis, septic shock, or
pulmonary embolism, were considered in the differential but were
not supported by the history, physical examination, or other
laboratory/imaging data. The patient's blood pressure was WNl at
discharge.
.
# Right groin hematoma. The patient had a recent cardiac
catheterization in which his right femoral artery was accessed.
he was discharged from the hospital on [**3-7**], and presented to
his PCP with hypotension on [**3-12**]. His INR at this time was 3.8,
as he was discharged on lovenox and coumadin for his atrial
fibrillation. His hematocrit at presentaiton was 26.7. Right
groin ultrasound showed a hematoma without fistula or
pseudoaneurysm. CT abdomen/pelvis ruled showed a large
intramuscular hematoma without retroperitoneal bleeding. The
patient was evaluated by vascular surgery. Vascular surgery did
not believe that surgery was necessary. The patient was
initially administered vitamin K, FFP, several liters of normal
saline and several units of packed red blood cells. By hospital
day #2, the patient was becoming quite edemetous and he was no
longer given normal saline. Over the first two hospital days,
he received a total of 5 units of FFP, and 6 units of packed red
blood cells. His INR eventually decreased to 1.7, and his
hematocrit increased to 30.0, where it remained stable for the
remainder of his hospitalization. A repeat right groin
ultrasound on [**3-15**] showed the hematoma was stable and not
enlarging. His coumadin was held during hospitalization, and
the patient was instructed to not restart his coumadin for two
weeks, or [**2120-3-26**].
.
#:Bilateral foot pain: The patient presented with bilateral foot
pain, right greater than left. Pain felt like a sharp ache, and
was reproduced with palpation over the balls of his feet. The
patient reports his pain began during his previous
hospitalization in early [**Month (only) 547**], after someone manipulated his
feet in the hospital. The pain began before he underwent
cardiac catheterization during his previous hospitalization. It
has limited his mobility, as he is only able to walk several
steps before being limited by the pain. His pain is thought
secondary to plantar fasciitis as the patient is quite obese,
and his legs are tremendously swollen, with pitting edema on top
of preexisting lymphedema. He was placed on standing tylenol
with some relief. He is scheduled for an outpatient podiatry
appointment on [**2120-4-5**]. He had bilateral foot x-ray's prior
to discharge but the results were not yet available. These
X-ray's should be followed up on at his podiatry appointment.
.
# CAD/Ischemia: CABG-5v in [**2098**]. Recent BMS to SVG-PDA in
[**2120-3-4**]. He had an initialincrease in CKs which were thought
secondary to demand ischemia, they were followed and were
trending down by HD #2. He was continued on aspirin and plavix
even in the setting of bleeding. He was started on metoprolol
once his hematocrit stabilized, and there was no evidence of
active bleeding. His lisinopril was restarted once his blood
pressure was stable.
.
# Pump: Bedside echo done in ED shows EF 45 with HK of the
inferorior
inferior, inferolateral and apical walls consistent with
mutlivessel coronary disease, not significantly changed from
[**2117**]. After resuscitation in the ED with 6 L IVF and 3 units
packed RBC's, the patient developed moderate pulmonary edema and
significant lower extremity edema. He was diuresed with lasix
initially, but then diuresed well on his own without lasix for
several days. He will be discharged on furosemide 20mg PO
daily. This dose can be increased if necessary.
.
# Rhythm: The patient appears to have been diagnosed with afib
on his last hospitalization at [**Hospital1 2025**]. He was predominately in NSR
with occ. paroxysmal afib while on telelmetry during this
hospital stay. He presented with a supratherapeutic INR to 3.5,
and his coumadin was held. He was instructed to not continue his
anticoagulation until [**2120-3-26**].
.
# ARF: Baseline creatinine about 1.5. Creatinine on admission
was 1.9, and decreased to 1.1 after fluid resuscitation. His
creatinine remained stable once he was fluid resuscitated,
indicating that his acute renal failure was prerenal.
.
#Positive Blood Culture: Cultured from Right IJ, coag negative
staph aureus. Only found in [**12-1**] bottles, and not found from
peripheral cultures. Patient was given one dose of vancopmycin
and his line was removed. Subsequent cultures have been
negative.
Medications on Admission:
Toprol-XL 200 mg once daily
Lipitor 40 mg once daily
Plavix 75 mg once daily
Warfarin 7.5 mg once daily,
Isosorbide mononitrate 60 mg once daily
Lisinopril 5 mg once daily
Omeprazole 20 mg once daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Continue until ambulatory.
8. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
9. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not restart until [**3-26**].
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right groin intramuscular hematoma within adductor compartment
Coronary Disease
Chronic Systolic Congestive Heart Failure
Myelodysplastic Syndrome
Atrial Fibrillation
Osteoarthritis
Discharge Condition:
Good, tolerating PO. Difficulty with ambulation.
Discharge Instructions:
You were admitted to the hospital with low blood pressure, and
found to have a right groin hematoma. You were administered IV
fluids, along with blood transfusions. In addition, your
anticoagulaiton was discontinued. Bleeding from your hematoma
stopped, and your blood pressure and hematocrit normalized.
.
Your isosorbide mononitrate was discontinued.
.
You were started on furosemide 40mg PO, to be taken daily for 7
days. Then you should go back to taking 20mg daily.
.
Please do not continue your coumadin until [**3-26**]. You will need
to make an appointment with the coumadin clinic after you
restart the coumadin.
.
Please [**Last Name (un) **] your medications as prescribed.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, or any other
symptom.
Followup Instructions:
The patient's foot X-ray's should be followed up on at his
podiatry appointment.
.
Your primary care physician should check your chem 7 and kidney
function at your next appointment.
.
Provider: [**Name10 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1144**] Date/Time: [**2120-3-29**]
10:15pm
Provider: [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2120-3-29**] 3:40pm
.
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (podiatry) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2120-4-5**] 2:00
|
[
"V45.81",
"272.0",
"428.42",
"303.90",
"584.9",
"427.31",
"433.10",
"238.75",
"790.92",
"E934.2",
"414.01",
"428.0",
"585.9",
"998.12",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
18639, 18718
|
11840, 17135
|
282, 288
|
18944, 18995
|
3767, 4893
|
19854, 20468
|
3094, 3128
|
17386, 18616
|
9269, 9358
|
18739, 18923
|
17161, 17363
|
19019, 19831
|
3143, 3748
|
4937, 5334
|
5368, 5431
|
231, 244
|
9387, 11817
|
5463, 5632
|
316, 2130
|
2152, 2905
|
2921, 3078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
590
| 172,260
|
46688+58935
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-11-2**] Discharge Date:
Date of Birth: [**2055-2-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old man
with a history of alcohol abuse who presented on [**2124-11-2**] with
lethargy, abnormal labs, dehydration and a low blood
pressure. The patient has long history of alcohol abuse with
question liver disease. He also had a prior GI bleed in the
past but is not known to have varices. He initially
presented to [**Hospital1 69**] Emergency
Room on [**2124-10-30**] with complaints of weakness, trouble
ambulating and requesting detox placement. He was discharged
to [**Hospital1 **] for detox. Upon arrival at [**Hospital1 **], labs were
drawn which revealed severely elevated liver function tests.
This included an AST of 99, ALT 32, alkaline phosphatase 496,
total bilirubin 16.4, albumin 1.6. It also showed that he
had a hematocrit of 22.2.
The patient was managed for approximately 1?????? days with a CIWA
scale, received 1-2 doses of Serax. He was also started on
Levaquin for a question of pneumonia. However, on the
evening of [**2124-11-1**], the patient was found to be hypotensive
and more lethargic. He was then transferred back to the [**Hospital1 1444**] Emergency Room for further
evaluation and management.
In the Emergency Room, a central line was placed and he was
given aggressive IV fluid and rehydration including
intravenous potassium chloride and potassium phosphate. A
rectal was guaiac negative and NG lavage was also negative
for GI bleed. A diagnostic paracentesis was performed which
yielded only about 10-15 cc of straw colored fluid. This
fluid was negative for suggestion of spontaneous bacterial
peritonitis. The patient had a blood pressure in the 70-80
range systolic and was felt to be too unstable for the
general medical floor and was transferred to the MICU on the
[**Hospital Ward Name **].
PAST MEDICAL HISTORY: Alcohol abuse with apparent liver
disease. History of withdrawal with delirium tremens but no
history of seizures. History of GI bleed, presumably
secondary to gastritis. Prostate cancer status post
resection [**12/2121**]. Pancreatitis. Chronic hypocalcemia. Status
post fracture and open reduction and internal fixation of his
left arm. Coronary artery disease. Cardiac catheterization
[**11-29**] showed an EF of 50%, mild to moderate single vessel
disease of the left circumflex artery, 50% stenosing lesion
was noted at the mid section of the artery. Hypertension.
MEDICATIONS: On transfer from [**Hospital1 **], Multivitamin,
Folate, Thiamine, Protonix, calcium carbonate, magnesium
oxide, Levaquin 500 mg, Lasix, Serax.
ALLERGIES: Aspirin.
SOCIAL HISTORY: The patient is married. He is a retired
telephone repairman. He has a history of alcohol abuse,
drinking at least 1?????? cups of brandy a day. His last drink
was reportedly on [**2124-10-30**]. He also smoked ?????? pack per day
times 30 years.
PHYSICAL EXAMINATION: Temperature 97.1, pulse 88-99, blood
pressure 70/42-117/64, respiratory rate 26, O2 saturation 99%
on four liters nasal cannula. The patient is a cachectic
elderly African American male in no acute distress. He is
lethargic. He is alert and oriented times two. HEENT:
Pupils equal, round and reactive to light and accommodation,
there is positive scleral icterus. His oropharynx is clear.
Neck is supple. Chest, bibasilar crackles without wheezing
anteriorly. Cardiovascular exam is regular rate and rhythm,
no murmurs are appreciated. Abdomen, positive bowel sounds,
very distended. Liver edge palpable about 5 cm below the
right costal margin and nontender. Tympanic abdomen. Guaiac
negative rectal exam. Extremities, trace edema in both feet.
Neuro exam, alert and oriented times two but lethargic. Does
not cooperate with full neuro exam but moves all extremities.
LABORATORY DATA: White blood cell count 16.0, hematocrit
23.7, platelet count 298,000, MCV 100, 74 neutrophils, 4
bands, 20 lymphs, 1 mono, 11 nucleated red cells, INR 1.4,
PTT 35.5, sodium 139, potassium 3.0, chloride 106, CO2 21,
BUN 19, creatinine 1.2, glucose 112, albumin 2.0, calcium
7.4, magnesium 2.1, phosphorus 0.6, ALT 32, AST 112, alkaline
phosphatase 523, total bilirubin 20.4, direct bilirubin 14.8,
indirect bilirubin 5.6, amylase 210, lipase 213. Chest
x-ray, heart size within normal limits, low lung volume, no
evidence of CHF. Blunted right costophrenic angle. No
obvious pneumonia. Abdominal ultrasound, no obvious evidence
of cholecystitis. There is positive sludging and stones
noted. No intra or extra hepatic ductal dilatation is noted.
Peripheral blood smear, target cells, poikilocytes, nucleated
red cells, few teardrops, reticulocytes, no schistocytes
seen. EKG, atrial tachycardia at 115, normal axis, short PR
interval, long QTC, superior T wave, T wave inversions in V1,
biphasic in leads V2 through V3, T wave flattening in 3, L.
HOSPITAL COURSE: The patient was admitted for management of
his apparent fulminant liver failure. CT scan of his abdomen
was performed after admission. This revealed bilateral
pleural effusions, diffuse fatty liver, no intra or extra
hepatic ductal dilatation, patent portal and hepatic veins,
diffuse colonic thickening which appears to be consistent
with pancolitis with some involvement of the terminal ileum.
Gallbladder shows some stones and sludging but no wall
thickening. There is a small amount of fluid around the tail
of the pancreas with no overt radiographic evidence of
pancreatitis. Diverticula were also noted. There is a
moderate amount of free fluid in the pelvis. There is not an
overt amount of ascites fluid. There is increased
attenuation in the right lobe of the liver.
The liver service was consulted as well as the surgical
service to comment on the patient's liver failure as well as
abdominal distention. The liver service felt that this was
most likely consistent with a picture of fulminant alcoholic
hepatitis. They did note that it is not uncommon to see
mildly elevated transaminases in the presence of severely
elevated alkaline phosphatase and total bilirubin. There
were initial discussions regarding performing an MRCP vs an
ERCP. By [**2124-11-3**] the patient's amylase and lipase had
decreased significantly. At that point, the liver service
suggested holding off on performing an MRCP. It was also
felt that the patient would likely not tolerate an MRCP given
his history of claustrophobia. If he required sedation for
the procedure, he likely would have required intubation for
airway management.
The liver service also felt that ERCP was likely not
indicated in his case regardless given the severity of his
liver failure. It was felt that if he had the unfortunate
complication of pancreatitis status post ERCP, that his
overall mortality would be unacceptably high.
Pentoxifylline was started initially to prevent the
development of renal failure given his liver failure.
However, this was later stopped due to the question of
possible sepsis.
The surgical service recommended no surgical intervention as
an option at this time. They felt that the increase in the
bilirubin, and the bowel wall thickening appeared to be
related to his extensive liver failure. They felt no
surgical intervention was indicated given his overall
clinical picture.
The patient was hemodynamically stable during his initial
stay in the MICU. He was transferred to the floor on
[**2124-11-4**]. However, on [**2124-11-5**] the patient became increasingly
confused and his temperature was noted to drop to 90.
Because of his confusion and severe hypothermia, he was
returned to the MICU service for further evaluation as he
appeared to be rapidly deteriorating. Also, the patient's
blood pressure had again dropped to the 70 range. He
received treatment with IV fluids, and antibiotics were
continued for broad coverage of bowel flora. Antibiotic
regimen which had been started on initial admission to the
MICU included Ampicillin, Levofloxacin, and Flagyl. His
Pentoxifylline was discontinued given the concern for the
development of sepsis at this point. The patient's liver
function tests showed a mixed picture of improvement vs
deterioration. His total bilirubin gradually was decreasing
after peaking in the 24 range. Meanwhile his amylase and
lipase had again returned to the 200 range after initial
improvement. His abdominal distention was worsening and
plain radiographs of the abdomen showed very distended loops
of bowel. There was no overt evidence of obstruction. The
patient was continuing to pass stool. The Metronidazole was
changed to an alternating dose between po and IV given the
concern for C. diff colitis. There was no radiographic
evidence of toxic megacolon.
On [**2124-11-6**] the patient became hemodynamically unstable with
blood pressures dropping to the 60's and 70's systolic range.
He was emergently intubated for airway protection given his
mental status, and he was started on pressors with Dopamine
initially. On the ventilator, the patient was
hyperventilated to attempt to compensate for his severe
metabolic acidosis. His serum PH ranged between 7.2 and 7.3
on the ventilator.
On [**2124-11-7**], the patient continued to deteriorate from a
hemodynamic standpoint requiring the addition of two more
pressor agents. He eventually was stabilized on a regimen of
Dopamine, Norepinephrine, and vasopressin. The
Norepinephrine and vasopressin were maintained at maximum
doses, while the Dopamine was at the range of [**5-7**]
mcg/kg/minute. The patient's central venous pressure
appeared to be low and he was continued to be aggressively
hydrated with multiple IV fluid boluses.
There was no obvious source of infection found at the time of
this dictation, however, his white count did continue to
trend upward into the 20 range. Blood cultures have been
sent again to seek a source of infection which may not be
covered by his current antibiotic regimen. Also, at this
time we are considering repeating an ultrasound to look for
any evidence of obstruction so that if his alkaline
phosphatase continues to elevate despite the improvement in
his total bilirubin and his other liver function tests. At
the time of this dictation, the patient is still too unstable
to have an MRCP performed nor would he potentially tolerate
therapeutic ERCP.
Extensive discussions have been held with the family to
discuss his overall condition and poor prognosis. The
patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**], has also
been involved in these discussions. At the time of this
dictation, the patient's family has decided that he will
remain a full code status. However, they wish that if he
does have an arrest, that a prolonged code not be performed
should he not be revivable in a quick manner.
A discharge summary addendum will follow this discharge
summary to summarize the remaining events during this
[**Hospital 228**] hospital course.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 16017**]
MEDQUIST36
D: [**2124-11-9**] 14:13
T: [**2124-11-11**] 13:14
JOB#: [**Job Number 99116**]
Name: [**Known lastname 15849**], [**Known firstname **] Unit No: [**Numeric Identifier 15850**]
Admission Date: [**2124-11-2**] Discharge Date: [**2124-11-15**]
Date of Birth: [**2055-2-20**] Sex: M
Service:
HOSPITAL COURSE ADDENDUM: The patient continued to be
hypotensive on multiple pressors. The patient appeared not
to be making any advances toward improvement. He continued
to bleed from above and below, his pressure became more
resistant to pressor therapy. He was continued on broad
spectrum antibiotics. After several family meetings it was
clear to the family that CPR was not indicated and an order
was written in the chart based on discussions with the
medical team and the family. Based on this the patient was
made CPR not indicated. He continued to decline and
ultimately ended up passing away on [**2124-11-15**] at 03:15 PM of
cardiopulmonary arrest from hepatic failure and multi-organ
failure secondary to that.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2124-11-15**] 18:39
T: [**2124-11-23**] 07:31
JOB#: [**Job Number 15851**]
|
[
"401.9",
"276.5",
"263.9",
"303.91",
"518.81",
"V45.82",
"785.59",
"414.01",
"571.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.04",
"99.15",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
4965, 12556
|
2992, 4946
|
139, 1917
|
1940, 2701
|
2718, 2969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,327
| 125,838
|
5922
|
Discharge summary
|
report
|
Admission Date: [**2184-11-25**] Discharge Date: [**2184-11-30**]
Date of Birth: [**2126-5-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Hypoglycemia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
58 y/o female with hypertension, type I diabetes s/p pancreatic
transplant (failed) and ESRD s/p renal transplant who was
transferred from [**Hospital6 85**] after
receiving [**Hospital6 8472**] 1000 Units (10 cc of 100 mg/cc). Patient was
admitted to [**Hospital1 18**] two weeks ago for foot surgery, was discharged
home with crutches, fell down a flight of stairs with sustained
loss of conciousness. The patient was found to have a subdural
hematoma with associated left arm and leg weakness. The patient
had an insulin pump that was removed during this most recent
admission and the patient was started on [**Hospital1 8472**] and Regular
insulin. She was discharged from [**Hospital1 18**] on [**2184-11-24**] to [**Hospital1 **] to receive physical therapy for her SDH. Her
evening insulin dose was administered unintentionally as per
above. The patient was found to be obtunded with a FSG of 17, at
which time she received an Amp of D50 and was sent to the [**Hospital1 2025**]
ED. Per the daughter's request, the patient was transferred to
[**Hospital1 18**] where she receives most of her care, including diabetes
management by [**Last Name (un) **].
On arrival to [**Hospital1 18**] ED, the patient had received a total of 3
Amps of D50 and was on a D10 drip. The patient was maintained on
a D10 drip at 80 cc/hr while in the ED and fingersticks were
checked hourly, ranging from 140s-190s, with the most recent
being 141 prior to transfer to the floor. [**Last Name (un) **] was consulted
for recommendations in the ED and recommended continuing D10
drip until patient was stable and then to resume her home
regimen.
Upon transfer to the ICU, the patient had a FSG of 149 and all
other vital signs were stable. The patient was without
complaints and stated that she felt well although she was unable
to remember ever receiving the [**Last Name (un) 8472**] or the surrounding events.
The patient's daughter stated that she was with the patient
yesterday evening until 7:30 PM and her mother had not yet
received the [**Name (NI) 8472**] at that point. She received a call at
approximately 2:30 AM regarding the incident. On interview, the
patient denied any fevers, chills, nausea, vomiting,
tremulousness, dizziness, numbness or tingling. She further
denied any headaches, blurry vision, chest pain, shortness of
breath or abdominal pain.
Past Medical History:
1. Diabetes mellitus, type 1 s/p pancreatic transplant, s/p
insulin pump that was removed [**11/2184**]
2. Renal transplant (living donor, brother) for diabetic
nephropathy
3. Pancreatic transplant in [**10/2182**]
4. Hypertension
5. Hypercholesterolemia
6. Hypothyroidism
7. Squamous cell carcinoma of RLE s/p excision
8. Chronic foot ulcers and multiple surgeries for Charcot foot
9. Bilateral fibroadenomas of the breast
10. H/O Vitrectomies, laser surgery, cataract surgery of
bilateral eyes
11. Subdural hematoma [**1-20**] fall in [**10/2184**] with left arm and leg
weakness
Social History:
Special education teacher currently on leave and in the process
of retiring. Lives with adult daughter. Denies every being a
smoker, does not consume alcohol and has never used any other
substances. Denies the use of any other over the counter
substances or herbal supplements, stating that she cannot take
them because of her transplant.
Family History:
Two brothers with diabetes. Sister with [**Name2 (NI) **]. Mother died at age
86 from "old age". Father died at 76 from Parkinson's disease.
Physical Exam:
Physical Exam:
AVSS
GEN: comfortable appearing, NAD
HEENT: no JVD, no TM
RESP: good air movement, crackles at bases bilaterally
CV: RRR, normal S1, S2, diffuse holosystolic murmur, III/VI
throughout the precordium
ABD: S/NT/ND, no HSM
EXT: WWP, pins in right first toe
NEURO: AAOx3, CN II-XII grossly intact, strength 4/5 in left
upper and lower extremities, [**4-21**] in right upper and lower
extremities, sensation intact to light touch
Pertinent Results:
Labs at Admission:
[**2184-11-24**] 06:25AM BLOOD WBC-11.9* RBC-3.41* Hgb-10.0* Hct-30.4*
MCV-89 MCH-29.5 MCHC-33.1 RDW-14.6 Plt Ct-416
[**2184-11-25**] 07:00AM BLOOD Neuts-47.9* Lymphs-44.4* Monos-3.9
Eos-3.0 Baso-0.8
[**2184-11-25**] 07:00AM BLOOD PT-13.1 PTT-24.8 INR(PT)-1.1
[**2184-11-24**] 06:25AM BLOOD Glucose-61* UreaN-18 Creat-1.0 Na-142
K-4.2 Cl-107 HCO3-24 AnGap-15
[**2184-11-24**] 06:25AM BLOOD Calcium-9.5 Phos-2.1* Mg-2.1
[**2184-11-25**] 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs at Transfer from the ICU:
[**2184-11-27**] 03:47AM BLOOD WBC-11.9* RBC-3.27* Hgb-9.8* Hct-28.3*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.5 Plt Ct-440
[**2184-11-27**] 03:47AM BLOOD Glucose-150* UreaN-22* Creat-1.2* Na-134
K-4.4 Cl-104 HCO3-25 AnGap-9
[**2184-11-27**] 03:47AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.7
.
Labs at discharge:
[**2184-11-30**] 08:00AM BLOOD WBC-11.6* RBC-3.51* Hgb-10.2* Hct-32.0*
MCV-91 MCH-28.9 MCHC-31.7 RDW-14.4 Plt Ct-465*
[**2184-11-28**] 06:40AM BLOOD Glucose-245* UreaN-26* Creat-1.1 Na-138
K-5.0 Cl-107 HCO3-22 AnGap-14
Brief Hospital Course:
This is a 58 year-old woman with history of hypertension,
diabetic nephropathy s/p renal transplant and type I diabetes
s/p failed pancreatic transplant with recent admission for SDH
s/p fall who was transferred from [**Hospital3 **] after
receiving an unintentional overdose of insulin.
# Hypoglycemia s/p Unintentional Insulin Overdose: Patient with
long-history of diabetes, previously on insulin pump s/p failed
pancreatic transplant who had insulin pump removed last
admission and was started on Glargine and Humalog sliding scale.
Patient was discharged to [**Hospital1 **] Rehabiliation from prior
admission where she was reportedly given an unintentional dose
of approximately 1000 Units of Glargine. Patient received 3 Amps
of D50 and was started on D10 drip prior to admission. The D50
drip was continued until the second hospital day and
discontinued when her sugars remained stable in the 200 range.
[**Last Name (un) **] was consulted and recommended for restarting her home
[**Last Name (un) 8472**] regimen at 22 units qhs. She was also started on humalog
sliding scale with meals, at the recommendation of the [**Last Name (un) **]
consult service. Her sugars remained between 77-240 on this
regimen. Ultimately, she would benefit from being back on an
insulin pump, however at this time with intermittent delirium,
this is not an option.
# Pulmonary Edema: Patient with crackles on exam, oxygen
saturations in the low 90s on room air, and CXR with evidence of
pulmonary edema with cephalization. Patient was previously on
Lasix but was stopped during her last admission given problems
with hypotension. She was diuresed with 20 mg IV Lasix on the
first hospital day. Afterwards, her oxygen saturations improved
and no further diuresis was felt to be necessary.
# Aspiration Pneumonia: Patient developed acute hypoxia during
her last admission on [**2184-11-15**] and was started on broad-spectrum
antibiotics for a presumed aspiration pneumonia. The regimen was
modified several times during her hospitalization with the
patient being discharged on Vancomycin, Flagyl and Cefepime to
complete a full 14-day course (to be stopped on [**2184-11-30**]). Given
her clinical improvement and clear chest x-ray at the time of
this admission, the antibiotics were stopped after approximately
an 8-day course.
# Subarachnoid Hemorrhage: Patient sustained a SAH after falling
at home, which was the cause of her last admission. Patient was
left with left-sided deficits though neurosurgery/neurology did
not feel the SAH could explain her deficits. Also with
persistent mental status changes per family and prior notes. She
was seen by rescreened for rehab. During hospitalization
[**2184-11-28**] she slid out of bed with some delerium. A repeat Head
CT was done and showed no recurent bleeding. Will need
outpatient f/u with neurosurg as previously planned.
.
# Type I Diabetes: Patient with long-standing diabetes as per
above. Her insulin regimen was modified as above.
.
# Leukocytosis: White count of 10 on admission. Review of
records indicates approximately at baseline. On steroids for
renal transplant.
.
#. S/P Renal Transplant: Creatinine 1.0, at baseline.
Mycophenolate, and prednisone were continued per her home
regimen. Tacrolimus was adjusted by renal transpant team
downards to current doses. A weekly level should be checked to
ensure a therapeutic level on her current dosing regimen.
.
# Hypertension: Patient's medications were adjusted during last
admission as had problems with hypotension during admission.
Lisinopril dose was decreased from 10 mg to 5 mg. Labetalol was
started at 200 mg PO TID. Lasix 20 mg PO daily was discontinued.
We continued the lisinopril at 5 mg daily and labetalol at 200
mg three times daily.
.
# Urinary Retention: On [**2184-11-28**] was acutely delirious with
bladder scan >400c. She fell aiming to get to commode. Foley
Cath placed and >600cc output. Delerium resolved. As her
mental status improves, a voiding trial should be done and if
she passes, her foley should be removed.
.
# Hypercholesterolemia: Stable. Her home pravastatin was
continued.
.
# Hypothyroidism: Her home levothyroxine was continued.
.
FEN: diabetic diet
Access: right midline
PPx: Heparin SC
HCP Sister:
[**Name2 (NI) 7092**]: full code
DISPO: [**Hospital 1739**] Rehab
Medications on Admission:
Medications at home:
1. Pravastatin 40 mg PO daily
2. Prednisone 2.5 mg PO daily
3. Bisacodyl 10 mg PO PRN constipation
4. Senna 8.6 mg, 1-2 Tablets PO BID PRN constipation
5. Docusate sodium 100 mg PO BID
6. Levothyroxine 150 mcg PO daily
7. Acetaminophen 325 mg PO Q6H:PRN fever
8. Labetalol 200 mg PO TID
9. Tacrolimus 4 mg Capsule PO BID
10. Sulfamethoxazole-Trimethoprim 400-80 mg PO daily
11. Insulin Aspart Sliding Scale
12. Insulin glargine 100 unit/mL (SEE ATTACHED)
13. Mycophenolate mofetil 250 mg PO BID
14. Lisinopril 5 mg PO daily
15. Lactulose 10 gram/15 mL, 15 mL PO BID PRN constipation
16. Aspirin 81 mg PO daily
17. Metronidazole 500 mg PO Q8H
18. Vancomycin 1,000 mg IV daily
19. Cefepime 2 gram IV Q12H
20. Calcium carbonate-vitamin D3 600-400 mg-unit, 2 tablets PO
daily
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. calcium carbonate 500 mg (1,250 mg) Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
8. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): please use if patient
not ambulating; for DVT propylaxis.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
16. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous before bedtime: Please give 22 units at
bedtime of [**Hospital 8472**] (glargine.
17. insulin lispro 100 unit/mL Solution Sig: as directed per
sliding scale Subcutaneous three times a day as needed for
sliding scale: Please see sliding scale for instructions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
- Hypoglycemia
Secondary Diagnoses:
- Insulin dependent diabetes
- Urinary Retention with delerium
- Subacute subarachnoid hemorrhage
- S/p renal transplant
- S/p pancreatic transplant (failed) in [**10/2182**]
- Hypertension
- Hypercholesterolemia
- Hypothyroidism
- Recent subdural hematoma after fall with left arm and leg
weakness
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital for low blood sugars felt to
be secondary to an overdose of insulin. You were treated
supportively with intravenous dextrose and your blood sugars
improved. At time of discharge, your insulin regimen has been
adjusted. Please continue to take all of your medicines as
prescribed.
.
You had urinary retention with mental clouding, for which a
foley catheter is in place. You slipped out of bed during this
episode. A Repeat CT Head did show any recurrent intracranial
bleeding.
Followup Instructions:
Department: PODIATRY
When: MONDAY [**2184-12-20**] at 3:20 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: TUESDAY [**2185-1-4**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: DERMATOLOGY
When: MONDAY [**2185-1-10**] at 9:15 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD [**Telephone/Fax (1) 3965**]
Building: [**Street Address(2) 7454**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2184-11-30**]
|
[
"E858.0",
"401.9",
"V42.0",
"V42.83",
"349.82",
"788.29",
"V10.83",
"244.9",
"507.0",
"272.0",
"250.83",
"V58.67",
"962.3",
"514"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12251, 12321
|
5384, 9708
|
284, 291
|
12720, 12835
|
4272, 5121
|
13433, 14457
|
3653, 3796
|
10552, 12228
|
12342, 12342
|
9734, 9734
|
12896, 13410
|
9755, 10529
|
3826, 4253
|
12398, 12699
|
231, 246
|
5141, 5361
|
319, 2674
|
12361, 12377
|
12850, 12872
|
2696, 3280
|
3296, 3637
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,696
| 169,247
|
6250
|
Discharge summary
|
report
|
Admission Date: [**2190-6-28**] Discharge Date: [**2190-7-6**]
Date of Birth: [**2110-6-4**] Sex: M
Service: MEDICINE
Allergies:
Augmentin / Bactrim / Clindamycin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Right heart catheterization
Left IJ cordis with swan-ganz catheter
Left A-line
Foley Catheter
NGT
History of Present Illness:
80 yo M with non-ischemic dilated cardiomyopathy with EF 10%,
afib, w BiV ICD s/p battery change on [**6-22**] who presents to the
CCU from [**Hospital 1902**] clinic with shortness of breath. Patient reports
that for the last few months he has experienced increasing
shortness of breath decreasing his usual activities. At baseline
he is asymptomatic at rest but becomes SOB with minimal activity
at home. He reports 2 pillow orthopnea and denies PND at
baseline. He has noticed increasing swelling in the legs over
the last few months as well. He denies increased salt intake,
and reports good medication adherence. He continues to have pain
in his left shoulder where his pacemaker was manipulated a few
days ago, and reports significant fatigue overall. The patient
reports one episode of lightheadedness on the saturday prior to
admission without LOC.
.
On further review of symptoms, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for dyspnea on exertion,
orthopnea, ankle edema and pre-syncopal episodes as per above.
He denies chest pain, palpitations, diaphoresis.
Past Medical History:
Non-ischemic dilated cardiomyopathy
CHF: last echo [**2189-7-19**] with EF 10-15%
CKD: baseline Cr [**1-16**] -> 2.7
Dyslipidemia
Basal cell cancer
Prostate cancer s/p prostectomy
Atrial/flutter fibrillation, s/p right atrial isthmus ablation
in [**3-17**], s/p BiV AICD placement in [**3-/2186**] on coumadin
Rheumatoid arthritis
Gout
Social History:
He is a widower and lives with his son. [**Name (NI) **] is a retired fireman.
He drinks one beer on rare occasions. He does not smoke. His is
extremely limited in his ADLs.
Family History:
His mother suffered from congestive heart failure and his father
died young.
Physical Exam:
VS: T 98, BP 82/54, HR 79, RR 20, O2 98% on RA
Gen: Elderly pleasant, tired appearing male in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of [**7-23**] cm. No bruits appreciated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, 3-6 SEM heard best at LLSB/apex with radiation to axilla
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, with scattered bibasilar rales, no wheezes
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. +BS
Ext: Significant 3+ bilat pitting edema, with coolness at feet.
Skin: Scattered ecchymosis. LLE abrasion without erythema or
purulence
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+
Left: Carotid 2+ without bruit; Femoral 2+
Pertinent Results:
Labs on admission:
[**2190-6-28**] WBC-16.2* RBC-3.17* Hgb-11.2* Hct-33.2* MCV-105*
MCH-35.3* MCHC-33.7 RDW-19.4* Plt Ct-94*
[**2190-6-28**] Neuts-87.4* Lymphs-6.3* Monos-4.8 Eos-1.1 Baso-0.3
[**2190-6-28**] PT-22.2* PTT-38.6* INR(PT)-2.2*
[**2190-6-28**] Glucose-98 UreaN-85* Creat-3.3* Na-138 K-4.7 Cl-106
HCO3-16* AnGap-21*
[**2190-6-29**] PSA-<0.1
Studies:
CXR ([**6-28**]): A pacemaker overlies the left chest, with leads
overlying the right atrium, right ventricle, and coronary sinus.
Cardiomegaly is unchanged, as is aortic calcification. There is
no consolidation or vascular congestion in the lungs. No pleural
effusion or pneumothorax. IMPRESSION: No evidence of congestive
failure.
CXR ([**6-29**]): Left-sided AICD with right atrial, right
ventricular, and coronary sinus leads in situ, are unchanged.
There is cardiomegaly and tortuosity of the thoracic aorta, but
no evidence for CHF or pulmonary edema and no new pulmonary
consolidations since the previous study of [**2190-6-28**].
ECHO ([**6-29**]): Biatrial enlargement. EF 20-30%. Dilated IVC with
estimated RAP 16-20 mmHg. Severe global LV hypokinesis. RV
hypertrophy with markedly dilated RA. Evidence of RV
pressure/volume overload. No AS, mild AR. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **],
severe TR. Moderate PA systolic hypertension. Trivial
pericardial effusion.
Right-sided cardiac cath ([**6-29**]): RA pressure 28/23. RVEDP 17.
PAP 57/24/36. Wedge 26/24. PVR 310.
Prior to milrinone infusion: CO/CI 3.1/1.7.
With milrinone infusion (stopped due to hypotension): CO/CI
3.7/2.0
ECHO ([**6-30**]):LV systolic function appears depressed. The RV
cavity is dilated. RV systolic function appears depressed. TR is
present but cannot be quantified. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2190-6-29**], no change.
Brief Hospital Course:
Mr. [**Known lastname **] is an 80 year old man with non-ischemic dilated
cardiomyopathy, EF 10-15%, afib s/p ablation, BiV ICD, who
presented from clinic with increasing SOB and fatigue over the
last few months.
#CHF: Pt was admitted for CHF exacerbation, right heart cath
with trial of milrinone. He was mildly fluid overloaded on exam.
CXR without overt edema. The patient's INR was reversed with 3
units of FFP and was taken for right heart catheterization for a
trial of Milrinone resulting in hypotension which the patient
was unable to tolerate. A 24-hour trial of dobutamine, despite
improved CO/CI, also resulted in hypotensive episode with SBP
into 60s. Dobutamine was weaned and dopamine added to support
SBP. Lasix drip was held and metoprolol discontinued at this
time. Hemodynamics were supported with 2 units PRBCs. It was
decided that the patient failed inotropic therapy and would be
returned to home meds. Low dose digoxin, statin continued
throughout hospital course. ACEI held given low BP and acute on
chronic renal failure. Dopamine drip was weaned to off with SBPs
in 70s -80s upon discharge. Patient was instructed to continue
digoxin and po lasix on discharge.
#Upper GI Bleed: Patient developed hematemesis on day 3 of
hospitalization while on heparin. Heparin was discontinued and
an NGT was placed with gastric levage after 180cc of saline
returning clear. GI was consulted and patient started on IV
protonix [**Hospital1 **]. INR was again reversed with three units of FFP.
Given the underlying cardiac problems and hemodynamic
instability, it was decided to monitor serial hematocrits and
continue with conservative treatment unless the patient
developed worsening bleeding. Patient had no further episodes of
hematemesis and hematocrit remained stable.
#? Aspiration Pneumonia: Patient developed new O2 requirement,
leukocytosis and LLL consolidation after episodes of emesis.
Sputum cultures remained contaminated with oral flora. Patient
treated with levaquin and flagyl for a 10 day course.
#Afib: Currently A-V paced. Coumadin held for right heart
catheterization and INR reversed with FFP. Patient was
anticoagulated with Heparin gtt after catheterization and
planned for restart of coumadin until patient experienced an
upper GI bleed. It was decided to hold all further
anti-coagulation.
#s/p ICD change on [**6-22**] during previous hospitalization: Site
sore but clean and dressing intact. Patient Completed 7 day
course of Cephalexin during this stay. ICD function was turned
off on [**7-2**] when patient was made DNR/DNI.
#Acid/Base: Patient presented with borderline anion gap
metabolic acidosis, likely related to progressive renal failure.
Pt is a non-diabetic, with no current medication/toxin
exposures. After episode of hypotension, patient developed
respiratory alkalosis, which thereafter resolved.
#Thrombocytopenia: Likely related to hepatic congestion and
resulting cirrhosis, with minimally elevated LFTs.
#Acute on CKD: Baseline 2.5 - 2.8. Currently 5. Likely related
to progressive CHF and poor forward flow. Transient improvement
in Creatine while on Dobutamine. All medications are renally
dosed.
#Dyslipidemia: Continued on Simvastatin 20mg daily while
inpatinet. Statin was stopped when discharged home with hospice.
#Gout: Continued on renally dosed Allopurinol throughout
hospitalization. Allopurinol stopped on discharge.
#Dispo: Patient's wishes are to return home and family agreed to
DNR/DNI status. Arrangements made for home w/ [**Hospital 2188**].
Code: DNR/DNI
Dispo: Home with hospice
Comm: [**Name (NI) **] (son) [**Telephone/Fax (1) 24318**]
Medications on Admission:
Lasix 40 mg [**Hospital1 **]
Toprol XL 12.5 mg daily
Digoxin 0.125 mg ?????? tab daily
Allopurinol 200 mg daily
Klor-con N-10 1 tab daily
Lisinopril 2.5 mg daily
Zocor 20 mg daily
Coumadin 4 mg M-W-F, and 2 mg T-R-Sat-Sun
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg SL PO q1hr
as needed for pain.
Disp:*30 ml* Refills:*0*
3. 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*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 5 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO q2-4hrs as
needed.
Disp:*10 mL* Refills:*0*
8. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 0.125 - 0.25 mg
Sublingual every four (4) hours as needed.
Disp:*60 tablets* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*2*
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): Please apply to affected groin area. Please
continue use until rash improves.
Disp:*1 bottle* Refills:*2*
11. Lasix 80 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
12. Home Oxygen
Please provide home oxygen via nasal canula. Titrate dosage to
comfort.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
congestive heart failure
dilated cardiomyopathy
atrial fibrillation
Discharge Condition:
fair
Discharge Instructions:
You were admitted with congestive heart failure. You underwent a
cardiac catheterization with a trial of IV medications that
resulted in low blood pressure. Also while you were in the
hospital you experienced bleeding from your GI tract which
resolved.
Please continue to take your medications as prescribed.
If you have any questions reguarding your medications or are
uncomfortable, please call Dr.[**Name (NI) 3536**] office for further
instructions.
Followup Instructions:
Titrate pain medications for patient's comfort. Please call
your physician as needed.
Communication as instructed by [**Hospital 2188**].
|
[
"584.9",
"585.9",
"287.5",
"427.31",
"V45.02",
"425.4",
"428.0",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
10597, 10648
|
5217, 8862
|
320, 419
|
10760, 10767
|
3333, 3338
|
11271, 11414
|
2409, 2487
|
9135, 10574
|
10669, 10739
|
8888, 9112
|
10791, 11248
|
2502, 3314
|
261, 282
|
447, 1842
|
3352, 5194
|
1864, 2202
|
2218, 2393
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,622
| 150,109
|
7191
|
Discharge summary
|
report
|
Admission Date: [**2123-6-3**] Discharge Date: [**2123-6-14**]
Date of Birth: [**2059-8-6**] Sex: F
Service: Otolaryngology
ADMISSION DIAGNOSIS: Recurrent squamous cell carcinoma of
the tongue.
DISCHARGE DIAGNOSIS: Recurrent squamous cell carcinoma of
the tongue.
PROCEDURES:
1. Total glossectomy.
2. Tracheotomy.
3. Right selective neck dissection.
4. Rectus free flap to the floor of mouth.
HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname 26681**] is a 64-year-old
female who was diagnosed back in [**2119**] with a left lateral
tongue squamous cell carcinoma. She underwent a partial
glossectomy and neck dissection at that time followed by
radiation therapy. She developed a recurrent tumor at the
left base of the tongue in [**2122-9-9**]. This was treated
with a combination of induction chemotherapy and followed by
radiation therapy and was completed in [**2123-1-9**]. The
tumor decreased in size but never resolved. On followup,
Dr. [**First Name (STitle) **] [**Name (STitle) **] performed a biopsy of the base of the tongue
and obtained the diagnosis of squamous cell carcinoma.
After consultation with [**Hospital6 8865**] and
[**Hospital 341**] Clinic she underwent a total glossectomy with neck
dissection and free flap. She was admitted postoperatively.
PAST MEDICAL HISTORY:
1. Asthma, with no recent acute exacerbation.
2. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: As above; and in addition, she had
tubal ligation and tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Preadmission medications included
Fentanyl patch 50 mcg per hour q.72h., Roxicet elixir p.r.n.,
Serevent, Flovent, Prozac, Nasacort, Singulair, Prilosec,
albuterol.
SOCIAL HISTORY: Social history positive for smoking
(70-pack-year history); stopped in [**2113**]. She denies alcohol
consumption. She has four grown children.
FAMILY HISTORY: She has two aunts with breast cancer and an
uncle with lung cancer.
HOSPITAL COURSE: On [**2123-6-3**] she underwent total
glossectomy with partial pharyngectomy, tracheotomy, right
selective neck dissection, and rectus free flap
reconstruction of the floor of the mouth.
Postoperatively, she was admitted to the Intensive Care Unit.
Her postoperative course in the Intensive Care Unit was
notable for a slow wean from ventilatory support and
aspiration pneumonia. She also had tachycardia secondary to
intraoperative blood loss with a postoperative hematocrit of
less than 25. The tachycardia resolved after blood
transfusion. For her aspiration pneumonia, she was placed on
levofloxacin and Flagyl. She was finally weaned of
ventilatory support then transferred to the floor on [**6-10**].
The remainder of her hospitalization was uneventful. She
tolerated tube feeds well. She ambulated well.
She was discharged to home with services on [**2123-6-14**]. At
the time of discharge, she still had sutures in her neck
incision. There was ecchymosis and superficial skin
breakdown at the right upper edge of her skin flap. This
area of skin ecchymosis and breakdown was stable.
The results of the pathology examination of her surgical
specimen revealed a tumor present at the margin at the tongue
base. She also had a positive node at level 2 of her right
neck dissection.
DISCHARGE DIAGNOSES:
1. Squamous cell carcinoma of the tongue.
2. Status post total glossectomy, tracheotomy, right
selective neck dissection, and rectus free flap
reconstruction of the floor of the mouth.
MEDICATIONS ON DISCHARGE:
1. Fentanyl patch 50-mcg per hour topical q.72h.
2. Lansoprazole 30 mg per G-tube q.d.
3. Aspirin 325 mg per G-tube q.d.
4. Flovent 110 mcg 4 puffs per trach q.d.
5. Salmeterol 2 puffs per trach q.d.
6. Calcium carbonate 1500 mg per G-tube q.d.
7. Vitamin E 400 IU per G-tube q.d.
8. Fluoxetine 20 mg per G-tube q.d.
9. Roxicet elixir 5 cc to 10 cc per G-tube q.6h. p.r.n. for
pain.
10. Colace 100 mg per G-tube b.i.d.
11. Peridex 15 cc swish-and-spit t.i.d. p.r.n.
12. Zolbid 5 mg per G-tube q.h.s. p.r.n. for insomnia.
13. Levaquin 500 mg per G-tube q.d. for five days.
14. Clindamycin 300 mg per G-tube q.d. for five days.
NUTRITION: Tube feed ProMod with fiber 330 cc q.i.d. with
water flush 50 cc before and after each feeding.
DISCHARGE INSTRUCTIONS: She was to follow up with Dr. [**First Name (STitle) **]
[**Name (STitle) **] in one week. She was also to follow up with her
plastic surgeon for removal of the sutures. She has [**Hospital6 3429**] services for home safety evaluation, wound
care, and routine tracheotomy and G-tube care.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Name8 (MD) 26682**]
MEDQUIST36
D: [**2123-6-14**] 19:08
T: [**2123-6-15**] 09:50
JOB#: [**Job Number 23320**]
|
[
"997.3",
"507.0",
"530.81",
"493.90",
"V15.82",
"518.5",
"196.0",
"285.1",
"141.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"25.3",
"96.6",
"96.72",
"31.1",
"29.59",
"29.33",
"27.56",
"40.41"
] |
icd9pcs
|
[
[
[]
]
] |
1922, 1991
|
3331, 3519
|
235, 419
|
3546, 4304
|
1574, 1740
|
2009, 3310
|
4329, 4871
|
1439, 1547
|
163, 213
|
448, 1308
|
1330, 1415
|
1757, 1904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,271
| 114,608
|
35325
|
Discharge summary
|
report
|
Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-7**]
Date of Birth: [**2057-1-21**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
66 yoF w/ a h/o myasthenia [**Last Name (un) 2902**] presents with labored
breathing. The patient had been at [**Hospital6 10353**] for the
past 1 month with pneumonia and COPD. She had planned on being
transferred to rehab today and had also had a scheduled
neurology appointment. While at the neurologist's office she was
noted to have labored breathing. She did not feel subjectively
short of breath and per her daughter, she had similar breathing
for the month. While at the neurologist's office the physician
stated that she appeared in no shape to go to rehab and should
go to the emergency room.
The patient currently denies any SOB, chest pain, pleuritic
chest pain, hemoptysis or cough. She has been relatively
immobile at the hospital, but with assistance can walk with a
walker. Her husband noticed some pedal edema (bilateral) 3 days
ago. Per her daughter she has memory deficits and occasional
confusion.
The patient denies urinary complaints, constipation or diarrhea,
nausea / vomiting, no fevers / chills.
In the ED, initial VS: T 97 HR 90 BP 128/80 RR 24 O2 sat: 100%
on 3L. She underwent a CTA of her chest which revealed
subsegmental PEs. Her EKG revealed an STE so a code stemi was
called, cardiology fellow evaluated the patient and deemed this
not to be a STEMI and suggested a CTA of her chest. The patient
had rec'd ASA and plavix load (300mg). VS prior to tranfer HR
92, BP 99/62, RR 28, 96% on 3L.
Past Medical History:
1. Myasthenia [**Last Name (un) 2902**] Dx in [**2121**]: primary neurologist in
[**Location (un) 38**], mild crisis in past marked by visual changes
(diplopia) nd generalized weakness, treated with mestinon 60mg
TID, prednisone and cellcept. At baseline, uses wheelchair for
any extended travel and walks around the home with a walker,
ADLs with support by her husband- primary caretaker
2. Stroke, [**2121**]- residual weakness in BLLE
3. History of lung CA in [**2116**], s/p chemoradiation, treated by
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**] in [**Hospital1 392**], ? small cell lung cancer.
4. Atrial fibrillation on dig/coumadin
5. Hypertension
6. Hypercholesterolemia
7. OSA
8. GERD
9. Chronic low back pain
10. Spine surgery, [**2120**]
11. Bilateral knee arthroscopy
12. Degenerative arthritis
13. Cholescystecomy
Social History:
She was discharged from [**Hospital1 18**] to [**Hospital 671**] Rehab. Has a prior
history of heavy smoking.
Family History:
Noncontributory
Physical Exam:
(Per Admitting Resident)
Vitals - T: 96.9 BP: 100/48 HR: 94 RR: 26 02 sat: 95% on 3L NC
GENERAL: NAD, AOx3
HEENT: MMM, EOMI, PERRL, conjunctiva pink, sclera anicteric
CARDIAC: RRR, no m/r/g
LUNG: CTAB although decreased breath sounds throughout
ABDOMEN: soft, NT, ND, no masses or organomegaly, BS+
EXT: WWP, trace bilateral edema
There is normal muscle bulk and tone throughout. Neck extension
is 5-/5, and neck flexion is 5-/5.
D B T WF WE ADM IP Q HS DF
L 4+ 5- 5- 5 5 4 4- 5 4+ 4
R 4+ 4+ 5- 5 5 5- 4- 5- 4+ 4
At time of discharge, VS 97.9 76 HR 70s-80s BP 120/72 RR 20-24
92-95% 2L NC
She had decreased BS on pulmonary exam with scant expiratory
wheezes and basilar rales. Has 1+ pitting edema B/L. Patient
weak overall related to illness and MG but neuro exam unchanged
from admission.
Pertinent Results:
Admission Labs
[**2123-4-2**] 01:10PM BLOOD WBC-7.9 RBC-4.15* Hgb-12.8 Hct-38.3
MCV-92 MCH-30.9 MCHC-33.5 RDW-17.6* Plt Ct-106*#
[**2123-4-2**] 01:10PM BLOOD Neuts-90.4* Lymphs-6.0* Monos-3.2 Eos-0.1
Baso-0.2
[**2123-4-2**] 01:10PM BLOOD PT-18.3* PTT-20.6* INR(PT)-1.7*
[**2123-4-2**] 01:10PM BLOOD Glucose-177* UreaN-28* Creat-1.1 Na-135
K-5.0 Cl-91* HCO3-32 AnGap-17
[**2123-4-2**] 01:15PM BLOOD Lactate-2.7*
Discharge Labs
[**2123-4-6**] 04:59AM BLOOD WBC-5.8 RBC-3.42* Hgb-11.1* Hct-32.3*
MCV-95 MCH-32.4* MCHC-34.3 RDW-18.1* Plt Ct-122*
[**2123-4-6**] 04:59AM BLOOD PT-19.7* PTT-84.5* INR(PT)-1.8*
[**2123-4-6**] 04:59AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-136
K-4.5 Cl-99 HCO3-29 AnGap-13
.
[**2123-4-7**] 05:25AM BLOOD WBC-5.6 RBC-3.21* Hgb-10.4* Hct-30.4*
MCV-95 MCH-32.3* MCHC-34.1 RDW-18.3* Plt Ct-127*
[**2123-4-7**] 05:25AM BLOOD PT-21.2* PTT-48.5* INR(PT)-2.0*
[**2123-4-7**] 05:25AM BLOOD Glucose-119* UreaN-18 Creat-0.9 Na-135
K-4.3 Cl-99 HCO3-24 AnGap-16
Cardiac Enzymes
[**2123-4-2**] 01:10PM BLOOD CK(CPK)-34 CK-MB-NotDone cTropnT-0.04*
[**2123-4-2**] 08:35PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-0.07*
[**2123-4-3**] 03:15AM BLOOD CK(CPK)-25* CK-MB-NotDone cTropnT-0.05*
proBNP-1523*
Urine Studies
[**2123-4-3**] 03:06AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.039*
[**2123-4-3**] 03:06AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2123-4-3**] 03:06AM URINE RBC-8* WBC-2 Bacteri-NONE Yeast-RARE
Epi-0
IMAGING:
CXR ([**4-2**]) - IMPRESSION: Left basilar atelectasis. Unchanged
cardiomegaly.
CTA Chest ([**4-2**]) - IMPRESSION:
1. Left lower lobe segmental and subsegmental acute pulmonary
embolism.
2. Persistent but slightly decreased right infrahilar density
now measuring 11 x 13 mm. As mentioned previously, PET-CT is
recommended to exclude underlying neoplasm.
3. Interval resolution of left upper lobe opacity. Left upper
lobe 7-mm nodule unchanged from the most recent prior, but new
from [**2122-3-8**]. Follow up chest CT in [**9-19**] months is
recommended.
4. Extensive atherosclerotic [**Date Range 1106**] disease.
5. Multiple new wedge deformities within the thoracic spine.
Bilateral LE LENIs - IMPRESSION: Nonocclusive thrombus extending
from the distal right common
femoral vein into the mid superficial femoral vein and proximal
deep femoral vein.
Echo ([**4-5**]) - The left atrium is elongated. The right atrium is
markedly dilated. The right atrial pressure is indeterminate.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The right ventricular cavity is moderately
dilated with borderline normal free wall function. The aortic
root is moderately dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
promient fat pad.
IMPRESSION: Normal left ventricular size with preserved global
and regional systolic and diastolic function. Moderately dilated
right ventricle with borderline normal free wall function in the
setting of abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Moderate aortic root
dilatation. Moderate tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2122-8-25**],
the pulmonary artery systolic pressures are higher. The other
findings are similar
Brief Hospital Course:
66 y/o F w/ a h/o myasthenia [**Last Name (un) 2902**], COPD and recent
hospitlization for PNA/COPD presents from neurologist oupt
office for labored breathing found to have pulmonary emboli.
# Pulmonary Emboli: The patient had no history of PE in the
past. She was on coumadin for afib and CVA but subtherapeutic on
admission. She was continued on coumadin, with an increased dose
and goal more in the 2.5-3 range. She was also started on a
heparin gtt which . She had lower extremity ultrasounds
performed which showed nonocclusive thrombus extending from the
distal right common femoral vein into the mid superficial
femoral vein and proximal deep femoral vein. Her clinical status
improved, and she was called out to the medicine floor service
on the day after her admission. She had an echo performed that
did show evidence of right-sided heart strain, consistent with
PE (see above for full report) but no evidence of right heart
failure and was relatively unchanged from prior. At the time of
discharge, her coumadin dose was still being titrated to bring
her INR to a therapeutic level. She remained on a heparin gtt to
bridge for 24-48 hours.
# COPD: She had significant wheezing initially and was
maintained on standing nebs then transitioned to home regimen
advair and tiotropium with albuterol prn. She was on 30 mg of
prednisone at the time of admission. She remained on this dose
throughout her hospitalization, and a taper was begun at the
time of discharge. Follow-up was arranged with an outpatient
pulmonologist given she did not have a pulmonologist or recent
PFTs
# ?STE in AVR on EKG: As stated in the HPI, cardiology fellow
evaluated the patient in the ED and deemed this not to be a
STEMI and suggested a CTA of her chest. She had serial cardiac
enzymes drawn which were stable. She denied any chest pain on
the medicine floor and repeat EKGs were without ST elevatoin. .
# Afib: She was continued on rate control with metoprolol and
cardizem. Digoxin was initially held but later restarted.
Metoprolol and cardizem doses were decreased, as pt had
bradycardia. Heparin gtt and coumadin as above.
# ARF: Improved with hydration to a normal creatinine level.
Lisinopril was initially held but then restarted when creatinine
improved and lasix dose was decreased to 20mg daily.
Electrolytes and renal function should be repeated in [**2-10**] days.
# OSA: Continued on CPAP at night.
# Myasthenia [**Last Name (un) **]: Continued on mestinon and imuran. Follow-up
arranged with neurologist Dr. [**Last Name (STitle) 1206**].
# Depression: Continued on provigil and zoloft.
# DM: Continued on lantus 20 units and insulin sliding scale.
# LLL nodule: Of note, imaging showed a LLL ground glass nodule
that should have f/u CT scan in [**9-19**] months (see report) and
also right infrahilar density which was decresae din size from
prior but which recommended outpatient PET scan to determine if
possible malignancy given history of lung cancer.
Medications on Admission:
advair 500/50 [**Hospital1 **]
cardizem cd 360mg daily
colace 100mg po bid
coumadin 5mg daily
digoxin 0.25mg daily
Duonebs qid
ferrous sulfate 324mg po daily
imuran 150mg po daily
K dur 20meq daily
Lantus sc qhs
RISS
Lasix 40mg po daily
Lopressor 25mg po q8hrs
Mestinon 60mg po tid
MVI daily
Oscal 1250mg po bid
Prednisone 30mg daily (plan taper, 30mg po daily until [**4-4**] then
20mg daily)
Prilosec 20mg daily
Lisinopril 20mg daily
Modafinil 200mg po daily
Senna
Spiriva daily
Vitamin D 400u [**Hospital1 **]
Zolfot 25mg po daily
Coumadin 5mg / 7.5mg daily
.
Discharge Medications:
1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO four times
a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin 3 mg Tablet Sig: Three (3) Tablet PO once a day.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation Q4H (every 4
hours).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
7. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO As Directed:
Please take 2 tablets (20 mg) daily for five days, then 1 tablet
(10 mg) daily for 5 days, then stop.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Modafinil 200 mg Tablet Sig: One (1) Tablet PO once a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO twice a
day.
17. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
18. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
22. Heparin (Porcine) in NS (PF) 1,000 unit/500 mL Parenteral
Solution Sig: Titrate to PTT 60-80 units Intravenous continuous
for Until INR therapeutic x 48 hours days: Please titrate to
goal PTT 60-80. Would d/c when INR [**2-10**] x 48 hours. .
23. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
24. Humalog 100 unit/mL Solution Sig: 1-12 units Subcutaneous
every 6-8 hours: Per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
- Pulmonary Embolism
- COPD exacerbation
SECONDARY:
- Myasthenia [**Last Name (un) **]
- Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were brought to the hospital for difficulty breathing, and
were found to have a blood clot in your lung. You were initially
admitted to the ICU, where you were treated with a heparin drip.
Since your coumadin levels were below therapeutic, your coumadin
dose was titrated to bring your anticoagulation levels within
the therapeutic range. You will remain on the heparin drip until
your INR (coumadin level) is in a good range for 48 hours.
Your medications have changed as follows:
- CHANGE cardizem to 60 mg four times a day
- CHANGE coumadin to 9 mg daily and your facility will follow
your coumadin levels
- DECREASE your metoprolol tartrate to 12.5 mg three times a day
- DECREASE your lasix to 20mg daily
- Your duonebs were changed to albuterol nebs
It was a pleasure taking part in your medical care.
Followup Instructions:
Please follow-up as below:
Appointment #1
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**]
Specialty: Neurology
Date/ Time: [**4-14**] at 11am
Location: [**Hospital Ward Name **], [**Hospital Ward Name 23**] bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 44**]
Appointment #2
MD: Dr [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) 437**]
Specialty: Pulmonology
Date/ Time: [**4-30**] at 8:30am
Location: [**Hospital Ward Name 516**], [**Location (un) 11633**], [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 612**]
Special instructions for patient: You will have a breathing test
first followed by an appt with the doctor
You should also arrange a follow-up appointment with a primary
care physician if you are discharged from [**Hospital 80550**] rehab facility
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
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50,216
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Discharge summary
|
report
|
Admission Date: [**2175-10-10**] Discharge Date: [**2175-10-19**]
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Syncope and Shortness of Breath, Hyptension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 yo F with h/o pulmonary fibrosis, CAD, presented to [**Location (un) 620**]
from [**Hospital 100**] Rehab for evaluation of syncope and SOB worse than
baseline. Pt reports feeling well until yesterday morning,
unable to have lunch due to feeling unwell, although denied
abdominal pain or nausea. After lunch pt had bowel movement and
afterwards had witnessed syncopal episode. No trauma was
reported. Pt denied any CP, Palp, Abd pain. Reported
cramping/nausea 2 days ago but nothing since.
.
At [**Name (NI) 620**], pt found to be hypoxic to mid 80s, intermittently
hypotensive. CXR showed baseline fibrosis and possible pulmonary
edema but was unable to rule out PNA so pt received Levaquin.
Head CT at [**Location (un) 620**] without intracranial process. Pt also
received 3L IVF and was transferred to [**Hospital1 18**] for furthur workup.
.
Here, initial vitals T98 HR84 BP100/60 RR24 O2 94%on Venturi
50%. Labs were significant for INR 1.4, WBC 13.7 (87%N), HCT
49->42, Trop 0.05, ALT/AST 61/142, Lipase 69, LDH 663, Cr 1
(Baseline 0.8), Lactate 2.8. UA was also positive, and urine and
blood cultures were sent. Abdomen completely benign, but given
elevated lactate, CTA abdomen was done and showed sigmoiditis
c/w ischemic process. Pt received Flagyl, ASA and Zofran, as
well as ativan. General surgery evaluated pt but pt refusing
surgery. Pt was also evaluated by GI who recommended tx with
IVF, ASA, Cipro/Flagyl but were not particularly impressed by
the extent of the bleed, given elevated Hct.
.
Family/pt discussion confirmed DNR/DNI based on prior
discussions and reassessment.
Past Medical History:
1) COPD on 3-4L home O2
2) pulmonary fibrosis,
3) hyperlipidemia,
4) CHF,
5) GERD,
6) AAA,
7) peripheral vascular disease, multiple bilateral LE stents.
8) NSTEMI [**8-30**] with episode of hypotension requiring pressors,
urosepsis vs cardiogenic.
9) s/p Cholecystectomy
[**75**]) s/p herniorraphy
11) Relatively sudden onset cardiac decompensation following
surgery [**2175-6-6**].
12) Abnormal echocardiogram with signs of RV pressure/volume
overload c/w pulmonary fibrosis.
13) Abnormal EKG, most recently NSR 91. LAA. S1, T3 pattern. QT
prolongation. IRBBB. Borderline PR prolongation. T-wave
inversion to 2, 3, F and V3-V6.
14) LV diastolic dysfunction
Social History:
Quit smoking at age 48, had smoked 3ppd. No alcohol.
She was widowed for the second time at age 46. She did not
remarry. She has 2 sons. She formerly worked as a retail sales
consultant for Lancombe and subsequently as an interior
decorator.
Family History:
One brother and 1 sister died of burst AAA. Mother with diabetes
Physical Exam:
ADMISSION EXAM:
GENERAL: Pleasant, well appearing elderly female, moaning but
appears in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dry MM on venti mask. OP clear.
Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Bibasilar crackles, exam complicated by pt moaning
ABDOMEN: NABS. Soft, nontender, ND. No HSM
EXTREMITIES: No edema or calf pain, DP pulses not palpable,
radial 1+.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
but anxious about being cold
vs 97.6 102/60 93 18 96 4L (90-96L on 4L)
Gen: elderly female, NAD
Neck: large bruise on posterior aspect of neck, non tender
CV: RRR. Nl S1 and S2
Lungs: bibasilar late inspiratory crackles
Abd: soft, non distended, non tender. ABS
Ext: trace to 1+ edema symmetrical bilaterally. 2+ DP pulses
Pertinent Results:
[**2175-10-9**]
WBC-13.7* RBC-5.54* Hgb-15.0 Hct-49.1* Plt Ct-239
Glucose-128* UreaN-45* Creat-1.0 Na-142 K-4.4 Cl-103 HCO3-24
AnGap-19
[**2175-10-17**]
WBC-8.6 RBC-4.12* Hgb-11.7* Hct-34.8* Plt Ct-222
Glucose-89 UreaN-24* Creat-0.8 Na-138 K-3.6 Cl-102 HCO3-26
AnGap-14
C spine CT:
no cervical spine fracture. grade I anterolisthesis of C7 on T1,
likely degenerative. if clinical concern for ligamentous injury,
an MRI is more sensitive for evaluation. multilevel degenerative
change.
.
Abd/Pelvis CT:
Circumferential wall thickening of the sigmoid colon, suggestive
of a colitis, which may be infectious/inflammatory. Though no
arterial thrombus is identified, given distribution, ischemia
cannot be excluded. Infrarenal AAA, measuring up to 5 cm in
maximal dimensions. Small pericardial effusion.
.
Most recent ECHO at [**Location (un) 620**]:
Mild biatrial enlargement. LVEF was 60%. There was moderate LV
diastolic dysfunction. There was marked PA systolic
hypertension. Pulmonary capillary wedge pressure was likely
elevated. RV cavity was markedly dilated with severe global RV
free wall hypokinesis and abnormal septal motion consistent with
RV pressure/volume overload. There was mild functional MS and
trivial MR. There was mild to moderate TR with moderate PA
systolic hypertension.
.
EKG:
NSR @ 85, rightward axis, normal intervals, diffuse
TWI/flattening, poor RWP, right atrial enlargement
.
CXR [**10-9**] at [**Location (un) **]:
Upper zone vacular redistribution more pronounced than [**7-19**] c/w
pulmonary edema.
Brief Hospital Course:
87 yo F with h/o CAD, Pulmonary Fibrosis and COPD, presents with
syncope and hypoxia likely secondary to poor cardiopulmonary
reserve during exertion. She was also noted to have one
melanotic BM.
## Hypoxia/IPF: At OSH, chest x-ray was felt consistent with
pneumonia and given levofloxacin. On transfer to [**Hospital1 18**], patient
had increased oxygen requirement over baseline. After transfer
from MICU to floor, oxygen was attempted to wean down, but
unsuccessful. Cardiology and pulmonology were consulted.
Cardiology felt that despite her hypoxia she was overalli
intravascularly deplete and recomended IVF. Pulmonology felt
that her hypoxia was likely [**1-23**] to progression of her fibrotic
lung disease. She was started on prednisone 50mg daily but was
without significant improvement. She was maintained on her
ativan prn given her chronic anxiety and small anxiety component
of her hypoxia. Vasodilators such as sidenafil were considered
but were thought to worsen her orthostasis and provide no
benefit in oxygenation. Her CT scan showed significant fibrosis
(irreversible) and no signs of inflammatory disease that may be
reversible. After disucssion with the palliative care team,
patient and her family decided to go home with hospice for
continued symptomatic treatment of her pulmonary disease.
.
#. Syncope: Likely due to tenuous balance of volume status.
Possibility that patient had orthostatic hypotension in setting
of hypovolemia due to requirement of 5-6L IVF on admssion.
Cardiac workup recently completed, recent ECHO, EKG unchanged,
CEs neg. Monitored on telemetry with no events. Repeat echo
during admission was stable, bubble study negative. Likely
patient has no cardiopulmonary reserve during exertion and was
unable to tolerate ambulation at home, especially being
hypovolemic. She was sent home with hospice for her end stage
pulmonary fibrosis with 24 hr home care.
#. Hypotension: Blood pressure was stable after recieving IV
fluids prior to transfer from outside hospital and additional
fluids in [**Hospital1 18**] ED. Total fluids approximately 5-6L. Patient
was admitted to the ICU for management, however, blood pressure
remained stable. No pressors required. Blood pressure remained
stable over the duration of admission.
# Hematochezia: Patinet had one episode of bloody stool that
were gauiac positive after admission. GI consult felt possible
infectious vs. ischemic colitis. CT abdomen and pelvis showed
mural wall edema and circumferential wall thickening that could
be consistent with ischemic colitis. Hematocrit was stable.
Patient started on cipro and flagyl empirically. Patient
completed 5 day course of antibiotics. Diet was advanced as
tolerated. She had no repeat bloody stools. C. diff negative x
2. Stool culture negative.
#. UTI: UA wa positive, Urine culture pending at [**Location (un) 620**] at time
of transfer. Previous UTI in [**Month (only) **] was Klebsiella, pansensitive.
UTI likely covered by Cipro and Flagyl for GI coverage. Patient
completed 5-day course of Cipro.
#. Elevated Trop: 0.05, CK flat, EKG unchanged. Continued
statin and aspirin. Patient was asymptommatic.
Medications on Admission:
1) Lasix 40 mg a day,
2) KCl 2x per day,
3) aspirin 325 mg daily,
4) Lopid 600 mg daily,
5) Lipitor 10 mg daily, xx
6) Celexa 20 mg daily,
7) Colace 100 mg daily,
8) Ativan 0.5 p.r.n.,
9) Armour Thyroid 60 mg daily,
10) Tylenol 325 at bedtime,
11) Patanol 0.1% 2 - drops twice per day,
12) Combivent 4x per day, Duonebs q4 prn
13) Imdur 1 tablet daily,
14) Zocor 10 mg/day xx
15) Lopressor 12.5 mg po day
16) Robitussin with codeine 5-10 cc po Q4 hours prn
Discharge Medications:
1. Outpatient Physical Therapy
Pt needs Wheelchair
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. Armour Thyroid 60 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) neb
Inhalation four times a day.
11. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) neb Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Patanol 0.1 % Drops Sig: Two (2) Drops Ophthalmic twice a
day.
14. Robitussin Chest Congestion Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 100**] Senior Life
Discharge Diagnosis:
primary: chronic obstructive pulmonary disease, idiopathic
pulmonary fibrosis
secondary: diastolic heart failure, dehydration,
gastrointestinal bleed, not otherwise specified, hypotension,
Discharge Condition:
stable, breathing comfortably on 4L NC
Discharge Instructions:
You were admitted for evaluation and treatment of your fall and
worsening shortnes of breath. You were evaluated by the
pulmonary and cardiac specialists and it was determined that
unfortunately there are no medical treatments for your advanced
pulmonary fibrosis. You were treated for your symptoms and
evaluated by physical thereapy. Arrangements were made for you
to go home with hospice care for symptom alleviation for your
respiratory disease.
A number of medications were changed on this visit. Please see
attached list for your new medication list.
We stopped your Lasix, you should have your primary care doctor
evaluate you for fluid overload and weigh your self daily. If
you gain more than 3 pounds call your doctor.
We stopped your potassium pills.
We stopped your Imdur, please discuss the possibility of
restarting this with your primary care doctor.
We stopped your lopressor (metoprolol), please discuss the
possibility of restarting this with your cardiologist and
primary care doctor.
We stopped your atorvastatin because you were also on zocor and
these medicines are essentially the same.
You should take robutussin instead of robutussin with codeine as
codeine may worsen your dizziness.
Please call your doctor or return to the emergency room if you
develop symptoms of chest pain, severe shortness of breath or
any other concerning symptoms.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] as needed for
follow up. He can be reached at [**Telephone/Fax (1) 81140**].
Completed by:[**2175-10-19**]
|
[
"416.8",
"573.0",
"300.00",
"V15.88",
"443.9",
"276.52",
"530.81",
"518.83",
"280.0",
"424.2",
"496",
"412",
"428.32",
"286.7",
"599.0",
"428.0",
"441.4",
"557.9",
"516.3",
"276.51",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10492, 10555
|
5643, 8822
|
315, 322
|
10787, 10828
|
4082, 5620
|
12248, 12420
|
2910, 2976
|
9330, 10469
|
10576, 10766
|
8848, 9307
|
10852, 12225
|
2991, 4063
|
232, 277
|
350, 1951
|
1973, 2633
|
2649, 2894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,232
| 166,243
|
34060
|
Discharge summary
|
report
|
Admission Date: [**2131-5-14**] Discharge Date: [**2131-5-18**]
Date of Birth: [**2083-10-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
47M with right ventricular mass
Major Surgical or Invasive Procedure:
1. Resection of right ventricular mass
2. Evacuation of right ventricular hemorrhage
History of Present Illness:
Mr. [**Known lastname 78604**] is a 47 y/o male with no prior past medical history
who describes three episodes of acute restlessness with a need
to walk non-stop and nasal congestion lasting 1-3 hours followed
by a headache. His first episode was in [**Month (only) 547**] while in [**State 2690**]
which self resolved. The second episode occured four days
ago when he went to [**Hospital6 6640**]. During that
admission he was ruled out for an MI and had a normal stress
test. The latest symptom occurred this am at 0430 when he awoke
him from sleep - he was congested, felt restless and then
developed a mild headache that he describes as a sinus headache
(has had intermittently for years).
Past Medical History:
None
Social History:
[**Name (NI) **], no children, works as an IT Lead Software
Designer. No smoking, rare alcohol
Family History:
Mother died at 59 of =lupus and emphysema. Father
died at age 71 of COPD/aspiration.
Physical Exam:
PHYSICAL EXAM on admission:
O: T:97.9 BP:149/103 HR: 102 R14 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-21**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-22**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-26**] throughout. No pronator drift
Sensation: Intact to light touch,
Reflexes: symetric 2+ in lower and 1+ in uppers
Toes upgoing bilaterally
Coordination: normal on finger-nose-finger,
Pertinent Results:
[**2131-5-14**] 12:25PM BLOOD WBC-6.7 RBC-5.07 Hgb-14.6 Hct-42.5 MCV-84
MCH-28.8 MCHC-34.3 RDW-13.3 Plt Ct-246
[**2131-5-14**] 12:25PM BLOOD PT-12.4 PTT-23.5 INR(PT)-1.0
[**2131-5-14**] 12:25PM BLOOD Glucose-87 UreaN-14 Creat-1.1 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
[**2131-5-14**] chest CT:
IMPRESSION:
1. No pulmonary embolism to the large subsegmental pulmonary
artery branches. Assessment of more distal branches is limited
due to suboptimal contrast opacification.
2. 6-mm pulmonary nodule in the right middle lobe. A followup
chest CT in
[**5-3**] months is recommended to assess stability.
[**2131-5-14**] NCHCT:
IMPRESSION: Approximately 3-cm mass within the right lateral
ventricle, with associated noncommunicating hydrocephalus and
mild transependymal leak of CSF. Differential diagnosis includes
an ependymoma, intraventricular meningioma, periventricular
astrocytoma, or other intraventricular tumors. This is not
typical location for metastatic lesion. An MRI may be obtained
for better characterization.
[**2131-5-14**] brain MRI:
IMPRESSION: Markedly limited study due to termination because of
claustrophobia. However, intraventricular mass in the right
lateral ventricle may represent an intraventricular meningioma,
ependymoma, or intraventricular astrocytoma. If the patient
cannot remain still for repeat study with IV contrast, conscious
sedation could be considered.
[**2131-5-15**] CTA:
Findings:
The right anterior choroidal artery is asymmetrically prominent
and appears to be supplying the intraventricular tumor. Vessels
are seen predominantly along the posterior and inferior aspects
of the tumor.
There are no intracranial aneurysms, stenoses, or occlusions.
Note is made of an infundibulum of the left posterior
communicating artery. The
vertebrobasilar system and the posterior cerebral arteries
appear normal.
IMPRESSION: Hyperdense enhancing mass within the right lateral
ventricle
causing trapping of the temporal and occipital horns of the
right lateral
ventricle. There is also adjacent edema of the right
frontoparietal lobe.
This tumor appears to receive arterial supply from a prominent
right anterior choroidal artery. The differential is as given
previously, but
intraventricular metastasis could also be considered, especially
given the
history of pulmonary nodule. However, the visualized arterial
feeder makes
metastasis less likely.
[**5-16**] NCHCT s/p resection:
FINDINGS: There has been an interval right parietal craniotomy,
with an
associated small amount of pneumocephalus. Additionally, there
is interval
postoperative hemorrhage within the right lateral ventricle,
filling the
occipital and temporal horns, with slight expansion of the right
frontal [**Doctor Last Name 534**] and leftward shift of normally midline structures
of 5 mm relative to the prior study. Dilatation of the temporal
and occipital horns of the right lateral ventricle is similar in
appearance from the prior study. Additionally, there continues
to be residual vasogenic edema of the right frontoparietal lobe.
There is no evidence of an acute major vascular territorial
infarction. Visualized paranasal sinuses and mastoid air cells
are clear. Again seen is a craniotomy defect of the right
parietal bone, with expected postoperative soft tissue air and
staples.
IMPRESSION: Postoperative changes, with a large amount of
hemorrhage within the right lateral ventricle, with slight
expansion of the right frontal [**Doctor Last Name 534**] and leftward shift of
normally midline structures.
[**5-17**] s/p hematoma evacuation:
Findings:
There has been interval evacuation of an acute
hemorrhage in the right lateral ventricle. There is a tiny
residual focus of blood products in the evacuation site. There
is no evidence of free
hemorrhage. There has been resolution of the left fourth midline
shift.
There is an expected amount of new pneumocephalus. There is no
evidence of
major vascular territorial infarct. There is no hydrocephalus.
IMPRESSION: Successful evacuation of postoperative hemorrhage
with
normalization of midline shift and no evidence of significant
hemorrhage.
[**2131-5-17**] brain MRI for residua:
Findings: Blood products and expected postoperative
pneumocephalus are identified adjacent to the posterior [**Doctor Last Name 534**] of
the right lateral ventricle. Lateral to the pulvinar, there is a
focus of restricted diffusion in a site of increased FLAIR
signal. These findings are consistent with vasogenic edema, or
possibly a small focus of ischemia. No other mass or
unexpected hemorrhage is identified. There is no unexpected
enhancement after contrast administration.
IMPRESSION: Increased FLAIR signal and restricted diffusion
lateral to the
right pulvinar is consistent with vasogenic edema, or possibly a
small focus of ischemia. Close followup will allow
differentiation of these two
etiologies.
Brief Hospital Course:
In the ED a chest CT revealed a 6 mm nodule in the right middle
lobe. A NCHCT and MRI of the brain on admission revealed a right
ventricular mass. A brain CTA revealed no aneurysms, stenoses,
or occlusion. Patient was evaluated on HOD#2 by Dr. [**Last Name (STitle) 724**] from
oncology, who recommended starting an antiepileptic. Patient was
started on Dilantin at that time. His PSA was normal. Patient
went to the OR for resection of the mass on HOD#3.
Postoperatively (POD#0), a left lateral visual field defect was
noted during the postop check. A subsequent noncontrast head CT
showed a right ventricular bleed, which was emergently evacuated
in the OR without complications. Postoperatively the patient
was transferred in stable condition to the SICU. His neuro
exams were stable without deficits (except for stable left left
vield deficit recognized postop) in the SICU and was
successfully extubated on POD#1. He was transferred to the step
down unit on POD#2 and continued to have a stable neurological
exam. He was transferred to the floor POD#3. PT/OT felt he was
safe to go home, but recommended a home PT evaluation. Pt
reminded to follow up with his PCP regarding his lung nodule,
which will require chest CT in a 6-12 months.
Neuro exam prior to discharge:
Patient was orientated x 3, speaking clearly and answering
questions appropriately. His EOMs were intact and he continued
to have a left lateral visual field cut. His pupils were
reactive and symmetric. His motor and sensory exam was normal,
and his reflexes were symmetric. Patient was neurologically
stable on discharge [**5-18**].
Medications on Admission:
None
Discharge Medications:
1. Dexamethasone 1 mg Tablet Sig: Four (4) Tablet PO Q8 hours ()
for 1 doses: Take 3mg Q8 hours x 3 doses 6/28.
Take 2mg Q8 hours x 3 doses 6/29.
Take 1mg Q8 hours x 3 doses 6/30.
Disp:*22 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
4 days.
Disp:*4 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed: No driving while on narcotics.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Right ventricle brain mass
lung nodule
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
You have an appointment with [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2131-6-4**] 3:00 on [**Hospital Ward Name 23**] 8 on the [**Hospital Ward Name 516**]. You
will have your staples removed at that time as well.
Please make an appointment to see your PCP to discuss
1)Your hospitalization and surgery
2)Your high blood pressure
3)You have a nodule in right middle lobe. You need a chest CT in
[**5-3**] months.
Completed by:[**2131-5-18**]
|
[
"518.89",
"225.2",
"431",
"E878.8",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"01.39",
"01.23",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
10315, 10388
|
7645, 9263
|
352, 438
|
10471, 10495
|
2749, 7622
|
11850, 12381
|
1320, 1407
|
9318, 10292
|
10409, 10450
|
9289, 9295
|
10519, 11827
|
1422, 1436
|
281, 314
|
466, 1163
|
1988, 2730
|
1450, 1695
|
1710, 1972
|
1185, 1191
|
1207, 1304
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,839
| 178,560
|
23921
|
Discharge summary
|
report
|
Admission Date: [**2108-4-1**] Discharge Date: [**2108-4-11**]
Date of Birth: [**2075-7-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
PFO
Major Surgical or Invasive Procedure:
s/p Minimal Invasive PFO closure on [**2108-4-3**]
History of Present Illness:
32 y/o female who sustained a Left PCA CVA in [**1-21**]. Work-up
revealed a PFO with left to right shunting. She complains of
continued fatigue, mild DOE and some chest pressure which
resolves spontaneously. She presents for surgical evaluation of
PFO.
Past Medical History:
Patent Foramen Ovale (PFO)
s/p Left Post. Cerebral Artery Cerebral Vascular Aaccident
s/p Dilation & Curretage
Social History:
Married, lives with her husband and three children. Denies
tobacco, EtOH, illicits.
Family History:
Non-contributory
Physical Exam:
VS 68SR BP 112/60 Ht 65 Wt 160
General: Well-appearing female in NAD
Skin: Unremarkable, -lesions or rashes
HEENT: EOMI, PERRLA, NC/AT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR +S1S2, -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -c/c/e, -varicosities
Neuro: Residual R-sided weakness and uncoordination. Blind spot
OD.
Pertinent Results:
[**2108-4-1**] 06:37PM BLOOD WBC-5.7 RBC-4.00* Hgb-12.2 Hct-35.8*
MCV-90 MCH-30.5 MCHC-34.1 RDW-13.1 Plt Ct-171
[**2108-4-7**] 05:12AM BLOOD WBC-3.8* RBC-2.62* Hgb-8.1* Hct-23.2*
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.4 Plt Ct-119*
[**2108-4-10**] 05:30AM BLOOD WBC-8.7# RBC-3.41*# Hgb-10.2* Hct-31.1*#
MCV-91 MCH-29.8 MCHC-32.7 RDW-14.0 Plt Ct-230#
[**2108-4-1**] 06:37PM BLOOD PT-13.3 PTT-28.5 INR(PT)-1.2
[**2108-4-10**] 05:30AM BLOOD PT-16.0* PTT-63.0* INR(PT)-1.7
[**2108-4-1**] 06:37PM BLOOD Glucose-143* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-105 HCO3-25 AnGap-12
[**2108-4-7**] 05:12AM BLOOD Glucose-124* UreaN-15 Creat-0.6 Na-140
K-3.1* Cl-106 HCO3-25 AnGap-12
[**2108-4-1**] 06:37PM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.3*# Mg-1.9
[**2108-4-7**] 05:12AM BLOOD Mg-1.7
[**2108-4-3**] 09:39AM BLOOD freeCa-1.18
[**2108-4-5**] 04:26AM BLOOD freeCa-1.26
Brief Hospital Course:
As mentioned in the HPI, pt. had a CVA in [**1-21**] and subsequently
found to have a PFO. She was started on Coumadin at that time
and presents for admission pre-operatively to start heparin (off
Coumadin). By HD#2 her INR was 1.2. On HD #3 she was brought to
the OR and underwent a Min. Inv. PFO closure. Pt. tolerated the
procedure well with a total bypass time of 45 minutes and no
cross clamp time. See op note for surgical details. She was
transferred to CSRU with a MAP of 79 and HR of 96 SR and being
titrated on Neo and Propofol. Later on op day, pt was weaned
from mechanical ventilation and propofol and was successfully
extubated. She was awake, alert, MAE and following commands.
Diuretics and B-blockade were started per protocol on POD #1.
Pleural tube was removed and CXR afterwards showed a moderate
PTX. On POD #2 Neo was weaned off and repeat CXR showed cont.
rt. PTX. She was transfused 1 unit of PRBCs and HCT increased to
26 afterwards. Heparin gtt and Coumadin were started. Patient
was appropriately anti-coagulated with an INR of 2 on date of
discharge.
Medications on Admission:
1. Coumadin 7.5/10 mg am/pm
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*14 Capsule(s)* Refills:*0*
7. Coumadin 5 mg Tablet Sig: 1.5 or 2 Tablets PO at bedtime: 7.5
mg alternating with 10 mg.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8117**] NH VNA
Discharge Diagnosis:
Patent Foramen Ovale (PFO) s/p Minimal Invasive PFO closure
s/p Left Post. Cerebral Artery Cerebral Vascular Aaccident
(stroke)
s/p Dilation & Curretage
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incision with warm water and mild soap.
Gently pat dry.
Do not bath or swim.
Do not apply lotions, creams, or ointments to incisions.
Do not drive if taking narcotics/pain meds. Otherwise can drive
after 2 weeks.
Do not lift anything greater then 10 pounds for 3-4 weeks.
Make/Keep all follow-up appointments.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Follow-up with Dr. [**First Name (STitle) **] in [**12-22**] weeks.
Follow-up with Dr. [**First Name (STitle) 1356**] in [**11-20**] weeks.
|
[
"V58.61",
"745.5",
"V58.83",
"289.81",
"355.2",
"512.1",
"782.0",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"39.61",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4155, 4217
|
2146, 3227
|
289, 342
|
4413, 4419
|
1273, 2123
|
877, 895
|
3305, 4132
|
4238, 4392
|
3253, 3282
|
4443, 4776
|
4827, 5029
|
910, 1254
|
246, 251
|
370, 625
|
647, 759
|
775, 861
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,900
| 118,520
|
51341
|
Discharge summary
|
report
|
Admission Date: [**2167-6-5**] Discharge Date: [**2167-6-10**]
Date of Birth: [**2084-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD [**6-8**]
Colonoscopy [**6-9**]
History of Present Illness:
Mr. [**Known lastname 106483**] is a 82 year-old man with history of CAD,
ischemic cardiomyopathy (EF 20-30%) s/p pacer/ICD, HTN, atrial
fibrillation on coumadin, diverticulosis, presents with BRBPR
since last evening. Pt was in his USOH until last evening when
he experienced an episode of watery, bloody bowel movement. He
proceeded to have [**1-28**] more episodes of BRBPR over the course of
the evening into the morning. Denies HA, LH, chest pain, SOB,
abdominal pain. No history of GI bleed in the past. His wife
brought him into the [**Name (NI) **].
.
In the ED, initial vs were: T 97.2, P 78, BP 116/56, R 16, O2
sat 100% on RA. Exam was notable for gross blood on rectal exam.
Hct was 33.3 (baseline 36-39), INR 4.9, lactate 2.4. Received
2L IVF, IV protonix. INR reversed with 5 IV vitamin K and 1
unit FFP. He remained asymptomatic and hemodynamically stable.
He was type and crossed for 4 units with plan to initiate first
transfusion prior to transfer. GI saw the patient in the ED and
recommended close monitoring and outpatient colonoscopy. No
further bleeding episodes in the ED. Admitted to the [**Hospital Unit Name 153**] for
close monitoring.
Past Medical History:
-Two-vessel Coronary artery disease s/p stent to the LCx [**10/2156**]
-Ischemic cardiomyopathy, TTE [**7-4**] with EF 20-30%, 3+MR, 2+TR
-Hypertension
-s/p Implantable cardioverter-defibrillator
-Atrial fibrillation, on coumadin
-Dyslipidemia
-Chronic kidney disease, baseline Cr 1.6-1.8
-High-grade papillary TCC, non-invasive, s/p transurethral
resection ([**2165-11-28**]) and 6 cycles of BCG (last on [**2166-2-13**]), s/p
urethral stricture
-Hypothyroidism
-Sigmoid diverticulosis, internal hemorrhoids on [**2160**]
colonoscopy
-Iron deficiency anemia
-History of deep venous thrombosis x3 ([**2101**], [**2135**], [**2139**])
-s/p left carotid endarterectomy [**2153**]
-History of syncope
-Left lower extremity stasis dermatitis
-s/p inguinal herniorrhaphy
Social History:
Lives with wife. Retired, former banker. Independent of ADLs,
wife does the cooking. Still works in the garden. Former
smoker, quit at least 10 years ago. Has not drank EtOH for
20-25 years.
Family History:
Father died of emphysema. Mother died at age [**Age over 90 **]. There is no
known history of kidney or GU tract disorders; there likewise is
no known history of platelet disorders.
Physical Exam:
Vitals: 97.7 116/49 76 18 98%RA
Pain: denies
Access: 2X PIVs
Gen: nad, appears younger than stated age
HEENT: o/p clear, mm dry
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: appropriate
.
Pertinent Results:
no leukocytosis
plt 90 (b/w 60-90 stable)
BUN 53->17
Creat 1.9-->1.2->1.5 (baseline)
Mag 1.9, K 4.1
HCT 33-->24-->1U prbc-->27-30 stable, today is 29.8 on discharge
INR 4.9->1.2 s/p 2U ffp
LFTs: AST 87->29 ALT 48->29
lipase 89->50
.
H pylori test: pending
.
EKG: V-paced at 70 bpm.
.
.
Imaging/results:
colonoscopy [**6-9**]:
Impression: Internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
.
EGD [**6-8**]:
Erosions in the antrum compatible with mild erosive gastritis
Small hiatal hernia on retroflex
Otherwise normal EGD to third part of the duodenum
.
[**6-5**] CXR: As compared to the previous radiograph, there is no
relevant change. The left pectoral pacemaker with normal course
of the leads. Minimal obviously post-infectious fibrosis at the
bases of the left lateral lung. The right lung base is
unremarkable. Slightly increased transparency of the lung
parenchyma could suggest the presence of mild-to-moderate
emphysema. No evidence of overhydration. No lung nodules or
masses. Normal size of the cardiac silhouette, mild tortuosity
of the thoracic aorta.
.
Colonoscopy [**4-29**]: Polyp at 40 cm in the proximal sigmoid colon
(biopsy showed fragments of adenoma). Diverticulosis of the
sigmoid colon. Internal hemorrhoids. Otherwise normal
colonoscopy to cecum.
.
.
Brief Hospital Course:
82 year-old man with afib on coumadin, CAD s/p stents, ICM 20%
s/p ICD, hypothyroidism, h/o recurrent DVT, diverticulosis/IH
who admitted with hematochezia in setting of elevated INR 4.9.
HCT drop from 33-->24, was initially admitted to ICU. Recieved
1U prbc and 2U ffp. Subsequently no more blood BMs. HCT
stabilized between 27-30. ASA and coumadin were held. Underwent
EGD which showed mild gastritis, PPI started, Hpylori serology
sent (pendign at time of discharge, Dr. [**Last Name (STitle) 665**] aware to f/u).
Cscope initially poor prep, underwent repeat prep and next day
[**6-9**] which showed diverticulosis and IH, no active bleeding, as
expected since HCT had remained stable. Suspect this was
diverticular bleed in setting of elevated INR. His ASA 81 and
coumadin (given h/o afib, recurrent DVTs, severe ICM 20%) were
resumed at time of discharge after discussion with PCP. [**Name10 (NameIs) **] will
be followed by coumadin clinic. Also he is asked to make an appt
to see PCP [**Last Name (NamePattern4) **] 2weeks ([**Name6 (MD) **] [**Name8 (MD) **], NP).
Other issues: his statin was initially held in settign of mildly
elevated LFTs, which subsequently resolved, thus this was
resumed. his LFTs can be rechecked in 2 weeks.
As above, PPI was resumed. Rest of his meds will be the same as
previous, including Fe supp. will add bowel regimen.
He did very well throughout hospitalization. Was walking around.
Will be d/c'd in good condition with home VNA services.
.
******Below is progress note from day of discharge which has
further details according to problem list:
.
Hematochezia: likely lower GIB [**12-29**] diverticulosis in the setting
of supratherapeutic INR. Has known history of sigmoid
diverticulosis as well as colonic adenoma s/p resection in [**2160**].
Could also have AVM. s/p EGD [**6-8**], only mild gastritis. Is
asymptomatic and has been hemodynamically stable, s/p 1U prbc,
HCT 27-30.
-s/p EGD [**6-8**], mild gastritis, PPI started
-c scope with IH and diverticulosis, no active bleeding as
expected given his HCT have bee stable
-holding asa and coumadin, will resume both but have pt f/u with
PCP and coumadin clinic
.
Acute on chronic blood loss anemia: s/p 1U prbc as above.
-on Fe supp qd as outpt (will add bowel regimen on d/c)
-HCT stabilized
.
Mild gastritis: as above. doesnt account for bleed.
-PPI therapy started
-pending serology H.pylori on discharge, communicated with Dr.
[**Last Name (STitle) 665**] for f/u.
.
Transaminitis/Elevated lipase: Mildly elevated on admission. Now
resolved. Pt asymptomatic for this. Is on statin.
-resolved, restarted statin, follow up LFTs as outpt in 1-2week
.
CAD s/p stent to LCx and severe ICM 20% s/p ICD:
-were holding ASA in setting of GIB, but will resume 81mg on
discharge esp given EGD unremarkable.
-on lisinopril 2.5qd, coreg 3.125mg [**Hospital1 **]. sl NTG at home, has not
needed
-statin resumed
-coumadin resumed for severe CM
-maintain K/Mag
.
A fib: Currently v-paced.
- will resume coumadin, discussed with PCP. [**Name10 (NameIs) **] high risk given
Afib, recurrent DVT, and severe cardiomyopathy
-follows coumadin clinic
- resumed amio 200mg qd, on BB
.
Chronic kidney disease: Cr 1.9 ->1.2-1.5 back to baseline.
- renally dose meds
.
Thrombocytopenia: chronic, stable. no known splenomegaly, liver
disease.
-needs f/u PCP for possible heme referral
.
Hypothyroidism: cont levoxyl 112mcg
.
Hypertension: resumed anti-hypertensives now that stable
.
Dyslipidemia: resume atorvastatin 20, ASA on hold
.
Recurrent VTEs: resumed coumadin as above
.
Code: full code, Wife/HCP [**Name (NI) 106484**] [**Name (NI) 106483**] [**Telephone/Fax (1) 106485**]
Medications on Admission:
Coumadin 2.5mg M/W/F/[**Doctor First Name **], 3.5mg T/Th/Sa
ASA 81mg PO daily
Atorvastatin 10mg PO daily
Coreg 3.125mg PO BID
Lisinopril 2.5mg PO daily
Pacerone 200mg PO daily
Levoxyl 112 mcg PO daily
Ferrous sulfate 325mg PO daily
Acetaminophen 650mg PO BID prn
SLN prn
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
take 1 tablet daily. dose will be adjusted by coumadin clinic.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: use as stool softner.
Disp:*60 Capsule(s)* Refills:*2*
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime: use
for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary:
Acute blood loss anemia, likely diverticular bleed s/p 1U prbc
coagulopathy due to coumadin, s/p ffp
Secondary:
Severe ICM 20%
atrial fibrillation
recurrent DVT
Discharge Condition:
stable.
Discharge Instructions:
YOu were admitted with a GI bleed which occured in the setting
of elevated Coumadin level. You had a EGD and colonoscopy which
showed mild inflammation in the stomach and hemmorhoids and
diverticulosis. you probably had a diverticular bleed in setting
of high coumadin level. your coumadin and aspirin will be
restarted at discharge (discussed this with Dr. [**Last Name (STitle) 665**]. Please
call the coumadin clinic tommorow to make arrangements to follow
coumadin levels.
.
only other new medications are protonix for stomach irritation
(Dr. [**Last Name (STitle) 665**] will follow up a blood test regarding this).
Continue the iron supplement, but not that this can make you
constipated. Also started on you some stool softners that will
help prevent further problems with [**Name2 (NI) 106486**] or divericulosiss.
Please seek immediate medical care if you develop abdominal
pain, fever, black or bloody stools, or any other concerning
symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere
to 2 gm sodium diet.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2167-6-10**] 11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**]
Date/Time:[**2167-6-11**] 10:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-10-12**]
10:30
|
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icd9cm
|
[
[
[]
]
] |
[
"45.23",
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] |
icd9pcs
|
[
[
[]
]
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9559, 9618
|
4438, 6012
|
319, 356
|
9833, 9842
|
3091, 4415
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9866, 10927
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2779, 3072
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274, 281
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384, 1560
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6026, 8099
|
1582, 2349
|
2365, 2563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,463
| 161,372
|
47458
|
Discharge summary
|
report
|
Admission Date: [**2140-5-23**] Discharge Date: [**2140-5-30**]
Date of Birth: [**2091-2-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
shortness of breath, hypoglycemia
Major Surgical or Invasive Procedure:
s/p laryngoscope
History of Present Illness:
CC:[**CC Contact Info 100379**]
Present Illness: Ms. [**Known lastname 100380**] is a 49 year old female with
history of HCV, obesity, and esophageal cancer who presents
after a family member found her unconscious, and noted a
fingerstick blood glucose [**Location (un) 1131**] of 40 mg%. The patient in ER
received glucagon, glucose, and IV hydration. FBS subsequently
normalized in field and transported to ER for further
management.
The patient reports taking her usual "70 mg" (?units) of insluin
qd, although her oral intake has been diminshed of late
secondary to esophageal pain. She has felt "odd" for
approximately 1-2 weeks, noting mild diaphoresis during day, "it
might be my sugars..."
In ER FBS 53 mg%, noted to be tranisently hypoxic with SpO2=76%.
This episode prompted concern for PE, and CTA was attempted.
~60 mL IV contrast dye extravasated into the patient's arm, and
a CT noncontrast of the chest was performed. No data regarding
the neck / glottis area was obtained.
Past Medical History:
PMH:
Esophageal cancer dx [**2138**] (T2N0) supraglottic, treated with
surgical resection and external beam radiation therapy. No
chemotherapy was advised given risks of toxicity and comorbid
conditions.
PEG tube placed [**11-28**], replaced [**12-30**] for nutritional support
Morbid obesity, unable to ambulate without wheelchair
Hepatitis C
History of IVDA (heroin). Last use unknown, remains on
methadone
Osteoarthritis of knees
Ulnar europathy
DM2 on insulin
PUD / GERD
Social History:
Social History (based from chart records):
EtOH: Drinks socially. Smoking: 30 p-y hx; now smokes about 4
cigarettes/day. Drug use: The patient is an IV heroin
abuser who was on methadone for the 2 years prior to last
month's hospitalization. The patient is on disability due to
her
obesity. She is a past victim of domestic violence. She has 4
children and lives with her son, who she reports dose not help
out much.
Family History:
One of the patient??????s aunts died of an unknown CA. The patient??????s
mother died of an MI, and she states that her father died of
??????diabetes.?????? Her two sons have schizophrenia.
Physical Exam:
VS: T98.2, BP 101/81, P80, R20, SpO2 99% RA. FBS 101
Gen: Obese female in no distress. Pleasant and conversant.
Clear sleep apnea with coarse, loud "snoring."
CV: S1 S2 with no MRG.
Lungs: Distant lung sounds difficult to auscultate secondary
to body habitus. No wheezes.
Abd: Overweight, NT/ND, normal bowel sounds. Well-healed
PEG insertion site.
Ext: No edema.
Pertinent Results:
Labs: 15.4 > 14.3/44.5 < 224
141 | 4.3 | 97 | 30 | 17 | 1.3 < 78
ALT 14, AST 46, LDH 526, AlkP 89, TBili 1.0, Alb 3.5
lactate 2.4
[**2140-5-23**] 08:50AM %HbA1c-4.8# [Hgb]-DONE [A1c]-DONE
.
Urine tox positive for cocaine, opiates, and methadone
Serum tox negative
.
[**2140-5-23**] 10:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR
[**2140-5-23**] 10:24PM URINE RBC-21-50* WBC-[**11-13**]* BACTERIA-MANY
YEAST-NONE EPI-21-50
.
CT chest non-contrast: Patchy opacity in the left lower lobe
most likely represent early infectious process.
.
CT neck non-contrast: No definite evidence of pathologic
adenopathy. Some distortion of intrinsic larynx. This can be
evaluated with direct observation. No definite evidence of
subglottic extension.
.
CXR: 1) Slight improvement in left basilar opacity.
2) Right base atelectasis.
.
Left lower extremity doppler:
No evidence of deep vein thrombosis within the common femoral or
superficial femoral veins. The popliteal vein demonstrates
normal color flow; however, secondary to body habitus, a
waveform could not be obtained. As flow proximally to this
vessel is normal, if a thrombus exists in the popliteal vein, it
is nonocclusive.
.
Brief Hospital Course:
1. Endo -49 year old female with esophageal cancer s/p resection
and radiation therapy admitted with hypoglycemia secondary to
poor po intake. Patient unsure of insulin regimen, but last
discharge [**12-30**] was 80 U [**Hospital1 **] of (70/30) mix. Standing insulin
regimen was held. Blood sugars were relatively well contolled on
[**Name (NI) **] alone. Pt had elevated BS in setting of high dose steroids,
but normalized after discontinuation of steroids and didn't
require sliding scale insulin. Pt's HgA1c is 4.8. Pt was
instructed to check [**Hospital1 **] BS at home and to treat with sliding
scale as needed. Standing dose of insulin was discontinued.
.
2. Epiglottitis/Supraglottitis: A few days into hospital course,
pt was noted to be strigorous and short of breath, while
maintaining O2 sats of mid 90s. Pt was seen by ENT who was
consulted to perform a laryngoscope to look for a structural
etiology of aspiration. At this point, ENT noted a significantly
compromised airway. Pt's baseline 50% narrowed airway was
decreased to 33% secondary to epiglotitis/supraglottisi. Pt was
also noted to be somnolent. ABG was performed which showed acute
respiratory acidosis secondary to CO2 retention (7.26/78/73). Pt
was transferred to the unit for close respiratory monitoring.
She was started on high dose steroids and IV unasyn with
significant decrease in supraglottis on serial scopes. ABG
normalized. Mental status and respiratory status normalized.
After a few days in the [**Name (NI) 153**], pt was transferred back to the
floor where she continued to have q2h O2 sat checks while her
steroids were tapered to off. Pt's respiratory status remained
stable. Pt will be followed up by her ENT doctor within one week
of discharge. Pt received around 5 days of unasyn and is to
complete a 14 day course of augmentin for treatment of
epiglottitis/supraglottitis.
.
3. Aspiration - She is clearly aspirating, noting that she
always coughs after drinking water. At this visit, the patient
took a sip of water and demonstrated aspiration, likely with
abnormal swallowing secondary to pain and surgical procedure /
radiation. Pt was evaluated by speech and swallow who performed
a video swallow and recommeded nectar thick liquids, ground
solids, meds crushed in puree. Pt was put on aspiration
precautions.
.
4. OSA: Pt may have underlying OSA in setting of morbid obesity.
Pt should obtain a sleep study as an outpatient.
.
5. ID - Pt had evidence of aspiration pna in LLL. Pt was started
on levo/flagyl, which were discontinued after initiation of
unasyn. Pt remained afebrile with minimal symptoms. Serial CXRs
showed improvement in LLL opacity. Pt also has UTI, which was
adequately treated with antibiotics. Blood and urine cultures
were negative.
.
6. Formication: Pt describes a several month history of feeling
hair falling on her skin. She describes the sensation as
tingling. Ddx includes cocaine (positive tox screen), other drug
use (i.e. heroin), pschiatric disorder. None of her current
medications are likely to cause such an adverse reaction.
.
7. Polysubstance use: Pt was continued on home dose of methadone
for hx of heroin use. She was seen by substance abuse social
work consult.
.
8. LE swelling: Pt was noted to have asymmetric left foot
swelling associated with pain. Pt reported a prior hx of DVT. LE
ultrasound was negative for DVT.
.
9. Loose stools: Pt had negative Cdiff x2.
Medications on Admission:
Methadone 90mg qd
Insulin 70/30 70-30 80U [**Hospital1 **]
Hydromorphone HCl 4 mg Tablet Sig: 1-2 Tablets PO Q3-4HRS as
needed for 4 days. (prescribed [**2139-12-26**])
Protonix 40mg po qd
Discharge Medications:
1. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Methadone HCl 40 mg Tablet, Soluble Sig: Two (2) Tablet,
Soluble PO DAILY (Daily).
3. Methadone 10 mg/mL Concentrate Sig: One (1) PO once a day.
4. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
6. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: in AM and before dinner.
7. Lancets Misc Sig: One (1) Miscell. twice a day.
Disp:*60 60* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Epiglottitis/supraglottitis
Aspiration pneumonia
Hypoglycemia
OSA
Discharge Condition:
Stable O2 saturations, breathing comfortably
Discharge Instructions:
If you develop fevers, chills, difficulty breathing,
lightheadedness, dizziness, or any other concerning symptoms
call your doctor or return to the emergency room immediately.
Followup Instructions:
Follow up with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**6-8**] at
3:45pm.(call ([**Telephone/Fax (1) 6213**] to reschedule)
.
Follow up with your primary care doctor Dr. [**Last Name (STitle) 100381**]
[**Name (STitle) **] have your primary care doctor follow up on your blood
sugars. we are stopping your insulin for now because your blood
sugars have been under good control.
.
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2140-7-19**] 11:00
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
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|
1913, 2339
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5,363
| 176,190
|
24659
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 62241**]
Admission Date: [**2186-9-29**]
Date of Birth: [**2186-9-29**]
Date of Discharge: [**2186-12-11**]
Sex: F
Service: Neonatology
IDENTIFICATION: Baby Girl ([**Known lastname 18488**]) [**Known lastname **] is a 73 day old former
31 [**4-22**] wk twin (twin #2) who is being discharged from the [**Hospital1 18**]
NICU.
HISTORY: Baby Girl [**Known lastname **] was a 1.010 kg product of a 31-5/7
week twin gestation born to a 33 year-old gravida I, para 0-II
mother. Pregnancy was conceived via in [**Last Name (un) 5153**] fertilization.
Prenatal laboratories: blood type is O positive, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, Rubella immune, GBS unknown. Pregnancy was
notable for intrauterine growth restriction in twin #2 and a
2-vessel cord in twin #2. Worsening growth restriction and
decreasd amniotic fluid volume for twin #2 eventually led to
c-section delivery. This infant emerged from breech presentation
vigorous with a good cry. Apgars were 8 and 8 and she was
admitted to the Neonatal Intensive Care Unit for prematurity.
PHYSICAL EXAMINATION: Weight was 1010 gm, less than 5th
percentile. Length was 36 cm, less than 5th percentile and
the head circumference was 25.5 cm, also less than 5th
percentile. Anterior fontanelle was flat. Palate was intact.
Coarse breath sounds with fair aeration. Heart was regular
rate and rhythm, no murmur. Abdomen is soft, nondistended,
good bowel sounds, with 2-vessel umbilical cord. Skin pink and
well perfused. Extremities: Left foot is noted to have shortened
digits #1 through 4 with a normal fifth toe. Anus is patent.
Normal female genitalia.
The baby was admitted with the diagnoses of symmetric
intrauterine growth restriction,, prematurity, 2 vessel
umbilical cord and amniotic band syndrome of the left foot.
HOSPITAL COURSE:
RESPIRATORY:
The patient was stable in room air at birth and never required
oxygen supplementation. Mild to moderate work of breathing and
tachypea were evident after birth, and gradually improved over
first several days of life. Infant subsequently developed
notable upper airway congestion, requiring periodic suctioning of
the nares. Viral panel was negative. The congestion has
persisted to the time of discharge, although it has not appeared
to affect work of breathing or feeding ability, and may have
improved somewhat after treatment for reflux was initiated (see
below). The infant was treated with caffeine for apnea of
prematurity from day of life 3 to day of life 19. Periodic
desaturations and spells were noted subsequently, mostly related
to feeds. The infant was prepared for discharge on [**12-5**], when
in the context of having received 2 month immunizations and
having a low-grade fever, infant had several desaturation and
bradycardic spells while at rest. Infant was overall
well-appearing, and was monitored. By the time of discharge,
infant has been stable without any desaturations or spells for
over 5 days.
CARDIOVASCULAR:
Infant was hemodynamically stable on admission, without need for
blood pressure support. ECHOs performed over first 2 weeks of
life secondary to murmur revealed a PDA that subsequently closed
without treatment and a secundum ASD. Of note, ECHO on [**10-9**]
revealed a 1 mm x 3 mm mass on the superior surface of the left
atrium, consistent with a thrombus. This had not been seen on
earlier ECHO on [**10-3**], and was thought to be most consistent with
a line-related thrombus; at the time, the patient did have UVC
in place which initially had crossed into the left atrium. The
thrombus was followed with serial ECHOs and remained stable. An
abdominal ultrasound on [**10-9**] revealed a small clot in the portal
vein but no thrombus in the IVC or aorta. Hematology and
cardiology were consulted, and as the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] was remaining
stable, no treatment was initiated. Last ECHO on [**11-28**] revealed
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] to be unchaged in size or appearance, and repeat
abdominal ultrasound on [**12-1**] showed portal vein thrombus had
resolved. Of note, ECHO on [**11-28**] did also show a small PDA with
high-velocity L to R flow; the PDA had been closed on several
earlier ECHOs.
Over the last several weeks of hospitalization, mild elevations
in blood pressures were noted, to approximately 90/40s with MAPs
50-60s consistently. These were considered high-normal to mildly
elevated, but not needing treatment. EKG was normal. An
extensive renal evaluation (see below) was negative without
concerns for renal dysfunction. The renal service was consulted,
and will follow the infant as an outpatient.
The patient will be followed as an outpatient with
cardiology to monitor the thrombus and the ASD. Follow-up can be
arranged with Dr. [**Last Name (STitle) 62242**], who can be reached at [**Telephone/Fax (1) 37115**],
for 2 to 3 months after discharge.
GASTROINTESTINAL:
The infant was initially maintained on IVF and IV nutrition, with
introduction of enteral feeds on day of life 4. These were
advanced without difficulty, to maximum intake of 150 cc/kg/day
of PE 30 calories/oz formula. With adequate weight gain,
calories were decreased, and by the time of discharge, the infant
is taking Enfamil 28 calories/oz formula on an ad lib PO basis,
taking approximately 150 cc/kg/day. Formula is Enfamil 24 with
additional 4 calories/oz corn oil. During the hospitalization,
clinical concerns for reflux became evident, and infant was begun
on zantac 2 mg/kg q8 hrs with improvement. This is continued at
the time of discharge. Discharge weight is 2.905 kg.
HEMATOLOGY:
Hematology service was consulted regarding the thrombus described
above. Given that the thrombus was likely line associated, an
evaluation for pro-thrombotic disorders was not undertaken. PT
and PTT were measured, and were normal. If follow-up with
hematology is required, referral can be made to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62243**]
at the [**Hospital3 328**], phone [**Telephone/Fax (1) 62244**] and pager [**Telephone/Fax (1) 47802**].
Hematocrit was followed periodically during admission, with last
value of 34.9 with retic count of 5.4% on [**11-28**]. Infant did not
receive any transfusions, and is being discharged on iron
supplementation. The patient had a maximum bilirubin of 7.2 and
0.3 and she received phototherapy from day of life 2 to 10.
Normal rebound values were obtained.
RENAL:
Secondary to the 2 vessel cord, renal ultrasound was obtained on
[**10-9**], which, other than the portal vein thrombus described
above, was normal. Due to the elevated blood pressures noted
over the last several weeks of hospitalization, renal evaluation
was undertaken including urinalysis, BUN/Cr measurement, and
repeat renal ultrasound. All were normal including the
ultrasound on [**12-1**]. Renal service was consulted, and
recommended a MAG-3 scan, which was performed on [**12-8**] and was
aalso normal. By the time of discharge, blood pressures were
stable at approximately 90/40-50; infant never required treatment
for hypertension. Renal service will follow the infant as an
outpatient, through the fellow [**First Name8 (NamePattern2) 62245**] [**Last Name (NamePattern1) 51466**] who
can be reached at [**Telephone/Fax (1) 50498**].
ORTHOPEDICS:
Orthopedics was consulted due to the amniotic band syndrome
of the left foot. She has partial amputation of the first 4
toes and a normal fifth toe. Their impression was that if
surgery was necessary it would not happen before 6 to 12
months of age and they would follow her in our clinic 2 to 3
months after discharge. Orthopedic doctor is Dr. [**First Name (STitle) 2920**] and he
can be reached at [**Telephone/Fax (1) 38453**].
NEUROLOGY:
Head ultrasounds were performed. due to low gestational age.
First HUS on [**10-9**] revealed mildly dilated ventricles, with
follow-up HUS on [**10-11**] being normal. Subsequently ultrasounds on
[**10-24**] and [**10-31**] were notable for an echogenic area anterior to the
left caudothalamic groove. This was read as a possible focal
hemorrhage or infarction. Neurology was consulted, and after
reviewing the images, believed the findings were consistent with
a left germinal matrix hemorrhage, not clinically significant.
No particular follow-up other than routine monitoring of
development was recommended.
The infant did undergo eye examinations, with immature retinas in
zone III seen on [**10-16**], and mature retinas without ROP seen on
[**10-30**].
PSYCHOSOCIAL: [**Hospital1 69**] social
work was involved with the family. The contact social worker
can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Stable.
DISPOSITION: To home.
NAME OF PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital **]
Pediatrics. His phone number is [**Telephone/Fax (1) 45985**].
FEEDINGS AT DISCHARGE: Enfamil 28 calorie which is Enfamil
24 calorie with corn oil supplemented at 4 calories per
ounces.
DISCHARGE WEIGHT: 2.905 kg.
MEDICATIONS:
1. Ferrous sulfate 25 mg/mL 0.5 mL po qd.
2. Zantac 2 mg per kilo per dose given q 8 hours.
RHCM: Car seat test was passed. State newborn screen was normal
on the [**10-2**] and [**10-13**]. Hearing screen was passed on [**11-28**].
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine [**11-6**]. On
[**12-4**] Pediarix and hemophilus influenza B, Prevnar on
[**12-5**] and Synagis on [**12-4**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) Born at less at 32 weeks, 2)
born at between 32 and 35 weeks with 2 of the following:
Day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings, or 3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life immunization against influenza is
recommended for household contacts and out of home
caregivers.
FOLLOW UP: Infant will follow-up with Pediatrician and VNA
within 1 week of discharge. In addition, follow-up with renal,
cardiology, and orthopedics should be arranged as described
above.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Intrauterine growth restriction, symmetric.
3. Two vessel umbilical cord.
4. Hyperbilirubinemia, status post phototherapy.
5. Amniotic band syndrome left foot, toes 1 though 4.
6. PDA, self resolved.
7. Left atrial thrombus secondary to a high UVC.
8. Elevated blood pressures.
9. Apnea of prematurity requiring caffeine.
10. Left germinal matrix hemorrhage.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 62246**]
MEDQUIST36
D: [**2186-12-5**] 16:27:08
T: [**2186-12-5**] 18:54:46
Job#: [**Job Number 62247**]
|
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icd9cm
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[
[
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[
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icd9pcs
|
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10556, 11203
|
1873, 8806
|
10355, 10535
|
1142, 1855
|
9053, 9594
|
9621, 10343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,322
| 157,171
|
31356
|
Discharge summary
|
report
|
Admission Date: [**2178-6-26**] Discharge Date: [**2178-7-15**]
Date of Birth: [**2124-3-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Transfer with spontaneous SAH
Major Surgical or Invasive Procedure:
Cerebral angiogram, aneurysm coiling
EVD placement
History of Present Illness:
54 y/o female with only PMH of Arthritis, headaches, and
obesity. Pt was in her usual state of health until 0800 this am
she was in the shower and felt sudden left sided neck pain and
then felt as if she was going to pass out and she eased herself
down in the shower. She called her partner who called 911. She
went to [**Hospital3 10310**] and found to have a SAH.
Past Medical History:
Arthritis, headaches, and obesity.
PSH: Appendectomy with complications and Tonsillectomy
Social History:
Married, no children, works as a computer programmer.
Non smoker, 1-2 drinks per day, +marijuana use
Family History:
Mother died at age 47 of Liver CA
Father died at age 80 of "stroke"
Physical Exam:
Exam upon admisssion:
BP:123/63 HR: 42 R 18 O2Sats 99%
Gen: Prefers eyes closed awakes easily to voice or light touch
HEENT: Pupils: [**4-6**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Visual fields intact
V, VII: Face left droop noted Facial strength and sensation
intact
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift
Sensation: Intact to light touch,
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Coordination: dysmetria on left
Pertinent Results:
MRCP (MR ABD W&W/OC) [**2178-7-12**] 11:57 PM
MRCP (MR ABD W&W/OC)
Reason: MRCP to rule out pancreatic/bile duct abnormatlities or
ston
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with SAH and abnormal LFTs
REASON FOR THIS EXAMINATION:
MRCP to rule out pancreatic/bile duct abnormatlities or stones.
EXAMINATION: MRCP.
INDICATION: Subarachnoid hemorrhage, abnormal LFTs, R/O
pancreatic duct or bile duct abnormality.
FINDINGS: In relation to the liver, some scattered subcentimeter
lesions of high signal intensity on T2-weighted imaging that do
not demonstrate enhancement post administration of contrast, on
T1-weighted imaging are identified and appearances are
consistent with cyst. No focal solid liver lesion identified.
Note is made of cholelithiasis without evidence of
cholecystitis. The bile ducts are normal. The spleen is normal.
The adrenals are normal. The kidneys are unremarkable apart from
some subcentimeter cysts bilaterally. The pancreas is normal
with no evidence of any peripancreatic edema and no loss of the
acinar features. No evidence of any pancreatitis. A note is made
of a subcentimeter periceliac lymph node. No significant
retroperitoneal lymphadenopathy by size criteria. The bowel
where visualized is normal. Some degenerative changes noted in
the lumbar spine especially at L3-L4 level.
Multiplanar 2D and 3D reformations provided multiple
perspectives for the dynamic series.
IMPRESSION:
1. Cholelithiasis.
2. Bilateral subcentimeter renal cysts.
3. Right lobe of liver subcentimeter cysts.
4. No evidence of pancreatitis.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2178-7-7**] 3:24 PM
LIVER OR GALLBLADDER US (SINGL
Reason: recent elevation in LFTs, evaluate for abdominal process
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with transaminase.
REASON FOR THIS EXAMINATION:
recent elevation in LFTs, evaluate for abdominal process. Please
add doppler to rule out arterial clot.
LIVER ULTRASOUND
INDICATION: Patient with elevated LFTs. Patient has had recent
cerebral inrtervention. For evaluation.
TECHNIQUE: Grayscale imaging, color flow, pulsed wave, and
Doppler insonation of the liver and its vasculature as well as
the remainder intra-abdominal vessels was performed.
COMPARISON: None.
REPORT:
The liver appears of normal echotexture throughout. No focal
masses are identified. Gallstones are identified in the
gallbladder but there is no evidence of cholecystitis. There is
no intra- or extra-hepatic biliary dilatation identified. The
largest gallstone measures about 2.3 cm.
Right kidney appears normal in size, shape, and echogenicity.
There are limited views of the pancreas.
Doppler insonation of the liver vasculature reveals normal and
patent hepatic veins, portal veins and arteries, with
appropriate waveforms and direction of flow. The common hepatic
duct measures 4.5 mm.
CONCLUSION:
Gallstones without evidence of cholecystitis or
choledocholithiasis. Region of the pancreas is not seen. Normal
vasculature.
CT HEAD W/O CONTRAST [**2178-7-6**] 1:34 PM
CT HEAD W/O CONTRAST
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with vert art aneursym s/p coiling
REASON FOR THIS EXAMINATION:
eval for interval change
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old female with vertebral artery aneurysm
status post coiling. Please evaluate for interval change.
COMPARISON: [**2178-7-4**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There are small residual foci of subarachnoid
hemorrhage posteriorly, but no evidence of new bleed. There is
no mass effect, shift of normally midline structures, or
hydrocephalus. There is no evidence of acute vascular
territorial infarct. Aneurysm coil is unchanged in position in
region of left vertebral artery aneurysm, and streak artifact
from the coils continues to limit evaluation of this area. Tract
from previous ventriculostomy is slightly less apparent than on
prior exam, and small foci of pneumocephalus have resolved.
Surrounding osseous and soft tissue structures are otherwise
unremarkable.
IMPRESSION: Status post vertebral artery aneurysm coiling, with
small foci of resolving subarachnoid blood, but no evidence of
new hemorrhage.
CT HEAD W/O CONTRAST [**2178-7-3**] 2:49 PM
CT HEAD W/O CONTRAST
Reason: eval
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with s/p coiling, eval change
REASON FOR THIS EXAMINATION:
eval
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT of the head without contrast.
INDICATION: 54-year-old female status post coiling of left
vertebral artery aneurysm. Evaluate change.
COMPARISONS: CTA from [**2178-6-30**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Streak artifact is again seen within the area of the
left vertebral artery coiled aneurysm and thus limits some
visualization of the surrounding structures. There are
persistent foci of subarachnoid hemorrhage in the left parietal
lobe. There is persistent intraventricular hemorrhage within the
occipital horns bilaterally. A ventricular catheter from a right
frontal approach terminating within the frontal [**Doctor Last Name 534**] of the
right ventricle is unchanged in position. There is no shift of
normally midline structures or hydrocephalus. Once again the
sphenoid sinus is noted to contain some low- density material.
Otherwise, the visualized portions of the paranasal sinuses and
mastoid air cells are unremarkable.
IMPRESSION: Status post coiling of left vertebral artery
aneurysm. Detection of acute changes in the immediate area
surrounding the aneurysm is limited secondary to streak
artifact, however, overall, there is stable appearance of
subarachnoid and intraventricular blood compared to the
examination from three days prior. Right ventricular catheter
remains in good position.
BILAT LOWER EXT VEINS [**2178-7-1**] 12:59 PM
A portable study was performed to evaluate the veins in the left
and right lower extremities. The left and right common and
superficial femoral veins and the popliteal veins are widely
patent and compressible with augmentation of flow and no
intraluminal filling defects.
IMPRESSION: No DVT in left or right lower extremity.
CTA HEAD W&W/O C & RECONS [**2178-6-30**] 2:46 PM
NON-CONTRAST HEAD CT: Non-contrast images demonstrate persistent
high-density material within the occipital horns of the lateral
ventricles bilaterally. A small amount of high-density material
within the occiptial horns is unchanged compared to the previous
examination. A ventricular catheter from a right frontal
approach terminating within the frontal [**Doctor Last Name 534**] of the right
lateral ventricle is unchanged in position. There is no shift of
normally midline structures or hydrocephalus. The sphenoid sinus
contains some low-density material. Otherwise, the visualized
portions of the paranasal sinuses and mastoid air cells are
unremarkable.
CT ANGIOGRAM OF THE HEAD: Note is made of extensive streak
artifact from the coiled aneurysm of the left vertebral artery.
Thus, evaluation of the vertebral arteries and the basilar
artery just adjacent is limited. No specific areas of vasospasm
are identified. The visualized tributaries of the circle of
[**Location (un) 431**] are patent without focal areas of stenosis or dilatation.
IMPRESSION: Unchanged amount of subarachnoid hemorrhage compared
to examination from one day prior. No new acute hemorrhage.
Evaluation of the vessels just adjacent to the coiled aneurysm
in the left vertebral artery is limited secondary to streak
artifact. No focal areas of vasospasm identified in the
visualized vertebrobasilar system.
CTA HEAD W&W/O C & RECONS [**2178-6-26**] 11:58 AM
COMPARISONS: No prior images are available for comparison.
CT ANGIOGRAM: Non-contrast axial images demonstrate hyperdense
material surrounding the superior aspect of the spinal cord,
extending into the fourth ventricle, the basal cisterns, and
tracking into the suprasellar cistern. Overall, the distribution
is greater on the left relative to the right side. There is a
small amount of hyperdense material layering within the
occipital [**Doctor Last Name 534**] of the lateral ventricles bilaterally as well.
There are a few foci of hyperdense material located within the
sulci of the frontal lobe more superiorly. There is no shift of
normally midline structures, hydrocephalus or major vascular
territorial infarction.
The internal carotid arteries, the anterior cerebral arteries,
the middle cerebral arteries, and the posterior cerebral
arteries are normal in caliber and contour. No focal areas of
aneurysmal dilatation or stenosis are identified. However, there
is a focal area of aneurysmal dilatation within the distal
portion of the left vertebral artery which measures 9 x 7 x 11
mm. This aneurysmal dilatation is distal to the posterior
inferior cerebellar artery branch of the left vertebral artery.
Just proximal and distal to this aneurysmal dilatation there are
focal areas of narrowing of the vertebral artery which overall
make the appearance of this dilatation concerning for an
underlying dissection. The right vertebral artery and the
basilar artery are normal in caliber and contour.
IMPRESSION: Extensive subarachnoid hemorrhage, left-sided,
centered mostly within the basal cisterns. Focal area of large
aneurysmal dilatation of the left vertebral artery with
underlying characteristics concerning for focal dissection. No
evidence of acute infarction.
Brief Hospital Course:
The patient is a 54 year old female with diffuse SAH and was
found to have a vertebral artery aneurysm. On the day of
admission she had a cerebral angiogram and coiling of the
aneurysm. One area remains that needs to be stented within the
next year. She had and EVD placed on [**6-27**] for obstructive
hydrocephalus caused by the SAH.
Her hospital course was complicated by fevers that ran 101-103
on [**7-1**] and she had increased LFTs as well. Her blood cultures
had no growth. The patient was switched from dilantin to keppra
due to continued fevers. Tylenol and cooling blankets were used
and her fevers continued. She was given Motrin and her fevers
improved.
She also had low sodium and required salt tabs as well as
hypertonic saline for a short time. Her sodium continued to
monitored [**Hospital1 **] and then daily as it improved. Prior to discharge
her sodium had normalized and the salt tabs were discontinued.
On [**7-4**] the patient pulled out her EVD and there was CSF leaking
from the incision site. The incision was reinforced with staples
and sutures. CSF leak continued, so she underwent lumbar drain
placement on [**7-10**] it was clamped on [**7-13**] and no leak was noticed
from her head so it was removed on [**7-14**] without further sign of
leak.
The patient contined to have elevated LFTs and hepatology was
consulted. They recommended stopping the Tylenol, compazine, and
not giving H2 blockers. GI was also consulted and they
recommended MRCP which showed some scattered subcentimeter
lesions of high signal intensity on T2-weighted imaging that do
not demonstrate enhancement post administration of contrast, on
T1-weighted imaging are identified and appearances are
consistent with cyst. No focal solid liver lesion identified.
Note is made of cholelithiasis without evidence of
cholecystitis. The bile ducts are normal. The spleen is normal.
The adrenals are normal. The kidneys are unremarkable apart from
some subcentimeter cysts bilaterally. The pancreas is normal
with no evidence of any peripancreatic edema and no loss of the
acinar features. No evidence of any pancreatitis. A note is made
of a subcentimeter periceliac lymph node. No significant
retroperitoneal lymphadenopathy by size criteria. The bowel
where visualized is normal. Some degenerative changes noted in
the lumbar spine especially at L3-L4 level.
Her LFTs decreased daily were thought to be related to
medications such as dilantin, keppra and tylenol. .
Neurologically, the patient was doing well. She remained alert
and oriented x 3, she had full strenth and sensation and she did
not have nausea or dizziness. Her headaches improved throughout
her hospital stay. On [**7-9**] she was transferred from the step-down
unit to the floor. She tolerated a regular diet and was
ambulating without difficulty and was found to need 24 hour
supervision. She was tolerating a regular diet and voiding
without difficulty.
Medications on Admission:
ASA 325 per day
Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
Disp:*16 Capsule(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Outpatient Physical Therapy
Treat and Evaluate also assess for safety
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Ruptured left intracranial vertebral artery aneurysm s/p coiling
Intraventricular hemorrhage
CSF leak from EVD site
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
- Do not get [**Last Name (un) **] wet
- Do not take Aspirin containing products, do not take Tylenol
but
okay to take Motrin
- No heavy lifting greater than 10lb
- 24 hour supervision until follow up with PT
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
See your primary care physcian in 1 week and have your liver
function tests done and to take out your suture in the back
You are scheduled to have a CTA on [**9-25**] at 1130 [**Hospital Ward Name **] clinic center [**Location (un) 470**] after CTA you will meet with Dr
[**Last Name (STitle) **] ([**Telephone/Fax (1) 73914**]) tell them at check-in you have an
appointment with him.
Also on [**9-25**] at 2pm you have an appointment with Dr [**Last Name (STitle) **]
[**Hospital Ward Name **] at [**Hospital Unit Name 31391**]. ([**Telephone/Fax (1) 11314**]
Completed by:[**2178-7-15**]
|
[
"278.00",
"331.4",
"305.20",
"430",
"997.09",
"593.2",
"E879.8",
"E849.7",
"573.8",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"38.93",
"96.71",
"02.2",
"38.91",
"96.04",
"03.31",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
15205, 15211
|
11883, 14822
|
306, 358
|
15395, 15404
|
2369, 2529
|
16708, 17301
|
1004, 1073
|
14889, 15182
|
6750, 6798
|
15232, 15374
|
14848, 14866
|
15428, 16685
|
1088, 1360
|
237, 268
|
6827, 8647
|
386, 756
|
1576, 2350
|
8656, 11860
|
1375, 1559
|
778, 870
|
886, 988
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,273
| 119,288
|
28667
|
Discharge summary
|
report
|
Admission Date: [**2148-7-23**] Discharge Date: [**2148-8-7**]
Date of Birth: [**2093-6-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Known firstname 5552**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
IR biliary tube placement/replacement
IVC Filter
PICC line placement
History of Present Illness:
55 yo man w/ h/o met pancreatic cancer and HTN who presents c/o
increased abdominal pain x several days. Patient has h/o
recently dx pancreatic adenocarcinoma in early [**2148-6-18**] and
is s/p percutaneous biliary drain to relieve obstruction.
Patient c/o lower abd pain x 2-3 days, [**4-27**] in severity.
+increased drainage from biliary tube, which wife reports was
green/yellow/brown in color. Patient reluctant to come to
hospital over the last few days. Patient then spiked fever to
102 this AM w/ chills, then wife brought patient to [**Name (NI) **].
.
In ED, patient given Vanc/Levo/Flagyl. Surgery consulted in
ED, recommended drain study. IR replaced perc drain with larger
tube. Patient admitted for further observation.
Past Medical History:
1. Pancreatic adenocarcinoma
2. Biliary obstruction s/p perc drain (could not have ERCP due
to gastric surgeries)
3. DVT on lovenox (d/c'd since [**2148-7-27**])
4. Hypertension
5. s/p parotidectomy
6. s/p gastric bypass in [**4-/2146**]
7. GERD
8. Ventral hernia repair
9. history of an SBO
10. s/p cholecystectomy
Social History:
Married. Past metal finisher but currently not working, [**12-21**] work
related injury. +Tob 1.5 ppd x many yrs. Past heavy EtOH but
none in 20 yrs
Family History:
Uncle w/ [**Name2 (NI) 499**] ca
Physical Exam:
VS: T: 99.1; HR: 83; BP: 108/77; RR 16; O2 96% RA
GEN: middle age man, lying in bed, NAD
HEENT: PERRL bilat, EOMI bilat, icteric, MMM, +thrush
NECK: JVP not elevated, no LAD
CV: RRR, normal s1s2, no murmurs, no S3/S4
CHEST: CTA bilat other than minimal wheezes.
ABD: NABS, soft, minimally distended, +tenderness diffusely, no
rebound/guarding
RECTAL: guaiac neg in ED
EXT: 2+ edema bilat
NEURO: A&Ox3, CN 2-12 intact bilat, sensory/motor exam intact
bilat
Pertinent Results:
[**2148-7-23**] 09:50AM PT-15.2* PTT-34.0 INR(PT)-1.3*
[**2148-7-23**] 09:50AM PLT COUNT-421
Brief Hospital Course:
Hospital course to date: Pt is a 55 yo male with metastatic and
obstructive pancreatic cancer that was initially admitted on
[**2148-7-23**] for abdominal pain, bacteremia and biliary tube
replacement.
- Biliary drainage and bleeding: Pt was initially evaluated in
the ED and interventional radiology was called for replacement
of the tube which was done. However, the patient was found to
have significant bleeding around the drain site (after dry
heaves) and was taken the following morning to the IR suite for
replacement of the biliary drain on [**7-25**] for a larger drain.
After initial bleeding, pt required 1 U transfusion. Pt
continued to have bleeding into biliary drain tube, and was
transfused 2 units on [**7-27**] due to low hct. Then on [**7-28**] patient
had episode of hematemesis with AM Hct was found to be 24. On
[**7-29**] patient had an angiogram that did not show any bleeding
location and cholangiogram. Hct after angiogram was 21. Pt was
then transfused 2 units. The following day, the patient had an
EGD that did not show any sign of bleeding. however, the night
of [**7-30**], pt was found to have excessive bleeding in biliary
drain with hypotension and was transferred to the ICU.
- [**Name (NI) 11646**] Pt was initially found to have [**1-20**] blood cultures
positive for pan sensitive Ecoli. This was treated with
Levofloxacin per ID recommendations. Flagyl was added for
elevated WBC.
- While in the ICU, the patient was transfused until he had a
stable hct. He required multiple transfusions as he had several
episodes of hematobilia. While in ICU, pt had an IVC filter was
placed as well as a PICC. CT was done that showed metastatic
lesions in spleen, liver and lymphadenopathy. Pt was placed on
PCA for pain management
-After discharge from the ICU the patient continued to have low
hct and the family and patient would like the patient to be
discharged home with hospice. The patient was weaned off PCA
and sent home with hospice care with appropirate pain
medications including dilaudid SL and a fentanyl patches.
Medications on Admission:
Lovenox 90mcg SC BID
Protonix 40mg PO BID
Fentanyl 50mcg TD Q72H
Colace
Dulcolax
Metoprolol 25 mg PO BID
Dilaudid 2mg PO Q3-4H prn
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Hydromorphone 1 mg/mL Liquid Sig: Two (2) mg PO q2-4h as
needed for pain.
Disp:*200 mL* Refills:*0*
3. Bisacodyl 10 mg Suppository Sig: One (1) Rectal at bedtime
as needed for constipation.
Disp:*40 supp* Refills:*0*
4. Compazine 25 mg Suppository Sig: One (1) Rectal every four
(4) hours as needed for nausea.
Disp:*60 supp* Refills:*0*
5. PICC
PICC line per protocol
Discharge Disposition:
Home With Service
Facility:
Health Care Dimensions
Discharge Diagnosis:
Metastatic pancreatic cancer
Persistent Hematobilia
Discharge Condition:
fair
Discharge Instructions:
You were admitted for management of your pancreatic cancer, pain
and biliary obstruction.
Followup Instructions:
As needed with Dr. [**Last Name (STitle) **]
|
[
"452",
"V45.3",
"576.1",
"286.6",
"V60.0",
"576.2",
"285.1",
"790.7",
"198.0",
"998.11",
"157.8",
"198.7",
"576.8",
"401.9",
"197.7",
"305.1",
"578.0",
"458.9",
"996.69",
"453.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"87.54",
"88.47",
"51.98",
"99.04",
"38.7",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5072, 5125
|
2292, 4364
|
280, 351
|
5221, 5228
|
2171, 2269
|
5367, 5415
|
1645, 1679
|
4546, 5049
|
5146, 5200
|
4390, 4523
|
5252, 5344
|
1694, 2152
|
226, 242
|
379, 1122
|
1144, 1462
|
1478, 1629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,084
| 113,268
|
6467
|
Discharge summary
|
report
|
Admission Date: [**2198-2-20**] Discharge Date: [**2198-2-24**]
Date of Birth: [**2137-5-11**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Bilateral iliac artery dissections.
HISTORY OF PRESENT ILLNESS: A 60 year old nondiabetic
Russian-speaking white male with coronary artery disease,
status post myocardial infarction/coronary artery bypass
graft with hypertension and hypercholesterolemia, complained
of sudden onset abdominal and back pain. The patient
presented to the Emergency Room at [**Hospital6 649**]. Abdominal computerized tomography scan
showed isolated bilateral iliac artery dissections. There
was no history of recent trauma or instrumentation. The
patient was admitted for further evaluation.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Myocardial infarction/coronary
artery bypass graft in [**2197-1-11**]; percutaneous
transluminal coronary angioplasty/stent of saphenous vein
graft in [**2197-5-11**].
2. Hypertension.
3. Hypercholesterolemia.
4. Severe, acute hemolytic anemia in [**2197-9-11**].
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: The patient emigrated from [**Country 532**] in [**2193**].
He lives with his wife. [**Name (NI) **] is an engineer. He does not
drink alcohol. He has a history of cigarette smoking.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Plavix 75 mg p.o. q.d.
2. Aspirin.
3. Atenolol 25 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Percocet prn.
PHYSICAL EXAMINATION: Vital signs revealed temperature 97.1,
pulse 65, respirations 18, blood pressure 161/80. General:
Alert, cooperative white male in no acute distress. Chest:
Heart regular rate and rhythm, lungs have slight expiratory
wheezing. Abdomen, soft, nontender. No palpable masses.
Rectal examination, normal sphincter tone, stool guaiac
negative. Pulse examination, carotid, radial, femoral,
popliteal and pedal pulses are all palpable. Neurological
examination, nonfocal.
LABORATORY DATA: Laboratory data on admission revealed white
blood count 16.0, hemoglobin 14.5, hematocrit 41.6, platelets
311,000. PT 12.2, PTT 25.9, INR 1.0. Sodium 142, potassium
3.9, chloride 109, bicarbonate 26, BUN 21, creatinine 0.9,
glucose 90. ALT 27, AST 19. Alkaline phosphatase 71,
amylase 64, total bilirubin 0.4. CK 179. Electrocardiogram
showed a sinus rhythm at 68. No significant change from
tracing of [**2197-9-13**]. Chest x-ray showed no acute
pulmonary disease, status post sternotomy.
HOSPITAL COURSE: The patient was evaluated in the Emergency
Room for epigastric pain radiating to the back. He had a
thallium scan which showed normal perfusion at rest. The
stress MIBI portion was cancelled.
The patient was evaluated for aortic dissection with
computerized tomography scan of the chest, abdomen and
pelvis. The aorta was intact. There was dissection of both
the right and left common iliac arteries with extension of
the left common iliac dissection to the external iliac. The
patient was admitted to the Vascular Surgical Service and was
admitted to the SICU for observation.
The patient's peripheral pulses were strongly palpable and
equal throughout his hospitalization stay. His epigastric
and back pain resolved. His abdomen remained soft. His
peripheral pulses remained equal and strongly palpable.
Systolic blood pressure was 110 on his usual 25 mg of
Atenolol. His creatinine was 1.0. His hematocrit was stable
at 38.
The patient was to follow up with his cardiologist, regarding
the need to continue Plavix nine months after having a
percutaneous transluminal coronary angioplasty/stent of his
saphenous vein graft in [**2197-5-11**]. The patient will follow
up with Dr. [**Last Name (STitle) **] in the office in four weeks after
having a repeat computerized tomography scan of the chest,
abdomen and pelvis.
MEDICATIONS ON DISCHARGE:
1. The patient was to resume all preadmission medications.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home.
PRIMARY DIAGNOSIS:
1. Isolated dissection of bilateral iliac arteries.
SECONDARY DIAGNOSIS:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2198-4-16**] 18:59
T: [**2198-4-16**] 19:25
JOB#: [**Job Number 24849**]
|
[
"V45.82",
"V15.82",
"443.22",
"272.0",
"V45.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1084, 1103
|
3879, 3940
|
1371, 1487
|
2518, 3853
|
1510, 2500
|
167, 204
|
233, 747
|
4095, 4451
|
4020, 4074
|
769, 1067
|
1120, 1345
|
3965, 4001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,599
| 106,986
|
27490
|
Discharge summary
|
report
|
Admission Date: [**2164-5-21**] Discharge Date: [**2164-5-27**]
Date of Birth: [**2083-4-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain/Dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 2 (Lima to LAD, SVG to PDA)
History of Present Illness:
81 y/o female with known coronary artery disease and a recent
increase in symptoms. Cardiac Catheterization revealed 3 vessel
disease and now presents for surgical revascularization.
Past Medical History:
Hypertension
Hypercholesterolemia
Peripheral Vascular Disease s/p Left CEA [**2153**]
Chronic Obstructive Pulmonary Disease
OS Blindness
s/p Appendectomy
s/p Hysterectomy
Social History:
Retired, Lives alone.
60+ yrs or [**1-30**] ppd (>100pkyrhx), Quit 1 month ago
Quit drinking ETOH 15 yrs ago
Family History:
?Mother with CAD
Physical Exam:
VS: 60 20 118/74 112/69 64" 124#
General: Frail, elderly caucasian female in NAD w/ mild SOB @
rest.
Skin: Warm, dry w/ mild darkening/yellowing of face/fingers
HEENT: NC/AT OS blindness, OP benign
Neck: Supple, FROM -JVD, +Carotid Bruits
Chest: Bibasilar rales
Heart: RRR, +S1S2, 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, Well-perfused, 1+ edema, -varicosities 2+ BFA, 1+
BDP, 1+ PT
Pertinent Results:
Echo [**2164-5-21**]: PRE BYPASS: The left atrium is mildly dilated.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Resting regional wall motion abnormalities include mild
hypokinesis of the anteroseptal wall and apex. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-30**]+) mitral regurgitation is seen.
POST BYPASS: Biventricular systolic function remains unchanged
from prebypass. MR is now mild (1+). Remaining study is
otherwise unchanged from prebypass
CXR [**5-25**]: Improvement of mild pulmonary edema. Small bilateral
effusions. Improving left basilar atelectasis.
[**2164-5-21**] 10:34AM BLOOD WBC-13.5*# RBC-3.06*# Hgb-8.9*#
Hct-26.1*# MCV-85 MCH-29.1 MCHC-34.2 RDW-14.3 Plt Ct-119*#
[**2164-5-23**] 01:54AM BLOOD WBC-18.1* RBC-3.19* Hgb-9.2* Hct-27.1*
MCV-85 MCH-28.8 MCHC-33.9 RDW-14.9 Plt Ct-163
[**2164-5-25**] 10:50AM BLOOD WBC-12.0* RBC-3.30* Hgb-9.5* Hct-28.8*
MCV-87 MCH-28.9 MCHC-33.2 RDW-15.3 Plt Ct-242
[**2164-5-26**] 05:05AM BLOOD WBC-10.2 Hct-27.5*
[**2164-5-21**] 10:34AM BLOOD PT-19.5* PTT-45.5* INR(PT)-1.9*
[**2164-5-24**] 05:08AM BLOOD PT-15.4* PTT-33.4 INR(PT)-1.4*
[**2164-5-21**] 11:17AM BLOOD UreaN-6 Creat-0.5 Cl-110* HCO3-21*
[**2164-5-24**] 07:19PM BLOOD Glucose-162* UreaN-12 Creat-0.7 Na-133
K-3.4 Cl-97 HCO3-25 AnGap-14
[**2164-5-26**] 05:05AM BLOOD UreaN-10 Creat-0.5 K-4.1
[**2164-5-26**] 05:05AM BLOOD Mg-1.7
Brief Hospital Course:
Following pre-operative work-up as an outpatient, Ms. [**Known lastname 67248**] was
a same day admit and brought to the operating room on [**2164-5-21**].
She underwent a coronary artery bypass graft x 2 by Dr. [**Last Name (Prefixes) **]. Please se op note for surgical details. Following surgery
she was brought to the CSRU in stable condition on
Neo-Synephrine. Later on op day, patient was weaned from
sedation, awoke neurologically intact and was extubated. Chest
tubes and epicardial pacing wires were removed per protocol. She
was started on Beta Blockers and diuretics. She was gently
diuresed towards her pre-operative weight during her post-op
course. All inotropes were weaned, she remained in the CSRU
until post-operative day three and was then transferred to the
cardiac surgery step-down floor. Physical therapy worked with
patient during entire post-op course for strength and mobility.
Over the next several days patient appeared to be recovering
quite well with stable labs, vs, and physical exam. She cleared
level 5 and was finally discharged on post-op day six with vna
and the appropriate follow-up appointments.
Medications on Admission:
Aspiriin 325mg qd, Atenolol 100mg qd, Lipitor 20mg qd, Norvasc
10mg qd, Betagen eye drops OD
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypas Graft x 2
([**2164-5-21**])
Hypercholesterolemia
Hypertension
Peripheral Vascular Disease
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Seek medical attention if you experience fever, chills, nausea,
vomiting, increased pain, or shortness of breath.
Do not lift anything heavier than 10 lbs for 4 wks.
Do not drive for 4 wks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Please call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office at [**Telephone/Fax (1) 170**] within the
next few days for a follow-up appointment in 4 weeks.
Please call your Primary Care Physician within the next few days
to schedule a follow-up appointment for general assessment and
monitoring of LFT's (on statin).
Completed by:[**2164-5-28**]
|
[
"414.01",
"443.9",
"272.0",
"496",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5060, 5122
|
2920, 4057
|
292, 352
|
5305, 5313
|
1335, 2897
|
900, 918
|
4200, 5037
|
5143, 5284
|
4083, 4177
|
5337, 5564
|
5615, 5983
|
933, 1316
|
234, 254
|
380, 564
|
586, 758
|
774, 884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,027
| 157,835
|
8249+8250
|
Discharge summary
|
report+report
|
Admission Date: [**2117-8-6**] Discharge Date: [**2117-8-11**]
Date of Birth: [**2046-7-8**] Sex: M
Service:
The patient was admitted to the Medical Intensive Care Unit
on [**2117-8-5**] and discharged from the Medical Intensive Care
Unit to the floor on [**2117-8-8**].
CHIEF COMPLAINT: Bright red blood per rectum times three.
HISTORY OF PRESENT ILLNESS: This is a 71 year old man with
a history of recurrent gastrointestinal bleeding in [**2117-1-23**] and [**2117-7-23**], also with diverticulosis and
[**Year (4 digits) 499**] polyps and internal hemorrhoids. He was recently
admitted to [**Hospital1 69**] from [**8-1**] through [**8-4**] for lower gastrointestinal bleeding with
a pre-syncopal episode and now presents again for bright red
blood per rectum.
The patient reports three episodes of hematochezia today with
a large amount of blood noted in the toilet. He complains of
lightheadedness in the evening with lower abdominal pain
relieved after defecation. The patient was noted to have two
bloody bowel movements in the Emergency Department. He
denies chest pain, shortness of breath, nausea or vomiting,
headaches, orthopnea or paroxysmal nocturnal dyspnea.
He denies leg swelling. No exertional dyspnea. No history
of cardiac disease or bleeding disorders. The patient has a
known history of hypertension and states that his blood
pressure runs in the 130s over 80s on a regular basis. Per
his family, the patient took an anti-inflammatory medication
for arthritic knee pain prior to the last admission that may
have precipitated his previous admission.
Recent studies include an esophagogastroduodenoscopy
performed [**2117-8-2**], which shows a small hiatal hernia, a
single 2 millimeter nonbleeding polyp in his fundus.
Colonoscopy performed [**2117-8-2**] shows nonbleeding Grade I
internal hemorrhoids, diverticulosis of the ascending and
sigmoid [**Year (4 digits) 499**]; otherwise normal the cecum. Small bowel
follow through on [**2117-8-3**], shows normal small bowel loops,
normal terminal ileum and pathology from [**2117-1-23**]
shows samples of [**Year (4 digits) 499**] polyps, evidence of fragments of
adenomas.
PAST MEDICAL HISTORY:
1. Diverticulosis.
2. Polyps.
3. Hemorrhoids.
4. Hiatal hernia.
5. Hypertension.
6. Hyperlipidemia.
7. Arthritis.
8. Status post transurethral resection of prostate and
inguinal hernia repair.
FAMILY HISTORY: Significant for a father with [**Name2 (NI) 499**] cancer.
SOCIAL HISTORY: No alcohol, smoking or intravenous drug
use.
MEDICATIONS ON ADMISSION:
1. Prilosec.
2. Vasotec.
3. Iron supplements.
4. Niacin.
5. B12.
6. Folic acid.
7. Colace.
ALLERGIES: Ampicillin and gentamicin; rash was noted.
PHYSICAL EXAMINATION: On admission, temperature 98.2 F.;
heart rate 85; blood pressure 136/71; O2 98% on room air.
Respiratory rate 18. Of note, the patient was orthostatic by
pulse 85 on sitting, 130 when standing. The patient appeared
tired, calm and pale. HEENT: Pupils are equal, round, and
reactive to light and accommodation. No conjunctival
petechiae. Oropharynx was clear; no lymphadenopathy.
Cardiovascular was regular rate and rhythm, S1, S2, no
murmurs, rubs or gallops. Lungs were clear to auscultation
bilaterally. Abdomen with positive bowel sounds, obese,
distended, tympanitic to percussion. Mild bilateral lower
quadrant tenderness, left greater than right. Extremities
with trace edema on the left side. Pulses one plus, no
femoral hematoma or bruits. No calf tenderness. Neurologic
examination was non-focal. The patient was moving all
extremities. Deep tendon reflexes one plus bilaterally.
Rectal was deferred. The patient was noted to have bright
red blood.
LABORATORY: On pertinent laboratories, the patient's
hematocrit was 32.5, recently noted to be 32.9 on discharge.
MCV of 87, RDW 14.9, CK was 98, CK MB not done. Troponin is
negative.
PT is 12.6, PTT 24.2, INR 1.1. EKG showed sinus rhythm at 90
beats per minute, normal axis, evidence of right bundle
branch block, J-point elevation in V2 to V5. No evidence of
acute ischemia and possible T wave inversion in lead III.
This electrocardiogram was compared to prior EKG from primary
care physician [**Name Initial (PRE) 3726**]. There were no acute changes.
The patient was sent for a mesenteric angiogram which did not
show any evidence of acute bleeding.
HOSPITAL COURSE: Peripheral access was obtained with two
large bore intravenous lines. The patient was appropriate
transfused to maintain his hematocrit above 30. Volume
resuscitation was given with normal saline. The patient was
started on proton pump inhibitor for gastrointestinal
prophylaxis.
Hematocrit was monitored serially. Colonoscopy was not
indicated at this time as patient just recently had received
this procedure.
The patient was observed in the Medical Intensive Care Unit
and remained hemodynamically stable. Hematocrit on discharge
from the Medical Intensive Care Unit was greater than 30.
The patient was transferred to the floor for further
monitoring and evaluation.
CONDITION ON DISCHARGE FROM THE MEDICAL INTENSIVE CARE UNIT
was stable.
MEDICATIONS were unchanged. Blood pressure medications were
held.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 20637**]
MEDQUIST36
D: [**2117-8-11**] 13:15
T: [**2117-8-12**] 23:47
JOB#: [**Job Number 29290**]
Admission Date: [**2117-8-6**] Discharge Date: [**2117-8-18**]
Date of Birth: [**2046-7-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a history of multiple gastrointestinal bleeds all of
unclear source but all self-resolved. First episode was 12
years ago when the patient developed rectal bleeding.
Multiple suspects including diverticulosis, gastric polyp,
internal hemorrhoids and gastric ulcer. Positive
gastroesophageal reflux disease and hiatal hernia. [**2117-7-30**]
the patient took Dextra for the fifth time for knee pain and
on [**8-1**] he had lower gastrointestinal bleed. Admitted [**8-1**]
to [**8-4**] and source was unclear. The patient had negative
esophagogastroduodenoscopy, negative colonoscopy except for
diverticulosis and internal hemorrhoids. On [**8-5**] he had
frank hematochezia with three bowel movements, had
lightheadedness. He went to the Emergency Room, no chest
pain, no shortness of breath, no nausea or vomiting. He did
have some positive lower abdominal pain during bowel movement
which was revealed after having bowel movement. In emergency
department the patient's hematocrit was 32.5 and stable. He
had one liter of IVF and mesenteric angiography which was
negative. He was orthostatic by heart rate. He was admitted
to the MICU. In the MICU the patient's hematocrit was 25.
He was transfused two units packed red blood cells,
hematocrit then stabilized. The patient had q 4 to 6 hours
hematocrit monitoring. In the MICU he did have melanotic
stool but hematocrit remained stable and was then transferred
to the Medicine floor for further management.
PAST MEDICAL HISTORY: Diverticulosis, internal hemorrhoids,
multiple gastrointestinal bleeds that self-resolved, gastric
polyp and shallow gastric ulcer, gastroesophageal reflux
disease, hiatal hernia, hypertension, status post
transurethral resection of prostate, status post bilateral
inguinal hernia repair, hypercholesterolemia,
hyperhomocystinemia. Anemia found to be iron deficiency
anemia.
MEDICATION:
1. Prilosec.
2. Vasotec.
3. Iron sulfate.
4. Colace
5. Vitamin B12.
6. Niacin.
7. Folate.
8. Dextra.
ALLERGIES: Ampicillin and Gentamicin which cause rash.
FAMILY HISTORY: Father had [**Name2 (NI) 499**] cancer, no inflammatory
bowel disease history, no bleeding disorder.
SOCIAL HISTORY: ETOH occasionally. No tobacco, he quit in
the 70's. He is retired and lives with wife.
PHYSICAL EXAMINATION: Temperature 97.5, pulse 84, blood
pressure 152/80, respirations 18, sating at 96% on room air.
Generally he is in no acute distress, pleasant, sitting in
chair [**Location (un) 1131**]. Head, eyes, ears, nose and throat:
Extraocular movements intact, pupils are equal, round, and
reactive to light and accommodation, no jugular venous
distention. Supple neck and moist mucous membranes. Heart
is regular rate and rhythm. Normal S1 and S2. No murmurs.
Lungs are clear to auscultation bilaterally. No wheezes or
crackles. Abdomen is soft, nontender, nondistended with good
bowel sounds. The patient is 1+ lower extremity edema. 2+
dorsalis pedis. Neurologic: Cranial nerves 2 to 12 are
intact. Strength is [**4-26**] and symmetric. Toes are downgoing.
White count 6.5, hematocrit 29.4, platelet count 247. Sodium
139, potassium 3.4, chloride 108, bicarbonate 25, platelet
count 9, creatinine 1.2. Glucose is 93. INR 1.1, PTT is
24.5. Prothrombin time is 12.7. CK and Troponins have
remained within normal limits and the patient has ruled out
for myocardial infarction.
During his transfer to the Medicine service the patient had
continued blood per rectum times 3 or 4 times. He had a
repeat esophagogastroduodenoscopy which was negative.
Surgery was consulted on the patient and felt that one option
included a Heparin induced bleeding in order to appreciate
the source of the bleeding. This was planned however, the
patient's bleeding spontaneously resolved and hence patient
was not taken to the operating room for Heparin induced
bleeding. Additionally given that he had no further episodes
of bleeding it was decided to just watch and see if the
patient had any other events. The patient then did have some
blood per rectum and a tagged red blood cell scan was
performed on [**8-11**] however, this did not reveal the source of
bleeding either so again it is felt that perhaps a Heparin
induced bleeding scan was the best course of action for this
patient however, as stated above the bleeding then
spontaneously resolved and the patient had no further episode
of bright red blood per rectum and he had a stable
hematocrit. Hence it was decided that the patient would be
discharged home for further follow-up with his primary care
physician and that further workup could be considered as an
outpatient should the patient have significant blood per
rectum.
MEDICATIONS ON DISCHARGE:
1. Prilosec 20 mg p.o. q day.
2. Colace.
3. Vitamin B12.
4. Folic acid.
5. Niacin.
The patient was to follow-up with his primary care physician
within one weeks time and was to report sooner should he have
any further episodes of bright red blood per rectum.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2117-9-18**] 16:40
T: [**2117-9-20**] 18:38
JOB#: [**Job Number 29291**]
|
[
"401.9",
"578.9",
"553.3",
"211.1",
"562.10",
"455.0",
"285.1",
"426.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7761, 7863
|
10404, 10939
|
2573, 2729
|
4409, 5627
|
7993, 10378
|
307, 349
|
5656, 7166
|
7189, 7744
|
7880, 7970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,734
| 141,740
|
19365
|
Discharge summary
|
report
|
Admission Date: [**2115-10-25**] Discharge Date: [**2115-11-2**]
Date of Birth: [**2067-10-16**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**Name Initial (NameIs) 7790**]
HPI:
47 yo male with ESRD on HD, DM, CAD, Addison's, presents with
fevers, hypoglycemia and coffee ground emesis from [**Hospital 4199**]
Hospital. He left [**Hospital1 18**] 10 days ago after admission
[**Date range (1) 52674**] for hyperkalemia, hypoglycemia and fever. Found
to have C. Diff and ?line infection (though blood cultures
negative). He was treated empirically with CTX/Vanco/Flagyl.
He went home, then brought back to [**Last Name (un) 4199**] ([**Date range (1) 52675**]/05)
unresponsive with hypoglycemia ([**Date range (1) 31567**] of 11), fever with 1/2 MSSA
from line, given vancomycin, tequin, was dialyzed then left AMA
on [**2115-10-20**]. On [**2115-10-24**] in the evening his [**Date Range 31567**] was 30 and he was
brought back to Widden febrile with coffee ground emesis, guaiac
+ stool, hyperglycemic, transferred to [**Hospital1 18**].
In the ER he was given Vanco IV, Flagyl 500 IV, decadron 10,
tylenol, 2 units FFP. LP equivocal but 1 WBC. NG Lavage with
minimal coffee grounds that cleared with ~250 cc.
Past Medical History:
IDDM diagnosed at age 29, hx of retinal hemorrhage, peripheral
neuropathy, nephropathy, Charcot
ESRD on HD Q Tues/Thurs. Awaiting transplant from sister
CAD s/p NSTEMI in 8/[**2113**]. Recent MIBI w/ no reversible flow
defects. Echo done [**6-/2115**] shows LVH, nl EF.
HTN
Hypercholesterolemia
Hypothyroidism
Addison??????s disease diagnosed at age 29
Anemia of chronic disease
Chronic LE edema
s/p recent medial tibial plateau/proximal fibula fracture
C. Diff colitis s/p Flagyl finished mid-[**8-/2115**]
Social History:
No tob, Etoh, illicits, He is single w/ no kids and lives in
[**Location 3146**]. He was a former clerk/supervisor but is currently on
disability.
Family History:
Father died age 50 due to cancer
Mother died age 60 due to breast cancer
4 brothers, 3 sisters: 2 siblings w/ DM
Physical Exam:
Temp: 101.2, HR:82, BP:137/85, RR:22, O2:97% RA
Gen: NAD. Somnolent. A/O x 3
HEENT: PEARLA. EOMI
CV: RR. No M/R/C
Pulm: Mild crackles at left base.
ABD: Distended. Soft Non-tender. No HSM
Ext: trace edema b/l, chronic appearing, non-pitting
Neuro: Motor [**3-21**] at all flex/ex. [**Last Name (un) **]: GI to LT b/l. CNII-XII
GI.
Rectal: Guaiac + Brown stool
Pertinent Results:
WBC:15.5 (N:77, L:8.0, E:12), Hct:33.8, Plt:238
131 90 25
------------<281
4.3 25 5.0
INR:2.1
TN:0.44, CK:77
Ca:9.7, Phos:1.5, Mg:1.4
Ammonia:16
CSF: Prot 157, Gluc 202, WBC:3, RBC:1, Opening pressure of 29
Serum/Urine tox (-)
U/A: Large blood, Nit (-), Prot 500, Gluc:1000, Ket:50, LE:Mod,
WBC:>50, RBC:[**10-6**], Epi:0-2
Lact:3.5
CT Head: No bleed
CXR: Mild cardiomegaly and mild pulm edema
ECG: NSR at 80 bpm, Nl Axis. LVH with slight J-pt elevation in
V2-V3 with peaked T waves somewhat more than prior.
Depressions with TWI in V5-V6.
Brief Hospital Course:
48 y.o. diabetic male with ESRD on HD, Addison's Disease,
hematemesis and high fevers with relative hypotension. His
blood cultures drawnn several days prior at [**Last Name (un) 4199**] grew 1 out
of 4 bottles Staph warneri (coagulase negative staph) from his
HD catheter. He had already been on vancomycin and this was
continued. He received one dose of levoquin and flagyl while in
the emergency room but this was stopped. His blood glucose was
390 in the setting of his infection and he had a small amount of
ketones in his blood. However he was not acidotic. he received
stress dose steroids given his Addison's disease and was placed
on an insulin drip for tighter control in the setting of his
sepsis and brittle type 1 diabetes. Blood and urine cultures
were drawn from his line and peripheral blood and grew nothing.
LP was performed because he was moderately confused and had a
high opening pressure of 29, elevated protein, but no WBC to
suggest infection. CSF gram stain and cultures were sterile. He
deferveced by hospital day 2 and was quickly weaned from his
stress steroids to his basal replacment dose. It was felt that
the likely source was his line, though renal consult feels that
the cultrues were probably contamination. His line was not
pulled plans are made to continue the vancomycin for 4 weeks
with end date = [**2115-11-22**]. Surveillance cultures will need to
be drawn 7 days after his vanco is stopped. Vanco should be 1g
qHD, with random levels drawn weekly to maintain a concentration
of 15-20. His levels should be checked at least every other day
to ensure a goal serum concentration of 15-20 and to avoid
toxicity.
.
In regards to his hematemesis, an NG lavage revealed coffee
ground emesis that cleared with lavage. No frank blood was
visualized. His hematocrit was stable. He underwent an EGD
that showed a normal duodenum and esophagus, however the large
degree of food left in the stomach precluded adequate
visualization of that organ. GI consult felt that his symptoms
were likely related to a stress ulcer in the setting of acute
illness and recommended he was safe for outpatient EGD. Since
he experienced such labile blood glucose while NPO for the
procedure, and the fact that he had no other symptoms while
maintaining an adequate and unchanged hematocrit, the EGD was
not performed while here and can be pursued later. For the food
findings in his stomach he was started on reglan for likely
gastroparesis. It was felt that he might also experienced
better blood sugar control with better peristalsis by mathcing
his glycemic load with PO intake with his humalog scale.
.
His sugars were labile while on stress steroids and NPO status.
These evened out by regularization of his diet and cessation of
stress steroids. He is very sensitive to insulin and should not
be treated aggressively for hyperglycemia. He was continued on
his lantus with his insulin gtt and quickly weaned off the gtt
to a humalog sliding scale. He was followed by the [**Last Name (un) **]
service while here.
.
His C. diff toxin was positive, however he did not have any
symptoms. We feel that this is indicative of persistent toxin
shedding but does not indicate on going infection. he will need
to continue flagyl until 7 days after he STOPS vancomycin to
PREVENT c. diff colitis from reoccuring with end date = [**2115-12-2**].
.
His blood pressure remained at this usual 160-200 systolic. His
hydralazine was increased to 50mg qid from 25mg qid with some
mild improvement. Renal is attempting to challenge his "dry
weight" of 64kg and he underwent additional ultrafiltration
sessions to accomplish this. His legs remained swollen in
between sessions. He had no evidence of pulmonary edema and was
asymptomatic at his blood pressures of 220 systolic. He had a
brief episode of atrial tachycardia in the 150's that was not
atrial flutter during the acute phase of his sepsis. This
resolved with treatment of his sepsis and did not recur.
Medications on Admission:
Meds at time of discharge from [**Last Name (un) 4199**] on [**2115-10-20**]:
Vanco 125 po q6
Lantus 20 SC HS
Labetolol 200 qid
Clonidine 0.2 tid
Calcium 100 tid
Lipitor 20 daily
Norvasc 10 daily
Fludrcort 0.05 [**Hospital1 **]
Hydrocort 25 qAM
Hydrocort 5 qPM M, Th, Sun
Hydrocort 10 qPM W/Sat
Hydrocort 15 qPM Tues/Fri
Cholecaciferol 400 daily
Neurontin 300 daily
Hydral 25 qid
Protonix 40 daily
Levothyrox 50 daily
ASA 81 daily
Humalog Scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
4. Fludrocortisone 0.1 mg Tablet Sig: one half Tablet PO Q 12H
(Every 12 Hours).
5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO
QMON/THURS/SUN ().
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): stop date = [**2114-11-29**] (7 days after stopping
vanco).
12. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO
QTUES/FRIDAY ().
13. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QWED/SAT
().
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
17. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
18. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
19. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32)
units Subcutaneous at bedtime.
20. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding
scale units Subcutaneous four times a day: sliding scale.
21. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
qHD: please check levels to ensure not toxic serum
concentration. goal 15-20.
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Coag negative staph wernari line sepsis
Addison's Disease
Hyperglycemia
Hypertension
End Stage Renal Failure
Discharge Condition:
stable, good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
.
continue taking your antibiotics as outlined in the discharge
summary.
.
do not eat too many carbohydrates as outlined by the [**Last Name (un) **]
physicians. Watch that you aren't given too much insulin for
sugars in the 400's as you respond very well with subcutaneous
treatment. follow the sliding scale you are discharged with.
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2115-11-4**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2115-11-4**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2115-11-13**] 3:40
See your endocrinologist within 7 days of being discharged.
continue with your hemodialysis sessions tues, thurs, sat.
follow up with your podiatrist and orthopedic surgeon as they
have planned with you.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"285.21",
"038.19",
"250.61",
"276.2",
"599.0",
"578.0",
"V58.67",
"995.91",
"244.9",
"996.62",
"008.45",
"713.5",
"403.91",
"585.6",
"357.2",
"V09.0",
"272.0",
"412",
"255.4",
"250.51",
"583.81",
"250.41",
"362.01",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"03.31",
"96.07",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9613, 9686
|
3212, 7205
|
281, 287
|
9838, 9852
|
2630, 2977
|
10365, 11100
|
2114, 2229
|
7700, 9590
|
9707, 9817
|
7231, 7677
|
9876, 10342
|
2244, 2611
|
233, 243
|
315, 1402
|
2986, 3189
|
1424, 1933
|
1949, 2098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,448
| 173,597
|
49968
|
Discharge summary
|
report
|
Admission Date: [**2183-9-29**] Discharge Date: [**2183-9-29**]
Date of Birth: [**2108-1-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
75 yo M with CAD, CHF, spinal stenosis, who presents with
several hours of increasing SOB. He denies CP, palps. He was
feeling in his usual state of health on morning of presentation
to ED and sx came on during the early evening of [**2183-9-28**]. He
denies dietary indescretion and medication noncompliance. He
does endorse episodes of SOB causing him to wake up during the
night presumed to be secondary to his sleep apnea. He notes a 15
lb weight gain and increase in abdominal girth over past few
weeks. He stopped his plavix sometime in the spring. He
presented to ED with BP of 210/110, oxygen sat 100% on NRB,
desatting to 80's on NC. He was given lasix 80 mg IV x1 and
started on nitro gtt, heparin gtt. He was given one dose of
levofloxacin for possible pneumonia on CXR. He put out 500 ml
urine in ED. He denies cough, fevers, chills.
Past Medical History:
CAD
CHF
Spinal stenosis
PFTs with decreased DLCO
Sleep apnea
CKD
Social History:
Former smoker, quit 25 yrs ago, smoke 5 PPD x15 yrs, former
heavy drinker - drank a fifth nightly for about 15 years, denies
drugs.
Family History:
Fa: HTN, mother died of breast ca
Physical Exam:
BP 210/110 -> 140/70's, HR 70's, 24, 100% on NRB, 80's on 4L NC
GENL: obese male in NAD
HEENT: thick neck, unable to appreciate JVP, no carotid bruits
CV: RRR, no MRG
Lungs: crackles at bases bl, bronchial breath sounds on R
Abd: distended, tympanitic, unable to appreciate organomegaly
Ext: 1+ pitting edema in lower legs bl, 2+ pedal pulses
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS:
[**2183-9-28**] 08:50PM PT-12.3 PTT-20.4* INR(PT)-1.1
[**2183-9-28**] 08:50PM PLT COUNT-261
[**2183-9-28**] 08:50PM ANISOCYT-1+
[**2183-9-28**] 08:50PM NEUTS-79.2* LYMPHS-17.2* MONOS-2.8 EOS-0.6
BASOS-0.2
[**2183-9-28**] 08:50PM WBC-25.3*# RBC-4.85 HGB-14.2 HCT-42.1 MCV-87
MCH-29.4 MCHC-33.8 RDW-16.3*
[**2183-9-28**] 08:50PM CALCIUM-9.4 PHOSPHATE-6.3* MAGNESIUM-1.9
[**2183-9-28**] 08:50PM cTropnT-0.24*
[**2183-9-28**] 08:50PM GLUCOSE-137* UREA N-50* CREAT-2.4* SODIUM-143
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-20
[**2183-9-28**] 09:57PM LACTATE-1.7
[**2183-9-28**] 11:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2183-9-28**] 11:05PM URINE GR HOLD-HOLD
[**2183-9-28**] 11:05PM URINE HOURS-RANDOM
[**2183-9-28**] 11:05PM TRIGLYCER-110 HDL CHOL-60 CHOL/HDL-2.9
LDL(CALC)-89
[**2183-9-28**] 11:05PM ALBUMIN-4.0 CHOLEST-171
[**2183-9-28**] 11:05PM CK-MB-12* MB INDX-7.2* cTropnT-0.40*
[**2183-9-28**] 11:05PM ALT(SGPT)-108* AST(SGOT)-36 CK(CPK)-166 ALK
PHOS-43 TOT BILI-0.7
.
DISCHARGE LABS:
[**2183-9-29**] 03:22AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2183-9-29**] 03:22AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2183-9-29**] 06:56AM PT-14.9* PTT-103.1* INR(PT)-1.3*
[**2183-9-29**] 06:56AM PLT COUNT-209
[**2183-9-29**] 06:56AM WBC-15.4* RBC-4.14* HGB-12.1* HCT-35.7*
MCV-86 MCH-29.2 MCHC-33.9 RDW-16.5*
[**2183-9-29**] 06:56AM CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-1.8
[**2183-9-29**] 06:56AM CK-MB-11* MB INDX-5.2 cTropnT-0.30*
[**2183-9-29**] 06:56AM CK(CPK)-211*
[**2183-9-29**] 06:56AM GLUCOSE-134* UREA N-52* CREAT-2.6* SODIUM-141
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-19
.
MICRO DATA:
[**2183-9-28**]: Blood and Urine cultures: Pending at discharge
.
IMAGING:
Chest X Ray [**2183-9-29**]:
Previous mild pulmonary edema has improved, previous right lower
lobe atelectasis has cleared, left lower lobe consolidation or
atelectasis persists. Heart size top normal, unchanged. No
pneumothorax or pleural effusion.
.
ECHO [**2183-9-29**]: Pending at discharge
Brief Hospital Course:
1. Shortness of Breath: The differential diagnosis originally
included MI, CHF exacerbation, pneumonia, PE. He was started on
a nitro drip and given Lasix 80mg IV in the ED and was brought
to the floor. His oxygenation improved, and by morning he was
oxygenating well on room air. He did not complain of further
shortness of breath. A follow up CXR showed improvement. An
ECHO was performed and the final [**Location (un) 1131**] was pending at
discharge. Because is cardiac enzymes had been elevated,
including CK-MB and Troponin, and his EKG showed ST changes, and
because of his significant cardiac history, he was also given
ASA and started on a heparin drip. We had wanted to perfrom a
cardiac catheterization, but the patient refused. He claimed he
did not need such a test. The cardiology fellow explained the
test, risks and benefits, and that we thought it would be wise
to have. After hearing the risks and benefits of the test, the
patient still refused. His cardiologist Dr. [**Last Name (STitle) **] also spoke
with the patient, trying to convince him to stay in the CCU for
catheterization. The patient refused. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was
also [**Last Name (STitle) 653**] and was to visit him in the CCU that day. The
patient left AMA before his PCP could arrive. His PCP was
[**Name (NI) 653**]. Further work up for his SOB could not be performed.
Upon leaving AMA, the patient did not complain of any symptoms.
In addition to his outpatient medications, the patient was
written prescriptions for Metoprolol, Atorvastatin, and Lasix
40mg PO qDay. he was also told to take aspirin.
.
2. Hypertension: On admission the patient's BP was in the 200s
systolic. The patient responded well to the nitro drip,
metoprolol, and lasix. His BP returned to the 110-120 systolic.
He did not experience any symptoms. Upon leaving AMA, the
patient's BP was stable off of the nitro drip. Further work up
could not be performed, but he was advised to follow up with his
cardiologist and PCP immediately to address his blood pressure.
.
3. Lymphocytosis: The patient had an elevated count on
admission. However, the patient was afebrile and did not have
any localizing symptoms. He was given a dose Levaquin in the
ED. Blood and urine cultures were sent. However, the patient
left AMA before further work up could be performed. Cultures
were still pending at the time of leaving AMA.
.
4. Disposition: The patient left AMA despite being urged to
stay. We told him that we were concerned about his heart, and
that we would want perform a cardiac catheterization to assess
his heart disease. The patient was decribed the consequences of
leaving and the risks/benefits of staying, including suffering a
heart attack or other acute event if he did not stay, and he
understood the risks and benefits. He was urged to follow up
with his PCP and cardiologist within a week. He was urged to
return to the hospital with any symptoms. He was also given
prescriptions for his medications and urged to take them
consistently and as prescribed. His blood and urine cultures
will need to be followed up, as well as his blood pressure and
respiratory symptoms.
Medications on Admission:
Lipitor
Toprol XL 25 mg QD (patient was unsure)
Testosterone tp
MVI
HCTZ 25 QD
ASA 325 mg QD
Lasix (patient could not recall the dose)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive urgency
2. Non-ST Elevation Myocardial Infarction
.
Secondary Diagnosis:
2. Pulmonary edema
3. Chronic kidney disease
Discharge Condition:
Afebrile, hemodynamically stable. - PATIENT LEFT AGAINST MEDICAL
ADVICE
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow up appointments. Please return to the hospital
immediately if you experience chest pain, shortness of breath,
fevers/chills, or any other symptoms that concern you
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 1 week
[**Telephone/Fax (1) 693**]. Please follow up with your Cardiologist Dr.
[**Last Name (STitle) **] within 1 week.
|
[
"410.71",
"425.4",
"585.9",
"414.01",
"401.9",
"327.23",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7988, 7994
|
4059, 7281
|
292, 300
|
8191, 8265
|
1859, 1859
|
8545, 8767
|
1431, 1467
|
7466, 7965
|
8015, 8015
|
7307, 7443
|
8289, 8522
|
2936, 4036
|
1482, 1840
|
233, 254
|
328, 1176
|
8123, 8170
|
1875, 2920
|
8034, 8102
|
1198, 1265
|
1281, 1415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,707
| 146,289
|
36631
|
Discharge summary
|
report
|
Admission Date: [**2181-9-18**] Discharge Date: [**2181-9-25**]
Date of Birth: [**2112-11-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2181-9-19**] Rigid Bronchoscopy
[**2181-9-21**] Flexible bronchoscopy with extubation.
[**2181-9-24**] Flexible bronchoscopy and airway inspection.
History of Present Illness:
Mrs [**Known lastname **] is a 68 year-old female with Fibrosing
mediastinitis with left mainstem stenosis. On [**2181-9-13**] she
underwent Placement of Alveolus covered stent [**82**] x 38 mm in the
left main stem. Following the procedure she developed
respiratory distress requiring re-intubation. A CCT done at
that
time showed Stent with distal migration, and located likely in
the left lower lobe bronchus. She was extubated without
respiratory distress. She was discharged to home and presented
the next day to [**Location (un) 61603**] ED with SOB and cough. She was
admitted started on antibiotics.
Past Medical History:
Fibrosing mediastinitis
S/P lung biopsy [**2174**], [**2174**] hospital, CT
Hypothyroidism
Social History:
Tobacco: Never
Alcohol: No
Lives with: family
Retired
Family History:
Mother-sudden cardiac death at age 64
Sister-Cardiac disease and lupus, death at age 55
Pertinent Results:
[**2181-9-22**] 06:35AM BLOOD WBC-7.1 RBC-4.17* Hgb-10.6* Hct-33.8*
MCV-81* MCH-25.5* MCHC-31.5 RDW-12.9 Plt Ct-254
[**2181-9-21**] 03:37AM BLOOD WBC-6.7 RBC-3.89* Hgb-10.3* Hct-31.2*
MCV-80* MCH-26.5* MCHC-33.0 RDW-12.8 Plt Ct-213
[**2181-9-19**] 03:45PM BLOOD WBC-8.7 RBC-4.35 Hgb-11.1* Hct-35.6*
MCV-82 MCH-25.5* MCHC-31.2 RDW-13.4 Plt Ct-220
[**2181-9-23**] 01:49PM BLOOD Glucose-138* UreaN-18 Creat-0.7 Na-135
K-3.8 Cl-99 HCO3-26 AnGap-14
[**2181-9-21**] 03:37AM BLOOD Glucose-139* UreaN-15 Creat-0.5 Na-140
K-4.3 Cl-105 HCO3-27 AnGap-12
[**2181-9-19**] 03:45PM BLOOD Glucose-215* UreaN-11 Creat-0.4 Na-138
K-3.9 Cl-101 HCO3-30 AnGap-11
[**2181-9-19**] 03:45PM BLOOD CK(CPK)-148*
[**2181-9-18**] 08:30PM BLOOD CK(CPK)-131
[**2181-9-19**] 07:30AM BLOOD CK(CPK)-181*
[**2181-9-23**] 01:49PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0
[**2181-9-21**] 03:37AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1
[**2181-9-20**] 01:57AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.8
[**2181-9-19**] 03:45PM BLOOD Calcium-8.3* Phos-3.4 Mg-1.7
[**2181-9-21**] 03:47AM BLOOD Type-ART pO2-195* pCO2-39 pH-7.49*
calTCO2-31* Base XS-6
[**2181-9-20**] 02:11AM BLOOD Type-ART Temp-36.3 pO2-220* pCO2-42
pH-7.46* calTCO2-31* Base XS-6
[**2181-9-19**] 02:49PM BLOOD pO2-383* pCO2-55* pH-7.32* calTCO2-30
Base XS-1
[**2181-9-19**] 03:53PM BLOOD Lactate-1.5 K-3.9
[**2181-9-19**] 02:49PM BLOOD Glucose-243* Lactate-2.4* Na-136 K-3.8
Cl-100
[**2181-9-21**] CXR: Overall improvement, since [**2181-9-18**]. The
airways stent
is in the left main bronchus.
[**2181-9-19**] CT Trachea:
1. Interval worsening of the consolidation of the left upper
lobe and left
lower lobe with post-obstructive pneumonic changes of left lung
and post-
obstructive bronchiectasis of the left lower lobe.
2. Interval development of mild-to-moderate left pleural
effusion.
3. Unchanged location of migrated stent of left mainstem
bronchus within the left lower lobe bronchus.
4. Complete collapse of the left mainstem bronchus in
inspiration and
expiration, which has progressed since prior study.
5. Improved areation of the right lung
Brief Hospital Course:
68 year.old female with Fibrosing mediastinitis with left
mainstem stenosis s/p LMS stent placement migration. Transferred
to [**Hospital1 18**] for further evaluation. On [**2181-9-19**] patient taken to OR
for: Rigid bronchoscopy using Dumon right bronchoscope.
Flexible bronchoscopy. Balloon dilatation of the left mainstem
bronchus. Retrieval of the distally displaced left main stem
alveolus stent. Placement of Ultraflex covered 14 x 40 mm left
mainstem stent. Developed respirtory failure with asytole on
[**2181-9-19**] intubated and admitted to ICU. On [**2181-9-21**] taken to the
OR for; Left main stem obstruction, status post recent left
mainstem stent placement complicated by
respiratory failure. PROCEDURE: Flexible bronchoscopy with
extubation. Patient did well. Transfered to the floor patiet
ambulatory tol pos denies shortness of breath cough or
secrtions. On [**2181-9-24**] Flexible bronchoscopy and airway
inspection performed. Bronchoscopy -Subglottic stenosis
secondary to recent intubation and
rigid bronchoscopy. Metal stent in proper place in the left
main-stem
bronchus, with patent distal airways and minimal secretions.
The patient was observed overnight with out complications. Plan
to re-evaluate her
airways in 2 weeks to ensure proper healing of her subglottic
stenosis and to evaluate the position of her metal stent.
Medications on Admission:
Moxifloxacin 400 mg IV q24
CLindamycin 600 mg IV Q6H
Levothyroxine 25 mcg daily
Fuaifenesin 600 mg q12
Albuterol Nebs Q4H
Mucomyst Nebs Q4H
Methylprednisolone 40 mgQ12H
Diltiazem 30 mg Q6H
Ambien 5 mg QHS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Fibrosing mediastinitis
Discharge Condition:
Stable
Discharge Instructions:
Please Call Dr. [**Last Name (STitle) **] with any questions or concerns
[**Telephone/Fax (1) 7769**]
Call with any fevers greater than 101.5
Call with increased shortness of breath, cough or change in
secretions.
Followup Instructions:
Please call your primary care physician for an appointment with
in the next week or two.Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 7769**]
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 82896**] Follow-up appointment
should be in 2 weeks-Please call.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2181-9-25**]
|
[
"519.19",
"934.1",
"518.5",
"E879.8",
"494.0",
"997.1",
"427.5",
"244.9",
"996.59",
"478.74",
"519.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"33.78",
"33.23",
"33.22",
"33.91",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
5867, 5873
|
3491, 4860
|
296, 449
|
5941, 5950
|
1403, 3468
|
6212, 6706
|
1294, 1384
|
5116, 5844
|
5894, 5920
|
4886, 5093
|
5974, 6189
|
236, 258
|
477, 1091
|
1113, 1206
|
1222, 1278
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
420
| 184,181
|
25457
|
Discharge summary
|
report
|
Admission Date: [**2140-7-27**] Discharge Date: [**2140-8-7**]
Date of Birth: [**2077-6-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
transferred for further management of tracheal stenosis
Major Surgical or Invasive Procedure:
Bronchoscopy with stent placement
Bronchoscopy
History of Present Illness:
63 y/o F w/hx of breast Ca s/p lumpectomy/chemo [**2135**], who
presented to [**Hospital 531**] [**Hospital 63637**] Hospital on [**2140-7-23**] with
shortness of breath. Per the pt, she initially noted swelling
in her left neck one year ago. Her oncologist at [**State 531**]
Presbyterian treated her with Femara which made no difference.
At that point he told her that her tumor was "receptor negative"
and the Femara was likely not helping. At this point (approx
one month ago) she developed swelling in her right neck as well.
She then went to The Oasis Center in Tijuana, [**Country 149**] in [**Month (only) **] of
this year, and was treated with a vaccine of some sort, as well
as numerous vitamins. A week after this, she developed
shortness of breath which progressively worsened, as well as
difficulty speaking/swallowing. She also has a nonproductive
cough but no fevers.
At the outside hospital, CXR demonstrated a mediastinal mass, no
infiltrates or effusions. LE dopplers were negative for DVT.
She was begun on Solumedrol 60 IV q12h and had a CT scan of her
chest (r/o PE) and neck (eval for tracheal compression). She
also was placed on ceftriaxone and azithromycin. She was
evaluated by Pulmonary, Thoracic Surgery, ENT, Heme-Onc, and
Rad-Onc who all agreed that she needed definitive therapy for
her extrinsic tracheal compression and she was transferred to
[**Hospital1 18**] for Interventional Pulmonary evaluation on [**7-27**]. She did
have a lymph node biopsy of her neck prior to transfer.
Past Medical History:
1. Breast Ca [**2135**], s/p lumpectomy. Refused XRT. s/p
cyclophosphamide and Taxol x 6 months in [**2135**]. Had recurrence
at left supraclavicular node s/p excision, refused chemo.
2. Endometrial Ca s/p hysterectomy [**2136**]
Social History:
Lives alone in [**State 531**], has 3 children who live nearby. No
history of tobacco use. No EtOH. Works as a legal assistant.
Family History:
Mother & Father w/CVA. Sister with brain cancer.
Physical Exam:
T: 99.1 P: 71 BP: 123/56 R: 16 98%RA
Gen: alert and oriented pleasant female in no acute distress,
but with audible inspiratory stridor and frequent coughing
during exam
HEENT: normocephalic, atraumatic, MM dry, anicteric.
Neck: matted, firm, nontender massive lymphadenopathy in L>R
cervical and supraclavicular regions. trachea deviated to left.
Lungs: bibasilar rhonchi, otherwise no crackles or wheezes
CV: regular rate and rhythm, no murmur/rub/gallop
Breasts: symmetric, no palpable masses
Abd: soft, nontender, nondistended, normoactive bowel sounds.
No hepatomegaly.
Ext: no edema, 2+ distal pulses
Skin: warm and dry
Pertinent Results:
Labs from OSH:
WBC 9.3
Hct 29.2
Plt 316
Na 138
K 4.4
Cl 103
HCO3 25
BUN 15
Creat 0.5
Glc 121
PT 11
PTT 27
INR 1.0
Ca 8.7
Alb 4.2
Total protein 8
Tot bili 0.3
Alk phos 59
ALT 12
AST 22
LDH 122
CEA 112.4
CXR [**7-24**]: large superior mediastinal mass with leftward
tracheal deviation, no infiltrate
CT neck with contrast [**7-23**]: extensive bilateral cervical
adenopathy up to 4 cm in diameter, some with moderate central
necrosis. moderate extrinsic compression and displacement of
the cervico thoracic trachea from adjacent nodal enlargement at
this level. Low attenuation lesion 1 cm in diameter in left
thyroid lobe.
CT chest [**7-23**]: large 5x7 anterior mediastinal mass continuous
with neck masses, with mixed attenuation and contrast
enhyancement. extends inferiorly compression the trachea.
multiple subcarinal nodes and few right hilar nodes with largest
at 1.5 cm. SVC patent and displaced anteriorly. 8 mm
spiculated pulmonary nodule in right apex. No effusion.
CT abd/pelvis [**7-23**]: normal, no evidence of metastasis.
Labs on admission:
[**2140-7-27**] 05:57PM BLOOD WBC-10.1 RBC-3.71* Hgb-10.7* Hct-32.1*
MCV-86 MCH-28.8 MCHC-33.3 RDW-13.0 Plt Ct-334
[**2140-7-27**] 05:57PM BLOOD PT-11.8 PTT-24.0 INR(PT)-0.9
[**2140-7-27**] 05:57PM BLOOD Calcium-9.4 Phos-2.5* Mg-2.0
Labs on discharge:
[**2140-8-6**] 06:35AM BLOOD WBC-10.4 RBC-3.78* Hgb-11.3* Hct-33.3*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.3 Plt Ct-404
[**2140-8-5**] 06:30AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-140
K-4.5 Cl-104 HCO3-27 AnGap-14
Procedure date Tissue received Report Date Diagnosed
by
[**2140-8-2**] [**2140-8-2**] [**2140-8-4**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/crxs
DIAGNOSIS:
Excised soft tissue, "Tracheal tumor versus granulation tissue."
Fibrinous exudate with admixed inflammatory and scattered
atypical cells considered to be reactive. No malignancy is
identified.
Clinical: History of breast cancer. Tracheal tumor versus
granulation tissue.
Gross: The specimen is received in formalin-filled container
labeled "[**Initials (NamePattern4) **] [**Known lastname 63638**]" and consists of an irregularly shaped
tan-white piece of soft tissue measuring 1.9 x 1.1 x 0.9 cm with
focal areas of hemorrhage. The specimen is inked in black,
serially sectioned and submitted in total in cassettes A-C.
Brief Hospital Course:
This is a 63 y/o F w/metastatic breast Ca who presents with
airway obstruction. Hospital course was remarkable for the
following issues:
1. Airway obstruction/SOB: Per review of outside hospital CT
scan, pt's trachea at smallest dimension is 3 mm, and she had
audible stridor on admission exam. She was admitted to the ICU
and went to the OR tomorrow the following day for rigid bronch
with placement of a Y stent by the interventional pulmonary
staff. She was monitored in the ICU for 1 day. She had a
stable airway and was subsequently transferred to the medical
floor on [**2140-7-30**]. Radiation oncology was consulted and the
decision was made to initiate radiation therapy locally in order
to monitor the patient's airway closely during radiation. She
initiated daily radiation treatments on [**2140-8-1**]. She tolerated
radiation treatments well without evidence of stridor or airway
compromise. She underwent repeat bronchoscopy on [**2140-8-2**] which
revealed boggy/infiltrate arytenoid with narrow glottis and
proximal trachea. A tissue flap partially occluding the proximal
tracheal stent was excised with forceps. Moderate secretions in
the mid-tracheal stent were therapeutically aspirated. Stent
limbs were patent. The patient was also continued on IV
dexamethasone while undergoing radiation. The patient is to
continue daily radiation therapy to complete a 10 day course.
Radiation oncologists at [**Hospital1 18**] contact[**Name (NI) **] radiation oncology at
[**Name (NI) 531**] [**Hospital 63637**] hospital and communicated the treatment plan.
The patient was continued on an aggressive anti-tussive
regimen and continued on pain medications prn. Her oxygen
saturations were stable in the mid-upper 90's on room air. It
is highly recommended that the patient continue to be monitored
by the pulmonary staff at [**State 531**] Methodist (Dr. [**First Name (STitle) **].
2. Metastatic breast cancer: Hematology/oncology was consulted
and recommended that the patient follow up with oncologists in
[**State 531**]. It was recommended that the patient's HER-2-NEU
status be clarified as to overexpressing or not. If 3+
HER-2-NEU, then herceptin should be considered as an additional
[**Doctor Last Name 360**] in additional to standard chemotherapy after radiation
therapy is completed.
3. FEN: The patient was was given a pureed diet and tolerated
this very well.
4. Prophylaxis: The patient was continued on subcutaneous
heparin for DVT prophylaxis and stool softeners while on
narcotic pain medications.
5. Disposition: The patient repeatedly requested transfer to [**Location (un) 5426**] if possible in order to be closer to her family. The
patient was a full code.
Medications on Admission:
numerous vitamins and herbal supplements
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
2. Lidocaine HCl 1 % Solution Sig: 2.5 MLs Injection Q1-2H () as
needed for cough.
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed: hold for diarrhea.
8. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed.
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
10. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed.
11. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
Q4H (every 4 hours) as needed.
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
14. Dexamethasone 4 mg IV Q6H
15. Guaifenesin 1,200 mg Tablet Sustained Release 12HR Sig: One
(1) tablet PO twice a day as needed for cough.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Metastatic breast Cancer
Tracheal stenosis/compression
Discharge Condition:
O2 sats stable on RA, no stridor
Discharge Instructions:
Follow up with your doctors at [**Name5 (PTitle) 531**] Methodist
Followup Instructions:
You are being transferred to an inpatient facility.
|
[
"V10.42",
"512.1",
"V10.3",
"197.1",
"196.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"92.29",
"31.5",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
9704, 9719
|
5512, 8223
|
384, 433
|
9818, 9852
|
3131, 4193
|
9966, 10021
|
2410, 2461
|
8315, 9681
|
9740, 9797
|
8249, 8291
|
9876, 9943
|
2476, 3112
|
289, 346
|
4460, 5489
|
461, 1988
|
4207, 4441
|
2010, 2245
|
2261, 2394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,332
| 161,256
|
50190
|
Discharge summary
|
report
|
Admission Date: [**2118-3-22**] Discharge Date: [**2118-4-4**]
Date of Birth: [**2043-6-24**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 11217**]
Chief Complaint:
74 year old Spanish-speaking male on Coumadin s/p unwitnessed
fall, +LOC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 74-year-old Spanish speaking man with a known
history of CAD,CRI, HTN, atrial fibrillation on Warfarin (INR
5.8) s/p fall down stairs with loss of consciousness.
Family reports that patient went grocery shopping and was
climbing stairs in home when he fell down [**11-9**] steps injuring
his face. The fall was witnessed by the patient's wife. [**Name (NI) **]
on 2.5 mg Coumadin and per PCP had stable INR 2.0-3.0.
EMS was called and in the field the patient had a BP 172/80, HR
100,100% O2 saturation, pupils were reactive to 2 mm, and GCS of
15.2. The patient was reported to be awake and alert with +
epistaxis. C-spine collar was put on.
Once he arrived in the Emergency Room he had a neurological
workup with a CT scan that showed temporoparietal
intraparenchymal hemorrhage. Hemorrhage within the septum
pellucidum, with some associated intraventricular hemorrhage
into both lateral ventricles.
Patient denied chest pain, SOB, H/A, dizziness, bleeding, vision
changes, light-headness, history of seizures or history of
falls.
ROS unremarkable.
Past Medical History:
--CAD
--CABG X 3 VD (70% distal LMCA, 100% PDA/PLV)
--HTN
--CHF LEVF 50% ([**11-1**])
--MR, TR
--Anemia (baseline 28.2-33.8)
--AFib s/p pacer, D/C cardioversion, on Warfarin
--SDH ([**11-1**]): 3 mm L frontoparietal SDH
--DM
--CRI (baseline Cr 1.5-1.7)
--LLE cellulitis
*
[**Doctor First Name **] Hx
--AAA repair '[**08**] w/ redo in '[**09**]
--TAA repair '95CAD
Social History:
Married, lives in [**Location (un) 538**]. He is currently retired, was an
independent truck driver. Tobacco remote history, quit over 10
years ago. Alcohol use is rare
Family History:
Unremarkable
Physical Exam:
VS 98.8 HR 100, BP 172/80, RR 18, 100 % RA
General: Lying flat in bed in no acute distress. Neurologically
alert and oriented x3,appropriate with limited English.
HEENT: PERRL, MMM, OP clear; dried blood at nares, no septal
hematoma, ecchymosis around right ear
Neck: C-collar
Chest: Clear to auscultation bilaterally
CV: Regular rate and rhythm
GI: soft, nontender, nondistended with normoactive bowel sounds.
Fast negative, guaic negative
Meuro: A X O x 3, MAE, CN II-[**Doctor First Name 81**] intact
Extremities warm and well perfused; Pulses showed radial 2 plus
on
the right, 1 plus on the left, dorsalis pedis 2 plus
bilaterally. Posterior tibial two plus bilaterally.
Pertinent Results:
[**2118-3-22**] 02:13PM URINE RBC-[**4-2**]* WBC-[**4-2**] BACTERIA-FEW YEAST-RARE
EPI-0-2 TRANS EPI-[**4-2**]
[**2118-3-22**] 02:13PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2118-3-22**] 02:13PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2118-3-22**] 02:13PM FIBRINOGE-384
[**2118-3-22**] 02:13PM PLT COUNT-281
[**2118-3-22**] 02:13PM PT-30.3* PTT-38.3* INR(PT)-5.8
[**2118-3-22**] 02:13PM WBC-8.7 RBC-4.41* HGB-12.6* HCT-38.2* MCV-87
MCH-28.7 MCHC-33.1 RDW-14.7
Brief Hospital Course:
Upon admission the patient was admitted to TSICU and was
followed by the trauma service and neurosurgery and medicine
were consulted.
Pertinent Results:
HeadCT: Left temporal intraparanchmal and [**Hospital1 **]-intraventricular
bleeds
Facial CT:No definite fx or swelling
ABDCT/Pelvis: neg
C-spineCT: neg
Chest: unremarkable for any acute cardiopulmonary process; old
arch dissection stable
Brief Hospital Course:
74 yo M with PMHX of HTN, CAD, DM/CRI, Afib on Coumadin with L
parietal IPH s/p fall
1.Intracranial bleed:
On day of admission INR 5.8, and Coumadin was stopped. Patient
received Vit k and FFP and 75% (2 vials) of predicted dose of
Proplex(Factor [**8-6**] combo) to correct coagulopathy.
Admission CT showed L parietal IPH and SAH, small
intraventricular bleed. The patient was started on Dilantin for
prophylaxis of post-traumatic head bleed and his dilantin was
subsequently stopped on day 8 after his admission. Shortly after
admission patient developed worsening mental status and the
patient was followed by neurosurgery. Repeat CT ([**3-23**]) showed
interval change in head bleed and follow-up CT on [**3-24**] showed
stable head bleed. Patient's aspirin continues to be held and
restarting should be considered following follow up appointment
with Dr. [**Last Name (STitle) 14074**].
2. Mental Status Change:
Throughout the patient's admission, he continued to wax and wane
and sundown. Etiology of mental status changes most likely
multifactorial etiology which include head bleed, possibilty of
medications and hospital-delirium (per family patient has
history of delirium when hospitalized per family). Throughout
his hospital course, avoided anticholingerics including
benadryl, and anti-psycotics as on sotalol & may lead to QT
prolongation. On the day of discharge, patient showed markedly
improved neurological examination and alert and talkative. He
was following simple commands but not 3-step commands.
3. Afib:
Patient had some bursts of tachycardia on telemtry and was
evaluated by EP and recommended to titrate Lopressor and
continue Sotalol on home dose. Due to head bleed, no further
Coumadin. Pt not on Amio due to adverse rxn (delta MS). Off of
coumadin due to head bleed
4.DM:
Covered with RISS and can have oral agents after mental status
cleared and taking good POs
5. Blood pressure:
Blood pressure initially high due to head bleed SBP >160 and
during hospital course was titrated with Lopressor and
Hydralzine to obtain normotensive blood pressure upon discharge
6. C-spine clearance:
Initial C spine CT showed no evidence of fracture however,
C-spine films were sub-optimal as unable to visualize all 7
Cervical vertebra. Due to mental status changes, c-spine
clearance via flex/ext films (to r/o ligamentous injury) was
pending improvement of mental status changes. Upon discharge to
rehab, patient's C-spine should be cleared with flex/extension
films when patient able to follow commands
7.
CHF
- EF > 55%. He was on regimen of metoprolol and [**Last Name (un) **]. Lasix was
held due to increase in BUN & Cr.
8.
CRI (baseline Cr 1.5-1.7)
Lasix was held due to increase in BUN & Cr. Upon discharge
patient's Cr at baseline.
Patient's condition at time of discharge is good. He is to be
discharged to rehab
Medications on Admission:
Lipitor 40 mg
Cozaar 50 mg
Citalopram Hydrobromide 20 mg
Aspirin 81
Lasix 20 mg
Avandia 4 mg
Toprol 200 mg
Sotalol HCl 40 mg [**Hospital1 **]
Coumadin
KCL
Norvasc 10 mg
Discharge Medications:
1. Sotalol HCl 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for Fever.
6. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Insulin Insulin sliding scale
11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Intraparenchymal hemorrhage
HTN
Afib
CRI
Delirium
DM
Discharge Condition:
stable. Has waxing and [**Doctor Last Name 688**] mental status. c-collar in place
Discharge Instructions:
Please seek medical assistance if you experience chest pain,
shortness of breath, headache, fever, or other concerning
symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where: LM
[**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2118-4-12**] 1:30
.
Follow up with [**Last Name (LF) **],[**First Name3 (LF) **] V. [**Telephone/Fax (1) 608**]
.
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2118-5-16**] 9:30
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2118-5-17**] 1:30
|
[
"564.00",
"780.6",
"428.0",
"790.92",
"424.0",
"V45.81",
"250.00",
"414.00",
"V58.61",
"E880.9",
"427.31",
"851.82",
"293.0",
"593.9",
"427.89",
"V53.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"99.07",
"89.45",
"96.07",
"88.43"
] |
icd9pcs
|
[
[
[]
]
] |
7751, 7821
|
3797, 6658
|
344, 351
|
7918, 8003
|
3533, 3773
|
8179, 8871
|
2059, 2074
|
6877, 7728
|
7842, 7897
|
6684, 6854
|
8027, 8156
|
2089, 2767
|
232, 306
|
379, 1469
|
1491, 1857
|
1873, 2043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,788
| 134,371
|
691
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 5181**]
Admission Date: [**2139-6-6**]
Discharge Date: [**2139-6-13**]
Date of Birth: [**2069-9-23**]
Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
woman with history of alcoholic hepatitis and GERD who
presented with sudden onset of abdominal pain, mostly
epigastric, accompanied by some nausea and vomiting, chills,
no fevers. Last bowel movement was the day prior. She was
passing gas. No chest pain, no shortness of breath. No
melena.
PAST MEDICAL HISTORY:
1. Alcoholic hepatitis.
2. Hypertension.
3. Gastroesophageal reflux disorder.
4. Hypercholesterolemia.
5. Anxiety.
6. History of ventral hernia repair.
ALLERGIES: Sulfa.
MEDICATIONS:
1. Atenolol 100 mg daily.
2. Hydrochlorothiazide 25 mg a day.
3. Multivitamin.
4. Prilosec 40 mg a day.
5. Folic acid 1 mg a day.
6. Protonix 40 mg a day.
PHYSICAL EXAMINATION: Pleasant, cooperative, in mild
distress. Regular rate and rhythm. Clear to auscultation
bilaterally. Abdomen is soft, tender to palpation ino the
epigastric area. Rectal exam - guaiac negative, no masses.
Labs include white blood cell count of 17, hematocrit of 44,
BUN of 7, creatinine of 0.9. AST is 106, ALT 419, alkaline
phosphatase 147, total bilirubin 4.4. Amylase 850, lipase
3234. LDH 408.
STUDIES: CT of the abdomen showed pancreatitis with regions
of relative hypo enhancement in the pancreas, a distended
gallbladder with stone, and distended cystic duct. No
intrahepatic ductal dilation.
HOSPITAL COURSE: The patient was admitted to the ICU and was
treated with fluid resuscitation. NPO. Gastroenterology
consultation was obtained. By the next day, her enzymes were
improved. The ERCP was held, in consideration that the
patient had probably already passed the stone and was now
improving. Her abdominal examination and her labs continued
to improve until [**2139-6-8**] when, already on the floor, the
patient started complaining of increased abdominal pain. The
abdomen showed some distension and the patient's hematocrit
dropped down from 31 to requiring blood transfusion. She
underwent emergent CT scan, which showed pseudoaneurysm in
adjacent to an SMA. The patient underwent angio, which
revealed a pseudoaneurysm which was coming off from branches
from the SMA, as well as having a feeder from PDA. They were
able to embolize this pseudoaneurysm, as well as embolize the
feeder from SMA, but not from the PDA.
The patient returned to the ICU, where her blood pressure was
initially controlled with nitroglycerin drip. Over the next
couple of days, the patient's condition has improved. Her
hematocrit remains stable. It was not requiring any
transfusion. Her abdomen, although still mildly distended,
was soft. She was passing gas and having bowel movements. Her
diet was advanced, initially to clears, and the patient went
to a regular diet, which she tolerated well. She started to
ambulate, initially with help, then on her own. She was
transferred to the floor. The vascular service was consulted.
Their CT was obtained on [**2139-6-8**], which showed no
changes in the pseudoaneurysm, with hematocrits remaining
stable. The patient was otherwise doing fine. The feeling was
that the patient does not need any procedures at this point.
On [**2139-5-13**], the patient is afebrile. Vital signs are
stable. The abdomen is soft, non distended. Tolerating a
regular diet and ambulating without help. No concerns.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged home. The patient
will follow up with Dr. [**Last Name (STitle) 5182**] in 2 weeks for discussing
cholecystectomy at a later date. The patient will also follow
up with Dr. [**Last Name (STitle) **] next week.
DISCHARGE MEDICATIONS:
1. Tylenol 1-2 tabs p.o. every 4-6 hours p.r.n. pain.
2. Ativan 1 mg p.o. at bedtime p.r.n..
3. Protonix 40 mg p.o. daily.
4. Lopressor 75 mg p.o. daily.
DISCHARGE DIAGNOSES:
1. Gallstone pancreatitis.
2. Hypertension.
3. Gastroesophageal reflux disorder.
4. Alcoholic hepatitis.
5. Hypercholesterolemia.
6. Anxiety.
7. SMA pseudoaneurysm status post bleeding and embolization.
[**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**], [**MD Number(1) 5185**]
Dictated By:[**Doctor Last Name 5186**]
MEDQUIST36
D: [**2139-6-13**] 12:11:22
T: [**2139-6-13**] 12:51:11
Job#: [**Job Number 5187**]
|
[
"530.81",
"442.84",
"272.0",
"571.1",
"577.0",
"401.9",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"39.79",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
3939, 4395
|
3762, 3918
|
1538, 3457
|
916, 1520
|
206, 527
|
549, 893
|
3482, 3739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,995
| 119,583
|
11193
|
Discharge summary
|
report
|
Admission Date: [**2137-11-19**] Discharge Date: [**2137-11-26**]
Date of Birth: [**2073-4-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
woman who was recently diagnosed with Wegener's
granulomatosis in [**2137-9-16**], who was readmitted in late
[**2137-10-17**], for dialysis graft clog and increased lethargy
and malnourishment. The patient was discharged to short term
rehabilitation after workup for lethargy which included MR of
her head, lumbar puncture and electroencephalogram were
nondiagnostic. She also had the dialysis catheter removed as
renal felt it was no longer necessary.
On presentation on [**2137-11-19**], the patient was noted to have
had three days of increased lethargy, confusion and abdominal
pain, nausea, vomiting. Apparently the patient also had not
eaten at home. Tube feeding had been proposed but the
patient refused. She complained of occasional nausea, no
vomiting, no melena or bright red blood per rectum. She did
complain of pain in multiple areas of her body especially in
her abdomen.
In the Emergency Department, the patient received one liter
of normal saline, Droperidol and Levofloxacin and Flagyl
intravenous for question of intra-abdominal processes.
PAST MEDICAL HISTORY:
1. Wegener's granulomatosis.
2. Acute renal failure.
3. Peripheral neuropathy.
4. Bilateral otitis media.
5. Basal cell carcinoma of the face.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Short term rehabilitation. Also significant
for death of husband approximately one year ago.
MEDICATIONS ON ADMISSION:
1. Zoloft 50 mg q.d.
2. Nystatin swish and swallow 5 cc q.i.d.
3. Calcium Carbonate 1500 mg t.i.d.
4. Neutra-Phos one packet t.i.d.
5. Cytoxan 75 mg q.d.
6. Prednisone 40 mg q.d.
7. Epogen 6000 units subcutaneous each week.
8. Potassium Chloride 40 meq q.d.
9. Lasix 80 mg q.d.
10. Multivitamin q.d.
11. Iron 325 mg q.d.
12. Bactrim DS q.o.d.
PHYSICAL EXAMINATION: On physical examination, the patient
is an ill appearing woman in no apparent distress. Her vital
signs include a temperature 98.9, blood pressure 132/80,
heart rate 124, respiratory rate 22, oxygen saturation 94% in
room air. The pupils are equal, round, and reactive to light
and accommodation. Her mucous membranes are dry and she has
oral thrush. Her neck is supple with no jugular venous
distention. Her heart is tachycardic with regular rhythm and
II/VI systolic murmur at the upper sternal border. Her lungs
are clear to auscultation bilaterally. Her abdomen is soft
with good bowel sounds and diffuse tenderness. Her
extremities showed 2+ pitting edema up to the thighs.
Neurologically, she is alert and oriented times one and
noncooperative and moves all four extremities spontaneously.
LABORATORY DATA: On admission, white count 12.1, hematocrit
33.5, platelets 113,000. Differential showed 98% polys, no
lymphocytes, 1% monocytes, 1% eosinophils. Chemistries
showed sodium 130, potassium 5.7, chloride 101, bicarbonate
18, blood urea nitrogen 75, creatinine 2.5 ALT 54, AST 49,
alkaline phosphatase 129, total bilirubin 0.4, albumin 2.6.
Prothrombin time 12.5, partial thromboplastin time 33, INR
1.1. Urinalysis revealed trace protein, 0-2 red blood cells,
0-2 white blood cells and occasional bacteria.
Electrocardiogram - sinus tachycardia at 120 beats per
minute, T wave flattening in lead I, T wave inversion in lead
aVL, new since [**Month (only) **].
Chest x-ray showed question of thickening in the right major
fissure, no congestive heart failure, no effusions.
KUB revealed thickened hepatic flexure of the colon, no
obstruction and no free air.
CT of the abdomen without contrast - no obstruction, no
inflammatory process, no abscess, no free air.
HOSPITAL COURSE: The patient is a 64 year old woman with a
prior diagnosis of Wegener's granulomatosis and associated
renal failure who presents with failure to thrive. Her
hospital course was significant for an episode of hypotension
and acute hypoxia on hospital day two with desaturation to
the 80s and hypotension to the 80s. She required
vasopressors and was intubated for hypoxic failure and
transferred to the Medical Intensive Care Unit for further
care.
Prior to intubation, a VQ scan was performed to assess for
pulmonary embolus which was read as intermediate probability,
although the patient was unable to perform the ventilation
portion of the examination. She was started on Heparin,
however, and the following day, the VQ scan was repeated
while the patient was intubated. This examination was read
as high probability.
However, in the interim, the patient's partial thromboplastin
time became supratherapeutic on Heparin and the patient had a
drop in hematocrit from 32.0 to 17.0, also in the setting of
five liters of volume resuscitation. The Heparin was
discontinued at this point and the partial thromboplastin
time was allowed to normalize.
There was also concern in the setting of her drop in
hematocrit and associated thrombocytopenia for DIC, and
hematology was consulted. The hematologist felt that the
smear was not consistent with DIC and suggested that in the
setting of pulmonary embolus and probable gastrointestinal
bleed, the best course was to place an inferior vena cava
filter.
The placement of the filter was scheduled for the following
morning, however, that morning the patient was noted to not
be moving her right extremities. She also was noted to have
a leftward gaze deviation and upgoing toe on the right. CT
of the head was performed and revealed a 5.0 by 7.0
centimeter infarct in the left middle cerebral artery and ACA
region as well as infarction in the pons. The stroke team
was consulted at this point but felt that there was no
additional intervention that could be offered.
Shortly thereafter, the patient's left pupil became fixed and
dilated. CT scan was repeated which showed no significant
change and no evidence of uncal herniation. At that point,
the inferior vena cava filter was placed by interventional
radiology. Neurology was consulted to comment on the
patient's prognosis which was felt to be poor.
The patient's family was contact[**Name (NI) **] and requested that the
patient be kept on ventilatory support until an additional
family member could arrive from overseas. The patient was
thus maintained on mechanical ventilation with additional
vasopressors.
In the interim, the patient's blood cultures grew out four
out of four bottles of coagulase negative Staphylococcus
aureus which was Methicillin resistant Staphylococcus aureus.
The patient had been started on Vancomycin and Ceftazidime
empirically prior to her transfer to the Medical Intensive
Care Unit.
With the arrival of the family member, support was withdrawn
and the patient passed away from respiratory failure
secondary to ischemic stroke and pulmonary embolus. Time of
death on [**2137-11-26**], was 09:35 p.m. An autopsy was requested
from the family and the decision was pending at this time.
At the suggestion of hematology service, laboratories for
hypercoagulability workup were sent prior to the patient's
death. These are pending at this time.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2137-11-26**] 22:14
T: [**2137-11-29**] 14:18
JOB#: [**Job Number 36005**]
|
[
"434.11",
"284.8",
"518.81",
"585",
"783.7",
"446.4",
"578.9",
"790.7",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.15",
"38.93",
"96.72",
"38.91",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
1603, 1956
|
3786, 7460
|
1979, 3768
|
158, 1256
|
1278, 1465
|
1482, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,224
| 192,866
|
32240
|
Discharge summary
|
report
|
Admission Date: [**2148-10-13**] Discharge Date: [**2148-10-17**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Cephalosporins /
Amitriptyline
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Hip repair [**2148-10-15**]
History of Present Illness:
89F s/p pacer for "rhythm issues" who presents withs/p
mechanical fall without trauma to the head, without LOC, bowel
or bladder incontinence, resulting in hip fracture. Patient also
denies lightheadedness, dizziness, palpiatation, chest pain,
SOB. Patient pulled herself to a rocking chair for 2 days and
ambulated occassionaly to get food. Patient found in chair on
day of admission and brought to ED where she was found to have
comminuted R IT Fx complicated by fevers 101.1 and lactate to
4.1
.
In ED, evaluated by [**Month/Day/Year **], with plan for operative fixation of
hip after medicine clearance, non-wt bearing RLE. Vitals in ED:
95.9 116 96/48 18 96. CK 1200, head CT (-), spine CT (-),
transfused 2 unit PRBC, 3L ivf. Noted to have fever to 101.2,
lactate 4.0
Past Medical History:
1. CAD s/p Pacer placement
2. Osteoporosis
3. NIDDM
4. hypothyroid
Social History:
denies etoh, tobacco
Family History:
NC
Physical Exam:
Vitals - T:96 BP:115/39 HR:68 RR:17 02 sat: 100% 5L NC
GENERAL: laying in bed, NAD, with neck collar in place
SKIN: cold extremities, large hematoma on r thigh
HEENT: dry MM, pale conjunctiva, no JVD
CARDIAC: distant heart sounds, RRR, S1/S2, no audible murmurs
LUNG: diffuse end expiratory wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: able to move toes bilaterally, no LE edema
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Imaging:
CT HEAD W/O CONTRAST [**2148-10-12**] 10:38 PM
IMPRESSION: No acute pathology.
.
CT L-SPINE W/O CONTRAST [**2148-10-12**] 10:35 PM
IMPRESSION:
No fracture or malalignment. Multilevel degenerative changes.
.
CT T-SPINE W/O CONTRAST [**2148-10-12**] 10:34 PM
IMPRESSION:
No acute fracture or malalignment. Multilevel degenerative
changes
.
CT C-SPINE W/O CONTRAST [**2148-10-12**] 10:34 PM
IMPRESSION:
1. No acute fracture or malalignment.
2. Mild prominence of the interstitial septae within the lung
apices may be chronic or related to an acute process such as
mild interstitial edema. Please correlate clinically.
3. Incidentally noted there is punctuate calcification on the
right side of the thyroid gland correlation with ultrasound is
recommended if clinically warranted.
4. Bilateral atherosclerotic calcifications in both carotid
arteries.
.
CHEST (SINGLE VIEW) [**2148-10-12**] 8:38 PM
IMPRESSION: No acute pulmonary process. No radiographic evidence
of traumatic injury to the chest.
.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) [**2148-10-12**] 8:38 PM
FINDINGS: There is a comminuted intertrochanteric fracture with
impaction of the major fracture fragments and varus angulation.
The femoral head remains appropriately located. Vascular
calcification is evident. The pelvis itself is intact.
Degenerative changes are noted in the included lower lumbar
spine. Surgical clips overlie the right iliac fossa.
IMPRESSION: Comminuted intertrochanteric fracture as above.
.
CHEST (PORTABLE AP) [**2148-10-14**] 5:33 PM
IMPRESSION: AP chest compared to [**10-13**]:
In addition to new mild pulmonary edema, there is a large region
of the right perihilar consolidation that has developed over 24
hours consistent with pneumonia, particularly suspicious for
aspiration, or given the appropriate clinical circumstances,
pulmonary hemorrhage. Transvenous right atrial and right
ventricular pacer leads are continuous from the right axillary
pacemaker. Heart size is normal. Pleural effusion, if any, is
minimal. No pneumothorax. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was paged to discuss
these findings at the time of dictation.
.
ANKLE (AP, MORTISE & LAT) RIGHT [**2148-10-16**] 4:09 PM
IMPRESSION: No fracture is seen and the ankle mortise is intact.
.
Micro:
Blood Cultures: NGTD
Sputum Cultures: NGTSD
.
Labs:
[**2148-10-12**] 08:30PM BLOOD WBC-18.2* RBC-3.19* Hgb-9.4* Hct-28.5*
MCV-90 MCH-29.5 MCHC-32.9 RDW-15.5 Plt Ct-245
[**2148-10-14**] 03:50AM BLOOD WBC-11.5* RBC-3.22*# Hgb-9.6*# Hct-27.8*
MCV-87 MCH-29.9 MCHC-34.5# RDW-15.5 Plt Ct-145*
[**2148-10-15**] 11:02AM BLOOD WBC-10.2 RBC-2.62* Hgb-8.3* Hct-23.6*
MCV-90 MCH-31.6 MCHC-35.0 RDW-15.5 Plt Ct-175
[**2148-10-16**] 03:47AM BLOOD WBC-8.1 RBC-3.24* Hgb-10.1* Hct-28.6*
MCV-88 MCH-31.3 MCHC-35.4* RDW-15.7* Plt Ct-115*
[**2148-10-17**] 03:26AM BLOOD WBC-7.4 RBC-2.88* Hgb-8.7* Hct-26.1*
MCV-91 MCH-30.4 MCHC-33.5 RDW-15.9* Plt Ct-112*
[**2148-10-12**] 08:30PM BLOOD Glucose-290* UreaN-54* Creat-2.9* Na-141
K-5.3* Cl-104 HCO3-17* AnGap-25*
[**2148-10-13**] 02:27PM BLOOD Glucose-152* UreaN-50* Creat-1.9* Na-146*
K-4.3 Cl-115* HCO3-25 AnGap-10
[**2148-10-15**] 04:03AM BLOOD Glucose-156* UreaN-31* Creat-1.3* Na-142
K-4.6 Cl-112* HCO3-24 AnGap-11
[**2148-10-16**] 03:47AM BLOOD Glucose-109* UreaN-29* Creat-1.3* Na-141
K-4.4 Cl-115* HCO3-23 AnGap-7*
[**2148-10-17**] 03:26AM BLOOD Glucose-141* UreaN-26* Creat-1.2* Na-140
K-4.5 Cl-113* HCO3-26 AnGap-6*
[**2148-10-12**] 08:30PM BLOOD CK(CPK)-[**2104**]*
[**2148-10-13**] 06:30AM BLOOD CK(CPK)-[**2165**]*
[**2148-10-13**] 02:27PM BLOOD CK(CPK)-1349*
[**2148-10-14**] 03:50AM BLOOD CK(CPK)-838*
[**2148-10-15**] 04:03AM BLOOD CK(CPK)-296*
[**2148-10-13**] 06:30AM BLOOD CK-MB-26* MB Indx-1.3 cTropnT-<0.01
[**2148-10-13**] 02:27PM BLOOD CK-MB-17* MB Indx-1.3 cTropnT-0.01
[**2148-10-14**] 03:50AM BLOOD CK-MB-11* MB Indx-1.3 cTropnT-0.01
[**2148-10-12**] 08:30PM BLOOD Calcium-9.3 Phos-5.5* Mg-2.7*
[**2148-10-14**] 03:50AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.6
[**2148-10-15**] 09:11PM BLOOD Calcium-6.4* Phos-1.7* Mg-2.3
[**2148-10-17**] 03:26AM BLOOD Calcium-7.6* Phos-2.0* Mg-2.2
[**2148-10-13**] 06:30AM BLOOD Free T4-1.5
[**2148-10-13**] 06:30AM BLOOD TSH-1.7
[**2148-10-15**] 09:17AM BLOOD freeCa-1.05*
Brief Hospital Course:
89 yo F with history of sick sinus syndrome s/p pacemaker who
presented after a mechanical fall with a broken right femur.
Comminuted R IT fx: mechanical in nature, does not appear to be
cardiac related or seizure related. Orthopedics took her to the
OR for surgery. She was given lovenox for ppx to continue for 4
weeks and acetaminophen and hydromorphone for pain control.
.
Anemia: Likely due to blood loss into the hip. Her hemodynamics
remained stable. She was given 2 units of PRBCs on [**10-13**] and
required an additional 3U following surgery. Her Hct was stable
on DC and shuold be checked each morning for 2 days following DC
to ensure stability.
.
Hyperkalemia: In the setting of increased muscle breakdown from
being down and also being seated for 48 hours. This resolved
with aggessive fluid hydration.
.
Rhabo: due to fall and being sedentary for 48 hours prior to
presentation. Likely contributing to ARF. She was aggressively
hydrated with IVF and her CK levels came down quickly and her
renal function normalized.
.
ARF: Likely pre-renal in setting of decreased intake. Urine
lytes suggested pre-renal etiology. Her Cr returned to baseline
after aggressive fluid hydration.
.
Elevated lactate: Likely due to decreased intake over 48 hours
prior to admission. Patient does not appear to be septic. She
was hydrated and her lactate normalized.
.
CAD: Patient continued on statin and ASA restarted following
surgery. BB was also continued [**Hospital 6028**] hospital stay.
PUMP: Patient restarted on BB although Lasix was not started on
discharge. Patient's BP was 120/50 while in house and will need
coverage with lasix started at rehab.
RHYTHM: s/p pacer placement, perhaps due to Afib. Amio initially
held and restarted at full dose prior to DC. She will require
uptitration of this medication.
.
Hypothyroid: Continued on Synthroid
.
Osteoporosis: Patient on Fosamax, although didn't receive a dose
in house. She was continued on vitamin D and calcium
.
.
After discussion with the patient, patient's family, and medical
staff all were in agreement that the patient was a suitable
candidate for discharge to rehab.
Medications on Admission:
Amiodarone 100 qd
Avapro 150 qd
Glipizide 5 mg qd
Vitamin E
Vitamine D
Atenolol 50 qd
Furosemide 20 qd
Synthroid 0.025 daily
ASA 81
Iron 325
Fosamax 70 weekly
Drisdol [**Numeric Identifier 1871**] IU weekly
Nitroquick prn
Lunesta prn
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. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Tablet, Chewable(s)
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: 40 mg Subcutaneous
Q24H (every 24 hours): Last dose on [**2148-11-15**].
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days. Tablet(s)
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
R Hip fracture s/p repair
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating with
assistance.
Discharge Instructions:
You were admitted after sustaining a hip fracture and underwent
a repair on [**2148-10-15**] that you've tolerated well. You also had
anemia from bleeding into your hip and received blood
transfusions. In addition you had acute renal failure,
increased potassium, and rhabdomyolysis all in the setting of
dehydration from the days preceeding admission.
.
1. Please take all medication as prescribed.
2. Please make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2148-11-21**] 9:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2148-11-21**] 9:40
Completed by:[**2148-10-23**]
|
[
"250.00",
"285.1",
"997.3",
"244.9",
"E888.9",
"507.0",
"733.00",
"V45.01",
"820.21",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
10061, 10140
|
6105, 8251
|
295, 325
|
10210, 10286
|
1817, 6082
|
10853, 11151
|
1274, 1278
|
8536, 10038
|
10161, 10189
|
8277, 8513
|
10310, 10830
|
1293, 1798
|
247, 257
|
353, 1129
|
1151, 1220
|
1236, 1258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,660
| 101,198
|
15995
|
Discharge summary
|
report
|
Admission Date: [**2184-1-17**] Discharge Date: [**2184-1-18**]
Date of Birth: [**2106-8-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vitamin B12-Intrinsic Factor
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 year-old female with COP/hypersensitivity pneumonitis, on
chronic steroids and O2, presents from NWH with abdominal pain,
n/v and hypotension. Patient was at rehab and had episode of
nausea and vomiting X [**11-15**] yesterday, she was taken to NWH
where cxr with bilateral PNA, WBC 22K, 95% poly, creat 1.4 and
pt noted to be hypotensive to 70s, she was given NS and started
on dopamine, also given azithro, vanc and ceftriaxone, decadron
10 mg IV and transferred to [**Hospital1 18**] for further care.
.
In [**Hospital1 18**] ER patient given 4L NS, hydrocortisone 50mg IV X 1and
unasyn 3gm IV and taken off dopamine with stable BP in 100s.
Initial labs with WBC 26K, she was febrile to 101.2, had
abdominal ultrasound which showed distended gallbladder but no
CBD dilation. After discussion with ERCP fellow, pt not likely
need emergent ERCP given normal [**Female First Name (un) 7925**]. Initially goals of care
DNR/DNI and no CVL however after a rediscussion plan was changed
and a central line placed. She was evaluated by surgery and is
now being transferred to MICU for futher care.
.
On transfer to the MICU, patient complained of sob. Denied any
abdominal pain or chest pain. Denies n/v/d.
Past Medical History:
cryptogenic organizing pneumonia and hypersensitivity
pneumonitis (formerly known as BOOP)--on steroids
DM2
COPD
s/p b/l cataract repair
t7, t11, t12 compression fx
s/p R hip fx
Social History:
lives with daughter, pt from [**Country **] > 15 years ago
denies tob, etoh, drugs
Immunizations/Travel: + pneumovax
Family History:
NC
Physical Exam:
Vitals: 95.7, HR 99 BP 119/39 RR 12 O2 sat 100% 10L NRB
GEN: Elderly female with mild respiratory discomfort
HEENT: dry mucous membranes
CHEST: CTAB, no crackles
CVR: RRR, II/VI systolic ejectio murmor LLSB
ABD: Soft, nt, nd, small umbillical hernia.
EXT: No edema
NEURO: A&O X 3, moves all extremities well.
Pertinent Results:
[**2184-1-17**] 08:08PM TYPE-[**Last Name (un) **] TEMP-37.2 O2 FLOW-4 PO2-41* PCO2-56*
PH-7.21* TOTAL CO2-24 BASE XS--6 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2184-1-17**] 08:08PM O2 SAT-68
[**2184-1-17**] 05:40PM GLUCOSE-214* UREA N-21* CREAT-1.2* SODIUM-139
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2184-1-17**] 05:40PM CALCIUM-7.0* PHOSPHATE-3.3 MAGNESIUM-1.8
[**2184-1-17**] 09:35AM LACTATE-1.6
[**2184-1-17**] 09:30AM GLUCOSE-247* UREA N-21* CREAT-1.5* SODIUM-137
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2184-1-17**] 09:30AM estGFR-Using this
[**2184-1-17**] 09:30AM ALT(SGPT)-197* AST(SGOT)-305* CK(CPK)-38 ALK
PHOS-346* AMYLASE-2504* TOT BILI-0.4
[**2184-1-17**] 09:30AM LIPASE-4580*
[**2184-1-17**] 09:30AM CK-MB-NotDone cTropnT-0.04*
[**2184-1-17**] 09:30AM NEUTS-80* BANDS-18* LYMPHS-2* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2184-1-17**] 09:30AM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-3+
POLYCHROM-OCCASIONAL TARGET-OCCASIONAL STIPPLED-OCCASIONAL
[**2184-1-17**] 09:30AM PLT SMR-NORMAL PLT COUNT-245
[**2184-1-17**] 09:30AM PT-14.9* PTT-48.6* INR(PT)-1.3*
[**2184-1-17**] 09:30AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2184-1-17**] 09:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
[**2184-1-17**] 09:30AM URINE RBC-[**4-6**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**4-6**] TRANS EPI-[**4-6**]
[**2184-1-17**] 09:30AM URINE HYALINE-<1
[**2184-1-17**] 09:07AM O2 FLOW-15 PO2-142* PCO2-62* PH-7.23* TOTAL
CO2-27 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2184-1-17**] 09:07AM GLUCOSE-246* LACTATE-0.9 NA+-136 K+-4.0
CL--105
[**2184-1-17**] 09:07AM freeCa-1.05*
Brief Hospital Course:
Pt was admitted with pancreatitis and congestive heart failure.
Her amylase and lipase improved and it was felt she likely had
had a GB stone obstructing her CBD which passed. The pt refused
BIPAP and was DNR/DNI. She remained tachypneic with O2 sats in
the 70s-80s with little urine output to increasing doses of
Lasix. She became very somnolent and family discussion resulted
in CMO status. Morphine gtt was initiated and titrated for
comfort. She expired at 8:55 PM of respiratory arrest in the
setting of CHF. Family was at the bedside and attending was
notifited.
Medications on Admission:
fosamax 1 tab qTueasday
avandia 4mg daily
lisinopril 5mg daily
prednisone 10 mg daily
vitamin D 400 IU daily
Omeprazole 20mg [**Hospital1 **]
lidoderm patch topically daily every 12 hours 5%
colace 100 [**Hospital1 **]
heparin sc tid
Calcium Carbonate 500mg tid
gabapentin 300mg qhs
Cipro 500mg [**Hospital1 **] for 10 days started [**1-14**].
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Pancreatitis
CHF
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"038.9",
"486",
"995.91",
"250.00",
"V45.61",
"584.9",
"518.81",
"285.9",
"574.51",
"428.0",
"577.0",
"516.8",
"V66.7",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5102, 5111
|
4102, 4678
|
315, 321
|
5171, 5180
|
2265, 4079
|
5233, 5240
|
1914, 1918
|
5073, 5079
|
5132, 5150
|
4704, 5050
|
5204, 5210
|
1933, 2246
|
263, 277
|
349, 1562
|
1584, 1763
|
1779, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,583
| 199,288
|
24610
|
Discharge summary
|
report
|
Admission Date: [**2189-6-4**] Discharge Date: [**2189-6-8**]
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] was an 83 yo female with history of dementia, who was
transferred to [**Hospital1 18**], after CT scan at [**Hospital3 417**] hospital
revealed extensive necrotizing pancreatitis. She recently had
been treated at [**Hospital3 417**] for severe pancreatitis and
discharged to rehab, but represented with nausea, vomiting, and
increased abdominal pain.
Past Medical History:
Dementia
DM
Anemia
HTN
CVA
s/p appy
s/p open chole
Social History:
Lives in nursing hoe
Physical Exam:
Disoriented, moderate distress
Course diffuse breath sounds
RRR
abomen mildly distended, obese, soft, epigastric/RUQ tenderness
to palpation, positive rebound tenderness with guarding
Brief Hospital Course:
As above, Ms. [**Known lastname **] presented to [**Hospital1 18**] on [**6-4**] with severe,
necrotizing pancreatitis, and was admitted to the surgical ICU
in the care of the Gold surgery service. Because of the near
100 percent mortality associated with Ms. [**Known lastname 62121**] disease, and
her associated, significant comorbidities, her family decided to
make Ms. [**Known lastname **] "CMO", as this was what Ms. [**Known lastname **] had previously
expressed she wanted if she were in such a dire physical state.
She was transferred from the ICU to a floor room. Her pain was
well treated and her condition, as expected deteriorated
rapidly. She passed away at 08:05 am on [**6-8**]. The family was
promptly notified, and they denied a post-mortem exam. The
medical examiner's office, as well, was notified, and the case
was waived.
Discharge Disposition:
Expired
Discharge Diagnosis:
Necrotizing Pancreatitis
Discharge Condition:
Deceased
|
[
"294.8",
"250.00",
"577.0",
"401.9",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"89.64",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1848, 1857
|
973, 1825
|
224, 231
|
1925, 1936
|
1878, 1904
|
765, 950
|
170, 186
|
259, 638
|
660, 712
|
728, 750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,260
| 153,500
|
44768
|
Discharge summary
|
report
|
Admission Date: [**2174-6-29**] Discharge Date: [**2174-9-12**]
Date of Birth: [**2124-8-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Oxycodone
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
[**6-29**]: Decompressive Craniectomy
[**7-9**]: PEG
[**8-27**]: Removal of PEG
History of Present Illness:
49M, hx of EtOH abuse and HTN, brought in by ambulance to [**Hospital1 18**]
for EtOH intoxication at approx 9pm. At approx midnight, the
patient was noted to be unresponsive and not moving his right
side. A code stroke was called at 1:00am. A large left-sided
intraparenchymal bleed was noted on CT scan. The neurosurgical
team was called to assist with ongoing management.
Past Medical History:
1) Alcohol abuse--extensive history of withdrawal, including
seizures and an intubation.
2) depression/anxiety
3) hypertension
4) frostbite bilateral hands "from walking in the cold without
gloves"
Social History:
The patient has never been married and lives alone in [**Location (un) **].
He began drinking at age 19. He does not work, previously worked
as a financial consultant and has a BA in political science. He
is living off of inheritance money he invested.
Family History:
Mother and sister both with diagnosis of anxiety disorder.
Physical Exam:
On Admission:
T:97.4 BP:184/122 HR:132 R:16 O2Sats: 100%CMV(.5/500*[**12-17**])
Gen: Intubated, NAD
HEENT: No obvious sign of head trauma Pupils: 4 to 2, sluggish
on
right, brisk on left EOMs: UTA
Neck: Supple.
Lungs: rhonchorous
Cardiac: tachycardic
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated, Somnolent, not following commands
Orientation: UTA
Recall: UTA
Language: UTA
Cranial Nerves:
I: Not tested
II: Pupils: 4 to 2, sluggish on right, brisk on left
III, IV, VI: UTA
V, VII: Corneal reflex present on left only
VIII: Does not open eyes to voice
IX, X: UTA
[**Doctor First Name 81**]: UTA
XII: UTA
Motor: Normal bulk and tone bilaterally. Right side with no
motor
activity. Left upper and lower with spontaneous movements. Left
upper extremity localizes to pain.
Sensation: Unable to assess
Reflexes: B T Br Pa Ac
Right 0 0 2 0 0
Left 0 0 2 2 0
Toes upgoing on right and downgoing on left
On Discharge: [**9-12**]
Awake, Alert, Easily oriented to person/place/date(best w/
"yes/no" options). Names [**2-15**] objects well. Dysarthric and mild
expressive dysphasia. PERRL, EOMI. Face symmetric, tongue
midline. Obvious Left hemicraniectomy defect. Wound is clean,
dry and intact withou erythema or drainage. Unable to assess
drift. LUE/LLE and RLE exhibit full strength throughout all
muscle groups. RUE exhibits [**4-17**], with an absent grip. Sensation
is intact to light touch throughout. No clonus was detected.
Pertinent Results:
Labs on Admission:
[**2174-6-29**] WBC-7.3 RBC-5.02 Hgb-14.2 Hct-42.0 MCV-84 MCH-28.2
MCHC-33.7 RDW-15.4 Plt Ct-167
[**2174-6-29**] Neuts-79.3* Lymphs-17.5* Monos-2.8 Eos-0.3 Baso-0.2
[**2174-6-29**] PT-12.1 PTT-23.1 INR(PT)-1.0
[**2174-6-29**] Glucose-132* UreaN-10 Creat-0.9 Na-139 K-3.7 Cl-99
HCO3-24 AnGap-20
[**2174-6-29**] ALT-23 AST-43* LD(LDH)-176 CK(CPK)-237* AlkPhos-75
Amylase-65 TotBili-0.6
[**2174-6-29**] Lipase-20
[**2174-6-29**] TropnT-<0.01
[**2174-6-29**] ASA-NEG Ethanol-352* Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2174-6-29**] Calcium-8.7 Phos-2.7 Mg-1.9
IMAGING:
CT Head [**6-29**]:
NON-CONTRAST HEAD CT: The patient is intubated with OG tube in
place. There
is new large intraparenchymal hemorrhage centered in the left
frontoparietal region measuring up to 8.1 x 4.8 cm on axial
imaging (2:18). This causes 8 mm rightward shift of normally
midline structures. Additional foci of intraparenchymal
hemorrhage is seen in the inferior right frontal lobe as well as
in the left temporal lobe. Right temporal sulcal high density
may represent acute subarachnoid hemorrhage. There is diffuse
sulcal effacement in the left cerebral hemisphere as well as
mass effect on the left lateral ventricle. No intraventricular
extension of hemorrhage is seen. There is extra- axial
hemorrhage along the left occipitoparietal region, measuring up
to 13 mm thick posteriorly. High- density blood is also seen
layering along the falx. In addition to rightward subfalcine
herniation, asymmetric widening of the left aspect of the
perimesencephalic cistern may represent early left uncal
herniation. There is effacement of the left suprasellar cistern.
The soft tissues, orbits, and skull appear intact. There is
fluid within the nasal cavity and mild mucosal thickening in the
maxillary sinuses, with mucous retention cyst in the left
maxillary sinus. The mastoid air cells and
external auditory canals are normally aerated.
IMPRESSION: Large left frontoparietal intraparenchymal
hemorrhage causes
rightward subfalcine herniation and likely impending left uncal
herniation.
Right inferior frontal and left temporal intraparenchymal
hemorrhage and right temporal subarachnoid hemorrhage. Left
extra-axial likely subdural
hemorrhage.
Head CT [**6-29**](Post-op):
1. Status post surgical evacuation of large left frontoparietal
intraparenchymal hemorrhage and left subdural hematoma. Residual
blood
products and air are noted within the region of hemorrhage
although markedly improved.
2. Significant improvement in the degree of mass effect and
midline shift
with 5 mm of subfalcine herniation. There is persistent
effacement of the
ambient cistern concerning for mild uncal herniation.
3. Residual small bilateral subdural hematomas. Unchanged
right-sided
subarachnoid hemorrhage and right inferior frontal
intraparenchymal
hemorrhage.
CT Torso [**6-29**]:
CT PELVIS: The urinary bladder appears normal with a Foley
catheter in place, and air bubbles within, likely from Foley
catheter placement. The sigmoid colon and rectum appear within
normal limits. There is a normal appearance of the seminal
vesicles and prostate. There is no free fluid in the pelvis.
There are no pathologically enlarged lymph nodes in the pelvis
or inguinal area.
OSSEOUS STRUCTURES: The osseous structures demonstrate a mild
compression
deformity of the T9 vertebral body, with similar appearance
since [**2171**].
Additionally, there is a superior endplate deformity of T10,
also likely
chronic. No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. Slight compression deformity of T9 vertebral body, likely
chronic.
2. Diffuse low attenuation of the liver consistent with fatty
infiltration.
3. Airspace opacity in the right lower lobe and right middle
lobe, likely
atelectasis; however, superinfection cannot be excluded.
Head CT [**6-29**]:
NON-CONTRAST HEAD CT: The patient is intubated with OG tube in
place. The
patient is status post recent right craniectomy with expected
postoperative changes including gas within the resection bed and
in the overlying soft tissues. Allowing for differences in
patient rotation, subarachnoid hemorrhage seen along the left
frontal superior convexity more likely also present. Otherwise,
the remaining foci of large left frontoparietal intraparenchymal
hemorrhage and inferior right frontal intraparenchymal
hemorrhage, bilateral foci of subarachnoid hemorrhage, and left
frontoparietal subdural hematoma appear similar to that seen 15
hours prior. Perhaps trace hemorrhage is seen in the occipital
horns. Otherwise, no interval development of hydrocephalus is
seen. 5 mm rightward shift of normally midline structures and
mild left uncal herniation appear similar. There is new fluid
layering in the sphenoid sinus, likely due to ET tube and OG
tube.
IMPRESSION: Little change in exam compared to 15 hours prior
with large left frontoparietal intraparenchymal hemorrhage and
surrounding edema causing unchanged rightward shift of normally
midline structures and mild uncal herniation. Other foci of
intraparenchymal, subarachnoid, and subdural hematoma are also
little changed.
Head CT [**7-7**] [**Known lastname **],[**Known firstname 1575**] Radiology Report CT HEAD W/ & W/O
CONTRAST Study Date of [**2174-7-7**] 2:44 PM
Provisional Findings Impression: AJy FRI [**2174-7-8**] 7:02 AM
PFI: Expected interval evolution of prior intraparenchymal
hemorrhage. There is decreased shift of midline structures.
There is transcranial herniation of the lt cerebral cortex.
There is no definite abscess. However, following administration,
there is mild diffuse cerebral enhancement in the region of the
surgical bed. This could suggest cerebritis, and MRI is
recommended as clinically indicated.
Final Report
HISTORY: A 49-year-old male status post craniotomy for traumatic
intraparenchymal hemorrhage. Rule out abscess.
COMPARISON: [**2174-6-29**].
TECHNIQUE: Contiguous axial images were obtained through the
brain prior to and following the administration of 90 ml of
Optiray intravenous contrast.
FINDINGS: There has been interval evolution of inferior right
frontal lobe
intraparenchymal hematoma, with decreased attenuation increased
surrounding edema. There is also decreased attenuation of the
large left intraparenchymal hematoma, with contraction and
decreased attenuation of blood products, and mild- to- moderate
surrounding edema. Mass effect has somewhat decreased, and there
is no persistent shift of normally midline structures. However,
there is herniation of the cerebral cortex through the
craniectomy defect. Expected postoperative changes are seen from
prior craniectomy. Low attenuation extraaxial fluid collection
likely represents postoperative fluid. There is no rim
enhancement to suggest abscess formation. There is a superficial
layer of hyperdense, enhancing soft tissue likely representing
granulation tissue. There is no new focus of hemorrhage.
Following contrast administration, there is no evidence for
rim-enhancing collection to suggest abscess. However, there is
mild diffuse cortical enhancement in the surgical bed. This may
represent postoperative change, although an early cerebritis
cannot be excluded. The visualized paranasal sinuses and mastoid
air cells are clear. The globes and orbits are normal.
IMPRESSION:
1. Interval evolution of bilateral intraparenchymal hemorrhage.
There is
persistent edema, with transcranial herniation of the left
cerebral cortex, but no persistent midline shift.
2. No definite abscess formation. However, there is mild
heterogeneous
cortical enhancement deep to the craniectomy site. Although this
may
represent postoperative change, an early cerebritis cannot be
excluded. MRI could be considered as clinically indicated for
further evaluation.
The study and the report were reviewed by the staff radiologist.
CXR [**7-1**]:
FINDINGS: In comparison with the earlier study of this date, the
Dobbhoff
tube has been pushed forward to the distal stomach. Otherwise,
little change.
LENIS [**7-4**]:
No lower extremity DVT.
LIVER/GALLBLADDER US: [**2174-7-6**]
The liver shows no focal or textural abnormality. The
gallbladder is normal without stones. The common duct is not
dilated measuring 3 mm. The pancreas is not well seen due to
overlying bowel gas and patient motion.
IMPRESSION: No intra- or extra-hepatic biliary ductal
dilatation. Normal
gallbladder. No explanation found to explain patient's
transaminitis.
CT HEAD W/ & W/O CONTRAST: [**2174-7-7**]
FINDINGS: There has been interval evolution of inferior right
frontal lobe
intraparenchymal hematoma, with decreased attenuation increased
surrounding edema. There is also decreased attenuation of the
large left intraparenchymal hematoma, with contraction and
decreased attenuation of blood products, and mild- to- moderate
surrounding edema. Mass effect has somewhat decreased, and there
is no persistent shift of normally midline structures. However,
there is herniation of the cerebral cortex through the
craniectomy defect.
Expected postoperative changes are seen from prior craniectomy.
Low
attenuation extraaxial fluid collection likely represents
postoperative fluid. There is no rim enhancement to suggest
abscess formation. There is a superficial layer of hyperdense,
enhancing soft tissue likely representing granulation tissue.
There is no new focus of hemorrhage.
Following contrast administration, there is no evidence for
rim-enhancing
collection to suggest abscess. However, there is mild diffuse
cortical
enhancement in the surgical bed. This may represent
postoperative change,
although an early cerebritis cannot be excluded.
The visualized paranasal sinuses and mastoid air cells are
clear. The globes and orbits are normal.
IMPRESSION:
1. Interval evolution of bilateral intraparenchymal hemorrhage.
There is
persistent edema, with transcranial herniation of the left
cerebral cortex, but no persistent midline shift.
2. No definite abscess formation. However, there is mild
heterogeneous
cortical enhancement deep to the craniectomy site. Although this
may
represent postoperative change, an early cerebritis cannot be
excluded. MRI could be considered as clinically indicated for
further evaluation.
CT HEAD W/O CONTRAST: [**2174-7-10**]
There has been interval evolution of a right frontal
intraparenchymal hematoma with a decreased area of hyperdensity.
There is effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle, similar to prior. In the left frontoparietal region,
an intraparenchymal hemorrhage has evolved. There is persistent
transcranial herniation at the craniotomy site. There is an
extra-axial fluid collection with high-density material within
it likely representing postoperative changes. There is no
dilatation of the ventricles. The basal cisterns appear
preserved. Mastoid air cells and paranasal sinuses are clear.
IMPRESSION: Interval evolution of bilateral intraparenchymal
hemorrhage with effacement of the frontal [**Doctor Last Name 534**] of the right tip
lateral ventricle and
transcranial protrusion of left cerebral cortex, unchanged from
3 days prior.
2. If infection is a consideration, consider either a CT with
contrast or MR for further evaluation.
VIDEO OROPHARYNGEAL SWALLOW: [**2174-7-13**]
An oral and pharyngeal swallowing videofluoroscopy was performed
today in
collaboration with speech and swallow specialist. Thin liquid,
nectar thick liquid, pureed consistency barium, and one ground
cookie coated with barium were administered.
ORAL PHASE: Bolus formation was mildly impaired with prolonged
chewing of the ground solids. Bolus control was also mildly
reduced with consistent
premature spillover before the swallow. Mild coating of the
residue remained on the tongue after the swallow that he cleared
spontaneously with a repeat swallow.
PHARYNGEAL PHASE: There was a mild delay in initiation of the
pharyngeal
swallow. Palatal elevation, laryngeal elevation, laryngeal valve
closure, and epiglottic deflection were complete. Pharyngeal
transit time was timely with adequate bolus propulsion. Mild
amount of residue was seen in the valleculae after the swallow.
ASPIRATION/PENETRATION: There was mild penetration before the
swallow with
thin liquids in part secondary to impulsivity and large sips
taken.
Penetration was secondary to premature spillover and swallow
delay but was
cleared at the height of the swallow. No aspiration was seen
today.
KUB [**9-3**]:
FINDINGS: The bowel gas pattern is nonspecific and
non-obstructive with no
evidence for free air, pneumatosis or ascites. Note should be
made that the distal pelvis and anal region were cut off from
view.
Rt. Hand/Shoulder [**9-7**]:
RIGHT SHOULDER:
Technically limited study due to scattered radiation. The
acromioclavicular joint is well maintained. No definite
abnormality is seen involving the glenohumeral joint, though it
is not seen tangentially. Visualized portion of the right lung
is clear.
RIGHT HAND: Three views show no evidence of acute bone or joint
space
abnormality. There is fairly prominent juxta-articular
demineralization at
the metacarpophalangeal level, though no evidence of erosive
changes.
Head CT [**9-9**]:
FINDINGS: Again seen are extensive changes underlying a left
frontal
craniectomy. There is now left frontal and temporal atrophy. The
left
hemispheric mass effect present earlier has resolved and there
is now ex vacuo dilatation of the left lateral ventricle. Again
seen is a small calcification in the left frontal lobe. There is
no evidence of hemorrhage. There are no findings to suggest
infection. Soft tissue swelling overlying the craniectomy site
has largely resolved. There appears to be a small fluid
collection inferiorly at the craniectomy site. There has been
evolution of the right frontal hematoma.
CONCLUSION: Reduction in postoperative swelling overlying left
craniectomy
site. There is now ex vacuo dilatation of the lateral ventricle.
Brief Hospital Course:
49M with a history of ETOH abuse and hypertension, presented to
[**Hospital1 18**] at approx 9pm on [**6-29**] for acute intoxication. At
approximately midnight, he was noted to be unresponsive and not
moving his right side. CT scan of the head was done and a large
right sided IPH was identified. He was brought emergently to the
OR for evacuation and decompression, as well as craniectomy.
Post-operatively, he was transferred to the ICU for q1h
neurochecks and futher managment. Post-op head CT showed
appropriate decompression. He examination immediatley post-op
was significant for eye opening, PERRL, and spont Lt sided mvmt.
Right sided w/drawl to noxious. On [**7-3**], he was extubated. On
[**7-4**], his examination was much improved with spontaneous
strong mvmt of LEU/LLE and right sided withdrawl. He was
minimally verbal, but vocalizing with slurred unintelligible
speech. LENIS were also done as routine to r/o LE DVT given
prolonged bedrest, and determined to be negative. He was
therefore transferred to the neurosurgery stepdown unit. He was
also fitted for helmut so that he would be able to get out of
bed safely to work with PT. He was seen by speech and swallow,
and determined to be unable to tolerate oral food stuffs at this
time, and to continue on tube feeds via dobhoff.
On [**7-7**] the patient had temp to 102, he was already being
treated for UTI and other cultures are pending, CXR was clear.
He repeat CT of his head was done to check for any collection
which did not show any collection. ESR was 127. CRP was done on
[**7-11**] resulted as 58.8. [**7-8**] he had a Gtube placed. He continued
to have low grade fevers which were considered to be related to
his UTI. Cultures returned klebsiella in the urine, and his
antibiotics were changed from Bactrim to Cipro.
He continues to be followed by PT and OT for reconditioning. On
[**7-14**] pt was reported to have fallen out of his chair, landing on
right side. He did not sustain any obvious injuries. He is
slightly more interactive with the therapists compared to days
just prior.
On [**7-19**] patient's speech is improved. He has been taking soft
foods, thin liquids by mouth and calorie counts were initiated.
His tube feed were adjusted. PT/OT has been working with him.
His PEG cannot be removed for 4-6 weeks per surgery. On [**7-22**]
nutrition felt that he was taking in about 85% of his calories
by mouth and his tube feeds were adjusted again. The results of
calorie counts indicate that the patient is taking almost all of
his calories by po intake, but requires tube feeds of
fibersource at 65cc/hr x 10 hours.
The patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 71113**], was
contact[**Name (NI) **] on [**7-28**] with an update and a request from the patient
that his PCP come to see him in the hospital.
The patient continues to have improving speech and interaction.
He has continued to work with physical and occupational therapy
and was ambulating in the [**Doctor Last Name **] with his brother on [**8-7**]. [**Name2 (NI) **]
management continues to work on placement at a rehab facility
but this has been an ongoing issue. He has been ready for
discharge for weeks.
Mr. [**Known lastname 95771**] has become more frustrated and depressed due to his
long hospitalization and due to his expressive aphasia. He was
also having difficulty sleeping. On [**8-10**] Ambien was started as
needed for sleep and Celexa was started for his depression. His
strength in the RUE has steadily improved throughout his
hospital course and on [**8-11**] he was able to provide some
resistance with that arm. His RLE was 4+/5 in the IP and [**5-17**] in
the hamstrings and quads.
The patient continued to be able to tolerate food by mouth and
his tube feedings were stopped on [**8-14**]. He complained of
epigastric pain on [**8-19**] that was worse during eating. He was
started on carafate and a PPI.
On [**8-21**] the epigastric pain was gone. The surgery team planned to
remove the PEG tube but they were concerned that he was not
receiving enough calories. Nutrition was asked to see the
patient again on [**8-22**] and calorie counts were done for
[**Date range (1) 52084**]. The removal of the PEG was deferred until calorie
counts were complete. On [**8-26**] the calorie counts were
completed, the patient was found to have gained 7 lbs over 14
days and nutrition cleared the patient to have the PEG tube
removed. On [**8-27**], the PEG was removed uneventfully.
The patient reported some LUQ pain on [**9-3**]. He had a KUB which
was negative and the pain resolved. On [**9-7**], the physical
therapists expressed concern that Mr. [**Known lastname 95771**] had exhibited some
pain of his RUE during their session. Imaging was obtained of
the RUE, and found to be negative for fracture or alternate
acute process.
On [**9-9**], he was complaining of a mild headache. Given his
prolonged hospital course, and intracranial hemorrhage; a CT
scan was performed. This was negative for any acute pathology
to explain his HA. He was treated with pain medication and
headache resolved.
On [**9-12**], he was discharged to rehab facility with follow
up instructions.
Medications on Admission:
Thiamine, Folic acid, MVI, HCTZ
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: caution not to exceed more than
4gm APAP in 24h.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Glycerin (Adult) Suppository Sig: One (1) Suppository
Rectal DAILY (Daily) as needed for constipation.
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 days: To be administered on [**9-8**] & [**9-9**].
19. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days: to be administered on [**9-10**] &[**9-11**].
20. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for shoulder pain: Caution not to
exceed more than 4GM APAP in 24hr
.
21. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
Intraparenchymal Hemorrhage
Urinary Tract Infection
Right Hemiplegia
Poor Oral intake
Gastric Ulcer(s/p tx)
Rt Shoulder Pain(neg for fx)
Discharge Condition:
Neurologically Stable/improved
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may shower.
?????? 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 are in
the process of tapering to off. Your last dose will be on [**9-11**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to [**Telephone/Fax (1) **] an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2174-9-12**]
|
[
"276.2",
"300.4",
"518.81",
"784.3",
"342.90",
"348.5",
"599.0",
"276.3",
"348.4",
"E884.2",
"431",
"291.81",
"E849.7",
"401.9",
"041.3",
"719.41",
"531.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.51",
"96.04",
"96.6",
"43.11",
"96.72",
"01.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
24286, 24333
|
16853, 22069
|
312, 394
|
24514, 24547
|
2886, 2891
|
26041, 26317
|
1308, 1369
|
22152, 24263
|
24354, 24493
|
22095, 22129
|
24571, 26018
|
1384, 1384
|
2353, 2867
|
249, 274
|
422, 798
|
1816, 2339
|
6759, 16830
|
2905, 3516
|
1711, 1800
|
820, 1020
|
1036, 1292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,535
| 115,632
|
9247
|
Discharge summary
|
report
|
Admission Date: [**2191-10-10**] Discharge Date: [**2191-10-19**]
Date of Birth: [**2116-7-3**] Sex: F
Service: Cardiothor
HISTORY OF PRESENT ILLNESS: This is a 75 year old Spanish
speaking female with a past medical history significant for
poorly controlled diabetes mellitus, hypertension, and
peripheral vascular disease, who presents with a two week
history of intermittent chest pressure and pain radiating to
the left arm. This pain began around two weeks prior to
admission, which was [**9-20**], while she was watching the
coverage of the World Trade Center attack. She describes the
sensation as pressure in the chest, substernal, radiating to
the arm where it becomes more crushing. The onset was
unpredictable but more often with exertion; not associated
with diaphoresis, nausea, vomiting or shortness of breath.
She denies any prior history of chest pain or pressure as
well as denying acid-reflux indigestion or any recent
illnesses.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: She was ruled out for myocardial infarction
with negative CPK times three. The patient was found to have
a positive stress test. Cardiac catheterization was
performed on [**10-14**] which revealed an ejection fraction
of 60% with normal valves, 20% stenosis of the proximal right
coronary artery, 20% stenosis of the mid- right coronary
artery, 90% of the distal right coronary artery, 90% of the
right PDA, 90% of the right PL, 80% of mid left anterior
descending, 50% of the first diagonal and 100% of the obtuse
marginal.
Cardiothoracic Surgery was called to the Catheterization
Laboratory to see the patient after stenting of her right
coronary artery and diagonal and left anterior descending
with a tamponade and cardiogenic shock, bleeding around 1300
cc in three to four hours, and a pH of 7.1, base access
negative 17 on Dopamine. She was taken emergently to the
Operating Room for exploration.
Preoperative diagnosis was cardiac tamponade with
percutaneous transluminal coronary angioplasty.
Postoperative diagnosis was a cardiac perforation times two.
The patient underwent a sternotomy and repair of cardiac
perforations times two [**2191-10-14**]. A hole was found in
the acute marginal pumping blood from the right ventricle, as
well as a hole in the obtuse marginal in the V1 distribution
which was bleeding. The holes were repaired and there was no
other further intervention necessary.
On postoperative day one status post repair of cardiac
trauma, the patient was in atrial fibrillation on Pronestyl
and Lopressor, temperature maximum of 101.5 F., to current of
101.5 F.; heart rate of 86; blood pressure of 106/82;
respirations 11, saturating at 99%. PA pressures of 49/31,
cardiac output 3.6, cardiac index of 2, CVP of 20 on vent
settings of IMV of 600, 10, 0.5, and 5 PEEP. Last gas 7.46,
32, 112, 23, and zero. Chest tube outputs 475 over the last
24 hours. White count of 13.5, hematocrit of 32.5, platelet
count of 151,000. Sodium 144, potassium 4.3, BUN 18,
creatinine 1.1, glucose 139, calcium 8.5, magnesium 1.7,
phosphate 4.3.
On physical examination, the patient was alert. She was
following commands. Lungs were clear to auscultation
bilaterally. Heart: Regular rate and rhythm with the
incision clean, dry and intact. Abdomen was soft and
nontender. Extremities were warm. Plan was to decrease the
Profadol, to continue Pronestyl, and to check the Procaine
and Napa levels. The patient was to get an EKG this morning;
discontinue the chest tubes and Lasix in the morning, wean to
extubate and start p.o. medications after extubation.
Continue to diurese and transfer to the floor.
Postoperative day two, the patient on Amiodarone and
Neo-Synephrine with temperature of 100.2 F., current of 100.0
F.; heart rate of 72 in normal sinus rhythm; blood pressure
112/70; respirations 23; saturating at 95%. Cardiac output
5.06, index of 2.92, PA pressures of 47/29; CVP of 19 with an
SVR of 870. Vent settings: She is on C-PAP of 10, 5 and 60.
Last arterial blood gas 7.43, 31, 10. Chest tubes put out
800 cc in the last 24 hours, 50 cc in the last hour.
Neurologically, on physical examination, the patient opened
her eyes and followed commands. Heart was regular rate and
rhythm. Chest is clear to auscultation bilaterally with
incision clean, dry and intact. Abdomen was soft.
Extremities with mild trace edema. Hematocrit of 32.6,
platelet count of 191,000, sodium of 143, potassium 4.3, BUN
30, creatinine 1.6 with glucose of 188, PT of 14.4. Plan was
to continue Nitroglycerin drip and continue diuresis.
Respiratory-wise the decrease of FIO2 to 50 and attempt
extubation and to discontinue the chest tube.
Postoperative day three, the patient was converted to normal
sinus rhythm with Amiodarone from her atrial fibrillation.
The temperature maximum of 100.6 F.; temperature current of
99.5 F.; the patient's heart rate is 75 in normal sinus
rhythm; blood pressure 109/68; respirations 15, saturating at
96%. CVP of 16, cardiac output 4.2, index of 2.28 with an
SVR of 1299, ventilator was on C-PAP and pressure support of
0.5, 8 and 5. The patient on an Amiodarone drip,
Nitroglycerin, Coumadin, sliding scale insulin, Lasix, Ceptaz
and Levofloxacin. On physical examination, the patient opens
eyes to commands. Heart was regular rate and rhythm. Wounds
were clean, dry and intact. Sternum stable. Lungs are clear
to auscultation bilaterally. Abdomen was softly distended,
but nontender. Extremities had one plus edema and they were
warm. Plan was to check chest x-ray, consider bronchoscopy,
continue vent settings with C-PAP, continue Lasix.
Infectious Disease wise, continue Levofloxacin and Ceptaz and
check cultures.
Postoperative day four, the patient was found to have right
lower lobe pneumonia with Gram negative rods. Temperature
maximum 100.2 F., temperature current 99.9 F.; heart 74 in
normal sinus rhythm; blood pressure 106/52; respirations 16,
saturating at 98%. CVP of 9, output of 5.1, index of 2.95
with an SVR of 1114. The patient on C-PAP and pressure
support, 0.5, 8 and 5; last gas 7.49, 40, 154, 31 and 7. The
patient on Ceptaz, Levofloxacin, Amiodarone, Nitroglycerin
and Lasix. White count of 13,000, hematocrit of 37, platelet
count of 243,000. Sodium 141, potassium 3.3, BUN 27,
creatinine 1.2. On physical examination, the patient was
awake, following commands. Heart was regular rate and rhythm
with wounds clean, dry and intact. Respirations: She had
coarse breath sounds bilaterally. Abdomen was soft,
nontender, nondistended. Extremities were warm with trace
edema. Plan was to continue pain control, wean the
Nitroglycerin, repeat the chest x-ray and continue pulmonary
toilet. Continue the Ceptaz and Levofloxacin.
On postoperative day five, the patient's temperature maximum
99.3 F.; heart rate 75 in sinus rhythm; blood pressure 124/61
on Nitroglycerin. Sodium 139, potassium 3.7, BUN 23, white
count of 10,000, hematocrit 31, platelet count of 275,000.
On physical examination, incisions were clean, dry and
intact. The sternum was stable. Chest x-ray was improved.
Plan is to extubate the patient and to transfer to the Floor.
Cardiac Surgery addendum postoperative day five, the patient
with complaints of chest pain that she described as
incisional and different from her angina preoperatively. EKG
showed less than 1 mm depressions in the lateral leads.
Cardiac enzymes were sent. Troponin was 12.5. Pacing wires
were discontinued. Plan was to transfer the patient to
Cardiology for further management. Surgical clips were to be
discontinued postoperative day number 14.
The plan was discussed with Dr. [**Last Name (STitle) **]. So the patient was
transferred with the diagnoses of:
1. Cardiac perforation times two status post percutaneous
transluminal coronary angioplasty.
TRANSFER MEDICATIONS: The patient was transferred to the
Cardiac Care Unit on the following medications:
1. Amiodarone 400 three times a day
2. Nitroglycerin drip.
3. Diamox 500 q. six.
4. Combivent four puffs q. six.
5. Levofloxacin 250 q. day.
6. Ceptaz two grams intravenously q. 12.
7. Protonix 40 mg intravenously q. day.
8. Sliding scale insulin.
9. Morphine, 8 mg in the last 24 hours.
The patient was stable when transferred to the Cardiac Care
Unit.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2192-1-11**] 08:44
T: [**2192-1-17**] 10:57
JOB#: [**Job Number 31730**]
|
[
"997.1",
"427.5",
"427.31",
"486",
"997.3",
"423.9",
"410.71",
"998.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"96.72",
"37.12",
"37.61",
"36.05",
"36.01",
"36.06",
"37.4",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
1042, 7870
|
7893, 8608
|
169, 1024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,784
| 121,518
|
23304
|
Discharge summary
|
report
|
Admission Date: [**2163-12-16**] Discharge Date: [**2163-12-21**]
Date of Birth: [**2093-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Betadine / Iodine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p cervical tracheoplasty; [**12-16**]
History of Present Illness:
Delightful 70y/o gentleman who is well known to me. He suffered
from
tracheobronchomalacia and required a right thoracotomy with
tracheobronchoplasty. He did well initially from that, but
subsequently developed recurrent dyspnea and was recently
found on functional bronchoscopy to have progression to his
untreated cervical trachea. In underwent a stenting trial
with a wire stent and had an excellent response. Therefore,
we took him forward for surgical repair.
Past Medical History:
hypertension, coronary artery disease, s/p coronary angioplasty
x2, gastric esophogeal reflux disease, trachealmalacia, s/p
intrathoracic tracheobroncheoplasty, s/p right femoral bypass
graft, s/p left femoral bypass, s/p bilat carpal tunnel [**Doctor First Name **],
s/p tracheal stent placement and removal, cataract surgery
Social History:
+cigs (45 pack years, quit 20 yrs ago)
1 beer/day
Retired pool worker
Family History:
Father colon ca, mother pacemaker
Physical Exam:
General NAD
HEENT- no adenopathy
Resp-CTA B
Cor-RRR
Abd-soft, NT, ND
Ext-+Pulses
Skin-Inc C/D/I
Pertinent Results:
[**2163-12-16**] 11:16AM freeCa-1.18
[**2163-12-16**] 11:16AM HGB-13.3* calcHCT-40 O2 SAT-99
[**2163-12-16**] 11:16AM GLUCOSE-108* LACTATE-1.9 NA+-139 K+-4.9
CL--105
[**2163-12-16**] 11:16AM TYPE-ART PO2-196* PCO2-44 PH-7.35 TOTAL
CO2-25 BASE XS--1
[**2163-12-16**] 03:58PM GLUCOSE-129* UREA N-17 CREAT-1.3* SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-19* ANION GAP-19
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2163-12-18**] 03:09AM 7.0 4.41* 13.4* 37.3* 85 30.4 36.0* 14.1
188
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2163-12-18**] 03:09AM 188
[**2163-12-18**] 03:09AM 13.0 29.1 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2163-12-19**] 06:20AM 109* 21* 1.2 140 4.1 102 261 16
1 NOTE UPDATED REFERENCE RANGE AS OF [**2163-5-27**]
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2163-12-19**] 06:20AM 9.0 3.5 2.0
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2163-12-18**] 9:58 AM
Reason: please eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with tracheomalacia s/p repair
REASON FOR THIS EXAMINATION:
please eval for interval change
AP CHEST PERFORMED ON [**2163-12-18**].
HISTORY: 70-year-old man with tracheomalacia status post repair.
Evaluate for interval change.
FINDINGS: Compared to previous study from [**2163-12-16**].
There is again seen a catheter within the lower trachea
consistent with the recent tracheal repair. The cardiac
silhouette and mediastinum are within normal limits. There are
no focal infiltrates or pulmonary edema. There is some minimal
blunting of the left CP angle suggestive of a small pleural
effusion.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 59842**],[**Known firstname **] [**2093-4-22**] 70 Male [**Numeric Identifier 59843**] [**Numeric Identifier 59844**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 14739**]/dif
SPECIMEN SUBMITTED TRACHEA,TRACHEAL BACK WALL.
Procedure date Tissue received Report Date Diagnosed
by
[**2163-12-16**] [**2163-12-16**] [**2163-12-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
Previous biopsies: [**-3/4541**] TRACHEAL STENT GROSS EXAM
DIAGNOSIS:
A. "Membranous trachea":
Respiratory mucosa with mild chronic inflammation and edema.
B. "Tracheal back wall":
Respiratory mucosa with mild chronic inflammation and edema.
Clinical: Cervical tracheomalacia.
Gross:
The specimen is received fresh labeled with "[**Known firstname **] [**Known lastname **]" and
the medical record number.
Part 1 is additionally labeled "membranous trachea" and consists
of a 0.9 x 0.4 x 0.2 cm piece of pink to tan tissue with
hemorrhage. It is entirely submitted in A.
Part 2 is additionally labeled "tracheal back wall" and consists
of a 1.4 x 0.9 x 0.3 cm piece of pink to tan soft tissue with
hemorrhage. It is entirely submitted in B.
Brief Hospital Course:
Patient admitted SDA for above operative procedure. Pt tolerated
procedure well, extubated in OR and transferred to ICU for close
respiratory observation overnight.
POD#1-stable, afebrile, no hematoma, Dsg C/D/I, guradian stitch
in place.
JP drainage- minimal. O2 - 2L- sat 98%. DB, poor cough- minimal
secretions, OOB> chair. Kefsol d#2.Pain control w/ MSo4 iv prn.
Diet advanced as tolerated. REmain in ICU for pulmonary toilet.
Lopressor po.
POD#2-Stable overnight, Kefsol d#3; taking po intake well, pain
contrl w/ MSo4; JP drain removed. Transfer to floor.
POD#3-Stable, O2 sat 95%RA; no stridor/SOB; tolerating po,
ambulation; lytes/CBC monitored.
POD#4- Stable overnight, nodysphagia, no SOB.O2 sat 95% RA. Pain
med po- taken rarely. Ambulation. NPO for bronch in am. wound
C/D/I. Chest XRY - no acute process.
POD#5- [**Name6 (MD) **] [**Name8 (MD) 59845**] NP for bronch. Bronch this am-
anastamosis stable and clean.
Pt discharged in stable condition to home in company of wife. Pt
f/u appts as below.
Medications on Admission:
Flomax.4'mg qam, lorazepam .5qam, avapro 150', protonix 40',ASA
81',betamethasone cream
Discharge Medications:
1. Betamethasone Dipropionate 0.05 % Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed for itching.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
hypertension, coronary artery disease, s/p coronary angioplasty
x2, gastric esophogeal reflux disease, trachealmalacia, s/p
intrathoracic tracheobroncheoplasty, s/p right femoral bypass
graft, s/p left femoral bypass, s/p bilat carpal tunnel [**Doctor First Name **],
s/p tracheal stent placement and removal, cataract surgery
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office/Thoracic Surgery office([**Telephone/Fax (1) 170**])
for: fever, shortness of breath, chest pain, difficulty
swallowing, swelling, reddness or foul smelling drainage from
incision sites.
REsume regular medications as previous to surgery as directed.
Take new medications as directed.
No lifting over 10 lbs for 6 weeks. No work for 6 weeks.
Appointments as below.
Followup Instructions:
Call for appointment in 2 weeks w/Dr. [**Last Name (STitle) 952**] in Thoracic Surgery
Clinic, [**Hospital Ward Name 23**] clinical center [**Location (un) **]. [**Telephone/Fax (1) 170**].
Call for Interventional Pulmonary appointment for bronchoscopy
in 4 weeks/1 month- [**Telephone/Fax (1) 3020**].
Completed by:[**2163-12-21**]
|
[
"496",
"519.1",
"V45.82",
"414.01",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
6251, 6257
|
4622, 5636
|
337, 379
|
6628, 6635
|
1493, 2569
|
7083, 7418
|
1327, 1362
|
5774, 6228
|
2606, 2653
|
6278, 6607
|
5662, 5751
|
6659, 7060
|
1377, 1474
|
278, 299
|
2682, 4599
|
407, 873
|
895, 1223
|
1239, 1311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,683
| 197,162
|
21687
|
Discharge summary
|
report
|
Admission Date: [**2197-4-12**] Discharge Date: [**2197-4-24**]
Date of Birth: [**2173-9-6**] Sex: F
Service: MEDICINE
Allergies:
Latex / Fentanyl / Risperidone
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
nausea, vomiting, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Doctor First Name **] is a 23 year-old FTM transgender patient with HIV ([**2197-2-7**]:
VL 931, cd4 318; started Truvada/atazanavir/ritonavir on
[**2197-2-21**], discontinued, restarted two weeks ago), chronic
untreated hepatitis C, and recent zoster who presents with two
days of acute on chronic headache, fevers, nausea, vomiting, and
diarrhea. He describes feeling well until [**2197-1-2**], when he
was hospitalized [**Date range (1) **] with epigastric/LUQ abdominal pain of
unclear etiology and herpes zoster. He began [**Date range (1) 2775**] [**2197-2-21**]
and was admitted [**2197-2-23**] for headache, fever to 103, nausea,
vomiting and ?zoster recurrence after not completing the course
of acyclovir from the prior admission. He had a negative LP and
largely unremarkable evaluation at that time.
.
He reports persistent malaise since [**Month (only) 956**], never returning to
baseline after the two admissions, and experiencing persistent
headache (distinguished from usual migraines by location and
absence of aura and photophobia), nausea, 2-3 episodes NBNB
emesis per week, intermittent fevers. Over the last few days,
he developed worsening of these symptoms (severe nausea, [**5-9**]
episodes vomiting, diarrhea x4, fever to 100.5, frontal headache
behind eyes, with new myalgias and arthralgias x1day) for which
he presented to the ED.
.
In the ED, initial vs were: 97.6 83 134/86 18 100. He was given
acylovir 600 mg iv, morphine 4 mg iv x 2, zofran 4mg iv x 1, and
2L NS. An LP was negative and she was treated empirically with
zosyn and acylovir. CT head and abdominal ultrasound were also
negative.
.
On the floor on the morning after admission, he is lying in bed,
mildly anxious, complaining of nausea, headache, and "general
malaise."
.
ROS as per HPI. In addition, he reports 13 lb weight loss over
2-3 months. He also notes rash and tingling/pain of left arm in
same distribution of previously treated shingles. Denies
rhinorrhea, congestion, sore throat. Denies cough, shortness of
breath, chest pain or tightness, palpitations, abdominal pain,
dysuria, recent change in bowel or bladder habits. Denies SI.
Past Medical History:
PAST MEDICAL HISTORY:
- HIV ([**Month/Day (3) 2775**] started [**2197-2-21**]: Truvada, atazanavir, ritonavir;
diagnosed approx [**2191**], took PMTCT 1 yr ago; [**2197-2-7**]: VL 931, cd4
318; no history OI)
- Hepatitis C diagnosed in [**9-6**], no IFN therapy, last Hep C VL
558,000 [**2197-2-25**]
- Cerebral Palsy, s/p multiple surgeries, persistent leg
spasticity requiring use of wheelchair for long distances, mild
urinary retention at times.
- Asthma, mild intermittent
- Prior thrush due to Advair for asthma
- h/o multiple UTIs secondary to neurogenic bladder
PSH:
- s/p appendectomy [**12-7**]
- c-section [**2194**]
PAST PSYCHIATRIC HISTORY:
- Depression: Sees Dr. [**Last Name (STitle) 57035**] at [**Hospital3 55848**] Health Center,
taking Cymbalta.
- History of suicide attempts: last SA was in [**10-8**], requiring
ICU admission at [**Hospital 8**] Hospital. Pt overdosed on his
medications at that point (Prozac, Trileptal, Seroquel). Reports
hx of 2 SA by OD, and 2 SA by cutting. First SA at age 13-14.
- History of self cutting, last circa [**2191**], self reports near
fatal cut.
- History of anorexia/bulimia, currently with active behaviors
including restricting and purging.
- PTSD - rape survivor
- ADHD - on Concerta
- OCD
- Trauma/Abuse
Social History:
Female-to-male gender, has all female organs, does not take
hormones. Currently lives in [**Hospital1 3494**] with 1 yo son and is in
a relationship with female partner. Hx of crystal meth, heroin,
cocaine use. Occasional EtOH, +tobacco, reports cutting down to
5 cig/day. Reports close relationship with his mother's
adoptive family (his grandparents).
Family History:
Mother: cancer, ? cervical, ovarian, endometrial (died [**2196-12-2**])
Physical Exam:
PHYSICAL EXAMINATION (on floor morning of [**2197-4-12**]):
Vitals: T: 98.2 BP: 108/68 P: 81 R: 16 O2: 99% RA
General: Alert, oriented, mild distress
HEENT: +sclera icteric, MMM
Neck: Supple, no meningismus, 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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Nonerythematous, papular lesions on left forearm and arm,
no vesicles.
Exam at discharge ([**4-24**]):
Vitals: T: 98.0 BP: 99/62 P: 64 R: 16 O2: 97% RA
General: Alert, oriented, no distress
HEENT: extraocular movements intact, conjunctivae noninjected,
sclera anicteric, moist mucous membranes
Neck: Supple, no meningismus, 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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No erythema, icterus, or exanthem
Pertinent Results:
[**2197-4-11**]: WBC-6.9# RBC-4.81 Hgb-12.3 Hct-37.8 MCV-78* RDW-14.0
Plt Ct-339
Neuts-66.9 Lymphs-26.4 Monos-5.3 Eos-0.8 Baso-0.6
[**2197-4-12**] calTIBC-355 Ferritn-50 TRF-273
[**2197-4-12**]: WBC-7.9 Lymph-7* Abs [**Last Name (un) **]-553 CD3%-80 Abs CD3-441*
CD4%-36 Abs CD4-200* CD8%-40 Abs CD8-220 CD4/CD8-0.9
[**2197-4-15**] ESR-30*
[**2197-4-12**] CRP-32.9*
[**2197-4-11**]: Glucose-98 UreaN-7 Creat-0.7 Na-135 K-4.0 Cl-98
HCO3-27 AnGap-14
ALT-49* AST-43* LD(LDH)-151 AlkPhos-89 TotBili-6.9* DirBili-0.2
IndBili-6.7 Lipase-27
[**2197-4-17**]: ALT-33 AST-30 AlkPhos-67 TotBili-0.4 DirBili-0.1
IndBili-0.3
[**2197-4-12**]: tTG-IgA-1
[**2197-4-12**] URINE RBC-0-2 WBC-[**5-11**]* Bacteri-FEW Yeast-NONE Epi-3-5
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
.
[**2197-4-12**] CEREBROSPINAL FLUID (CSF):
WBC-3 RBC-0 Polys-0 Lymphs-93 Monos-7 TotProt-29 Glucose-60
HERPES SIMPLEX VIRUS PCR-NEGATIVE
CRYPTOCOCCAL ANTIGEN NEGATIVE
.
[**4-12**]: blood culture negative x2
[**4-12**], [**4-13**]: blood culture positive x3 for Group B Strep
[**4-12**]: urine culture positive for Group B Strep
.
HCV VIRAL LOAD (Final [**2197-4-13**]): 2,720,000 IU/mL.
CMV PCR negative
.
Head CT ([**2197-4-12**]): negative for mass or bleed
CXR ([**2197-4-12**]): negative
RUQ Ultrasound ([**2197-4-12**]): no abnormalities noted
KUB ([**2197-4-12**]): no abnormalities noted
.
TTE ([**2197-4-14**]): no evidence of endocarditis
TEE ([**2197-4-20**]): no evidence of endocarditis
.
CT abd/pelvis ([**2197-4-14**]): 1. New left hydronephrosis and
hydroureter. While no obstructing stone or mass is seen, stones
in patients who are on Indivir are not radioopaque on CT and
this cannot be excluded. 2. Mild periportal edema and probable
mild gallbladder wall edema represent nonspecific findings. No
biliary ductal dilatation. 3. Splenomegaly, similar to before.
4. Borderline retroperitoneal and pelvic lymph node enlargement
redemonstrated. 5. Dependent atelectatic changes in both lung
bases.
.
Abdominal ultrasound ([**2197-4-15**]): no hydronephrosis; small
amount of fluid at superior pole of right kidney; gallbladder
with large amount of sludge, not overly dilated, apparent
gallbladder wall thickening and edema is seen, but the patient
was not in pain and there was no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign.
.
Labs on discharge ([**4-24**]):
[**2197-4-23**] 07:12AM BLOOD WBC-6.7 RBC-4.27 Hgb-10.9* Hct-34.4*
MCV-81* MCH-25.4* MCHC-31.6 RDW-14.8 Plt Ct-457*
[**2197-4-23**] 07:12AM BLOOD Neuts-65.4 Lymphs-27.2 Monos-6.5 Eos-0.2
Baso-0.8
[**2197-4-23**] 07:12AM BLOOD Glucose-76 UreaN-12 Creat-0.5 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
Brief Hospital Course:
Reviewed by problem:
.
1. Group B Strep (GBS) bacteremia. On the day of admission
([**2197-4-12**]), [**Doctor First Name **] developed fever to 100.5. The next day, he
was hypotensive to SBP of 70 (responsive to IVF) and his
temperature spiked to 104. Blood and urine cultures drawn [**4-12**]
were positive for gram positive cocci, and he was started on
vancomycin; once the results showed Group B Streptococcus, he
was changed to ceftriaxone. Blood and urine cultures cleared by
[**2197-4-14**], and he remained afebrile throughout the
hospitalization. AFB/fungal blood cultures were negative. No
source for the bacteremia was identified on CT abd/pelvis or
abdominal US and the patient refused a pelvic exam. TTE was
negative for endocarditis. TEE performed [**4-20**] was also negative
for endocarditis, but was complicated by respiratory distress
(stridor, but no airway obstruction or inflammation on
laryngo-bronchoscopy) leading to intubation. [**Doctor First Name **] was extubated
the next day without incident. A midline was placed [**4-20**] and
the patient was discharged with VNA and infusion services to
complete a 3 week course of IV antibiotics.
.
2. Respiratory distress ([**2197-4-20**]). Per the report of the PACU
staff, the patient recovered from the TEE sedation (primarily
propofol) well, and the patient reports being awake and feeling
fine. Then around 5:15pm, he developed tachypnea and chest
discomfort, "as if someone was sitting on my chest", that was
unlike any of his previous asthma exacerbations. He began
making stridorous upper airway sounds and using accessory
muscles to breath, though he remained normotensive and was
satting in the mid to upper 90s. Epinephrine had no effect and
no airway edema was visualized on laryngoscopy, but given the
persistent distress, the team decided to electively intubate,
and the patient was transferred to the MICU. After intubation,
the respiratory team in the PACU performed bronchoscopy, which
failed to reveal any evidence of airway inflammation or
obstruction. The patient was extubated the following morning
without incident. The etiology of the distress seems most
likely to be psychiatric in etiology.
.
3. Headache. The patient reported a different quality to this
headache than is usual for his migraines, but neurological exam
was nonfocal and CSF was negative for infection. He was treated
symptomatically with acetaminophen, ketorolac, fioricet, and at
times po narcotics. It improved during the hospitalization and
the patient denied headache on the day of discharge.
.
4. Nausea and emesis. The etiology is unclear from prior
studies and abdominal exam was benign throughout the
hospitalization. His symptoms seemed to be exacerbated by the
antiretrovirals, especially ritonavir. He was treated
symptomatically with ondansetron and metoclopramide. Compazine
was tried, but made the patient sedated; he also reported a
dystonic type reaction.
.
5. HIV. Truvada, atazanavir, and ritonavir were continued during
the hospitalization. His unconjugated hyperbilirubinemia was
attributed to atazanavir and was probably exacerbated by
decreased urine output secondary to neurogenic bladder.
.
6. Neurogenic bladder. A Foley was placed during the admission
after hydronephrosis was seen on CT abd/pelvis; the
hydronephrosis resolved after placement. He was discharged with
a Foley in place (to be changed by VNA) and to follow up with
urology.
.
7. Left arm pain/tingling. Initially was thought to be possible
zoster recurrence, but absence of rash/progression was more
consistent with post-herpetic neuralgia. Was initially treated
with gabapentin (which was discontinued due to sedation and
possible GI side effects) and lidocaine patch (which was
continued throughout hospitalization).
.
8. Gallbladder wall thickening/edema. Unclear significance,
with no clinical correlation, most likely related to aggressive
IV fluid hydration for hypotension.
--Would recommend following up with RUQ US in [**1-4**] months.
Medications on Admission:
1. Oxcarbazepine 300 [**Hospital1 **]
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Concerta 18 daily
6. Truvada, Reyataz, Norvir
Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Concerta 18 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
8. Outpatient Lab Work
Weekly (on [**4-10**], [**5-9**]): CBC, chem7, ALT, AST, alk phos,
bilirubin (total and direct), CRP, ESR, tox screen
Please fax results to [**Telephone/Fax (1) 1419**], attn: [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**].
9. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 12 days: starting
[**2197-4-24**]
last dose [**2197-5-5**].
Disp:*12 bags* Refills:*0*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*40 Tablet(s)* Refills:*0*
12. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**12-3**] Tablet,
Rapid Dissolves PO every 4-6 hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
14. Foley
Please change Foley on [**2197-5-22**].
15. Foley Catheter 14 Fr Misc Sig: One (1) Miscellaneous once a
month.
Disp:*2 * Refills:*0*
16. leg bag for Foley
dispense 20
17. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous once
a day for 12 days.
Disp:*12 * Refills:*0*
18. Saline Flush 0.9 % Syringe Sig: Two (2) Injection once a
day as needed for before and after antibiotic for 12 days.
Disp:*36 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
group B strep bacteremia
Secondary:
HIV
chronic hepatitis C
Discharge Condition:
Hemodynamically stable, ambulating without assistance,
tolerating oral diet and medications.
Mental Status: Clear and coherent.
Completed by:[**2197-4-24**]
|
[
"041.02",
"571.5",
"311",
"300.01",
"276.51",
"302.50",
"305.53",
"300.3",
"309.81",
"053.19",
"V08",
"790.7",
"784.0",
"V13.02",
"305.73",
"596.54",
"518.82",
"591",
"070.54",
"V15.41",
"305.1",
"343.9",
"305.63",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31",
"96.04",
"88.72",
"38.93",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
14879, 14954
|
8307, 12331
|
316, 323
|
15068, 15161
|
5589, 8284
|
4181, 4255
|
12774, 14856
|
14975, 15047
|
12357, 12751
|
4270, 5570
|
250, 278
|
351, 2500
|
15176, 15227
|
2544, 3792
|
3808, 4165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,775
| 157,061
|
24837
|
Discharge summary
|
report
|
Admission Date: [**2200-6-1**] Discharge Date: [**2200-6-8**]
Date of Birth: [**2128-8-22**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2200-6-1**]:
1. Exploratory laparotomy
2. Abdominal adhesiolysis
3. Small bowel resection
History of Present Illness:
71yo F h/o R oopherectomy during childhood, in USGH until
last evening at dinner began experiencing abdominal pain, BL
lower quadrants. Progressed to constant abdominal pain ~3am,
followed by nausea and emesis x3 (non-bilious). Presented to
[**Hospital3 3583**] earlier today, where noted tachycardia,
leukocytosis, focal RLQ tenderness, and CT showing SBO.
Provided
IVF bolus, morphine 16mg and zofran, NGT, and transferred to
[**Hospital1 18**] where patient routinely receives her medical care. Foley
placed. Currently reports abdominal mildly improved with
morphine and nasogastric decompression. Denies fever or chills.
Last BM yesterday morning; last flatus possibly yesterday
morning
too.
Past Medical History:
PMH: HTN
PSH: R oopherectomy at age 12 for "mass", BL tubal ligation
(open
due to adhesions) 38y ago
Social History:
SocH: no Tob. 1 glass of wine nightly. lives with husband who
accompanies her tonight
Family History:
FH: father passed away from mouth cancer. mother lived until her
90s.
Physical Exam:
PE: 99.1 111 105/59 18 94 on RA
A&Ox3, NAD, fatigued appearing
CTAB with end-expiratory wheeze
RRR
soft, moderately distended, + tap tenderness diffusely,
exquisitely tender to palpation in RLQ with referred pain to RLQ
from other locations, + rebound, no guarding.
rectal deferred
WWP sans C/C/E
NGT, foley in place
Pertinent Results:
[**2200-6-1**] 05:30PM PT-11.5 PTT-23.0 INR(PT)-1.0
[**2200-6-1**] 05:30PM PLT COUNT-324
[**2200-6-1**] 05:30PM WBC-18.4* RBC-5.22 HGB-16.2* HCT-48.2* MCV-92
MCH-31.1 MCHC-33.6 RDW-13.8
[**2200-6-1**] 05:30PM NEUTS-93.0* LYMPHS-3.5* MONOS-3.1 EOS-0.1
BASOS-0.2
[**2200-6-1**] 05:30PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-4.5
MAGNESIUM-1.9
[**2200-6-1**] 05:30PM LIPASE-29
[**2200-6-1**] 05:30PM ALT(SGPT)-19 AST(SGOT)-18 ALK PHOS-55 TOT
BILI-0.6
[**2200-6-1**] 05:30PM GLUCOSE-161* UREA N-22* CREAT-1.1 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
[**2200-6-1**] 05:40PM LACTATE-1.9
[**2200-6-1**] 06:50PM URINE RBC-0-2 WBC-[**3-21**] BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2200-6-1**] 06:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2200-6-1**] 06:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.048*
[**2200-6-1**] Pathology: Small intestinal, resection
Unremarkable small intestinal segment; no ischemia identified.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2200-6-1**], the patient underwent
exploratory laparotomy, and small-bowel resection with primary
anastomosis, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
NPO, on IV fluids and antibiotics, with a foley catheter, and IV
pain control. The patient was hemodynamically stable.
Neuro: The patient received morphine initially, but was switched
to dilaudid for better effect. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. She also had an NG tube which came out on POD 4. Diet
was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient's
dressings were changed regularly and the wound was monitored for
signs of infection but remained without erythema/induration.
She did have a positive UA on [**6-6**] for which she was started on
Cipro.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
ASA 81qod, lisinopril-HCTZ 10-12.5', MVI, Ca, glucosamine,
chondroitin, ambien prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO EVERY OTHER DAY (Every Other Day).
2. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: Continue until [**6-9**].
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Small bowel obstruction.
Abdominal adhesions.
Small bowel necrosis.
Urinary tract infection.
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your surgeon 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. 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 10 lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2047**] to schedule a follow-up appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks.
|
[
"560.2",
"789.59",
"557.0",
"401.9",
"599.0",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
5814, 5875
|
2859, 5231
|
293, 388
|
6012, 6020
|
1794, 2836
|
8195, 8363
|
1364, 1436
|
5364, 5791
|
5896, 5991
|
5257, 5341
|
6171, 7130
|
7683, 8172
|
1451, 1775
|
7162, 7668
|
239, 255
|
416, 1120
|
6035, 6147
|
1142, 1245
|
1261, 1348
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,828
| 132,939
|
23910
|
Discharge summary
|
report
|
Admission Date: [**2103-4-24**] Discharge Date: [**2103-4-26**]
Date of Birth: Sex:
Service:
HISTORY: This was a 37-year-old man who while riding a
bicycle was struck by a motorcycle in [**Hospital3 **]. He was
emergently transferred here by helicopter. Upon arrival, he
was intubated and unresponsive. He appeared hemodynamically
stable. He had an open tibial and fibular fracture with
probable dislocation of the left knee. And he had no palpable
pulses at the ankle.
PAST MEDICAL HISTORY: Unremarkable.
HOSPITAL COURSE: The patient underwent a diagnostic
peritoneal lavage which was negative. He was then brought to
the CT scanner. The CT scan at admission on [**4-24**]
demonstrated diffuse intraparenchymal hemorrhage with a
moderate amount of swelling. A CT scan of the chest
demonstrated a possible tear of the descending thoracic
aorta. He had bilateral pneumothoraces and mediastinal blood.
There was no obvious intraperitoneal injury. He had both left
and right-sided pubic ramus fractures and a left iliac pelvic
fracture. He had a left femoral head dislocation. Further
examination demonstrated a left open elbow fracture and a
fracture of the left proximal phalanx of the hand.
It was decided to bring him to the operating room for
relocation of the hip, on-table angiography, and possible
vascular reconstruction of the lower leg. On the day of
admission, he underwent successful operative relocation of
the hip. Dr. [**Last Name (STitle) **] [**Location (un) **], of orthopedics, then irrigated the
left open elbow injury. He placed an external fixator on the
left tibial-fibular fracture. The hand fracture was reduced.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1391**] of vascular surgery then
performed a left above knee popliteal-to-posterior tibial
saphenous bypass graft. The patient was then returned to the
intensive care unit.
The following day, a repeat head CT showed progression of his
intracerebral hemorrhage with marked edema and subfalcine
herniation. After discussion with the family, it was elected
to make him comfort measures only. Accordingly, he expired on
the 3rd hospital day, [**4-26**].
DISPOSITION: Deceased.
CONDITION ON DISCHARGE: Deceased.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2103-12-25**] 18:41:04
T: [**2103-12-26**] 04:21:52
Job#: [**Job Number **]
|
[
"860.4",
"813.31",
"E813.6",
"904.7",
"728.89",
"901.0",
"958.4",
"286.9",
"808.0",
"285.1",
"823.32",
"851.45",
"816.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"79.62",
"99.05",
"01.18",
"99.04",
"88.48",
"79.02",
"99.07",
"88.72",
"79.04",
"79.06",
"88.42",
"39.29",
"78.17",
"79.66",
"79.09",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
558, 2202
|
525, 540
|
2227, 2507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,803
| 191,425
|
49884
|
Discharge summary
|
report
|
Admission Date: [**2156-6-26**] Discharge Date: [**2156-7-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Worsening hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 88 yo male with CAD, GERD, Hyperlipidemia, who
presented on [**2156-6-26**] with shortness of breath. He had seen his
PCP two days prior to admission with fevers to 102.5, chills,
dry cough, and started on Levaquin for community acquired
pneumonia. He got worsening shortness of breath and went to the
emergency room. In the ED, noted to be 96% on room air with
ambulatory sat of 93%. CTA was negative for PE. He was started
on levaquin for likely community acquired pneumonia as well as
prednisone for a likely reactive airway component.
ROS: normally, able to walk 1.5 miles stopping secondary to leg
pain. No CP/PND/orthopnea. No recent travel. No pets. No sick
contacts. [**Name (NI) **] recent weight loss. No night sweats.
Past Medical History:
1. Coronary artery disease
2. Hypertension
3. Hypercholesterolemia
4. Status post catheterization in [**2149**] with a stent of the
first diagonal
5. Gastroesophageal reflux disease.
6. Depression.
7. Benign prostatic hypertrophy.
8. Status post cholecystectomy.
Social History:
FOrmer vocational school teacher. No tobacco. Rare EtOH.
Family History:
No lung or heart disease in family. M: died of CVA
Physical Exam:
T: 95.3, BP: 136/60; HR: 73; RR: 19; O2: 98 NRB
Gen: On NRB, comfortable, able to speak in 5 word sentences. No
accessory muscle use.
HEENT: PERRL; EOMI; sclera anicteric; OP clear
Neck: No LAD. JVD flat
CV: distant, S1S2. No M/R/G
Lungs: Diffuse rhnochi bilaterally in all lung fields. +wheezing
Back: no spinal, paraspinal, CVA tenderness
Abd: Soft, NT, ND
Ext: No edema. DP 2+
Neuro: A&O x 3. Conversant and appropriate.
Pertinent Results:
CXR PA/LAT 5/19/07-1. No pneumonia is identified.
2. Low lung volumes are diminished bilaterally, some of which
is related to poor inspiratory effort and some of which is
related to dependent atelectatic changes which is more severe on
the left side.
3. Severe osteoarthritis of the right acromioclavicular joint.
An old fracture deformity of the right distal clavicle.
.
CTA [**2156-6-26**]-
1. No evidence of pulmonary embolism.
2. Mild bronchiectasis in both lower lobes posteromedially,
with mild bronchiectasis in the right middle lobe. There is
bronchovascular thickening and bronchial wall thickening in both
lower lobes. Findings may represent early pneumonia.
.
EKG: Atrial fibrillation at 62. Normal axis. Normal intervals.
No ST
changes.
[**6-28**] ECHO
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta
is mildly dilated. The aortic valve leaflets appear structurally
normal with
good leaflet excursion. No aortic regurgitation is seen. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
There is
borderline pulmonary artery systolic hypertension. There is an
anterior space
which most likely represents a fat pad.
IMPRESSION: Preserved global biventricular systolic function.
CT HEAD WO CONTRAST [**6-30**]
FINDINGS: The study is limited by patient motion. No intra or
extraaxial hemorrhage, mass effect, or shift of normally midline
structures is identified. Ventricles and sulci are slightly
prominent consistent with age-related involutional change and
stable since the prior study. The previously noted right
sphenoid [**Doctor First Name 362**] meningioma is not well seen on the current study.
There is an air-fluid level in the left maxillary sinus. Soft
tissues appear unremarkable.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
Air-fluid level in the left maxillary sinus.
[**2156-6-26**] 06:18PM PT-12.4 PTT-31.7 INR(PT)-1.1
[**2156-6-26**] 06:18PM D-DIMER-1858*
[**2156-6-26**] 04:00PM GLUCOSE-110* UREA N-26* CREAT-1.3*
SODIUM-130* POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-25 ANION GAP-13
[**2156-6-26**] 04:00PM estGFR-Using this
[**2156-6-26**] 04:00PM CK(CPK)-216*
[**2156-6-26**] 04:00PM CK-MB-3 cTropnT-<0.01 proBNP-374
[**2156-6-26**] 04:00PM WBC-10.6# RBC-4.66 HGB-15.3 HCT-43.3 MCV-93
MCH-32.8* MCHC-35.3* RDW-13.0
[**2156-6-26**] 04:00PM NEUTS-80.0* LYMPHS-12.3* MONOS-6.9 EOS-0.1
BASOS-0.7
[**2156-6-26**] 04:00PM PLT COUNT-157
[**2156-6-26**] 03:59PM LACTATE-1.5
Brief Hospital Course:
88 yo male with HTN, CAD, hyperlipidemia, presents with hypoxia,
thought to have pneumonia.
# Hypoxemia- The patient was initially diagnosed with CAP and
was stable on [**3-14**] L nc on the floor. On day 2, O2 saturtion
noted to be 93 on 3L NC. On routine vital sign check at 9 pm,
noted to have O2 saturations 81-88%. A nebulizer treatment
improved O2 saturations to 90% to 94% on NRB. ABG on 5L was
7.52/28/56. On NRB it was 7.48/32/79 with a lactate of 3.2. Per
wife, at 6 pm pt sounded "congested" on the telephone, which was
a change. Also, pt reported that a piece of rice may have been
aspirated when he coughed at lunchtime. He was transferred to
the ICU for 24 hours, was able to wean down NRB to FM and then
again nc. Acapella device was used, pt thought to have
bronchiectasis besides pneumonia. A speech and swallow
evaluation was normal. Initially on levaquin, later switched to
azithromycin and CTX. Received 3 days of steroids.
.
# Atrial fibrillation-a fib on EKG on floor. Repeat in unit
showed sinus tachycardia. Likely [**3-12**] hypoxia. No acute EKG or ST
changes. He was monitored on telemetry with no events, and an
echo was wnl, showing only slight diastolic CHF.
Anticoagulation not indicated.
.
# MS changes: 2 days prior to discharge, the patient became
combative and confused in the evening and had to be restrained.
CT head was normal. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1634**] consult was obtained, recommendations
were 0.25 mg Haldol prn and zyprexa standing at night. The pt??????s
confusion resolved prior to discharge and was thought to be due
to hospital environment, ICU, and medications.
# CAD- no changes on EKG. Continued ASA, statin, BB
# CKD- creatinine baseline 1.3. s/p mucomyst and bicarb post
contrast. Improved to 1.2
.
# HTN- continue CCB, restart BB.
.
# FEN cardiac diet
.
# Access PIV
.
# PPx- hep sc, PPI per outpt
.
# Code status- Full Code
.
# [**Name (NI) **] wife [**Name (NI) **] [**Name (NI) 1313**] [**Telephone/Fax (1) 104215**]
Medications on Admission:
PRILOSEC CAP 20MG CR QD
PROSCAR TAB 5MG one po QD three times a week
VERAPAMIL HCL CR TBCR 120 MG qd
REMERON TABS 15 MG qd
ATENOLOL TABS 25 MG qd
FAMVIR 250 MG TABS one po tid
ACLOVATE 0.05 % CREA as directed
FLOVENT 110 MCG/ACT AEROSOL one puff [**Hospital1 **]
NITROTAB 0.4 MG SL TAB USE AS DIRECTED
LIPITOR TABS 10 MG qd
LIBRIUM CAP 10MG QD prn
Aspirin
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Capsule(s)* Refills:*0*
4. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO QHS
(once a day (at bedtime)) as needed for Anxiety.
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*0*
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One
(1) Inhalation twice a day as needed for wheezing.
Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Caregroup Vna
Discharge Diagnosis:
Primary
Community Acquired Pneumonia
Delirium
Secondary
Hypertension
Discharge Condition:
Good. Breathing comfortably on room air. Ambulatory. Alert and
Oriented x 3
Discharge Instructions:
You were admitted to the hospital because you have a bacterial
pneumonia. This was causing severe shortness of breath. You
needed to be transferred to the ICU for 24 hours due to this
problem. [**Name (NI) **] also became acutely delirious.
Please take all your medicines and antibiotics as prescribed,
and return to the ED if you have any concerns. Please see your
doctor within one week of discharge.
Followup Instructions:
With your Primary Care provider within one week of discharge.
Please call to make an appointment.
|
[
"V45.82",
"600.00",
"272.0",
"486",
"403.90",
"311",
"414.01",
"585.9",
"427.31",
"293.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8336, 8380
|
4706, 6727
|
278, 285
|
8494, 8572
|
1943, 4683
|
9024, 9125
|
1431, 1483
|
7134, 8313
|
8401, 8473
|
6753, 7111
|
8596, 9001
|
1498, 1924
|
221, 240
|
313, 1053
|
1075, 1340
|
1356, 1415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,271
| 151,184
|
46444
|
Discharge summary
|
report
|
Admission Date: [**2161-4-7**] Discharge Date: [**2161-4-17**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a [**Age over 90 **] y/o f with htn, dm2, cad s/p cabg who presents with
lightheadedness starting this AM. She states she'd been under
severe stressors recently and had not been eating well as a
result. She awoke the morning of presentation, feeling her
normal self, went to the bank, became rather irritated while
dealing with the teller, and began to feel "spacy." It is
difficult for her to further characterize this, yet she denies
confusion or disorientation; the symptoms sound most like
lightheadedness, without chest pain, palpitations, shortness of
breath, or diaphoresis. The symptoms had resolved by the time
she reached the ED, where she was found to be afebrile,
normotensive, non-tachycardic, and satting 100% on room air. Her
ECG was unchanged.
She does have a recent h/o falls, though she denies any syncope
during these episodes, and no preceding symptoms, continually
asserting these were mechanical falls.
Within hours of reaching the floor on the first night of
admission, she became increasingly disoriented and hypotensive.
An ABG was 7.34/40/131 with a lactate of 0.9. She responded
initially to volume resucitation but despite 2L normal saline
she became hypotensive again with a SBP in the high 70s and low
80s and was thus transferred to the ICU for further monitoring.
Past Medical History:
-coronary artery disease: s/p CABG x 4 in [**2150**] (SVG to LAD, D1,
OM2, PDA), recent catheterization in [**11-6**] showed 3VD including
occluded mid LAD which could not be revascularized. Most recent
TTE [**1-6**] with normal valves, LVEF > 55%.
-type II diabetes mellitus
-hyperlipidemia
-GERD
-h/o pulmonary embolus
-anxiety
-HTN
-?atrial fibrillation, not on anticoagulation
-?COPD, nl. PFTs in [**11-4**]
-diverticulosis
-thrombocytopenia
-S/P L hip arthroplasty
-S/P lung resection for [**Doctor First Name **] in 7/00
-S/P TAH BSO
-S/P L cataract surgery
-S/P appendectomy
-h/o falls
Social History:
Patient lives alone in an apartment and noted to be fully
independent in her ADLs. Potential family support includes a
daughter that lives in [**State 350**] (poor relationship with her
daughter) and a son in [**Name (NI) 108**] (but currently in [**Male First Name (un) 1056**]).
No use of tobacco, alcohol or illicit drugs.
Family History:
Remarkable for diabetes mellitus and coronary artery disease in
a number of family members.
Physical Exam:
t- 97.9, bp 110/86, hr 74, rr 14, spo2 99%ra
gen- thin, elderly female, not acutely ill, nad
heent- bruise below right eye, anicteric sclera, op clear with
mmm
neck- no jvd, no lad, no thyromegaly
cv- rrr, s1s2, no m/r/g
pul- decreased breath sounds throughout, though moves air well,
no w/r/r
abd- soft, nt, nabs, no organomegaly
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- a&ox3, language fluent, affect anxious with pressured
speech. cn: eomi, perrl, facial motion intact/symmetric, tongue
midline without fasiculations. no gross motor or sensory
deficit.
Pertinent Results:
Hematology
[**2161-4-7**] 01:15PM BLOOD WBC-2.2* RBC-3.83* Hgb-11.8* Hct-33.9*
MCV-89 MCH-31.0 MCHC-35.0 RDW-12.6 Plt Ct-76*
[**2161-4-10**] 04:58AM BLOOD WBC-4.1# RBC-3.76* Hgb-11.5* Hct-33.0*
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.4 Plt Ct-65*
[**2161-4-15**] 05:55AM BLOOD WBC-2.5* RBC-3.50* Hgb-10.7* Hct-31.6*
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.5 Plt Ct-84*
[**2161-4-8**] 10:30AM BLOOD Ret Aut-1.2
[**2161-4-11**] 04:53AM BLOOD calTIBC-196* Ferritn-498* TRF-151*
[**2161-4-8**] 10:30AM BLOOD VitB12-670 Folate-18.8
Chemistries
[**2161-4-7**] 01:15PM BLOOD Glucose-157* UreaN-20 Creat-1.1 Na-129*
K-5.6* Cl-
93* HCO3-27 AnGap-15
[**2161-4-11**] 04:53AM BLOOD Glucose-163* UreaN-12 Creat-0.8 Na-138
K-3.6 Cl-102 HCO3-25 AnGap-15
[**2161-4-15**] 05:55AM BLOOD Glucose-163* UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-30* AnGap-10
[**2161-4-15**] 05:55AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8
[**2161-4-15**] 05:55AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8
[**2161-4-15**] 05:55AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8
Cardiac Enzymes
[**2161-4-8**] 10:30AM BLOOD CK(CPK)-29
[**2161-4-8**] 10:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2161-4-8**] 08:29PM BLOOD CK(CPK)-56
[**2161-4-8**] 08:29PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2161-4-9**] 04:22AM BLOOD CK(CPK)-143*
[**2161-4-9**] 04:22AM BLOOD CK-MB-16* MB Indx-11.2* cTropnT-0.96*
[**2161-4-9**] 12:45PM BLOOD CK(CPK)-118
[**2161-4-9**] 12:45PM BLOOD CK-MB-11* MB Indx-9.3* cTropnT-0.68*
[**2161-4-10**] 04:58AM BLOOD CK(CPK)-204*
[**2161-4-10**] 04:58AM BLOOD CK-MB-18* MB Indx-8.8* cTropnT-0.69*
[**2161-4-11**] 04:53AM BLOOD CK(CPK)-534*
[**2161-4-11**] 04:53AM BLOOD CK-MB-15* MB Indx-2.8 cTropnT-0.34*
[**2161-4-13**] 05:10AM BLOOD CK(CPK)-710*
[**2161-4-13**] 05:10AM BLOOD CK-MB-10 MB Indx-1.4 cTropnT-0.24*
[**2161-4-14**] 06:55AM BLOOD CK(CPK)-213*
[**2161-4-14**] 06:55AM BLOOD CK-MB-5 cTropnT-0.16*
[**2161-4-14**] 06:55AM BLOOD CK-MB-5 cTropnT-0.16*
[**2161-4-14**] 06:55AM BLOOD CK-MB-5 cTropnT-0.16*
Lipids
[**2161-4-12**] 06:25AM BLOOD Triglyc-95 HDL-37 CHOL/HD-2.6 LDLcalc-39
Brief Hospital Course:
[**Age over 90 **] y/o female with type II diabets, htn, cad s/p cabg and ptci,
and anxiety who presented with transient lightheadedness, was
transferred to the MICU for hypotension and there experienced an
[**Age over 90 7792**], and once stable was transferred to the floor with
resolving chest pain.
1.)Coronary artery disease -- Given the extent of the patient's
disease, her poor overall health, and her recent cardiac
catheterization showing a non-intervenable lesion in the LAD,
Mrs. [**Known lastname 98664**] was maximally medically managed in the MICU
early in her admission. Once back on the floor, she again
experienced chest pain with increasing CK's, and the heparin
drip was restarted; her pain soon resolved, with declining CK's,
allowing the discontinuation of heparin. Aspirin, isosorbide
dinitrate, and atorvastatin were continued, clopidogrel was
added to the regimen (given its known benefit in medically
managed acute coronary syndrome), and her metoprolol was
titrated up to achieve a goal resting hear rate of 55-60. On
this regimen, she remained chest pain free without further
evidence of ischemia. The plan was to discharge Mrs.
[**Known lastname 98664**] on this regimen and to have her follow-up with her
outpatient cardiologist, Dr. [**First Name (STitle) 2031**], who also followed her while
an inpatient.
2.)Delirium -- During her ICU stay, Mrs. [**Known lastname 98664**] evinced
signs of delirium, most prominently disorientation and
fluctuating levels of conciousness. This was attributed to
multiple medical problems, including her [**Name (NI) 7792**], pneumonia, and
the ICU environment (ICU delirium). These problems were each
treated individually as described elsewhere with good effect.
3.)Pneumonia -- Seen initially on a routine chest x-ray, this
radiologic finding, in conjuction with her symptoms of
productive cough, prompted the team to initiate levofloxacin for
a probable pneumonia. The patient tolerated the medication well
and remained afebrile with declining symptoms. Early in the
treatment course she required a modicum of supplemental oxygen
support (two liters) but soon demonstrated good saturation
(96-98%) on room air. The plan was to finish a ten day course
of levofloxacin.
4.)Hypotension -- Only noted during her admission day and not
again after her MICU transfer, this abnormality was felt to be
due to a combination of hypovolemia and the receipt of her blood
pressure medications at the same time. There was some question
of whether she actually took both atenolol and lisinopril at
home, and if she did not, perhaps the combination of both
medications, taken at the same time, in the setting of
hypovolemia, produced this effect. As previously described, she
remained normotensive throughout the remainder of the admission,
tolerating increasing doses of metoprolol.
5.)Cell counts -- Mrs. [**Known lastname 98664**] has been thrombocytopenic for
as far back as her lab values reach in the [**Hospital1 18**] system, back to
[**2151**]. This, taken with her anemia and low white count certainly
raises concern for a myelodysplastic or other marrow-based
process. As her counts remained stable and she was not
neutropenic, it was felt that this should be followed-up as an
outpatient when the patient had improved from her more acute
issues.
6.)Diabetes -- Her blood sugars were intially controlled with
sliding scale insulin, but she was transitioned back over to
metformin towards the end of the hospital course.
Medications on Admission:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze, shortness
of breath.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS PRN () as needed for extreme agitation.
14. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
15. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
16. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Failure to thrive
Non-ST elevation myocardial infarction
Pneumonia
Secondary:
-coronary artery disease: s/p CABG x 4 in [**2150**] (SVG to LAD, D1,
OM2, PDA), catheterization in [**11-6**] showed 3VD including
occluded mid LAD which could not be revascularized. TTE [**1-6**]
with normal valves, LVEF > 55%
-type II diabetes mellitus
-hyperlipidemia
-GERD
-h/o pulmonary embolus
-anxiety
-HTN
-?atrial fibrillation, not on anticoagulation
-?COPD, nl. PFTs in [**11-4**]
-diverticulosis
-thrombocytopenia
-S/P L hip arthroplasty
-S/P lung resection for [**Doctor First Name **] in 7/00
-S/P TAH BSO
-S/P L cataract surgery
-S/P appendectomy
-h/o falls
Discharge Condition:
Fair, with resolution of chest pain, lightheadedness
Discharge Instructions:
Please call your PCP or return to the emergency department for
chest pain, shortness of breath, fevers/chills, confusion, or
other concerning symptoms.
Take medications as prescribed.
Follow-up as below.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-4-20**] 3:00
Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 3152**] [**Hospital 1947**] CLINIC Where: CC-2 [**Hospital 1947**]
UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2161-4-28**] 2:10
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-6-4**] 2:00
Please follow-up in the hematology clinic for you low red blood
cells, white blood cells, and platelets; call ([**Telephone/Fax (1) 14703**] to
make an appointment.
|
[
"401.9",
"276.5",
"414.01",
"410.71",
"427.31",
"530.81",
"287.5",
"293.0",
"250.00",
"V45.81",
"272.4",
"496",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11211, 11296
|
5354, 8855
|
235, 241
|
11991, 12045
|
3295, 5331
|
12299, 13048
|
2549, 2643
|
9727, 11188
|
11317, 11970
|
8881, 9704
|
12069, 12276
|
2658, 3276
|
180, 197
|
269, 1572
|
1594, 2188
|
2204, 2533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,721
| 153,932
|
29730
|
Discharge summary
|
report
|
Admission Date: [**2200-1-26**] Discharge Date: [**2200-3-6**]
Date of Birth: [**2122-1-20**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Trauma/intracranial hemorrhage
Major Surgical or Invasive Procedure:
Mechanical Ventilation
s/p Open GJ tube placement
History of Present Illness:
Patient is a 78 yo (?age) male with DM, dylipidemia who was
found down by a neighbor after what seems like a fall down the
stairs on [**2200-1-26**] and suffered multifocal left-sided
intracranial
hemorrhage. Patient lives alone and is intubated now so full
history is limited. According to ED note, patient was found down
at base of 10 stairs on concrete floor. He was found LOC and
bleeding from left facial laceration. He was brought to ED in
"semi-conscious state". Admission vitals from [**2200-1-26**] 1pm were
AF, HR 80, BP 158/60. He was intubated for airway protection.
Head CT done and showed acute intracranial hemorrhage seen in
left basal ganglia, left frontal lobe, and both lateral
ventricles and C-spine CT showed nondisplaced fracture of left
C7 transverse process and severe degenerative changes at
multiple levels. Patient admitted to Trauma Surgery who did
CT-pelvis and abdomen both negative. Neurosurgery consulted and
no surgical intervention recommended. Repeat head CT on [**2200-1-27**]
showed some interval increase in amount of intraventricular
blood. Neurology called to consult as concern of left sided
weakness and on exam may suggest stroke.
Past Medical History:
DM
dyslipidemia
depression
Social History:
Unknown
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: Tm: 97.8-100.3 BP: 113/49-159/57 HR: 57-64
RR: [**10-12**] O2Sat 100% on CPAP 5
Gen: Intubated, alert
HEENT: Roving eyes, conjugate movement. Midline at rest
Neck: C-collar in place. L. clavicular deformity
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR
Abd: Soft, NT, ND, +NABS. No rebound or guarding.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Opens eyes to voice. Follows midline and
appendicular commands though inconsistent
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Does not blink to threat on left.
III, IV, VI: Does not track but has horizontal conjugate eye
movements with no full abduction bilat.
V, VII: Facial assym with ETT. Coreals intact bilat
VIII: Turns to voice bilat
IX, X: deferred
[**Doctor First Name 81**]: deferred
XII: deferred
Motor: Increased tone bilat legs. Lifts left arm AG spont.
Lifts
left leg spont AG and flexes. Has minimal spont AG movement of
right leg. Right arm flexes only to deep nail bed pressure
though
minimal spont finger movement seen on this side. Fasiculations
noted in left hand and bilat thighs
Sensation: Withdraws more briskly on left than right UE and LE.
Withdraws more UE> LE overall.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 2
Left 2 2 2 3 2
Grasp reflex absent. Toes downgoing bilaterally. No clonus
Pertinent Results:
LABS ON ADMISSION:
[**2200-1-26**] 01:45PM WBC-9.5 RBC-2.74* HGB-8.8* HCT-24.6* MCV-90
MCH-32.2* MCHC-36.0* RDW-13.2
[**2200-1-26**] 01:45PM PT-15.7* PTT-38.4* INR(PT)-1.4*
[**2200-1-26**] 01:45PM FIBRINOGE-128*
[**2200-1-26**] 01:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2200-1-26**] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2200-1-26**] 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2200-1-26**] 01:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2200-1-26**] 01:45PM CK-MB-NotDone cTropnT-<0.01
[**2200-1-26**] 01:45PM CK(CPK)-89 AMYLASE-24
[**2200-1-26**] 06:41PM TYPE-ART TEMP-36.6 RATES-12/ TIDAL VOL-600
PEEP-5 O2-100 PO2-382* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2
AADO2-301 REQ O2-56 -ASSIST/CON INTUBATED-INTUBATED
IMAGING STUDIES:
CT-Head [**2200-1-26**]:
1. Acute intracranial hemorrhage seen in left basal ganglia,
left frontal lobe, and both lateral ventricles. The other
suspicious mass lesion seen within the lateral ventricles also
most likely represents hematoma.
2. No fracture is noted. Scalp hematoma is noted on the left
frontal side
CT C-spine [**2200-1-26**]:
IMPRESSION:
1. Nondisplaced fracture of left C7 transverse process.
2. Severe degenerative changes at multiple levels, with severe
disc space
narrowing and osteophyte formation.
3. A small ossific density anterior to the C4-7 vertebral
bodies is most
likely due to prior injury or might be secondary to degenerative
effects.
CT Sinus [**2200-1-26**]:
IMPRESSION: No facial fractures. Left occipital and mandibular
soft tissue injuries. Intracranial hemorrhage better
characterized on the dedicated head CT.
CT Torso [**2200-1-26**]:
CT CHEST: The heart size is normal. Vascular calcifications
are identified.
There is no axillary, mediastinal, or hilar lymphadenopathy.
There is
dependent atelectasis. The lungs are otherwise clear. There is
no evidence
of pneumothorax or pleural effusion.
CT ABDOMEN: Tiny left hepatic hypodensity is too small to be
characterized. The liver is otherwise unremarkable. The
gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach,
and bowel loops are unremarkable within the limits of this study
without oral contrast. There is no free air or free fluid. No
mesenteric or retroperitoneal lymphadenopathy is identified.
CT PELVIS: Foley catheter and air are noted in the bladder.
The prostate, seminal vesicles, sigmoid colon, and rectum are
unremarkable. There is no free fluid and no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic
osseous lesions. No fractures are identified. Degenerative
changes of the thoracic and lumbar spine are noted with minimal
lumbar levoscoliosis.
MRI Head [**2200-1-29**]:
IMPRESSION: Tiny foci of hemorrhage within the left cerebral
hemisphere and blood within the ventricles, potentially related
to recent traumatic injury, v. hemorrhagic residua from prior
small vessel infarcts (the latter consideration referring to the
brain parenchymal lesions). The focus of hemorrhage within the
left internal capsule and a small focus adjacent to the
occipital [**Doctor Last Name 534**] of the right lateral ventricle demonstrate
restricted diffusion, a finding that is nonspecific in etiology.
However, diffuse axonal injury is a diagnostic consideration, as
opposed to evolving infarcts.
MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**] [**2200-1-31**]:
IMPRESSION:
1. Mild compression of T3 vertebra without retropulsion with
marrow edema seen on inversion recovery images.
2.Subtle increased signal visualized at the site of nondisplaced
fracture
visualized on transverse processes of C7 on the left. No
evidence of hematoma seen.
3. Multilevel degenerative changes with mild-to-moderate spinal
stenosis at C3-4 level. No evidence of ligamentous disruption,
intraspinal hematoma, or extrinsic spinal cord compression.
Video Swallow [**2200-2-25**]:
INDICATION: Aspiration.
TECHNIQUE/FINDINGS: An oropharyngeal swallowing video
fluoroscopy study was performed in conjunction with speech
pathology department. Varying
consistencies of barium were administered orally under constant
video
fluoroscopy. Moderate impairment of the oral phase of
swallowing was seen, with severe difficulties of the bolus
transfer. Residue is seen within the vallecula and piriform
sinuses. Patient demonstrated penetration with honey and nectar
thin liquids, with aspiration of nectar thin liquids before
swallowing. This appeared to clear with cough.
LABS ON DISCHARGE:
WBC 15.9 Hct 35.6 Plts 444
Na 137 K 4.1 Cl 103 HCO3 24 BUN 15 Cr 0.7 Glu 89
Ca 8.1 Mg 2.1 Phos 2.9
Brief Hospital Course:
Patient was admitted to Trauma Service and placed in Trauma ICU
on Admission due to intubation for protection of airway.
1) s/p fall with intracranial hemorrhage: Secondary to the fall,
patient developed intracranial hemorrhage and diffuse axonal
injury (seen on CT and MRI) leading to a some cognitive
impairment and right hemiparesis. EEG was done and had
non-specific findings. Patient completed 7-day course of
phenytoin for seizure prophylaxis in setting of traumatic brain
injury. He continues to have residual right-sided deficits and
depressed mental status that seem to be improving slowly. He was
discharged to for long term rehab.
2) C7 fracture: Trauma workup revealed nondisplaced fracture of
left C7 transverse process and severe degenerative changes at
multiple levels. Patient was initially in cervical collar for
this but was later cleared by neurosurgery. CT abdomen, pelvis
were done and showed no acute injury. He will need follow-up
with neurosurgery as an outpatient.
3) Nutrition: Initially, he was started on tubefeedings while
intubated. However, after he removed his nasogastric tube, oral
diet was attempted. However, having failed 2 video swallow
evaluations, patient's PO intake was limited by
coughing/aspiration. After discussion with patient and his
healthcare proxy, since there was a possibility of recovery of
some function, a decision was made to place a percutaneous
gastrostomy tube for nutritional supplementation. Unfortunately,
a PEG was unable to be placed by GI safely due to a large hiatal
hernia and could not be placed by IR secondary to overlying
mesentery and colon. Surgery was consulted for placement of an
open GJ feeding tube and due to the increased morbidities of an
open procedure, calorie counts and the patient's po intake was
monitored closely for several days prior. The patient was again
evaluated by speech and swallow who felt that his aspiration
risk was compounded by the fact that he fatigued very easily
during feeding. Thus, he went for placement of an open GJ tube
by surgery. Tube feeds were initiated 24 hrs afterwards, which
the pt tolerated with addition of standing reglan. During tube
feed titration, it was noted that his residuals were
gastrooccult positive, which was accompanied by a Hct drop.
Surgery was called who felt that this was likely due to a
hematoma that is breaking down. His Hct was followed and
remained stable without further transfusion and was placed on a
[**Hospital1 **] ppi. By the time of discharge, the patient was tolerating
his tube feeds at 70 cc/hr and residuals were gastrooccult
negative.
4) Resp: Patient came to trauma service intubated in the ED for
airway protection. He was extubated in MICU without
complications.
5) Diabetes mellitus: Patient was maintained on glargine and
sliding scale in house for glycemic control. He had several
episodes of am hypoglycemia and his lantus was titrated down to
20 U qhs. Although his FS were noted to be not persistently at
goal, his insulin regimen was not further titrated up.
6) Leukocytosis: Pt with leukocytosis during majority of
hospital course with low grade fevers initially, and then
without fevers during the last 3 weeks of hospitalization.
Cultures only significant for a sputum culture with MRSA;
however no evidence of PNA on CXR. Was swabbed for MRSA both
nasally and rectally and found to be carrier of MRSA. Completed
10 day course of IV Vancomycin and Zosyn regardless. A trial of
Foley d/c was attempted on multiple occasions, but was replaced
each time for failure to void and high residuals on bladder
scan. Review of medications was not significant for agents that
would cause significant urinary retention, beyond prn dilaudid,
which the pt was not receiving. He will need his Foley clamped
during his rehab stay several times prior to d/c of Foley to
help promote bladder function.
.
Code: DNR but may intubate.
He was discharged to rehab in fair condition for continued
stroke PT and OT, and tube feeds.
Medications on Admission:
1. Glyburide
2. Prozac
3. Trazadone
4. Aspirin
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: 1-2 tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 tablets* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*500 ML(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*2*
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): apply to medial aspect of L thigh/leg.
Disp:*1 tube* Refills:*2*
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*0*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
Disp:*1 bottle* Refills:*0*
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
Disp:*30 nebulizer* Refills:*0*
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
Disp:*30 nebulizer* Refills:*0*
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*600 units* Refills:*2*
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: per
enclosed sliding scale chart units Subcutaneous qachs.
Disp:*500 units* Refills:*2*
16. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Hydromorphone 2 mg/mL Syringe Sig: 0.5 - 2 mg Injection Q6H
(every 6 hours) as needed for pain.
Disp:*50 mg* Refills:*0*
19. tube feeds
Nutren Pulmonary full strength
Starting rate: 10 cc/hr, advancing 10 cc q4h to goal rate of 80
cc/hr (feeds running at 70 cc/hr by time of transfer)
Please cycle: start 4 pm, end 10 am
Residual check q4h, holding for residuals > 100 cc
Flush with 250 cc free H20 q6h
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
s/p fall with L basal ganglia and intraventricular bleed
C7 fracture
Secondary Diagnosis:
DM II
Hyperlipiedemia
Depression
Discharge Condition:
Fair, eating fair amt of pos with assitance, breathing well on
room air, not ambulatory.
Discharge Instructions:
You were admitted after a fall and were found to have a C7
fracture as well as a head bleed that has resulted in an
inability to move the right side of your body.
You had a feeding tube placed to help support your nutrition
needs pending further improvement in your mental status.
Please take all medications as prescribed.
Call your physician or return to the emergency room if you
experience any of the following: increasing confusion and
altered mental status, fever > 101, shortness of breath,
abdominal pain.
Followup Instructions:
Please follow-up with neurosurgery within 2-4 weeks for your
stable C7 fracture. Call [**Telephone/Fax (1) 1669**] to make an appointment.
Completed by:[**2200-3-6**]
|
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"348.30",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.05",
"45.13",
"96.71",
"86.59",
"43.19",
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] |
icd9pcs
|
[
[
[]
]
] |
14562, 14632
|
7946, 11943
|
299, 351
|
14819, 14910
|
3093, 3098
|
15475, 15644
|
1650, 1659
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11969, 12017
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14934, 15452
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229, 261
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7812, 7923
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379, 1558
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2187, 3074
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14672, 14742
|
3113, 4028
|
2087, 2171
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1580, 1609
|
1625, 1634
|
4046, 7793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,282
| 166,481
|
54879
|
Discharge summary
|
report
|
Admission Date: [**2186-8-28**] Discharge Date: [**2186-8-31**]
Date of Birth: [**2127-2-20**] Sex: F
Service: NEUROLOGY
Allergies:
scallop
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
(obtained from transfer medical records, OMR, and transfer s/o)
Mrs. [**Known lastname 4048**] is a 59-year-old right-handed woman with history of
HTN, HLD, COPD on home O2, CHF, cervical and endometrial
adenocarcinoma, paraganglioma of the left skull base s/p
radiation, seizure disorder due to paraneoplastic limbic
encephalitis who is transferred from OSH intubated after episode
of unresponsiveness for further of current presentation and
skull base tumor. Mrs. [**Known lastname 4048**] initially presented to OSH on
[**2186-8-24**] after having a transient (seconds to minutes) loss of
consciousness. She was sitting at the dining room table with her
mother when she went from alert, at baseline, to snoring
respirations. She then fell off her chair to the right and lost
consciousness. No activity concerning for seizure. By time EMS
arrived she had returned to baseline alertness. In the ED she
was found to have a UTI and was started on cipro and admitted.
On [**2186-8-25**] neurology and heme/onc were consulted for the
transient LOC. She had had 2 prior epsiodes similar in nature in
the past 6 weeks, although one of these was possibly in the
setting of choking. During all 3 of these events it was unclear
why she had the transient LOC as she had normal EEGs and TTEs.
On [**2186-8-26**] she was noted to be more confused and was hypoxic. The
rapid response team was called, and after further decompensating
to unresponsiveness with a O2 sat of 92% on high flow O2 (35%),
she was intubated. Notes indicate that blood was flowing out of
the nasal trumpet. She was initially hypertensive but then
required pressors for blood pressure support. She was
transferred to the ICU. They could find no clear cause for the
decompensation. Of note her INR was therapeutic at admission,
decreased to 1.8 on [**8-25**], and then again therapeutic [**8-26**]. It
appears coumadin was continued until yesterday, when it was held
for pending evaluation here of skull base tumor. On [**2186-8-28**] they
noted that the patient was alert and could follow commands but
they were unable to wean her from the vent. Given concern that
the skull base lesion may be contributing, they pursued transfer
here as her Neuro-oncologist is Dr. [**Last Name (STitle) 724**].
Mrs. [**Known lastname 4048**] was seen in [**Hospital **] clinic [**2186-8-21**] for a
putative, non-biopsy proven, paraganglioma of the left skull
base, invasive. The patient has undergone radiation, without
resection, of this lesion. This paraganglioma has since
enlarged extending further, invasive of the left skull base and
petrous temporal bone. Her last brain MRI was done [**2-/2186**]
(report in Atrius) which noted that "there was a marked increase
in size of the metastatic lesion in the left petrous apex bone.
There is extension of the mass into the posterior fossa, the
foramen magnum, and into the infratemporal fossa on the left.
The lesion has increased in size from approximately 1.5 cm to
4.5 cm in size."
With respect to Mrs. [**Known lastname 4048**]' oncologic history, a paraneoplastic
limbic encephalitis was the first presenting suggestion of an
oncologic process. She developed a complex partial seizure
disorder greater than three years ago culminating in the
diagnosis of a paraneoplastic limbic encephalitis with increased
FLAIR signal in both medial and temporal lobes on MRI. She
received one course of IVIG, steroids and plasmapheresis which
apparently halved the antibody titer. The primary tumor giving
rise to the paraneoplastic process was not found. Nonetheless,
around the same time, she was diagnosed with a synchronous
cervical and endometrial adenocarcinoma. The grade of the
cervical carcinoma was T1N1M1,and the grade of the endometrial
adenocarcinoma was grade I, T1b. She underwent resection with
chemoradiation for these.
The seizure disorder is characterized by complex partial
seizures which do not generalize. The husband does not notice
the seizures, but the daughter notices them, and these have been
previously captured on EEG, per the patient. Per the husband,
the daughter notices a vacant look, and the patient seems spacey
for a short time.
Early last summer, the patient began to experience difficulty
swallowing. She had difficulty swallowing boluses with gagging,
choking, and demonstrated projectile vomiting. Soon after this,
she was noted to have a hoarse voice. Workup included imaging
of
the skull base, which included an MRI in [**Month (only) 956**] this year as a
follow up set of images. The MRI read from [**Month (only) 956**] suggests "a
metastatic lesion." Thus, paraganglioma was considered the most
likely diagnosis. She saw an ear, nose and throat surgeon at
[**Hospital 13128**] who suggested that intervention surgically
would
be dangerous and result in significant morbidity given the
location of the tumor at the skull base adjacent to cranial
nerves and great vessels. Therefore, she underwent radiation
treatment with the radiation to it including the left skull base
and the lesion. There has been no biopsy of this lesion to
demonstrate its underlying nature. She has not undergone Gamma
Knife or proton beam therapy. She was evaluated by Dr. [**Last Name (STitle) 724**] in
[**Hospital **] clinic to discuss surgical intervention or proton beam
or Gamma Knife intervention.
Although hoarseness appeared almost one year ago, it has
recently
worsened. Hoarseness had appeared last summer, improved about
three months ago, and then worsened again about two months ago.
At the present time, her husband, also with her on the visit
today, and the patient deny a modified diet, but it does appear
that the husband is giving her food that is easier to swallow at
the present time. She is taking thin liquids and somewhat soft
solids. She denied any difficulty swallowing recently with no
choking or vomiting.
Of note, in clinic the patient mentions a left-sided ptosis that
has appeared about two months ago. No appreciated change in
sweating on
the left side of the face.
ROS: unable, pt is intubated.
Past Medical History:
PMHx:
-Hypertension
-Hyperlipidemia
-hx of traumatic SDH that did not require surgical intervention
-hx of T3 vertebral fx s/p fall
-Paraneoplastic limbic encephalitis in [**2183**] resulting in
seizures and some difficulty with memory.
-Seizure disorder (complex partial, do not generalize)
-Cervical and uterine cancer 2.5 years ago s/p surgery and
chemoradiation
-COPD with chronic CO2 retention; with minimal tobacco history;
baseline bicarb 36; able to
walk about 40 to 50 feet, meaning that she can get to and from
the kitchen and to his car without difficulty.
-CHF (unknown EF)
-morbid obesity
-Hypercoaguable with Factor V Leiden mutation and positive lupus
anticoagulant - hx pulmonary embolism, on lifelong Coumadin.
PSHx:
Cholecystectomy
Recent herniorrhaphy
Social History:
-she lives with her daughter and husband. The daughter and
husband work alternating shifts and are able to help her home.
They get no further assistance in the house or visiting nursing.
-The patient previously smoked in her teens and young adult
group, but this was less than one pack a day and was only for
several years. Quit [**2165**].
-She drinks no alcohol and had previously only had rare alcohol.
At
home, she is able to walk around as mentioned above. The
patient
is presently not working.
-She does not use a walker, a cane, or a wheelchair at home.
Family History:
-no lung disease, COPD, seizures, or known cancers.
-mother: scoliosis and hypertension.
-has no siblings, attributed to Rhesus compatibility, per her
husband. Apparently, the patient's own birth was also
difficult, but they do not know further details.
Physical Exam:
Physical Exam on Admission:
Vitals: T 98.5 HR 73 BP 99/31 RR 16 96% on vent: CMV 60%
General: Intubated, sedated, morbidly obese.
HEENT: NC/AT
Neck: Supple
Pulmonary: Diminshed breath sounds throughout. No wheezes,
rales, rhonchi
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: trace pedal edema, 1+ DPs
Skin: no rashes or lesions.
Neurologic: (off proprofol for 10 minutes)
-Mental Status: Eyes open spontaneously. Attends to visual
stimuli. Will follow simple commands axially (Close eyes, stick
out tongue, look right/left) but not appendicular. Gaze midline,
possibly R preference but will cross midline to left. Intially
as propofol had been off for 5 minutes, eyes were slowly bobbing
vertically, which resolved spontaneously minutes later.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. Blinks to threat bilaterally. Corneals
intact. Full EOMI to the right, unable to bury sclera on
leftward gaze with 2-3 beats of fatigueable right beating
nystagmus. Strong gag.
-Motor: No spontaneous movement of extremities or movement to
command. Withdraws to noxious in bilateral UEs, triple flexes to
noxious in b/l LEs. No adventitious movements.
-Sensory: Grimaces to noxious throughout
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2+ 2+ 2+ 1 2
R 2+ 2+ 2+ 1 2
Plantar response was flexor bilaterally.
Physical Exam on Discharge:
expired
Pertinent Results:
Labs on Admission:
[**2186-8-28**] 09:20PM WBC-10.2 RBC-3.93* HGB-11.9* HCT-36.3 MCV-92
MCH-30.2 MCHC-32.7 RDW-14.9
[**2186-8-28**] 09:20PM PT-17.2* PTT-28.9 INR(PT)-1.6*
[**2186-8-28**] 09:20PM FIBRINOGE-434*
[**2186-8-28**] 09:20PM CALCIUM-8.0* PHOSPHATE-4.5 MAGNESIUM-2.2
[**2186-8-28**] 09:20PM GLUCOSE-134* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-30 ANION GAP-10
[**2186-8-28**] 09:26PM TYPE-ART PO2-81* PCO2-54* PH-7.35 TOTAL
CO2-31* BASE XS-2 INTUBATED-INTUBATED
Relevant labs:
[**2186-8-29**] 06:18AM BLOOD CK-MB-1 cTropnT-<0.01
[**2186-8-29**] 06:18AM BLOOD CK(CPK)-278*
Imaging:
MRI C spine
1. The left skull base mass involves the anterior and posterior
elements of C1 and C2. Though paravertebral expansion is
present, there is no significant spinal canal encroachment, and
no spinal cord compression.
2. Abnormal high T2 signal in the [**Doctor Last Name 352**] matter of the spinal
cord from the craniocervical junction through C3, with patchy
associated contrast enhancement, most likely related to subacute
infarction, given the presence of contiguous subacute infarction
in the left lateral medulla and the left posterior inferior
cerebellar hemisphere. Recommend follow-up to exclude the less
likely possibility of malignant involvement.
3. Chronic compression deformities of T1 through T3 vertebral
bodies, without evidence of associated masses. Mild
retropulsion at T3 does not compress the spinal cord.
4. Cervical degenerative disease from C3-4 through C6-7 without
spinal cord compression. Multilevel neural foraminal narrowing.
MRI head/MRA head/MRI skull base
1. Large infarction with hemorrhagic transformation in the left
posterior inferior cerebellar artery territory, involving the
cerebellar hemisphere as well as the left lateral medulla. The
infarction appears to extend into the imaged upper cervical
cord.
2. Severe compression of the fourth ventricle. No dilatation
of the third and lateral ventricles at this time.
3. 8 mm rim-enhancing leptomeningeal nodule in the left
inferior parietal region, likely a metastasis. No associated
edema.
4. Large left skull base mass invading the clivus, petrous
temporal bone, occipital bone, and the C1 vertebra. The mass
abuts the carotid canal and multiple skull base foramina. The
petrous carotid artery could be assessed by CTA, if clinically
indicated.
5. Irregularity and narrowing of the distal cervical and
proximal
intracranial left vertebral artery at the level of the left
skull base mass, where the artery is encased by the mass.
Brief Hospital Course:
Mrs. [**Known lastname 4048**] is a 59-year-old right-handed woman with history of
HTN, HLD, COPD on home O2, CHF, cervical and endometrial
adenocarcinoma, paraganglioma of the left skull base s/p
radiation, seizure disorder after episode of paraneoplastic
limbic encephalitis who is transferred from OSH intubated after
episode of unresponsiveness for evaluation of skull base tumor
and recurrent episodes of unresponsiveness.
# Neuro: On admission exam, patient was alert, opened eyes to
voice, following axial simple commands (closed eyes and opened
eyes, stuck out tongue), with impaired left gaze>right and R
gaze preference. Corneal reflex was present on the right, but
absent on the left. No motor response to noxious stimuli in
UEs/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l and triple flexion to noxious stimuli in LLE. Per
husband who is in the room, prior to hospitalization on [**8-24**],
Mrs. [**Known lastname 4048**] was able to walk without assistance, feed herself and
bathe with minimal assistance. Thus, quadriplegia was of new
onset. This was quite concerning for metastatic or compressive
involvement of the cervical cord.
Her presentation of at least 3 transient losses of consciousness
and then a more severe unresponsiveness with is concerning for
possible seizure activity vs. autonomic dysfunction vs. cardiac
cause. None of the events had reports of seizure-like activity
and previous cardiac work up for syncope has been unrevealing.
Given the location of the skull base mass and the mass effect
seen on the medulla and cerebellum, it is plausible that this
mass could be causing a vagal effect. We pursued further
evaluation of this mass to look for potential treatment. Patient
with known skull base mass, seizure disorder,and several
episodes of unresponsiveness.
On admission, initiated 24 hour urine metanephrines and
catecholamines to eval for paraganglioma. Also, continued home
AEDs: Keppra 1500mg [**Hospital1 **] and lacosamide 250mg bidAlso, new onset
quadriplegia from hospitalization on [**8-24**]. MRI C spine with
invasion of skull base mass into C1, C2 also with T2 enhancement
of the cord from cervicocranial junction to C3. MRI head w/
subacute left posterior inferior cerebellar infarct extending
into the lateral medulla with hemorrhagic conversion. Severe
compression of the 4th ventricle. Given hemorrhagic
converstion, discontinued heparin drip yesterday. EEG with no
seizure activity, but did have decreased amplitude since
midnight. Most likely, this was c/w increasing ICP. Currently,
on exam, patient has locked in syndrome--she is quadriplegic,
only eye movements intact, but, has R III and VI palsy as well
as L VI. Prognosis is extremely grim. Had family meeting with
husband present and son, daughter, mother on conference call on
[**8-31**]. Explained to the family that, unfortunately, Mrs.[**Known lastname 4048**]
will not be able to make a recovery from this and that at this
point, we should focus on comfort care and allow her to pass
away peacefully and with dignity. Family agreed. Patient was
extubated with plans to move to comfort measures only on [**8-31**] at
12pm. She passed away peacefully with family at bedside at
12:05pm.
# Cardiac: labile BP, hx of CHF with unknown EF. Did have b/l
pleural effusions concerning for component of CHF exacerbation
contributing to poor respiratory status. SBPs haveranged
88-154, now off levophed. This is also likely due to autonomic
dysfunction. CMO as above.
# Pulmonary: intubated, CO2 retainer. Also has b/l pleural
effusions further adding to her barriers to extubation
initially. Extubated as above once she was made CMO.
Medications on Admission:
Home Meds:(per transfer paperwork)
CITALOPRAM 20 mg tablet - 1 tablet(s) by mouth at bedtime
FUROSEMIDE 20 mg tablet - 1 tablet(s) by mouth once a day
LACOSAMIDE 250 mg tablet by mouth twice a day
LEVETIRACETAM 1500mg by mouth twice a day
LISINOPRIL 40 mg tablet by mouth once a day
OXYCODONE 5 mg tablet by mouth every 6-8 hours
WARFARIN 9 mg tablet by mouth at bedtime
FENTANYL patch 75 q3 days
ALBUTEROL prn
ACETAMINOPHEN 500 mg tablet by mouth as needed for fever or pain
Medications on Transfer:
Propofol gtt
Norepi gtt
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
skull base tumor, likely paraganglioma
right cerebellar infarct with hemorrhagic conversion
infarct from C3 of cord extending to lateral medulla
COPD
CHF
Factor V leiden mutation
Cervical/endometrial cancer
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2186-9-3**]
|
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"198.3",
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"348.4",
"336.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
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] |
icd9pcs
|
[
[
[]
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|
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|
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|
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|
238, 256
|
329, 6395
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9509, 12077
|
8481, 8838
|
16312, 16337
|
6417, 7191
|
7207, 7773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,952
| 156,903
|
26892
|
Discharge summary
|
report
|
Admission Date: [**2194-1-24**] Discharge Date: [**2194-4-3**]
Date of Birth: [**2145-5-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Admission for Allogeneic Stem Cell Transplant for AML
Major Surgical or Invasive Procedure:
1. Placement of right central venous line.
2. Intubation/extubation
History of Present Illness:
Mrs. [**Known lastname 66174**] is a 48 year old woman with M5b AML who has
completed induction chemotherapy and three cycles of Ara-C
consolidation and is now being admitted for an allogeneic stem
cell transplant from her brother. [**Name (NI) 6419**] recipient and donor are
CMV negative and A positive.
Upon admission she reports being well at home. She denies
heaches, chest pain, SOB, changes in her bowel habits, rashes,
chills, night sweats. She does note intermittent hip pain.
She notes that she has R lower jaw pain from a mobile tooth and
has also had recent wisdom teeth extraction.
Past Medical History:
Onc History:
[**9-/2193**]:
Developed progressive lethargy -> elevated WBC count -> BMBx ->
diagnosis of M5b AML.
Underwent 7+3 (with mitoxantrone) -> followed by 3 doses of AraC
consolidation. Comes in [**2194-1-24**] for allogeneic transplant from
brother.
.
PMHx:
1. Cholecystectomy: during induction chemotherapy
2. Wisdom teeth extraction x 2 ([**1-10**])
Social History:
She notes exposure to a number of chemicals including organic
solvents and possibly benzene. She did have a history of a one
to two pack a day cigarette smoking for approximately 10 years,
and she stopped smoking 10 years ago. She drinks alcohol
socially.
Married with 2 adult children
Family History:
Mother: [**Name (NI) **] Ca
Father: heart disease
- she believes both of her parents died from clots.
Physical Exam:
T: Afebrile Pulse Ox: 98% RA P: 89 BP: 115/86 RR:20
Gen: Middle aged woman seeming anxious
HEENT: No lesions. Multiple tooth fillings. R lower molar pain -
partially mobile.
CV: +s1+S2 RRR No M/R/G
Resp: CTA B/L No wheezing or crackles appreciated
Abd: Soft, NT ND
Ext: No pretibial edema
Skin: No rashes
Neuro: CN 2-12 grossly intact, speech appropriate
Pertinent Results:
Labs:
labs at discharge:
wbc, hct, plt, ANC
Na K Cl HCO3 BUN Cr glucose Ca Mg Ph
.
Microbiology:
[**1-25**], [**2-1**], [**2-7**] Urine clx: < 10,000 organisms.
[**1-29**], [**2-7**] Blood clx: negative.
.
[**2-1**] Stool: C. difficile positive, no enteric gram negatives, no
salmonella/shigella, no campylobacter, no ova and parasites.
[**2-14**], [**2-23**], [**2-25**] Stool: C. difficile negative.
.
[**2-1**] HBV, HCV viral load: no HBV or HCV DNA detected.
[**2-4**] CMV antibodies: negative IgG, IgM.
[**2-20**] CMV VL: no CMV DNA detected.
[**2-25**] CMV VL: no CMV DNA detected.
.
Imaging:
[**1-27**] RUQ Ultrasound:
IMPRESSION: No evidence of thrombus. Diffuse heterogeneous
echogenic liver consistent with fatty liver.
.
[**2-1**] RUQ Ultrasound with Doppler:
1. Heterogeneous liver parenchyma, which may be related to
fatty
infiltration. Other forms of liver disease and more advanced
liver disease, including hepatic fibrosis/cirrhosis, cannot be
excluded by ultrasound in the presence of fatty infiltration.
2. Normal appearance of large hepatic and portal veins.
Small-vessel
venoocclusive disease cannot be excluded by this study.
.
[**2-4**] RUE Ultrasound: No evidence of deep venous thrombosis in
the right upper extremity.
.
[**2-7**] CXR: No evidence of pneumonia.
.
[**2-13**] Portable abdomen:
No evidence of obstruction.
.
[**2-26**] CXR: Mild right lower lobe atelectasis. No evidence of
pneumonia.
.
[**2-26**] CXR: Increased bilateral lower lung opacities could be
consistent with developing infection or aspiration. Endotracheal
tube in good position.
.
[**2-26**] TTE: The left atrium is normal in size. 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)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The left ventricular
inflow pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
[**2-27**] LENIs: There is normal compressibility, augmentation,
respiratory variation within deep veins of both lower
extremities. No evidence of DVT is seen.
.
[**2-27**] CXR: 1. Normal position of NG tube.
2. No change in the bilateral lung opacifications.
.
[**2-27**] Bronchial Lavage: negative for malignant cells.
.
[**2-27**] TTE: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
small. Left ventricular systolic function is hyperdynamic (EF
70-80%). Right ventricular chamber size and free wall motion are
normal. The aortic valve is not well seen. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a small to moderate sized pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
Compared with the findings of the prior study (images reviewed)
of [**2194-2-26**], a pericardial effusion with evidence of
cardiac tamponade are now present.
.
[**2-28**] CXR: Status post right-sided thoracentesis without evidence
for pneumothorax.
.
[**2-28**] CT Torso: 1. Large bilateral pleural effusions and
bilateral lower lobe atelectasis.
2. Multiple pulmonary nodules within the aerated portions of
right upper and middle lobes. Three-month followup CT is
recommended to assess stability. The appearance of the aerated
portions of lungs is not suggestive of ARDS.
3. Diffuse mesenteric stranding and small-to-moderate ascites.
Prominent stranding about the pancreatic head suggests
pancreatitis. Clinical correlation is recommended.
4. Anasarca.
.
[**2-28**] Pleural fluid cytology: negative for malignant cells.
.
[**2-28**] TTE: Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF 80%). No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is a
small pericardial effusion. No right atrial diastolic collapse
is seen. There is significant, accentuated respiratory variation
in mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. Pericardial constriction cannot be excluded
(however, definitive signs of constrictive physiology were not
evident on this study).
Compared with the findings of the prior study (images reviewed)
of [**2194-2-27**], the pericardial effusion appears smaller.
.
[**3-3**] Head CT: Multiple abnormal foci within both frontal lobes,
of undetermined etiology. The findings may represent small
hemorrhages with surrounding edema, or foci of infection.
Infarcts are thought to be less likely, given that edema appears
largely confined to the white matter.
Further evaluation with gadolinium enhanced MRI is recommended.
Diffusion-weighted imaging should also be performed.
.
[**3-3**] TTE: 1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2194-2-28**], the pericardial effusion appears smaller and the
pleural effusion is not seen.
.
[**3-4**] MR [**Name13 (STitle) 430**]: 1. MRI of the brain [**Name13 (STitle) 4059**] areas of cortical
infarction, primarily involving the frontal and parietal lobes,
which are in a watershed distribution. They are likely early
subacute, and by clinical history stroke likely occurred about
four days ago.
2. MR venography reveals normal flow in the major intracranial
veins.
3. MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4059**] normal flow signal in the major
branches of the circle of [**Location (un) 431**].
.
[**3-4**] EEG: The record displayed only low voltage slow and very
slow
activity and is consistent with a patient in a barbiturate coma.
No
discharging features were seen.
.
[**3-5**] LENIs: No DVT involving either lower extremity, acute or
chronic. The right common femoral vein was not interrogated due
to dialysis line.
.
[**3-5**] EEG: This bedside telemetry recorded brain activity from [**3-4**] to [**2194-3-5**] at the bedside intermittently. There
appeared
to be very little cortical activity in the latter half of the
tracing.
No epileptiform features or electrographic seizures were seen.
.
[**3-6**] EEG: This telemetry captured no pushbutton activations. The
baseline recording showed an extremely low voltage slow
background with
no prominent focal features or any epileptiform activity. The
slow and
low voltage background indicates a severe and widespread
encephalopathy
which may come from large amounts of medication, from ischemia,
or from
many other causes. No evidence of seizures was present.
.
[**3-6**] TTE: No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Compared to the previous study of [**2194-3-3**], the EF may be
marginally less.
.
[**3-7**] EEG: This telemetry captured no pushbutton activations. The
background throughout was a very low voltage that included some
bursts
of generalized slowing of apparently cortical origin. There were
no
prominent focal features. There were no epileptiform
abnormalities.
.
[**3-8**] EEG: This telemetry captured no pushbutton activations.
There
were no epileptiform features or electrographic seizures. The
background showed a persistent low voltage somewhat regular
background
with some episodes of generalized slowing. The background
appeared less
suppressed again on some previous days. The most common
explanation for
this change would be a lessening of medication effect.
.
[**3-9**] EEG: This telemetry captured four pushbutton activations for
three episodes. No changes in the background were seen at this
time.
Otherwise, the EEG was fairly invariant throughout and showed a
widespread encephalopathy, largely unchanged from the previous
day's
recording. There were no epileptiform features or electrographic
seizures, including at the time of activations.
.
[**3-10**] EEG: This telemetry captured no pushbutton activations.
Routine
sampling showed an encephalopathic slow low voltage background
persisting through the first many hours of the recording but a
much
lower voltage background after that, including most of that from
[**3-10**]. Overall, the tracing indicates a severe encephalopathy.
There
were no prominent focal features. There were no epileptiform
abnormalities.
.
[**3-25**] RUQ U/S: Essentially normal right upper quadrant
ultrasound. Equivocal mild enlargement of the liver. Normal
Doppler evaluation of the hepatic and portal veins.
Brief Hospital Course:
Mrs. [**Known lastname 66174**] is a 48 yo woman with M5 AML, s/p induction and
consolidation who was admitted for an allogeneic SCT from her
brother (recipient and donor CMV negative, A positive) with
cytoxan and TBI conditioning.
.
.
Initial BMT course:
.
1. AML
She underwent an allogeneic SCT from her brother (recipient and
donor CMV negative, A positive) with cytoxan and TBI. Her
cytoxan was held for one day due to elevated LFTs (ultrasound
was normal with the exception of a fatty liver) but was then
given after her LFTs trended down. She received her cells on
[**1-31**] and quickly became neutropenic. Over the next two weeks
her counts recovered.
.
2. Immunosuppression:
She was started on continuous infusion cyclosporine on day -1
and this was adjusted for a goal 475-525.
.
3. Graft vs. Host disease:
On day +15 she began to develop watery brown diarrhea (up to 1
liter/day). Initially this was thought to potentially be due to
her recent c. difficile infection ([**2-1**]) although a repeat c.
difficile test was negative and she had been treated with
flagyl. She was started on steroids (35 mg of solumedrol [**Hospital1 **])
and entocort and her diarrhea improved. Her steroids were then
tapered down.
.
4. ID:
She was started on levofloxacin, fluconazole (this was stopped
after several days due to elevated LFTs), and acyclovir per the
alloSCT protocol. On [**2-1**] she developed diarrhea which was
c.difficile positive and she was started on flagyl. She then
had expected febrile neutropenia and both vancomycin and
caspofungin were added. As she recovered her white blood cells
and remained afebrile, antibiotics were gradually stopped and
she remained afebrile. It was planned that she would continue
to take flagyl for two weeks following the resumption of her
counts (originally planned to finish [**3-4**]). She will also take
prophylactic fluconazole, acyclovir, and bactrim.
.
5. Elevated LFTs:
She was noted to have elevated LFTs two times during her early
hospital course. The first elevation was thought to be due to
cytoxan and resolved once cytoxan was stopped. The second
elevation was thought to be due to fluconazole and also resolved
following the cessation of these medications. The hepatology
service was consulted and involved in her care. An ultrasound
showed a heterogenous fatty liver but no signs of VOD.
Hepatitis serologies were negative. Her liver enzymes gradually
trended down and were stable for several days prior to her
planned discharge.
.
6. F/E/N:
She was maintained on IVF and TPN was started when she began to
develop mucositis. As her counts recovered, her mucositis
improved and she was able to tolerate po food and water. By the
time of planned discharge she was eating and drinking well
without any nausea.
.
.
On [**2-26**] the pt was walking in the hallway when she desatted to
88%RA. CXR revealed minimal opacities in the BL bases. On exam
the pt had diffuse rales. Beside TTE revealed preserved
systolic function. THe pts sats increased to 94% on 50%FM. 4
hrs later the pt was again dyspneic, satting at 70%. ABG was
7.44/37/64 on a questionable amt of O2. THe pt was intubated
for worsening resp distress and hypoxemia. On transfer to the
[**Hospital Unit Name 153**], the pt was considered to be in ARDS. She was placed on AC
with TV 450 and 90%FIO2 with ABG of 7.34/37/66. Given the pt
was felt to be in dysynchrony with the vent, she was paralyzed
with vecuronium, with ABG improving to 7.32/38/121. THe pt was
then paralyzed with Cis gtt. Her WBC was noted to rise from 28
to 102 within 12 hrs. Her lactate rose up to 6.8. The pt was
started on neosonephrine for MAP<60 and tachycardia, lactate
6.8. The pt became anuric. A RIJ line was placed. The pt was
started on cefepime, vanc, and levoflox. Her Na dropped from
137 to 126 and her Cr increased from 0.7 to 1.5 within 6 hrs.
Repeat ABG later in the night was 7.06/46/89. Insulin gtt was
started for FS in the 300s. GIven BP of 76/57 maxed out on both
levophed and neo, vasopressin was started. The pt was given 3
amps of Na bicarb and then 1.5L of 3amps Na bicarb in D5W for
her pH of 7.06. Her ABG subsequently improved to 7.25/50/0.8.
The pt remained anuric on HD2 in the [**Hospital Unit Name 153**]. Her phos rose to 9.
Renal was consulted re need for CVVH. Valganciclovir was added
for empiric CMV coverage, IV Bactrim was started for empiric PCP
coverage, and po Vanc was given for empiric C diff coverage.
She was loaded with IVIG. ID was consulted re tailoring abx.
The pt was felt to be too unstable to go to CT the first 24 hrs
in the ICU.
MICU course:
Her MICU course was quite complicated and included hypotension
requiring up to three pressor agents at one point, renal failure
that required one session of hemodialysis, elevated LFTS,
question of TTP that required one session of plasmapheresis,
multiple small cortical infarcts noted on her head CT/MRI, and
questionable seizure activity that required both phenytoin and
phenobarbital to control.
The etiology of her acute decompensation was not discovered but
was thought to be an acute systemic inflammatory response that
led to multi-organ failure. With supportive care she eventually
stabilized, including stabilization of her blood pressure,
resolution of her renal and hepatic failure, and pancreatitis.
She was extubated on [**2193-3-11**] and her O2 sat was stable on room
air thereafter.
.
.
BMT Course:
Once stable, the patient was transferred back to the BMT
service. She worked with physical and occupational therapy and
gradually regained motor function. Neurology was consulted on
the patient and the most likely explanation for CVA's was felt
to be watershed infarctions from hypotension (unclear what
ultimate cause of hypotension was). No seizure activity was
noted, and she was continued on prophylactic dilantin. However,
d/t interaction of phenytoin with cyclosporin levels, she was
transitioned to Keppra with a bridge of ativan 0.5 mg PO TID.
Goal Keppra level is 1000mg PO BID, which will be accomplished
as an outpatient. Ativan will be stopped once the patient is at
1000mg PO BID for 2 days (increased dose by a total of 250 mg
QD). This should continue for a total of 6 months per neurology
recommendation. The patient's blood counts remained stable and
she did well from a transplant standpoint. She was switched to
PO cyclosporine prior to discharge and dose is still being
adjusted in setting of interaction with phenytoin (needs to be
increased). Additionally, she had significant wasting of
magnesium d/t cyclosporin, and she was maintained on 2400 mg of
PO magnesium oxide without complications of diarrhea, and she
was discharged on this dose (with the hope that magnesium
wasting would decrease once cyclosporin dose decreased once
phenytoin levels fall). Her steroid taper continued, and she
was switched from methylprednisolone IV to prednisone PO. She
remained afebrile and her cultures remained negative, so she was
kept only on prophylactic acyclovir, bactrim, and fluconazole.
The patient was noted to have hypertension, likely a side effect
of cyclosporine, which was treated with nifedipine. She was
noted to have a new mild elevation in her LFTs. RUQ ultrasound
was unrevealing. There was no other evidence of GVH, so it was
felt that this was due to medication effect, and the plan was to
likely stop fluconazole as an outpt to see if LFT's improved.
However, review of date suggests patient had shock liver while
in ICU and she is just recovering from hepatic injury. The
patient was followed closely by the social worker for help in
coping with her long and difficult hospital course. She was
also evaluated by psychiatry, but no antidepressants were
started as the patient was not interested in starting such a
medication.
Medications on Admission:
none
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
2. 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*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Lightweight 18 inch wheelchair
8. Hospital Bed
9. 3 + 1 Commode
10. Tub chair with arms
11. Rolling Walker
12. Geriatrics Chair
13. Cane
14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
15. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
16. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO QM,W,F.
Disp:*30 Tablet(s)* Refills:*2*
17. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*0*
18. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO See
below: [**4-3**]: 750 mg QHS; [**4-4**]: 500 mg QAM, 750 mg QPM; [**4-5**]: 750
mg PO BID; [**4-6**]: 750 mg QAM, 1000 mg QPM; [**4-7**] and thereafter 1000
mg PO BID.
Disp:*30 Tablet(s)* Refills:*2*
19. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO See
below: [**4-3**]: 750 mg QHS; [**4-4**]: 500 mg QAM, 750 mg QPM; [**4-5**]: 750
mg PO BID; [**4-6**]: 750 mg QAM, 1000 mg QPM; [**4-7**] and thereafter 1000
mg PO BID.
Disp:*30 Tablet(s)* Refills:*2*
20. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day for 8 days: Please stop taking after third dose on [**2194-4-10**].
Disp:*23 Tablet(s)* Refills:*0*
21. Cyclosporine Modified 100 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health
Discharge Diagnosis:
1. Acute myelogenous leukemia, s/p allogeneic stem cell
transplant.
2. Watershed Infarctions
Discharge Condition:
Stable.
Discharge Instructions:
1. You are being discharged to home.
2. Please return to 7 [**Hospital Ward Name 1826**] for your appointments (see
below).
3. Please take your medications as prescribed.
4. If you experience any fevers, chills, sweats, or other
concerning symptoms, please seek medical attention.
Followup Instructions:
1) Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2194-4-4**] 2:00
2) Provider: [**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-4-4**] 2:00
3) Provider: [**Name10 (NameIs) 4253**], [**Name11 (NameIs) **]; [**Telephone/Fax (1) 45043**]. [**2194-4-28**] at 3:00
p.m.
|
[
"785.59",
"205.00",
"008.45",
"518.81",
"284.8",
"434.91",
"420.99",
"345.3",
"693.0",
"790.4",
"038.9",
"584.5",
"288.0",
"577.0",
"E947.9",
"401.9",
"995.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.15",
"99.04",
"96.72",
"38.93",
"00.91",
"99.05",
"41.05",
"34.91",
"99.71",
"38.95",
"99.28",
"92.29",
"99.07",
"86.05",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
22001, 22059
|
12016, 19837
|
368, 438
|
22196, 22206
|
2264, 2270
|
22535, 22927
|
1767, 1870
|
19892, 21978
|
22080, 22175
|
19863, 19869
|
22230, 22512
|
1885, 2245
|
275, 330
|
2289, 7319
|
466, 1064
|
7328, 11993
|
1086, 1448
|
1464, 1751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,678
| 151,535
|
3436
|
Discharge summary
|
report
|
Admission Date: [**2154-1-24**] Discharge Date: [**2154-1-28**]
Date of Birth: [**2096-4-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
57yo woman with h/o gastric bypass in [**2147**] comlicated by ventral
hernia and ulcer near the anastomotic site presented with coffee
ground emesis. She described several episodes of vomiting in the
preceding days, followed by [**1-26**] bouts of coffee ground emesis,
reportedly about [**1-26**] cups in total. She also described ongoing
"gnawing" pain consistent with the pain previously attributed to
her ulcer disease. She denied any melena or hematochezia. Of
note, she reported having run out of her PPI 2weeks ago.
Otherwise, review of systems was only positive for resolved
lightheadedness. She had no chest pain or dyspnea.
.
In the [**Name (NI) **], pt was guaiac positive. NG lavage was positive with
coffee grounds, turned into bright red blood after 750cc. Pt was
tachy to 100s, SBP in 120s. GI was consulted. She was admitted
to the MICU. Her Hct had trended down from 36 to 27.
.
In the MICU, she received IVF, was started on IV PPI gtt, and
underwent endoscopy. This was notable for a near-circumferential
ulceration at the gastro-jejunal anastamosis site. There was
fresh clot, and further areas of bleeding were cauterized.
Thereafter, she remained hemodynamically stable, Hct remained
stable, and she had no further episodes of hematemesis.
.
On interview now, she confirms no further episodes of
hematemesis, denies any chest pain or shortness of breath, and
otherwise has no new complaints on review of systems.
Past Medical History:
- H/o bleeding gastric ulcer
- h/o morbid obesity s/p gastric bypass [**2147**], c/b ventral hernia
and marginal ulcer
- DM2
- sleep apnea - On BiPAP but has not used it for 1 month
- diverticulosis
- arthritis
- GERD
- asthma
- chronic fatigue syndrome
- Fibromyalgia
- Restless leg syndrome
Social History:
Lives in [**Location 4288**] with husband. Trained as a psychologist,
hasn't been working due to chronic fatigue syndrome. Recently
tried to quit smoking, on nicotine patch, 5 cigarettes within
last 2 weeks. No EtOH or IVDU.
Family History:
Mother had diabetes and MI in 50's
Physical Exam:
VS: AF, 98.9, 81, 110/69, 17, 97% RA
Gen: well appearing
HEENT: no scleral icterus though muddy appearing, EOMI, MM dry
Neck: no JVD
CV: regular, nl S1/S2, no m/r/g
Pulm: CTAB, no wheezes or crackles
Abd: soft, ventral hernia at site of old incision which is well
healed, no tenderness to palpation, + BS
Ext: no c/c/e
Pertinent Results:
[**2154-1-24**] 01:45PM PT-12.0 PTT-21.9* INR(PT)-1.0
[**2154-1-24**] 01:45PM PLT COUNT-537*
[**2154-1-24**] 01:45PM HYPOCHROM-1+
[**2154-1-24**] 01:45PM NEUTS-73.8* LYMPHS-18.4 MONOS-2.6 EOS-4.7*
BASOS-0.4
[**2154-1-24**] 01:45PM WBC-9.6 RBC-3.07*# HGB-8.9*# HCT-27.2* MCV-89
MCH-28.9 MCHC-32.6 RDW-14.4
[**2154-1-24**] 01:45PM HGB-9.3* calcHCT-28
[**2154-1-24**] 01:45PM CK-MB-2 cTropnT-<0.01
[**2154-1-24**] 01:45PM CK-MB-2 cTropnT-<0.01
[**2154-1-24**] 01:45PM LIPASE-20
[**2154-1-24**] 01:45PM ALT(SGPT)-12 AST(SGOT)-12 CK(CPK)-132 ALK
PHOS-65 AMYLASE-53 TOT BILI-0.2
[**2154-1-24**] 01:45PM CK(CPK)-132
[**2154-1-24**] 01:45PM estGFR-Using this
[**2154-1-24**] 01:45PM GLUCOSE-148* UREA N-19 CREAT-1.2* SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
[**2154-1-24**] 09:21PM HCT-24.2*
Brief Hospital Course:
57F with h/o gastric bypass c/b marginal ulcer, p/ with
hematemesis x3 day secondary to anastamosis site ulceration.
called out of MICU hemodynamically stable with no further
bleeding.
.
# hematemesis: was secondary to anastamosis site ulcer. pt was
hemodynamically stable and did not have further bleeding. we
followed serial Hcts which were stable. EGD showed a 3cm ulcer,
with a blood clot (which was not dislodged), and also stigmata
of recent bleeding was found in the Jejunum, adjacent to the
anastomosis. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis
on the ulcer at the sites with stigmata of bleeding with
apparently successful hemostasis. pt was started on sucralfate
and [**Hospital1 **] PPI.
.
# asthma: continued albuterol prn.
.
# DM2: does not take any meds at home. sliding scale, qid
fingersticks
.
#Restless legs: continued amitriptyline, alprazolam
.
# FEN/GI: diabetic diet.
.
# PPx: Protonix. did not need dvt ppx as pt was ambulating
.
# Access: 2 peripheral IVs
.
# Code: full
.
# Dispo - likely home
Medications on Admission:
acarbose 100mg before every meal
sucralfate 1g 4x/day
protonix 40mg before meals
[**Doctor First Name 130**] 60mg [**Hospital1 **] prn
amitriptyline 25-50mg qHS prn
alprazolam 0.25mg [**Hospital1 **] prn
mirapex 0.5mg qHS
pulmicort 2 puffs [**Hospital1 **]
albuterol inh prn
nasonex 50mcg each nostril daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): NO
SUBSTITUTIONS PLEASE.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Amitriptyline 25 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Acarbose 50 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*30 Tablet(s)* Refills:*2*
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding gastric ulcer
.
Secondary:
- h/o morbid obesity s/p gastric bypass [**2147**], c/b ventral hernia
and marginal ulcer
- DM2
- sleep apnea
- diverticulosis
- arthritis
- GERD
- asthma
- chronic fatigue syndrome
Discharge Condition:
stable
Discharge Instructions:
please take all medications as prescribed. please take the
protonix tablet twice daily without fail.
If you have chest pain, shortness of breath, nausea, vomitting,
diarrhea, blood in vomit, blood in stools please call your
doctor or go to the emergency room
Followup Instructions:
Please make a follow up appoinmtment with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 1395**] ([**Telephone/Fax (1) 15863**]) within 2 weeks of discharge
.
Please make a follow up appointment with your gastroenterologist
Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 2744**]) within 1 weeks of discharge
Completed by:[**2154-5-17**]
|
[
"534.40",
"276.50",
"280.0",
"327.23",
"V45.86",
"401.9",
"493.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
6085, 6091
|
3625, 4672
|
329, 335
|
6353, 6362
|
2766, 3602
|
6670, 7040
|
2375, 2411
|
5031, 6062
|
6112, 6332
|
4698, 5008
|
6386, 6647
|
2426, 2747
|
275, 291
|
363, 1800
|
1822, 2117
|
2133, 2359
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,898
| 115,391
|
33527
|
Discharge summary
|
report
|
Admission Date: [**2165-5-4**] Discharge Date: [**2165-5-25**]
Date of Birth: [**2093-12-17**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transfer from outside hospital for respiratory failure and shock
Major Surgical or Invasive Procedure:
Mechanical ventilation
Central venous line placement
History of Present Illness:
Mr. [**Known lastname **] is a 75 year-old man with a history of COPD, CAD,
CHF who presents with respiratory failure, transferred from an
OSH.
.
Per the OSH records, patient had a gradual onset of shortness of
breath over the 24 hours prior to admission. Also with cough;
no reported fevers or chills.
.
Per EMS report, "pt had been having difficulty breathing and
chest pain since yesterday which worsened this morning...Pt
states pain and difficulty breathing began at the same time...he
points just to the (R) of his sternum and on his sternum
mid-chest when asked for the location of the pain. O2 sat 97%
on NRB."
.
Vitals at the OSH showed a temparature of 97.2, BP of 114/90, HR
90, RR 35 and an oxygen saturation of 88% on room air. Lungs
were reported as "diminished but clear". The O2 deteriorated to
the 50s on 3 liters and the patient was intubated with a #8 ETT.
Subsequently, blood pressure fell and dopamine was started.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease
2. Congestive heart failure
3. Chronic obstructive pulmonary disease on 1 liter home O2
4. Hypetension
5. History of DVT
6. Atrial fibrillation
7. s/p PPM
.
PAST SURGICAL HISTORY:
1. s/p Total hip replacement ([**6-/2153**])
2. s/p Breast mass biopsy ([**12/2162**])
3. s/p Umbilical hernia repair ([**4-/2161**])
4. s/p Vasectomy ([**11/2143**])
5. s/p Ankle (left) fracture/repair with screws ([**12/2132**])
Social History:
Until most recent admission, was still smoking and drinking.
Lives at home.
Family History:
not obtained
Physical Exam:
Vitals - T 99.4, BP 106/39, HR 123
GEN - Intubated. Not responsive.
HEENT - Sclera anicteric. No palor. Prominent jugular
pulsations.
CV - Irregular and tachycardic. No obvious murmurs.
PULM - Moving air without rales/rhonchi.
ABD - Soft. Non-distended. No apparent tenderness. RLQ scar and
midline herniation noted.
EXT - Warm. Venous stasis changes. +edema. Scar from prior ankle
surgery noted on left.
NEURO - Pupils 3mm --> 2mm and equal.
Pertinent Results:
[**2165-5-4**] 01:54PM BLOOD WBC-4.1 RBC-4.18* Hgb-13.0* Hct-44.0
MCV-105* MCH-31.2 MCHC-29.6* RDW-14.7 Plt Ct-192
[**2165-5-7**] 02:12AM BLOOD WBC-13.2* RBC-3.56* Hgb-11.1* Hct-35.2*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.3 Plt Ct-124*
[**2165-5-13**] 03:06AM BLOOD WBC-9.7 RBC-3.15* Hgb-9.9* Hct-32.4*
MCV-103* MCH-31.4 MCHC-30.5* RDW-15.8* Plt Ct-162
[**2165-5-22**] 03:07AM BLOOD WBC-6.5 RBC-2.71* Hgb-8.5* Hct-26.4*
MCV-98 MCH-31.3 MCHC-32.1 RDW-17.3* Plt Ct-232
[**2165-5-23**] 03:37AM BLOOD WBC-6.3 RBC-2.76* Hgb-8.8* Hct-26.3*
MCV-96 MCH-31.8 MCHC-33.3 RDW-17.6* Plt Ct-247
[**2165-5-4**] 01:54PM BLOOD PT-68.9* PTT-56.7* INR(PT)-8.4*
[**2165-5-11**] 03:33AM BLOOD PT-39.8* PTT-43.6* INR(PT)-4.3*
[**2165-5-22**] 03:07AM BLOOD PT-14.2* PTT-96.4* INR(PT)-1.2*
[**2165-5-23**] 03:37AM BLOOD PT-15.0* PTT-64.6* INR(PT)-1.3*
[**2165-5-4**] 01:54PM BLOOD Glucose-86 UreaN-60* Creat-1.9* Na-137
K-4.2 Cl-94* HCO3-34* AnGap-13
[**2165-5-13**] 04:40PM BLOOD Glucose-105 UreaN-75* Creat-2.0* Na-146*
K-5.0 Cl-118* HCO3-21* AnGap-12
[**2165-5-15**] 05:18PM BLOOD Glucose-84 UreaN-87* Creat-2.4* Na-149*
K-3.1* Cl-115* HCO3-22 AnGap-15
[**2165-5-17**] 06:28PM BLOOD Glucose-146* UreaN-84* Creat-2.3* Na-145
K-3.8 Cl-112* HCO3-25 AnGap-12
[**2165-5-19**] 02:52AM BLOOD Glucose-173* UreaN-60* Creat-1.7* Na-148*
K-3.9 Cl-114* HCO3-27 AnGap-11
[**2165-5-21**] 03:30AM BLOOD Glucose-146* UreaN-35* Creat-1.1 Na-142
K-4.0 Cl-107 HCO3-31 AnGap-8
[**2165-5-4**] 01:54PM BLOOD ALT-14 AST-17 LD(LDH)-210 CK(CPK)-20*
AlkPhos-65 TotBili-0.8
[**2165-5-7**] 05:30PM BLOOD Fibrino-1773*
[**2165-5-7**] 06:02AM BLOOD Hapto-417*
[**2165-5-12**] 02:30AM BLOOD TSH-2.5
[**2165-5-12**] 09:29AM BLOOD Cortsol-18.1
[**2165-5-12**] 10:35AM BLOOD Cortsol-25.1*
[**2165-5-4**] 04:30PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2165-5-10**] 04:30PM PLEURAL TotProt-1.4 Glucose-186 LD(LDH)-414
Albumin-LESS THAN
[**2165-5-10**] 04:30PM PLEURAL WBC-2250* RBC-[**Numeric Identifier 36575**]* Polys-88*
Lymphs-9* Monos-3*
[**2165-5-4**] 1:55 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2165-5-8**]**
GRAM STAIN (Final [**2165-5-4**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2165-5-8**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. RARE GROWTH.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
[**2165-5-12**] 2:20 am BLOOD CULTURE Source: Line-aline.
**FINAL REPORT [**2165-5-18**]**
Blood Culture, Routine (Final [**2165-5-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2165-5-15**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77738**] @ 0315 ON
[**2165-5-15**]-CC6D-[**Numeric Identifier 19457**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
All other Cx including blood, sputum, urine, pleural fluid were
negative
CXR [**5-4**]
There is new right IJ line with tip in the SVC. The pacemaker is
unchanged. ET tube tip is 6.9 cm above the carina. The NG tube
tip is not well visualized. The right-sided airspace opacities
are again visualized as is volume loss/infiltrate in the left
lower lobe. The CP angles are off the film, and thus difficult
to assess for effusion on this film. Overall with exception of a
new line, there has been no significant interval change
EKG on admission:
Atrial fibrillation with a ventricular premature beat and
probably two
ventricular paced beats. Since the previous tracing of [**2165-5-5**]
ventricular
pacing is new. The first paced beat appears early and may be
related to
a non-sensed ventricular premature beat. Clinical correlation is
suggested.
Portable TTE (Complete) Done [**2165-5-7**] at 3:05:11 PM
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 40-50 %), most likely due
in part to the presence of reduced ventricular filling secondary
to atrial fibrillation with relatively rapid ventricular rate.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2165-5-12**] 2:49 PM
Cholelithiasis, and mild gallbladder wall thickening without
significant gallbladder distention. Wall thickening may be
secondary to underdistention of the gallbladder, or third
spacing. Given the minimal gallbladder distention, this is less
likely secondary to acute cholecystitis. Evaluation of the
common duct in the region of the pancreatic head is limited by
ultrasound technique.
US EXTREMITY NONVASCULAR RIGHT [**2165-5-12**] 2:09 PM
Focused ultrasound scanning was performed in the area of the
patient's pacemaker in the right upper chest. Pacemaker leads
are identified in the subcutaneous tissues, and there is no
evidence of surrounding fluid collection or abscess.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2165-5-12**] 11:55 AM
No evidence of acute sinusitis
CT CHEST/ABD W/CONTRAST [**2165-5-12**] 11:56 AM
1. There is no CT evidence of an inflammatory collection or an
inflammatory process in the chest, abdomen, or pelvis to explain
the patient's symptoms.
2. Bilateral bibasilar mild-to-moderate pleural effusion with
adjacent bibasilar atelectasis. No radiographic evidence of
pneumonia.
3. Ascites confined to the right upper quadrant with no
enhancing wall septations or loculations.
4. Sludge/stones in the gallbladder.
5. Cluster of calcification and hypodensity seen in the head and
uncinate process of the pancreas in close proximity may
represent a focus of chronic pancreatitis.
6. Equivocal filling defect in the lower CBD and prominant
appearance of the region of the papilla. As the patient has a
pacemaker, MR evaluation is precluded. ERCP may be useful for
further assessment/diagnosis as clinically dictated.
7. A complex cystic mass with solid enhancing rim is seen
arising from the left kidney suspecious for a renal cell
carcinoma. A targeted renal US should be confirmatory.
Brief Hospital Course:
NEURO: The patient was transferred intubated and sedated on the
ventilator. Throughout his hospital course, he had daily
wake-ups through the sedation and pain medication. Early in his
course, he awoke very agitated and not following commands,
though was alert, looking around the room and moving all
extremities with equal and reactive pupils. He had a history of
alcohol use, and had experienced DT's in the past with
withdrawal. Consequently, he was maintained on a versed drip and
much of the confusion was attributed to possible withdrawal in
addition to delerium. With re-evaluation by wake-ups, the
patient slowly became more attentive and did not have
tremors/shakes, was following commands and communicated that he
was not in any discomfort. After extubation, a full neuro exam
was normal including strength/sensation, cranial nerves, DTRs,
cerebellar exam and speech/memory.
HEENT: The patient was noted to have poor dentition, but no
signs of abscess/infection on oral exam. In addition, a CT scan
of his head was normal and showed no signs of sinusitis.
PULMONARY: His active problems during this admission were
respiratory failure, pneumonia, pleural effusion. The main
concern for this patient was that of pneumonia, and strep
pneumonia grew in the first sputum culture on admission. He was
noted to have a large R pleural effusion, which was tapped, but
did not show evidence of empyema. He remained on the ventilator
for 17 days. Upon extubation, he did well, had minimal
secretions and strong cough, O2 sats in the 90's, work of
breathing was easy.
CARDIAC: Active issues during this admission included
hypotension and atrial fibrillation, with a history of CAD and
CHF. The hypotension was not fluid responsive and he required
levophed pressor support for the first 15 days of
hospitalization. This was weened off and he was eventually
restarted on all of his home HTN medication. The hypotension was
felt to be sepsis physiology, without evidence of new mycardial
injury. The atrial fibrillation remained rate controlled, and at
first anticoagulation was held [**3-9**] a supratherapeutic INR. This
came down to normal levels, and a heparin drip was started and
he is being bridged back onto coumadin. In terms of his CHF, an
echo revealed only mildly depressed LVEF at 40-50%, and
specifics are listed in the report above.
GI/FEN: patient was aggressively volume resuscitated early on,
being at the highest 27 liters positive on his i/o's. This
eventually was diuresed to a slightly positive volume status,
and he will go to rehab with continued diureses. He was started
on tube feeds with help from the nutritionists, and will be
going to rehab taking PO.
RENAL/GU: The patient came to the service with mildly reduced
renal function. Upon receiving his CT his renl function
deteriorated and was felt to have contrast nephropathy. Over the
next week this resolved to his baseline.He responded well to
Lasix and metolazone diuresis as described above.
HEME/ID: Active issues included elevated INR (as described
above), and positive cultures included strep pneumonia on sputum
and 1/2 bottles of GPC bacteremia. His antibiotic course
intially was broad, including levaquin, ceftriaxone, vancomycin
and zosyn (broad plus double coverage). This was tailored down
to ceftriaxone to cover the strep pneumonia that was speciated
from the sputum. The patient started requiring slightly higher
pressor support 1.5 weeks into admission, started spiking
nocturnal fevers, and subsequently grew the coag negative staph.
He was broadened again for this, though was felt this was likely
contaminant. His fever curve and white count normalized and the
course of antibiotics was d/c'd. He also developes some
diarrhea, but c.diff was negative x 3 (got PO flagyl until
negative cx came back)
Prophylaxis: remained on sch, then hep gtt/coumadin, pneumoboots
and PPi
Code: remained full code throughout
Dispo: discharge to rehab facility
Medications on Admission:
1. Atenolol 50mg [**Hospital1 **]
2. Diamox 500mg daily
3. Torsemide 100mg daily
4. Digoxin 0.25mg daily
5. Coumadin 5mg daily
6. Duoneb QID
7. Theophylline 200mg [**Hospital1 **]
8. Floridil x1 month
9. Flovent 110mcg [**Hospital1 **]
10. Spiriva daily
11. Tylenol PRN
12. Mucinex 400mg PRN
13. Viagra 100mg PRN
14. Chantix
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): hold for loose stool.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for agitation or anxiety.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Titrate to INR [**3-10**].
9. Heparin Drip
Titrate to goal PTT 60-80. Discontinue once INR = [**3-10**].
10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day:
Check digoxin level qweek. .
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Diamox Sequels 500 mg Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
13. Torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.
14. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: [**2-6**] capsule Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] ne [**Location (un) **]/[**Hospital1 **]
Discharge Diagnosis:
Sepsis
Streptococcal Pneumonia
respiratory failure
Acute renal failure
congestive heart failure
COPD
Atrial fibillation with rapid ventricular response
kidney cystic lesion
Discharge Condition:
Stable
Discharge Instructions:
During this admission you were treated for a severe pneumonia,
requiring intubation and life support. You will be discharged
to a rehab facility. Please continue to take all medications as
prescribed, and follow up with your PCP within [**Name Initial (PRE) **] few days of
leaving rehab.
On the CT scan of your abdomen, there was a cystic lesion found
on your left kidney. This was an incidental finding and not
associated with your problems during this hospitalization,
however, this should be followed up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 6349**], as it is possible this may represent
carcinoma.
Followup Instructions:
follow up with your PCP within [**Name Initial (PRE) **] few days of leaving rehab.
[**Last Name (LF) 16826**],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 33980**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-5-23**]
|
[
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"785.50",
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"276.7",
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"V45.01",
"285.9",
"428.32",
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"E930.8",
"564.00",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.73",
"96.6",
"96.72",
"38.91",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
14987, 15071
|
9327, 13275
|
343, 397
|
15288, 15296
|
2454, 6041
|
15990, 16324
|
1961, 1975
|
13651, 14964
|
15092, 15267
|
13301, 13628
|
15320, 15967
|
1618, 1851
|
1990, 2435
|
239, 305
|
425, 1367
|
6055, 9304
|
1411, 1595
|
1867, 1945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,246
| 122,852
|
50833
|
Discharge summary
|
report
|
Admission Date: [**2192-4-28**] Discharge Date: [**2192-5-3**]
Date of Birth: [**2147-5-13**] Sex: M
Service:
ADMISSION DIAGNOSIS:
Acute cholecystitis.
HISTORY OF PRESENT ILLNESS: The patient is a 44 year-old
gentleman with a past medical history significant for HIV and
hepatitis B who through the Emergency Room was evaluated for
the onset of acute right upper quadrant pain following meals.
This pain was consistent with pain that he has had on four
previous episodes. As such was worked up for acute
cholecystitis and biliary colic. A son[**Name (NI) **] through the
Emergency Department did not reveal cholelithiasis, however,
there was a dilated gallbladder and some pericholecystic
fluid. It was unclear whether there was definitive wall
thickening.
LABORATORY: The patient's laboratories at the time of
admission revealed a white blood cell count of 7.9, but on
the 18th the next day it was as high as 23.7, which was
verified and doubly checked.
The patient remained with some focal tenderness in the right
upper quadrant and as such was taken to the Operating Room
for laparoscopic cholecystectomy. Intraoperatively there was
a complication of some bleeding at the triangle of Calot.
After clipping and dividing the cystic duct, this turned out
to be a small bleeding from a venous vessel of the
gallbladder. An intraoperative cholangiogram was performed
and revealed normal anatomy of the cystic duct and common
duct prior to cholecystectomy. There were no stones and no
ductal dilatation observed. Due to the nature of the
bleeding the patient's laparoscopic procedure was converted
to an open cholecystectomy, which was then able to clearly
identify the source of the venous bleeding from the
gallbladder, which was appropriately treated. Hemostasis was
adequate at that point in time and the patient went to the
Intensive Care Unit after this procedure. Postoperatively,
the patient went to the Intensive Care Unit for hemodynamic
monitoring. He was found to have a hematocrit that started
preoperatively of 43 and postoperatively was down to 29.
There was no evidence of further bleeding and no further
evidence of a drop in hematocrit. The patient remained
stable and was therefore transferred to the floor.
Postoperatively in the Intensive Care Unit the patient
remained hemodynamically stable and was transferred to the
floor on postoperative day number one. His hematocrit was
checked daily, which revealed a hematocrit drop down to about
25 or 26, but he had received approximately four to six
liters of IV fluid and was quite positive. This was felt to
be hemodilution and it's effect, he was not symptomatic from
this hematocrit change. The patient's diet was advanced
slowly as tolerated. He remained afebrile. His morphine PCA
was changed to an oral pain medication, which he tolerated
without difficulty. He is being discharged home with a
hematocrit checked on the 22nd of 30 with stable
hemodynamics. No tachycardia. No dizziness. He has resumed
all of his anti HIV medications without difficulty. He is
tolerating a regular diet and he is tolerating Percocet for
pain relief. He will follow up with Dr. [**Last Name (STitle) **] for a follow
up appointment and removal of surgical clips.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Last Name (STitle) 105707**]
MEDQUIST36
D: [**2192-5-6**] 12:35
T: [**2192-5-7**] 07:04
JOB#: [**Job Number 40627**]
|
[
"572.8",
"V64.4",
"998.11",
"070.30",
"575.0",
"V08",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"54.59",
"87.53",
"39.32"
] |
icd9pcs
|
[
[
[]
]
] |
147, 169
|
198, 3540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,359
| 176,458
|
47224
|
Discharge summary
|
report
|
Admission Date: [**2195-1-8**] Discharge Date: [**2195-1-22**]
Date of Birth: [**2131-8-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea on Exertion, dark tarry stools
Major Surgical or Invasive Procedure:
1. EGD with hemoclip placement
2. Angiography with coiling to the gastroduodenal artery
3. Repeat EGD to evaluate clips
History of Present Illness:
63-year-old gentleman with history of diastolic CHF, chronic
kidney disease stage III, hypertension, hyperlipidemia, and
history of upper GIB from AV malformation in [**2192**] who presented
to the ED on evening of admission with shortness of breath for
one week. He noticed difficulty breathing when walking up to 40
feet with oxygen set at 2 liters for the last 4-5 days. He was
also complaining of some "chest tightness." He had called his
primary care physician earlier on day of admission who told him
to come to the emergency room for evaluation.
In the ED, his initial vital signs were T 96.8, HR 77, BP
122/59, RR 20, satting 96%RA. A chest x-ray showed question of
pulmonary edema, per report, and patient was given 40 mg of
intravenous furosemide prior to labs being drawn. Labs then came
back showing a hematocrit of 16.5 down from recent baseline in
the mid 30s. White count was stable at 6.3 and platelets were
276. INR was 1.1, and PTT was slightly elevated at 38.0. Notably
the BNP was 1243, which was down from 5088 one month ago.
Patient was then given 1L of normal saline. Rectal exam showed
guiaic positive brown stool, per report. 2 peripheral IVs were
placed, GI was consulted and an NGT lavage performed which was
reportedly negative. GI saw the patient and plans for upper
endoscopy and colonoscopy tomorrow, as they are uncertain where
the bleeding is coming from. Patient was typed and crossed for
four units PRBCs prior to transfer. Current vital signs are BP
103/45, HR 80s (patient takes carvedilol as outpatient).
Of note, patient was recently admitted to the hospital [**Date range (1) 74897**]
for shortness of breath requiring intubation. He was treated for
congestive heart failure and pneumonia with vancomycin and
levofloxacin, ultimately completing a seven-day course of the
latter. Addtionally, he was started on CPAP to treat suspected
obstructive sleep apnea. He was discharged with home oxygen due
to desaturations to 85% on ambulation.
ROS: No cough, fever, chills, or pedal edema. Appetite normal.
Patient currently without chest pain, shortness of breath (at
rest), leg swelling, palpitations, lightheadedness, or
dizziness.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Rt heart failure with diastolic dysfunction
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
MGUS
Acquired [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Disease
H/O RESPIRATORY FAILURE
H/O RT HEART FAILURE
Diastolic dysfunction.
H/O MORBID OBESITY
RENAL INSUFFICIENCY
FACTOR VIII DEFICIENCY
ERECTILE DIFFICULTY
MONOCLONAL GAMMOPATHY
HYPERTENSION
IRON DEFICIENCY ANEMIA
h/o ugi bleed from AV malformation seen on endoscopy 08.
PROBLEMS WITH BALANCE
SECONDARY HYPERPARATHYROIDISM
+Lupus anticoagulant
Social History:
Quit smoking in [**2190**] (20 pack year history of smoking), denies
alcohol or drug abuse.
Family History:
Significant for cancer and sickle cell trait (sister). The same
sister is also s/p kidney transplant.
Physical Exam:
Admission Exam:
General: overweight man in no acute distress, breathing
comfortably
Vitals: T afebrile, HR 79, BP 111/58, RR 16, O2 sat 100% 2L
HEENT: PERRLA, non-icteric sclera, moist mucus membranes
Neck: supple, difficult to assess JVP
Heart: RRR, normal and distant s1/s2
Lungs: faint bibasilar crackles, no wheezes
Abdomen: obese, soft, non-tender, no focal tenderness, [**Doctor Last Name 515**]
(-)
Extremities: warm, well-perfused, non-edematous
Rectal: dark, guiaic positive stool in the rectal vault, no
frank blood, no external anal lesions or fissures
Pertinent Results:
Admission Results [**2195-1-8**]
WBC-6.3# RBC-2.08*# Hgb-5.3*# Hct-16.5*# MCV-80* MCH-25.6*
MCHC-32.2 RDW-17.3* Plt Ct-276#
Neuts-85.0* Bands-0 Lymphs-10.5* Monos-3.4 Eos-0.9 Baso-0.1
PT-12.9 PTT-38.0* INR(PT)-1.1
Glucose-103* UreaN-46* Creat-2.0* Na-136 K-4.8 Cl-99 HCO3-29
AnGap-13
ALT-16 AST-52* LD(LDH)-103 AlkPhos-37* TotBili-0.4
calTIBC-346 Hapto-98 Ferritn-7.1* TRF-266
ECG ([**2195-1-9**]): Blood in the stomach body. Blood in the pylorus.
Polyp in the duodenal bulb. Red blood is active oozing from the
duodenal bulb. However, there is no visible vessel or ulcer
seen. (injection, endoclip)
Otherwise normal EGD to third part of the duodenum.
ANGIO ([**2195-1-13**]):
1. SMA, celiac and common hepatic arteriograms reveal
conventional arterial anatomy.
2. No active contrast extravasation or AVM seen.
3. Multiple GDA branches seen in close proximity to the clips
placed on
endoscopy.
4. Successful embolization of the gastroduodenal artery using 4
mm x 3 cm
coils.
5. Post-coil deployment angiogram reveals markedly reduced flow
through the GDA and is expected to completely occlude with time.
Discharge Labs:
[**2195-1-22**] 05:20AM WBC-3.5* RBC-2.68* Hgb-7.4* Hct-22.6* MCV-84
Plt Ct-126*
[**2195-1-22**] 05:20AM PT-12.5 PTT-33.2 INR(PT)-1.1
[**2195-1-22**] 05:20AM FacVIII-149
[**2195-1-20**] 05:33AM VWF AG-GREATER TH VWF CoF-337*
[**2195-1-22**] 05:20AM VWF AG-PND VWF CoF-PND
[**2195-1-22**] 05:20AM Glc-100 UreaN-16 Creat-1.3* Na-137 K-4.4 Cl-97
HCO3-39*
Brief Hospital Course:
Mr [**Known lastname 99999**] is a 63 year old man admitted for dyspnea and found
to have a Hct of 15.4. He is known to have acquired [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] syndrome factor VIII deficiency) attributed to his
underlying MGUS.
1. Acute upper GI bleeding. Presented with dyspnea and found to
have HCT of 15.4 in setting of guaiac positive stools and known
bleeding disorder (VWD). He underwent EGD which showed bleeding
at the duodenal bulb with hemoclip placement. Post-procedure
his HCT continued to trend slowly down so he underwent
angiography with coiling of gastroduodenal artery on [**1-13**].
Before each of these two procedures he recieved Humate-P
infusions, under the guidance of hematology and the blood bank.
He did not appear to respond to these treatments. A repeat EGD
was performed on [**1-19**] which did not show persistent bleeding.
An impacted clip was seen, and surgical and GI consultants felt
that this could be observed unless bleeding recurred. His
hematocrit was subsequently stable, and at the time of discharge
he was having one dark brown to black stool a day. He was sent
home on pantoprazole 40mg PO BID with instructions to continue a
low-residue diet for two weeks. He will follow-up with
Dr.[**Last Name (STitle) **] in GI at the beginning of [**Month (only) 958**].
2. [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) 100000**]'s Disease. In addition to giving Humate-P
infusions, the Hematology service further recommended checking
vWF levels and ristocetin cofactor assay levels. IVIG was
initiated in addition to the factor VIII, given persistent
bleeding and lack of hemostasis at the GI site. The factor VIII
levels increased following this treatment, administered with the
assistance of the hematology consult team. He will follow-up
with Dr.[**Last Name (STitle) 3060**] on [**Last Name (LF) 2974**], [**1-30**].
3. Acute renal failure. Creatinine was variable during
admission with ACEI and furosemide held at times given blood
loss and use of contrast for angiography. His serum creatinine
also remained stable after the IVIG infusions. His Lisinopril
was resumed at his home dose on the day of discharge, and his
Lasix was resumed at half his home dose. He will have his
electrolytes checked on Saturday, [**1-24**], with results sent
to Dr.[**Last Name (STitle) 11616**].
Medications on Admission:
- carvedilol 25 mg [**Hospital1 **]
- aminocaproic acid
- furosemide 40 mg once daily
- lisinopril 10 mg once daily
- sildenafil prn
- B complex vitamins once daily
- calcium and vitamin D
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. aminocaproic acid Oral
3. calcium carbonate Oral
4. cholecalciferol (vitamin D3) Oral
5. 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*
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Outpatient Lab Work
Please have a Chem 10 and a CBC checked on Saturday, [**1-24**]
or Monday [**1-26**] and have the results sent to Dr[**Doctor Last Name **]
office.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Gastrointestinal bleeding
Acute blood loss anemia
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Known lastname 99999**],
It has been a pleasure to care for you during this admission. As
you know you were admitted with new anemia, and were found to be
bleeding from your duodenum or small intestine. You had several
procedures, including endoscopies to clip the area that was
bleeding and an angiogram to embolize the bleeding.
You had several treatments for your [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease,
including humate (factor 8) and IVIG (intravenous
immunoglobulin). The combination seemed to help you stop
bleeding.
It is very important that you follow-up with Hematology next
week, and continue a low-residue diet for two weeks. If you
notice an increase in black stools, please call your PCP or come
back to the hospital immediately.
Your Lasix and Lisinopril were initially held due to your
bleeding. Your Lisinopril was re-startd at your regular dose on
the day of discharge, and your Lasix was re-started at half your
normal dose. You should have your electrolytes checked on
Saturday, [**1-24**] and have the results sent to Dr.[**Last Name (STitle) 11616**].
If these are stable, he may increase your Lasix back to its
regular dose.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2195-1-29**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
PLEASE HAVE YOUR BLOOD DRAWN PRIOR TO THIS APPOINTMENT AND STOP
BY [**Hospital Ward Name **] 9 AFTER THIS APPOINTMENT TO SEE DR.[**Last Name (STitle) **].
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: [**Hospital1 **] [**2195-1-30**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: MONDAY [**2195-4-20**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You also have an appointment with Dr.[**Last Name (STitle) **] at the beginning
of [**Month (only) 958**]. His office will call you with the details.
|
[
"585.3",
"403.90",
"428.0",
"428.32",
"327.23",
"532.40",
"211.2",
"278.01",
"276.2",
"287.49",
"272.4",
"V85.41",
"286.4",
"584.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.44",
"99.14",
"88.47",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8947, 9004
|
5670, 8046
|
342, 464
|
9164, 9164
|
4164, 5278
|
10530, 11792
|
3461, 3564
|
8285, 8924
|
9025, 9143
|
8072, 8262
|
9314, 10507
|
5294, 5647
|
3579, 4145
|
2759, 2877
|
264, 304
|
492, 2665
|
9179, 9290
|
2908, 3335
|
2687, 2739
|
3351, 3445
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,424
| 162,051
|
43132
|
Discharge summary
|
report
|
Admission Date: [**2147-1-9**] Discharge Date: [**2147-1-18**]
Date of Birth: [**2066-12-19**] Sex: F
Service: SURGERY
Allergies:
Digoxin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Colostomy takedown and ventral hernia repair
Major Surgical or Invasive Procedure:
1. component separation, ventral hernia repair, colostomy
takedown [**2147-1-9**]
History of Present Illness:
This is a 80 year-old female with a history of a.fib on
coumadin, hx of small cell lung cancer s/p lung resection,
perforated diverticulum s/p sigmoid Hartmann in [**4-21**],
hypothyroidism, diastolic heart failure who presents for
colostomy takedown and ventral hernia repair.
The patient underwent a colstomy takedown and ventral hernia
repair and was in the OR for almost 6 hours and received 3 L of
LR. She became hypotensive with SBP's in the 70s and required a
neo gtt, however was weaned off this in the PACU. EBL was
recorded as minimal. She was given another 4 L or LR in the
PACU. She was oliguric intra and postoperative only putting out
160 cc in the OR and 32 cc in the PACU (5 hours).
ROS: The patient admits to diarrhea recently and nausea this am.
She denies any recent fevers, chills, vomiting, abdominal pain,
constipation, melena, hematochezia, chest pain, shortness of
breath, lower extremity edema, cough, urinary frequency,
urgency, dysuria, lightheadedness.
Past Medical History:
1. Atrial flutter and fibrillation on amiodarone and Coumadin.
2. Small cell lung cancer status post lung resection.
3. Perforated diverticulum [**4-21**] s/p sigmoid Hartmann's.
4. Sleep apnea, does no wear CPAP
5. Diastolic heart failure secondary to hypertension with
preserved ejection fraction.
6. Hypothyroidism.
7. Pacemaker for tachy-brady syndrome status post AV junctional
ablation.
8. Chronic renal insufficiency (baseline Cr of 0.8-1, but more
recently elevated to 1.8)
9. COPD
10. History of embolus to the Left arm
11. Hypertension
PSH:
s/p hysterectomy
Left lower lobe resection for lung nodule. [**1-22**]
Laparoscopic R colectomy [**10-21**] for adenoma c high grade
dysplasia
Social History:
The patient lives alone. Was born in [**Country 6171**]. Retired, but had
worked as a secretary. Quit smoking 40 years ago. Drinks 1
glass of wine a day.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 97.4 BP: 94/40 HR: 62 RR: 13 O2Sat: 95% on 2 L NC
GEN: Well-appearing, well-nourished, elderly female lying in bed
in NAD
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no MRG
PULM: The patient is breathing comfortably, CTAB
ABD: Large midline incision with an abdominal binder over her
abdomen. Her abdomen is soft. No active bleeding. 2 JP drains
with bloody fluid present.
EXT: No C/C/E. 2 + DP
NEURO: Sleepy, but arousable. Oriented to person, place, and
time. Moves all extremities spontaneously. Grossly nonfocal
exam.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2147-1-9**] 02:13PM SODIUM-140 POTASSIUM-3.3 CHLORIDE-101
[**2147-1-9**] 02:13PM MAGNESIUM-2.3
[**2147-1-9**] 02:13PM HCT-37.3
[**2147-1-9**] 05:16PM HCT-33.2*
[**2147-1-9**] 05:16PM CK-MB-6 cTropnT-0.02*
[**2147-1-9**] 05:16PM GLUCOSE-133* UREA N-23* CREAT-1.4* SODIUM-139
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2147-1-9**] 08:55PM PT-19.2* PTT-40.8* INR(PT)-1.8*
[**2147-1-9**] 08:55PM PLT COUNT-169
[**2147-1-9**] 08:55PM WBC-5.7 RBC-2.68*# HGB-6.5*# HCT-22.0*#
MCV-82 MCH-24.3* MCHC-29.7* RDW-17.2*
[**2147-1-9**] 09:09PM OTHER BODY FLUID HCT-3.5*
[**2147-1-9**] 10:09PM HCT-26.7*
ECG: Atrial pacing at 60 bpm, nl axis, TWI in I, II, V2-V6.
Widened QRS. No STE or STD.
Imaging:
CXR ([**2147-1-5**]): No acute cardiopulmonary process.
Brief Hospital Course:
Neuro: She was managed with pain control in the immediate
postoperative period. On POD #5, she was noted to be somnolent
with left-sided neglect. She was able to follow commands but
not moving her left side. An emergent CT head was obtained that
demonstrated a significant right sided MCA stroke. An immediate
Neurology/Stroke consult was obtained, and their service
followed the patient closely. She was given a poor prognosis
given the size of the stroke. In the immediate period, cerebral
edema was minimized by limiting her IVF and allowing her to
become hypernatremic. Anticoagulation was not started given the
risk of conversion to hemorrhagic stroke.
CV: She had a history of atrial fibrillation, and was managed
with Lopressor IV. In the initial period of her ATN,
Electrophysiology was asked to interrogate her pacemaker and
increase her rate from 60. It was felt that increasing her HR
may improve cardiac output and increase perfusion to her
kidneys.
Resp: Given the large volumes of fluid that she received in the
immediate postoperative period, her respiratory status was
closely monitored. She did require periods of bipap, but never
progressed to intubation. As she began to diurese, her
respiratory status improved and had good O2 saturations by POD
#5.
GU: In the PACU, she was anuric, and considered to be in a
pre-renal state. She was aggressively resuscitated. Despite
multiple fluid boluses, she remained oliguric, and was
transferred to the ICU for central line placement to transduce a
CVP to obtain objective measures of her fluid status. A bedside
echo was obtained that demonstrated respiratory variation in her
aortic flow, suggestive of a hypovolemic state. A renal
consultation was also obtained, and again felt to be in
pre-renal ATN. She was initially unresponsive to Lasix,
however, by POD #4, began to diurese and over the next few days
had an improving creatinine level.
After conversations with the ICU team, the primary team, and the
Neurology/Stroke service, given the patient's poor prognosis,
she was made CMO, and expired on [**2147-1-18**].
Medications on Admission:
Amiodarone 200 mg daily
Lipitor 20 mg daily
Lasix 60 mg daily ([**Hospital1 **] on Monday and Friday only)
Synthroid 75 mcg daily
Toprol 25 mg daily
Warfarin 2 alternating with 3 mg daily(stopped [**2147-1-4**]) with a
lovenox bridge
Caltrate 1 tab daily
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Atrial flutter and fibrillation on amiodarone and Coumadin.
2. Small cell lung cancer status post lung resection.
3. Perforated diverticulum [**4-21**] s/p sigmoid Hartmann's.
4. Sleep apnea, does no wear CPAP
5. Diastolic heart failure secondary to hypertension with
preserved ejection fraction.
6. Hypothyroidism.
7. Pacemaker for tachy-brady syndrome status post AV junctional
ablation.
8. Chronic renal insufficiency (baseline Cr of 0.8-1, but more
recently elevated to 1.8)
9. COPD
10. History of embolus to the Left arm s/p LUE thrombectomy '[**38**]
11. Hypertension
12. R MCA stroke [**12-23**]
s/p hysterectomy
Left lower lobe resection for lung nodule [**1-22**]
Laparoscopic R colectomy [**10-21**] for adenoma c high grade
dysplasia
Discharge Condition:
Expired
|
[
"342.00",
"585.2",
"458.29",
"496",
"790.92",
"427.89",
"553.29",
"348.5",
"567.82",
"285.9",
"V45.01",
"428.32",
"404.91",
"276.2",
"427.31",
"428.0",
"V55.3",
"327.23",
"V66.7",
"709.2",
"434.11",
"276.52",
"427.32",
"V10.11",
"V58.61",
"244.9",
"584.5",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.83",
"86.3",
"54.4",
"38.93",
"46.52",
"38.91",
"53.69"
] |
icd9pcs
|
[
[
[]
]
] |
6286, 6295
|
3877, 5980
|
311, 394
|
7098, 7108
|
3069, 3854
|
2330, 2348
|
6316, 7077
|
6006, 6263
|
2363, 3050
|
227, 273
|
422, 1410
|
1432, 2138
|
2154, 2314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,965
| 154,849
|
23025
|
Discharge summary
|
report
|
Admission Date: [**2150-2-1**] Discharge Date: [**2150-2-10**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
ERCP [**2-3**]
ERCP [**2-5**]
EGD [**2-5**]
History of Present Illness:
Ms. [**Known lastname 59386**] is a [**Age over 90 **] year-old female who experienced 1 episode
of severe, crampy abdominal pain 2 days prior to admission prior
to going to sleep. The pain was located in her epigastrium and
gradually dissipated on its own. It has not returned since. It
was accompanied by shaking chills. She has felt weak and
lethargic and was brought to the hospital by her neighbor. She
currently denies abdominal pain, fever, chills, nausea, and
vomiting. Her BMs and voiding have been normal. At
[**Hospital1 18**]-[**Location (un) 620**] a RUQ Ultrasound revealed a large gall bladder
stone and lab work was significant for transaminitis and
hyperbilirubinemia. She was transferred to [**Hospital1 18**]-Main for
urgent ERCP and monitoring.
Past Medical History:
hyperthyroidism
Macular degeneration
s/p TAH BSO
s/p nephrectomy
s/p appendectomy
s/p hip hemiarthroplasty
s/p cataract surgery bilateral
Social History:
She lives alone and is completely independent. She is a
nonsmoker, no EtOH, no illicit drugs.
Family History:
Non-contributory.
Physical Exam:
On Discharge:
VS: Temp 98.8, HR 71, BP 133/59, RR 16, O2 sat 95% on room air
Gen: no acute distress
CV: RRR
Pulm: clear bilaterally
Abd: soft, nontender, nondistended
Ext: no edema
Pertinent Results:
Admission labs:
[**2150-2-2**] 03:06AM BLOOD WBC-9.8 RBC-3.78* Hgb-11.6* Hct-33.2*
MCV-88 MCH-30.6 MCHC-34.9 RDW-12.6 Plt Ct-140*
[**2150-2-2**] 03:06AM BLOOD PT-15.3* PTT-27.9 INR(PT)-1.3*
[**2150-2-2**] 03:06AM BLOOD Glucose-121* UreaN-18 Creat-1.0 Na-139
K-3.6 Cl-105 HCO3-26 AnGap-12
[**2150-2-2**] 03:06AM BLOOD ALT-318* AST-292* AlkPhos-116 Amylase-35
TotBili-4.9*
[**2150-2-2**] 03:06AM BLOOD Lipase-14
[**2150-2-2**] 03:06AM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.9 Mg-2.0
Discharge labs:
[**2150-2-8**] 08:10AM BLOOD WBC-7.7# RBC-3.45* Hgb-10.2* Hct-31.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-13.5 Plt Ct-335#
[**2150-2-8**] 08:10AM BLOOD Glucose-112* UreaN-12 Creat-0.9 Na-132*
K-4.8 Cl-101 HCO3-25 AnGap-11
[**2150-2-7**] 08:05AM BLOOD ALT-52* AST-35 LD(LDH)-146 AlkPhos-117
Amylase-95 TotBili-0.7
[**2150-2-7**] 08:05AM BLOOD Lipase-58
[**2150-2-8**] 08:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
Brief Hospital Course:
Mrs. [**Known lastname 59386**] was transferred from [**Hospital1 18**]-[**Location (un) 620**] for an urgent
ERCP and monitoring. She was admitted to the SICU on [**2150-2-1**]
with a diagnosis of cholangitis and a UTI. She was started on
IV Zosyn for broad spectrum coverage. An ERCP was attempted on
[**2150-2-2**] but deep cannulation of the biliary tree was
unsuccessful. A limited cholangiogram at that time showed
mildly dilated biliary tree with no filling defect. Blood
cultures drawn at [**Location (un) 620**] revealed gram-negative bacteria that
was pansensitive. A urine culture grew E.coli. Repeat cultures
drawn on arrival at [**Hospital1 18**]-Main are no growth. She remained in
the SICU post-ERCP for monitoring. Her LFTs and bilirubin
trended downward and she was tranferred to the floor on [**2150-2-4**].
A repeat ERCP was performed on [**2150-2-5**] and revealed a CBD
measuring 12mm and an 8mm stone in the distal third of the CBD.
The stone was successfully removed and a sphincterotomy was
performed. While in the recovery room after the ERCP she had an
episode of hematemesis. An urgent EGD was performed and
revealed a large amount of fresh blood in the duodenum with
active bleeding in the sphincterotomy site. Hemostasis was
successfully obtained with epinephrine injections and
electrocautery. She was transferred to the [**Hospital Unit Name 153**] for monitoring
overnight and transferred back to the floor on [**2150-2-6**]. She has
been afebrile throughout her hospital stay and her hemodynamics
have been stable. A physical therapy consult was obtained and
they recommended discharge to a rehab facility. Her hematocrit
has been stable at 31. Her bilirubin and LFTs have normalized
except for a slight elevation in her ALT of 57. She is
tolerating a regular diet and having regular nonbloody BMs. She
has been screened and accepted by a rehab facility.
Medications on Admission:
Multivitamin
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) 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. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Cholelithiasis/Choledocholithiasis
Cholangitis
E. Coli Bacteremia
Post ERCP ampullary bleeding
UTI
Discharge Condition:
Good
Discharge Instructions:
Call your surgeon if you experience:
- fever >101.5
- chills
- increasing pain not controlled by medication
- persistent nausea/vomiting
- inability to eat or drink
Antibiotic regimen: Patient is currently on
Sulfameth/Trimethoprim DS 1 TAB PO BID. This regimen will be
completed on [**2149-2-20**].
New medications since admission: Lopressor 25mg orally twice a
day.
Resume all of your home medications.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Call his office at ([**Telephone/Fax (1) 35203**] to schedule your appointment.
Please follow-up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3142**] in [**2-4**] weeks.
Completed by:[**2150-2-10**]
|
[
"574.90",
"790.7",
"362.50",
"242.90",
"599.0",
"E878.8",
"576.1",
"998.11",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85",
"44.43",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
5057, 5129
|
2579, 4487
|
285, 331
|
5272, 5279
|
1658, 1658
|
5735, 6084
|
1423, 1442
|
4550, 5034
|
5150, 5251
|
4513, 4527
|
5303, 5712
|
2154, 2556
|
1457, 1457
|
1471, 1639
|
221, 247
|
359, 1133
|
1674, 2138
|
1155, 1294
|
1310, 1407
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,049
| 198,088
|
14621+56560
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-5-21**] Discharge Date: [**2181-6-6**]
Date of Birth: [**2116-8-2**] Sex: F
Service: [**Last Name (un) **]
BRIEF CLINICAL HISTORY: The patient is a 64-year-old
Caucasian woman with an extensive surgical medical history,
who is well known to Dr. [**Last Name (STitle) 957**]. History is notable for
history of gallbladder hydrops. Most recently, she was
treated for an abscess near her cholecystostomy tube and was
discharged from the [**Hospital1 69**] on
[**2181-4-21**]. On [**2181-4-30**], the patient was readmitted
for severe right upper quadrant pain and persistent output
from her cholecystostomy tube. At that time, right upper
quadrant ultrasound showed resolving collection, however,
the cholecystostomy tube was putting out a consistent amount
of yellow drainage, and it was felt better to undergo a
definitive procedure at that time.
On [**2181-5-7**], the patient was discharged with a plan to
undergo a cholecystectomy, ileostomy takedown, ventral
herniorrhaphy in conjunction with Plastics on [**2181-5-22**].
Patient was admitted on [**2181-5-21**] to the Blue Surgery
service with this plan in mind. Since her last
hospitalization, she had actually done quite well managing to
gain [**10-12**] pounds and had some resolution of her pain.
PRIOR MEDICAL HISTORY: Gallbladder hydrops.
CHF.
Diverticulitis.
Enterocutaneous fistula.
Hypercholesterolemia.
Peripheral vascular disease.
Right footdrop.
History of VRE, MRSA in her bile duct and her biliary system.
History of cecal volvulus.
PRIOR SURGICAL HISTORY: Ileocecectomy with ileostomy in
[**2180-10-28**].
Status post cholecystostomy tube placement [**2181-2-26**].
Status post splenectomy [**2179-4-28**].
Status post left colectomy [**2179-4-28**].
Status post incision and drainage of abdominal abscess.
Status post appendectomy.
Status post aortobifem bypass.
Status post sigmoid colectomy for diverticulosis.
Status post exploratory laparotomy, lysis of adhesions,
colostomy takedown, and proctostomy in [**2179-1-29**].
Status post exploratory laparotomy and lysis of adhesions and
right colectomy with creation of a Hartmann's pouch and an
ileocolostomy in [**2180-10-28**].
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q.d.
2. Levo/Flagyl unknown dose.
3. Sucralfate 1 gram p.o. q.i.d.
4. Miconazole powder 2 percent applied to infected areas
q.i.d.
ALLERGIES: Dilaudid is known to cause confusion.
SOCIAL HISTORY: Patient has a 30 pack year history of
tobacco smoking, but denies alcohol ingestion.
EXAMINATION: Examination on presentation to the hospital,
patient had a T max and T current of 96.2, pulse of 80, blood
pressure 110/62, respirations 18, and saturation of 96
percent on room air. In general, the patient is described as
a moderately obese Caucasian female in no acute distress and
alert and oriented times three. HEENT examination shows the
head to be normocephalic, atraumatic. Sclerae are
nonicteric. Pupils were equal and reactive to light.
Cranial nerves II through XII are grossly intact. Anterior
and posterior lymph node chains are noninflammed and
nontender. Virchow's nodes is likewise noted not to be
tender nor inflamed. Lungs are clear to auscultation
bilaterally. Cardiac examination shows regular, rate, and
rhythm. Abdominal exam shows several prior scars, all well
healed. There is no evidence of any breakdown. Ostomy is
pink and healthy appearing with an appliance in place.
Cholecystostomy tube is secured in place with a yellowish
drainage. Otherwise, the abdomen is soft, diffusely tender
with bowel sounds on auscultation. Lower extremities are
warm and well perfused with a palpable dorsalis pedis pulse
bilaterally and no evidence of any edema.
LABORATORIES ON ADMISSION: White blood cell count 7.3,
hematocrit 27.6, platelets 351. PT is 9.8, INR is 2.0.
Sodium of 137, potassium 4.3, chloride 102, CO2 22, BUN 23,
creatinine 0.8, glucose 106.
RADIOLOGY: Chest x-ray shows focal linear atelectasis
bilaterally, otherwise no active disease.
Urinalysis shows no evidence of any infection.
ECG shows sinus rhythm at 89 beats per minute.
CLINICAL COURSE: On [**2181-5-21**], the patient was admitted to
the Surgical service for preoperative work. Once on the
floor, IV was started and she was made NPO at midnight. On
the morning of [**2181-5-22**], patient was taken to the operating
room, where she underwent cholecystectomy, ileostomy
takedown, and incisional hernia repair, jejunostomy tube
placement, lysis of adhesions. Then, in conjunction with the
Plastic Surgery team, a component separation and definitive
closure of ventral hernia was performed. The procedure was
described as being without complications. Estimated blood
loss was recorded at 400 cc. The patient received 3 units of
packed red blood cells during the surgery.
Patient was kept intubated and transferred to the Surgical
Intensive Care Unit. In the Surgical Intensive Care Unit,
she was kept on a ventilator overnight. Initial blood gas
was a pH of 7.36, pCO2 of 35, pO2 of 170, bicarb 21, gap
negative 4. CBC that same evening was a white blood cell
count of 6.8, hematocrit 32.4, and platelets of 199.
The patient was started on levofloxacin 500 mg IV q.d. and
Flagyl 500 mg IV q.8. Analgesia was provided via an epidural
and the patient was kept sedated with a propofol drip.
On postoperative day one, the patient was started to be
weaned from her ventilator. She was started on TPN...
DICTATION ENDED HERE.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2181-6-6**] 17:07:03
T: [**2181-6-7**] 06:47:52
Job#: [**Job Number 43106**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 7849**]
Admission Date: [**2181-5-21**] Discharge Date: [**2181-6-6**]
Date of Birth: [**2116-8-2**] Sex: F
Service: [**Last Name (un) **]
Continuation of dictation number [**Serial Number 7850**].
Late on day on postoperative day two, the patient's epidural
was capped and ultimately removed. Analgesia was provided
via IV Morphine at that time. On postoperative day two, the
patient was successfully weaned from the ventilator. Vital
signs all remained stable. TPN was reduced to 1.5 and tube
feeds of 1.5 strength of Impact was started at 10 cc an hour.
JP drain output remained scant.
By postoperative day four, the patient is felt to be stable
enough to be transferred to the normal surgical floor. She
was, however, given a transfusion of 2 units of packed red
blood cells for a hematocrit of 24.7. Through postoperative
day six, tube feeds were gradually increased to a rate of 50
cc an hour.
On morning of postoperative day seven, on examination the
midline incision was found to have moderate amount of
erythema. A seven day course of Kefzol was started. The
erythema did not progress any further.
On postoperative day eight, the patient still had not had
first bowel movement, although she had some flatus. At that
time, Morphine IV was discontinued and analgesia was provided
via Vicodin. Soon thereafter, the patient had a bowel
movement in response to a glycerine suppository.
On postoperative day nine, there was a brief setback with
patient having period of nausea and vomiting. The tube feeds
were held for 24 hours and then ultimately restarted without
any problems. The patient was also given three doses of
Lasix over the next 36 hours of 5 mg. She responded to this
with a brisk diuresis, which helped her shortness of breath.
On postoperative day 11, the TPN and tube feeds were switched
to a p.m. cycle and p.o. intake was gradually increased. The
patient tolerated this extremely well. Has reflected daily
calorie counts.
By postoperative day 14, patient had been advanced to a
regular soft diet. She was tolerating it extremely well,
having bowel movements.
On postoperative day 15, after final evaluation by Physical
Therapy to ensure the patient could go home, arrangements
were started to be made for discharge to her sister's house.
After final exam by Dr. [**Last Name (STitle) **] on [**2181-6-6**] and the rest of
the surgical team, it was deemed that patient was an
appropriate candidate for discharge. She was discharged to
home.
FOLLOW UP: An appointment has been made for patient to
followup with Dr. [**Last Name (STitle) **] in 10 days. She will have daily
[**Last Name (STitle) **] visits to provide flushes of her J tube, and ensure that
the wound has continued to heal well.
DISPOSITION: The patient is discharged to home in the care
of her sister, and will also have home [**Name (NI) **] once a day.
MEDICATIONS ON DISCHARGE:
1. Miconazole powder one application t.i.d. prn.
2. Percodan tablets 1-2 tablets p.o. q.4-6h. prn pain.
3. Phenergan 25 mg p.o. q.12h. as needed for nausea.
4. Lopressor 50 mg p.o. b.i.d.
5. Reglan 10 mg p.o. q6.
6. Loperamide 1 mg in 5 mL liquid total of 2 mg alternating
with 4 mg q.6h. It should be noted that the patient has
been having brand named Imodium and had been told not to
use the generic subsidy.
7. Zinc sulfate 220 mg one p.o. q.d.
8. Aspirin 81 mg p.o. q.d.
The patient had all of her prescriptions filled prior to
departing the hospital and indeed had at least one month's
supply of all of her medications at the time of discharge.
DISCHARGE DIAGNOSES: Enterocutaneous fistula.
Gallbladder hydrops.
Congestive heart failure.
Diverticulitis.
Hypercholesterolemia.
Peripheral vascular disease.
Bilateral footdrop.
Postoperative ileus.
Malnutrition.
Postoperative blood loss anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 7851**]
Dictated By:[**Last Name (NamePattern1) 7852**]
MEDQUIST36
D: [**2181-6-6**] 17:55:41
T: [**2181-6-7**] 07:51:39
Job#: [**Job Number 7853**]
|
[
"263.9",
"574.10",
"560.1",
"997.4",
"285.1",
"575.3",
"V55.2",
"443.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
"54.59",
"99.04",
"46.39",
"46.51",
"45.92",
"99.15",
"45.62",
"96.6",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
9495, 9996
|
8811, 9473
|
2251, 2461
|
8413, 8785
|
3792, 8401
|
2478, 3777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 197,293
|
4820
|
Discharge summary
|
report
|
Admission Date: [**2103-6-5**] Discharge Date: [**2103-6-7**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 y/o male with HTN, CAD(nstemi in [**2101**]), COPD(fev1 20%, home
o2 4l, chronic steroids; intubated x2) who presented after acute
onset of shortness of breath upon waking at 3 AM on the morning
of admission. He denied wheezing at the time. He states that
this felt like his typical COPD exacerbations. He reports h/o
cough productive of sputum. No fevers/chills. He reports
chronic chest pain, though this has been going on for about one
year, located left chest, achy pain, made worse when he lies on
the left side and relieved when he rolls off the left side,
resolving in [**2-10**] minutes, non-exertional.
.
In the ED he was febrile to 101.3 and was satting 92-94% on 4L.
He got frequent nebs, levofloxacin, ceftriaxone, azithromycin,
and solumedrol 125mg IV x 1. His CXR showed severe COPD without
definite evidence of pneumonia. Was initially going to be
admitted to the floor, but due to ongoing concerns in ED that he
looked "bad" on presentation, he was admitted to the ICU for
COPD exacerbation.
.
Currently, the patient reports feeling well. He feels that his
breathing is almost back to baseline and has been ambulating in
the [**Doctor Last Name **]. He denies CP,
Past Medical History:
1. COPD on 4 L O2 at home and s/p multiple admissions and
intubations for flares-FEV1/FVC 35%
2. Hypertension
3. Hyperlipidemia
4. CAD s/p NSTEMI ([**2101**])
5. Chronic low back pain L1-2 laminectomy from accident at work
6. Steroid induced hyperglycemia
7. Left shoulder pain for several months
8. Cataract
9. GERD
Social History:
Married with six children. Lives at home in [**Location (un) 16174**] with
wife.
Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint.
Former smoker. Quit 25 years ago. 20 pack year history.
Occassional EtOH
Quit marijuana 3 years ago. Denies IV drug use.
Activity limited due to prior spine and current shoulder
problems.
Family History:
Mother with asthma and [**Name (NI) 2481**]
Father with [**Name2 (NI) 499**] cancer
Physical Exam:
VS: 98.0 (Tm=98.9) - 109/60 - [**Medical Record Number 20175**]% (4L)
gen- sitting in chair, speaking in complete sentences, NAD
heent- PERRL OU, cataract OD, MMM, OP nl
cvs- RRR, s1/s2, no M/R/G
pulm- quiet BS bilat, no wheezes, no rales appreciated
abd- soft, NT, ND, NABS
ext- + clubbing bilaterally; no edema, 2+ DP/PT pulses
Pertinent Results:
[**2103-6-5**] 11:30AM WBC-21.3* RBC-4.25* HGB-11.5* HCT-35.8*
MCV-84 MCH-27.0 MCHC-32.0 RDW-14.8
[**2103-6-5**] 11:30AM NEUTS-95.0* BANDS-0 LYMPHS-3.1* MONOS-1.7*
EOS-0.1 BASOS-0.1
[**2103-6-5**] 11:30AM PLT SMR-NORMAL PLT COUNT-235
[**2103-6-5**] 11:30AM GLUCOSE-121* UREA N-19 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-30* ANION GAP-14
.
CXR ([**2103-6-5**]):
The lung fields are clear. There is flattening of the
diaphragm,
and increased interstitial markings consistent with chronic
emphysematous changes. Pulmonary vasculature is within normal
limits. The heart size and mediastinal contours are stable in
appearance. There is calcification of the aorta noted. No
pleural effusions or pneumothorax. Soft tissue are unchanged.
No acute cardiopulmonary abnormalities are identified.
Brief Hospital Course:
.
1) DYSPNEA - The patient presented with complaints of dyspnea,
which likely represented a COPD exacerbation. In addition,
there was most likely also an associated bronchitis given his
fever and leukocytosis. He was initially admitted to the MICU
for "looking bad" in the ER. For his COPD flare, he was started
on prednisone and eventually tapered, continued on salmeterol,
albuterol and ipratropium nebs. He was also started on Azithro
for presumed bronchitis. The day following admission, the
patient was transferred to medical service for further
management. He was continued on the above mentioned therapy and
discharged home the following day. He was given a longterm
steroid taper at the time of discharge.
.
3) CAD - There were no signs of ischemia on this admission. He
was continued on his outpatient doses of [**Month/Day/Year **], statin, ACE, and
calcium channel blocker. Betablockers were not given due to
COPD exacerbation.
.
4) LOW BACK PAIN - This is a long-standing, chronic issue. He
was continued on his outpatient therapy with percocet.
.
5) PROPHYLAXIS - Given his baseline steroid use, VitD and
Calcium were initiated on this admission. He also also received
a PPI and RISS for steroid use during this admission. Bactrim
was not started on this admission.
.
6) CODE - full
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
[**Month/Day/Year **]:*60 Tablet, Chewable(s)* Refills:*2*
8. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
[**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 1 doses.
[**Month/Day/Year **]:*1 Capsule(s)* Refills:*0*
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
15. Prednisone 10 mg Tablet Sig: see below Tablet PO once a day:
take 4 tabs daily x 7 days, then take 3 tabs daily x 7 days,
then 2 tabs daily x 7 days, then resume taking 1 and 1/2 tabs
daily.
[**Month/Day/Year **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) COPD exacerbation
2) Bronchitis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return the ER if you experience
shortness of breath, chest pain, fever, or chills. Take your
medications as prescribed and follow up as scheduled below.
Followup Instructions:
1) [**Location (un) 394**],OD/[**Name8 (MD) **],MD Where: [**Hospital6 29**] [**Hospital3 1935**]
CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-6-28**] 12:30
2) [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: OFF CAMPUS
[**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2103-7-10**]
9:00
3) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2103-11-26**] 11:30
|
[
"414.01",
"412",
"491.21",
"724.2",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6701, 6707
|
3534, 4843
|
291, 298
|
6786, 6794
|
2692, 3511
|
7023, 7606
|
2240, 2326
|
4866, 6678
|
6728, 6765
|
6818, 7000
|
2341, 2673
|
232, 253
|
326, 1519
|
1541, 1861
|
1877, 2224
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,966
| 178,929
|
28470
|
Discharge summary
|
report
|
Admission Date: [**2136-10-7**] Discharge Date: [**2136-10-8**]
Date of Birth: [**2059-5-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Attempted Right internal Jugular central line
Attempted L femoral central line
Intubation
History of Present Illness:
Mr. [**Known lastname **] is a 77 year old male with PMH significant for CAD
with 2 prior bypass surgeries and 2 PCIs, PAD s/p carotid
stenting and per patient b/l LE bypass, hypertension,
hyperlipidemia, chronic stable angina who presented with
shortness of breath in the setting of recent percutaneous aortic
valve placement at [**Hospital 69016**] Hospital in [**Location (un) 311**].
This hospitalization is the continuation of an extensive disease
course. He was admitted to the [**Hospital1 18**] recently between [**9-10**] and
[**9-11**] after VF arrest during a board meeting. He underwent CPR
with shock, was rapidly intubated and then extubated. He had
subsequent chest pain with EKG changes that led to
catheterization; Catheterization demonstrated patent stents and
LIMA and prominent severe AR.
He was transferred to [**Hospital1 3278**] because his primary cardiology, Dr.
[**Last Name (STitle) 14714**] is there. A single lead ICD was placed on [**2136-8-17**]; the
patient was discharged to home but sustained two further
ventricular fibrillation arrests. He was readmitted to [**Hospital1 3278**]
with SOB; during that admission he underwent a CT angiogram as
part of preparation for transcatheter aortic valve implantation
which resulted in contrast nephropathy. The patient was
transported on [**2136-9-23**] to [**Location (un) 311**] for TAVI procedure
(transcatheter placement of aortic valve) at [**Hospital 69016**]
Hospital. On arrival to [**Location (un) 311**] he had continued SOB with
singifcant peripheral edema. TAVI was performed on [**2136-9-26**]. He
was in complete heart block after the procedure and so his
single chamber ICT was upgraded to a dual chamber ICD. Of note,
ASA and Plavix were held on transfer from [**Location (un) 311**] back to [**Hospital1 3278**]
out of concern for dropping HCT. He was diuresed after the
procedure, but per notes continued to have some SOB upon
transfer back to [**Hospital1 3278**].
At [**Hospital1 3278**], he continued to be diuresed, and was discharged
yesterday morning. Of note, during that hospitalization the
patient requireed several blood transfusions for anemia; one
source was epistaxis.
After discharge, he immediately tried to walk around his house
and had an episode of SOB after walking that took one hour to
resolve yesterday. The patient's wife started giving him
continuous oxygen from 2L to 4L. He did not have any chest pain
during this episode. He denies any changes in his bowel or urine
habits. Again this morning around 9:30 AM, he had extreme SOB,
this time with minimal exertion when moving from bed to a chair.
This time he felt dizzy but did not have syncope and again had
no chest pain.
In the ED, initial VS were 98 111/45 16 97% 10L. The patient was
started on a Lasix bolus with drip and placed on BiPAP. His
breathing improved during his ED stay. CXR showed pulmonary
edema with possible consolidation; he was given Lasix 40 IV x1.
In the setting of WBC 20, Vancomycin was started.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY: CAD: CABG x2 [**45**] years; Cath x3 with 2
stents placed, last 2 years ago; Carotid endarterectomy 3 years
ago
3. OTHER PAST MEDICAL HISTORY:
OSA on CPAP
HTN
HL
DM
Osteoporosis
Social History:
Smokes [**12-17**] ppd
EtOH- daily wine. Occasional vodka/irish whiskey.
Family History:
CAD with MI on both mother and fathers side of the family
Physical Exam:
Admission Exam:
GENERAL: Oriented x3 and in NAD. Mood, affect appropriate.
HEENT: NCAT. Moist mucous membranes.
CARDIAC: RR, normal S1, S2. No murmur.
LUNGS: No chest wall deformities. Resp unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi. Decreased air
movement at the bases.
ABDOMEN: Soft, NTND.
EXTREMITIES: Trace lower extremity edema.
Pertinent Results:
[**2136-10-7**] 09:58PM TYPE-ART PO2-95 PCO2-24* PH-7.39 TOTAL
CO2-15* BASE XS--8
[**2136-10-7**] 09:58PM LACTATE-4.7*
[**2136-10-7**] 05:05PM GLUCOSE-149* UREA N-55* CREAT-2.5* SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
[**2136-10-7**] 05:13PM LACTATE-4.0*
[**2136-10-7**] 05:05PM CK-MB-73* MB INDX-12.2* cTropnT-1.71*
[**2136-10-7**] 05:05PM WBC-15.9* RBC-2.95* HGB-10.0* HCT-30.3*
MCV-103* MCH-33.9* MCHC-33.0 RDW-20.5*
[**2136-10-7**] 12:25PM cTropnT-0.33*
[**2136-10-7**] 12:25PM CK-MB-10
STUDIES:
CT Ab/Pelvis [**10-7**]
IMPRESSION:
1. No evidence of retroperitoneal or other hematoma. Small
region of
stranding in the right groin may relate to recent
catheterization.
2. Bilateral pleural effusions, atelectasis, and pulmonary
edema.
3. Cholelithiasis.
4. Atherosclerotic disease, infrarenal abdominal aortic
aneurysmal dilation
(2.7 cm). Apparent aneurysmal dilation at origin of bilateral
common femoral
grafts. Correlation with surgical history and any possibly
available prior
contrast enhanced studies is recommended. Evaluation of
vasculature is limited
on this noncontrast examination.
5. Small bilateral adrenal adenomas vs. nodular hyperplasia.
ECHO [**10-7**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular
chamber size is normal. A well-seated CoreValve bioprosthetic
aortic valve is seen with mobile leaflets. The transaortic
gradient is normal for this prosthesis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a prominent anterior fat pad.
IMPRESSION: Suboptimal image quality. Well-seated CoreValve
bioprosthesis with normal gradient and mild aortic
regurgitation. Mild global left ventricular hypokinesis.
Mild-moderate mitral regurgitation.
If clinically indicated, a formal complete study by lab
personnel may be useful in better defining the source of aortic
regurgitation.
Brief Hospital Course:
77 year old male with PMH significant for CAD with 2 prior
bypass surgeries and 2 PCIs, PAD s/p carotid stenting and per
patient b/l LE bypass, hypertension, hyperlipidemia, chronic
stable angina who presented with shortness of breath in the
setting of recent percutaneous aortic valve placement at [**Hospital 69017**] Hospital in [**Location (un) 311**].
His shortness of breath was attributed to PNA in the setting of
NSTEMI given rising enzymes; in addition he was thought to have
some fluid overload from a CHF exacerbation and was initially
given Lasix in the ED. On presentation, he also had an anion gap
metabolic acidosis with elevated lactate & uremia that was
thought to be due to infection; this was accompanied by
transaminitis and acute renal failure. Antibiotics were started.
A CT was done on admission to rule out RP bleed given there had
been a concern for anemia at an OSH and the patient was
complaining of severe back pain. After this was negative for
bleed, heparin drip was started for NSTEMI.
Throughout the evening, the patient developed increasing signs
and symptoms of cardiogenic shock with worsening shortness of
breath and hypotension. CPAP and BiPAP were attempted with only
temporary relief. The patient was finally intubated with the
intention of central line placement for blood pressure support.
However, immediately after intubation he developed PEA arrest.
The patient underwent two sessions of CPR for a total of 1.5
hours, regaining a pulse for only a 10 minute period between
sessions. The patient expired at 4 AM on [**2136-10-8**].
Medications on Admission:
MEDICATIONS ON LAST DISCHARGE FROM [**Hospital1 18**]:
Toprol XL 25 mg once daily
Zolpidem 5 mg Tablet QHS
Dipyridamole-Aspirin 200-25 mg Cap PO BID
Niacin 750 mg Capsule daily
Ipratropium Bromide Inhaler
Ezetimibe 10 mg daily
Clopidogrel 75 mg daily
Valsartan 80 mg daily
Allopurinol 300 mg Tablet daily
Rosuvastatin 20 mg PO daily
Folic Acid 5 mg daily
Oxycodone-Acetaminophen 5-325 mg q8h as needed for pain
Isosorbide Mononitrate 60 mg Tablet once daily
Furosemide 20 mg Tablet once daily
Namenda 10 mg once daily
Tricor 145 mg once daily
Boniva 150 mg once monthly
Zyrtec 10 mg once daily
Mucinex 600 mg twice daily
Calcium Citrate +D (600/300) daily
Nitromist 0.4 mg/Dose Aerosol
Translingual once a day as needed for chest pain.
.
MEDICATIONS ON DISCHARGE FROM [**Hospital1 **]:
Lasix 80 mg PO daily
ASA 81 mg daily
Amiodarone 200 mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
expired
|
[
"428.0",
"410.71",
"V43.3",
"785.51",
"486",
"305.1",
"276.2",
"327.23",
"250.00",
"V45.02",
"V45.82",
"V45.81",
"272.4",
"V12.53",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"93.90",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9011, 9020
|
6497, 8074
|
343, 434
|
9071, 9080
|
4317, 6474
|
9136, 9146
|
3858, 3917
|
8972, 8988
|
9041, 9050
|
8100, 8949
|
9104, 9113
|
3932, 4298
|
3570, 3683
|
284, 305
|
462, 3459
|
3714, 3750
|
3481, 3549
|
3766, 3842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,988
| 187,355
|
47680
|
Discharge summary
|
report
|
Admission Date: [**2102-7-5**] Discharge Date: [**2102-7-13**]
Date of Birth: [**2045-8-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
back pain, lower extremity numbness
Major Surgical or Invasive Procedure:
Intubation, extubation
T3-T7 laminectomy and T3-T9 fusion
CVL placement and removal
History of Present Illness:
Mr. [**Known lastname 100713**] is a 56 yo male with severe COPD and CAD who
presented with lower extremity numbness and worsening back pain
found to have T6 vertebral compression fracture with cord edema.
History was obtained from wife and from limited medical record.
Of note, patient fell 2-3 weeks ago down two stairs. He
subsequently underwent a CT scan at [**Hospital **] Hospital whcih
revealed "spots on his lungs, a problem with his spinal cord,
and a cyst on his tailbone." He was told at this time that he
was not an operative candidate and was discharged home. He was
seen by his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 4223**] this past Monday and was prescribed
Percocet for pain control. His wife reports that over the two
days prior to presentation, he had no appetite, and lost all
sensation in his lower extremities. He had also reported a
burning sensation in his chest and excruciating escalation of
his back pain. Review of systems is positive for urinary
incontinence and constipation but now bowel incontinence. His
wife reports that he had developed acute worsening of the mid
and low back pain that he had been experiencing for the past
year. He was taken to [**Hospital **] Hospital again for further
evaluation, and because their MRI was not functioning, he was
transferred to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**], he was intubated for MRI which showed T6
compression fracture with cord edema. An urgent Spine
consultation was obtained and urgent operative decompression was
recommended.
.
Patient was taken to OR, and T3-T7 laminectomy and T3-T9 fusion
were performed. Patient received 4 units PRBC's, 3 units
platelets in the OR. EBL was 1.5 liters. Two drains were placed
to posterior wounds, one superficial and one deep to fascia. He
arrived to SICU intubated, paralyzed, and sedated.
Past Medical History:
COPD on 2L NC at home
CAD s/p stent
h/o alcohol abuse
Hypertension
Social History:
currently smokes a few cigarettes per day, previously 1 PPD x
40+ years. Consumes 1 alcoholic beverage per month, per wife.
Family History:
Father died of emphseyma in early 60's.
Physical Exam:
VS: T 97.2, BP 110/49, HR 65, RR 18
Gen: intubated, sedated, paralyzed; cushingoid appearance
HEENT: clear OP, MMM
CV: RRR
Lungs: air movement in all lung fields, no audible expiratory
wheezes
Abdomen: soft nt/nd
Extrem: warm, well-perfused, no edema
Skin: wound drains in tact with clean, dry dressings
Pertinent Results:
[**2102-7-5**] 12:25AM WBC-18.5* RBC-4.53* HGB-9.7* HCT-34.9*
MCV-77* MCH-21.4* MCHC-27.8* RDW-15.1
[**2102-7-5**] 12:25AM NEUTS-97.6* BANDS-0 LYMPHS-1.7* MONOS-0.7*
EOS-0 BASOS-0.1
[**2102-7-5**] 12:25AM PLT COUNT-420
[**2102-7-5**] 12:25AM PT-12.1 PTT-21.4* INR(PT)-1.0
[**2102-7-5**] 12:25AM GLUCOSE-116* UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-34* ANION GAP-14
[**2102-7-5**] 12:25AM CK(CPK)-40
[**2102-7-5**] 12:25AM LIPASE-29
.
[**2102-7-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2102-7-7**] URINE URINE CULTURE-FINAL neg
[**2102-7-5**] 12:44 pm TISSUE **FINAL REPORT [**2102-7-11**]**
GRAM STAIN (Final [**2102-7-5**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2102-7-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2102-7-11**]): NO GROWTH
[**2102-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL neg
[**2102-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL neg
[**2102-7-5**] MRI T/L SPINE:
1. Acute severe T6 vertebral body compression fracture
associated with posterior longitudinal ligament injury, and
bulging of the posterior aspect of the vertebral body, causing
indentation of the spinal cord at this level. Associated
increased STIR signal in the cord likely represents edema
secondary to cord compression at this level. A small amount of
epidural hematoma is seen. There may be a small superior
fracture fragment which may be mildly retropulsed; CT may be
performed for confirmation if clinically indicated.
2. Mild compression deformity of T3 is chronic.
.
PATHOLOGY SPECIMEN SUBMITTED: epidural collection, left T6
vertebral body biopsy, right T6 Vertebral body biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2102-7-5**] [**2102-7-5**] [**2102-7-12**] DR. [**Last Name (STitle) **].
[**Doctor Last Name 2336**]/mb????????????
DIAGNOSIS:
I) Epidural collection (A):
Adipose tissue with blood and inflammatory cells.
No evidence of malignancy.
Multiple levels are examined.
II) Vertebral body, left T6, biopsy (B):
Bone with reparative changes, and acute and chronic
inflammation, and changes consistent with fracture site.
Trilineage hematopoietic marrow.
Cartilage with degenerative changes.
Multiple levels are examined.
No evidence of malignancy.
III) Vertebral body, right T6, biopsy (C):
Bone with reparative changes, acute and chronic inflammation,
changes consistent with fracture site.
Cartilage with degenerative changes.
No evidence of malignancy.
Multiple levels are examined.
.
CXR [**2102-7-5**]: The heart size is normal. Opacity over the medial
right apex likely represents underlying tortuous vessels. Lung
volumes are low accentuating the pulmonary vessels. There is
slight fullness in the vascular pedicle with increased
interstitial opacity consistent with mild volume overload. No
sizable pleural effusion is seen. No pneumothorax is identified.
IMPRESSION: Low lung volumes with mild interstitial edema. No
consolidation to suggest pneumonia.
.
ECG Study Date of [**2102-7-9**] 8:48:48 AM
Sinus bradycardia. Non-specific ST-T wave abnormalities with
occasional
premature atrial contractions. Short P-R interval. No previous
tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 96 96 460/449 102 72 76
.
TTE [**7-11**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF 70-80%). There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
Brief Hospital Course:
Mr. [**Known lastname 100713**] is a 56 yo male with severe COPD who presented with
T6 compression fracture, now s/p T3-T7 laminectomy and T3-T9
fusion on [**7-5**].
.
# Compression fracture: The patient had a T6 compression
fracture and was intubated for a T3-T7 laminectomy and T3-T9
fusion on [**2102-7-5**]. He was extubated the following day. The
etiology of the compression fracture was initially concerning
for malignancy vs. osteoporosis in the setting of chronic
steroid use. Gram stain/tissue culture of specimen obtained in
OR was negative for organisms and pathology showed chronic
inflammatory changes and was negative for malignancy,
sugggesting osteoporosis the most likely etiology. Once
extubated, the patient had a TLSO fitted per ortho recs
(activity as tolerated when brace in place) and PT worked with
him to get OOB to chair. His strength in his lower extremities
slowly improved (intact plantar/dorsal flexion, able to barely
resist gravity for hip flexion, knee flexion). He was started on
a morphine PCA initially for pain control, which was weaned off
when transitioned to oral pain medications with oxycontin and
oxycodone prn. He was also given an aggressive bowel regimen
given his narcotics. The patient should follow up with surgery,
Dr. [**Last Name (STitle) 1007**], as an outpatient in on [**2102-8-9**] and with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4223**], on [**2102-7-27**].
.
# Respiratory difficulty/COPD: The patient was extubated easily
the day after his procedure. He initially required CPAP but was
transitioned to his usual home BIPAP regimen, which consists of
wearing BIPAP for approximately 16 hours a day. In addition he
was continued on a prednisone taper. In addition he was kept on
his home nebulizer albuterol and ipratroprium therapies in
addition to [**Hospital1 **] salmeterol. He is not on predinisone at
baseline according to his primary pulmonologist and should
complete his tapering regimen of prednisone as instructed in the
discharge medication section.
# Hypertension: The patient was on betablocker at home but
anti-hypertensives were held due to episodes of hypotension and,
at other times, bradycardia. His heart rate and blood pressure,
however, stabilized by discharge, and he was discharged with
lisinopril.
# Bradycardia: Patient experienced episodes of mostly
asymptomatic bradycardia during his stay. His ECG revealed sinus
bradycardia. Cardiology was consulted. He never needed atropine.
The etiology was unclear, but given his history of beta
blockade, glucagon was given, and his beta blocker was not
restarted at discharge. His heart rate was stable by discharge.
# CAD: continued on patient's home regimen of ASA, clopidigrel,
statin, lisinopril.
# Hypothyroidism: continued levothyroxine.
# Depression/anxiety: The patient was continued on his home
regimen of sertraline, alprazolam, clonazepam.
# PPx: The patient was maintained on a PPI while on high-dose
steroids as well as TMP/SMX for PCP [**Name Initial (PRE) 1102**]. He received
heparin SQ for DVT ppx.
# FULL CODE
Medications on Admission:
Plavix 75 mg daily
Metoprolol 100 mg [**Hospital1 **]
Percocet [**2-1**] q4-6 horus PRN
Alprazolam 1 gram TID
Sertraline 100 mg daily
Atenolol 25 mg daily
Clonazapam 1 mg qAM
Lasix 20 mg daily
Omeprazole 20 mg [**Hospital1 **]
Cefpodoxime 100 g [**Hospital1 **] x 10 days (start date [**6-24**])
Simvastatin 80 mg daily
Prednisone 20 mg daily
Theophylline 200 mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: see attached
scale Injection ASDIR (AS DIRECTED).
3. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) inh
Inhalation Q12H (every 12 hours).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
17. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): PCP prophylaxis until patient is off
steroids.
18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for gerd.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): tapering: 40 mg daily on [**2108-7-12**], 30 mg on [**2012-7-14**], 20
mg on [**2016-7-18**], 10 mg on [**2020-7-22**].
21. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
22. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
23. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
24. Ipratropium Bromide 0.02 % Solution Sig: [**2-1**] neb Inhalation
Q6H (every 6 hours) as needed.
25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis: thoracic spine compression fracture
Secondary diagnoses: chronic obstructive pulmonary disease,
coronary artery disease, alcohol abuse, hypertension
Discharge Condition:
stable respiratory status with BiPAP at night and as needed, [**2-4**]
strength in hip flexion bilaterally, making him immobile
Discharge Instructions:
You presented to [**Hospital1 18**] with leg weakness and spine compression
fracture. You underwent a spine surgery. You experienced some
breathing difficulty after being extubated, but your breathing
returned to baseline at discharge. Your heart rate was low at
times but by discharge the heart rate has stabilized. Please
take your medications and go to your follow-up appointments as
needed.
Followup Instructions:
* Surgery: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2102-8-9**] 2:45
* Primary care: Dr. [**First Name (STitle) 4223**] [**Telephone/Fax (1) 8506**], 11 am [**2102-7-27**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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"336.1",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
] |
12531, 12603
|
6583, 9692
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307, 392
|
12816, 12946
|
2906, 6560
|
13389, 13813
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2525, 2566
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12624, 12624
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9718, 10088
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12970, 13366
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2581, 2887
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12701, 12795
|
232, 269
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420, 2277
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12643, 12680
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2299, 2368
|
2384, 2509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,713
| 141,576
|
28433
|
Discharge summary
|
report
|
Admission Date: [**2130-10-15**] Discharge Date: [**2130-10-20**]
Date of Birth: [**2052-1-2**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
transferred from OSH with cerebellar infarct
Major Surgical or Invasive Procedure:
MRI/MRA
History of Present Illness:
78F h/o DM, HTN, previous lacunar strokes, hyperlipidemia,
PAF who was admitted on [**10-10**] to [**Hospital1 **] after acute onset of
nausea, vertigo, headache and staggering gait, will falling to
the right per her chart but to the left by her report today. She
was admitted to medicine with the diagnosis of peripheral
vertigo
but concern for posterior circulation stroke, with the plan on
imaging if her condition deteriorated. On [**10-12**], per her chart,
the nurses noticed that her right eye "was not working well" but
there is no further information. On [**10-13**] she was noted to be
lethargic and refused to eat or get OOB and psychiatry was
consulted. She was incontinent the next day and put in for an
MRI, which was obtained on [**10-15**], by which point neurology was
consulted. On exam, she was arousable to speak and followed some
commands but she was transferred here to our ICU for possible
neurosurgical intervention. She was started on dexamethasone.
Neurosurgery felt she was improved on steroids and has deferred
surgical intervention.
Past Medical History:
DM
Peripheral neuropathy
HTN
hyperlipidemia
paroxysmal atrial fibrillation
PVD
syncope
pericarditis
L lung granulomatous dz
diverticulosis
PBC
L lacunar stroke
s/p cystocele
macular degeneration and surgeries
Social History:
lives at home with her daughter, independent in ADLs
Family History:
negative for stroke
Physical Exam:
VS Tc 96.1/Tm 99.1 60-71 108-149/30-40 [**9-28**] 98-100% 680/297
fs176-225
Gen Lying in bed, NAD
HEENT neck supple
CV rrr
Pulm CTAB
Abd soft nt/nd +BS
Ext no edema
NEURO
MS Lying in bed with eyes closed but opens eyes to command.
Responds verbally to questions but prefers to keep her eyes
open.
Oriented to date, month and year but thought she was in
[**Location (un) 16965**] Hospital. Recites DOW backwards w/o difficulty.
No dysarthria. Speech fluent with intact naming and repetition
and without errors. No neglect.
CN VFF no extinction. Counts two fingers. EOM full but does not
sustain L gaze and L eye drifts back to midline and has
left-beating nystagmus on looking to the left. Eyes midline and
conjugate in primary gaze. Facial sensation intact to LT, but
decreased to PP on the right in V1, V2, V3. No facial asymmetry
or droop, [**5-19**] eye closure. Decreased hearing on the right
(chronic) to finger rub. Palate rises symmetrically. Tongue
midline. Shrug [**5-19**]
MOTOR Holds both arms up for 10 seconds. No drift. Needs
frequent
encouragement to cooperate with exam. R wrist extensors unable
to
assess, due to wrist board protecting A-line. Ceased cooperating
with exam in lower extremities, covering her eyes with her left
arm and saying she's tired. Normal tone.
D B T WE IP Q H DF
L 5 5 5 5 5 5 5 does not cooperate
R 4 5 4 - 4 does not cooperate
SENSORY
Intact to LT, PP throughout left side, decreased in right
arm/leg. Withdraws left leg to nailbed pressure, no response on
R.
REFLEXES
2+ in both arms, unable to obtain in the legs. R toe up, L down.
COORD
FTN intact b/l but slow.
GAIT
Deferred
Pertinent Results:
WBC 17.3, Hct 36.4, Plt 383
PT 12.3, PTT 31.5, INR 1.1, Fibrinogen 615
Na 132, K 3.8, Cl 96, CO2 26, BUN 42, Cr 1.5, Glu 422
U/A few bact, >50 WBC, mod leuk's, neg nitrite
Imaging
MRI from OSH (to be scanned into PACS): MRI from OSH shows L
cerebellar infarct involving entire L cerebellum, into R
cerebellum and L pons. Likely obstruction of 4th ventricle and
increased prominence of temporal horns of lateral ventricles
NCHCT [**10-16**]: (prelim) hypodensity seen throughout entire L
cerebellum and part of the medial R cerebellum, extending into
the pons/midbrain
Brief Hospital Course:
Patient was evaluated by neurosurgery but no intervention
indicated as she was past her maximum point of swelling per
history. Was started on Dexamethasone and responded will with
deficits less prominent over the next few days. Was continued
on dexamethasone and tapered off [**10-18**]. Transferred from ICU to
step down. Then transferred to floor [**10-18**] with telemetry.
Neuro: Still weak but able to lift everything anti-gravity and
has decent strength. Slow but not dysmetric on exam. Mental
status very good. Had sppech/swallow with video and passed for
softs and nectar thicks.
CVS: on telemetry as she has reported h/o PAF, but no affib
seen. Was not anticoagulated as no afib seen and risk of bleed
in posterior compartment.
REsp: no issues
ID: had elevated white count initially but afebrile and no
source of infections. Then grew pansensitive ecoli in urine.
afebrile. started bactrim ss.
Endo: elevated BS while on steroid but covered with RISS. HBA1c
mild/moderately elevated at 7.2
Medications on Admission:
Dexamethasone 4 mg IV Q6H
Insulin SC Sliding Scale
Bisacodyl 10 mg PO/PR DAILY:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Pantoprazole 40 mg IV Q24H
Labetalol HCl 10 mg IV Q2H:PRN SBP>180
Metoprolol 7.5 mg IV Q6H
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Insulin Regular Human 100 unit/mL Solution [**Month/Day (4) **]: per sliding
scale Injection ASDIR (AS DIRECTED).
Disp:*1 1* Refills:*2*
4. Aspirin 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (4) **]: One (1) PO BID (2
times a day).
Disp:*30 1* Refills:*2*
7. Senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily): hold for SBP < 120.
Disp:*30 Tablet(s)* Refills:*2*
9. Moexipril 15 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY (Daily):
hold for SBP<120.
Disp:*30 Tablet(s)* Refills:*2*
10. Lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): crush.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
11. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable [**Last Name (STitle) **]:
One (1) ML Injection ONCE (Once) for 1 doses.
Disp:*1 ML(s)* Refills:*0*
12. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
Disp:*10 ML(s)* Refills:*2*
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): hold for sbp<120 or hr<60.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **], [**Location (un) **]
Discharge Diagnosis:
Cerebellar infarct
Discharge Condition:
fair
Discharge Instructions:
You have had a large cerebellar stroke. Fall precautions needed
and PT/OT. Follow up with appointments as below.
Followup Instructions:
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2130-11-21**]
2:30
Also, make an appointment to follow up with your PCP after
discharge from rehab.
|
[
"250.60",
"427.31",
"599.0",
"434.91",
"443.9",
"041.4",
"357.2",
"787.2",
"438.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7409, 7474
|
4075, 5091
|
362, 371
|
7536, 7542
|
3479, 4052
|
7705, 7938
|
1783, 1805
|
5358, 7386
|
7495, 7515
|
5117, 5335
|
7566, 7682
|
1820, 3460
|
278, 324
|
399, 1463
|
1485, 1696
|
1712, 1767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,310
| 140,811
|
25020
|
Discharge summary
|
report
|
Admission Date: [**2121-1-22**] Discharge Date: [**2121-1-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] yo female with a PMH of CVA, MI, L Breast CA, PUD,
CHF, Parkinson's with dementia, who presents from [**Hospital1 62825**] after an episode of respiratory distress. The pt was found
by EMS to be satting 68%RA->87-93% on 100%NRB.
.
In the ED, the pt was thought to be in CHF with BNP of [**Numeric Identifier 62826**] and
was in afib with RVR (rate 110s-160s). Her HR ranged from
112-162 with RR 19-32. The pt was placed on BIPAP with
ABG-->7.35/63/225 on 100% FiO2. She was given Lasix 40 mg IVx1,
Ativan, Lopressor 5 mg IVx1. The pt developed a temp of 104.8
and her BP dropped from 113/58 to 90/63 and then 80/palp. Code
sepsis was called and pt received 3L IVF with R subclavian line
placement. Pt was given Levoflox 500 mg IV x1. Lactate was 2.3,
down to 1.3 after fluids. Pts UA was suggestive of a source of
the fever with 21-50 WBC and mod bacteria. CXR revealed ?LLL PNA
vs atelectasis.
Past Medical History:
CVA [**2099**]
MI approx 20 yrs ago
h/o CHF
h/o L breast cancer s/p radical mastectomy [**2079**]
h/o PUD with GIB
Parkinsons with dementia
dysphagia
s/p PEG tube placement
h/o cellulitis
Social History:
Pt lives at [**Location (un) 55**] [**Hospital1 599**] since [**8-5**].
Family History:
Mother, sister--CVA
Uncle, [**Name (NI) 62827**]
Physical Exam:
Vitals: T 97.3 BP 80-113/58-72 P 112-162 RR 19-36 Sat 73%RA, 99%
15LNC neb
Gen: sleepy elderly woman, NAD
HEENT: PERRL, BL arcus senilis, pale conjunctivae but
noninjected and anicteric
Neck: no JVD, no LAD
CV: tachy, no appreciable murmurs
Lungs: diffuse coarse ronchi
Ab: soft, non-reducible hernia in LLQ, NT to palp, PEG site
c/d/i
Extrem: no c/c; 1+pitting edema throughout LUE, weak distal
pulses, cool extremities
Neuro: arousable but not speaking, sleepy
Skin: large eccymosis on abdomen
Pertinent Results:
[**2121-1-22**] 04:20PM CORTISOL-46.3*
[**2121-1-22**] 03:50PM GLUCOSE-108* UREA N-50* CREAT-1.2* SODIUM-141
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2121-1-22**] 03:50PM CK(CPK)-75
[**2121-1-22**] 03:50PM CK-MB-3 cTropnT-0.12*
[**2121-1-22**] 03:50PM CALCIUM-6.8* PHOSPHATE-1.9* MAGNESIUM-2.0
[**2121-1-22**] 03:50PM CORTISOL-38.7*
[**2121-1-22**] 03:50PM WBC-14.9* RBC-2.77* HGB-8.7* HCT-27.5*
MCV-99* MCH-31.3 MCHC-31.6 RDW-15.0
[**2121-1-22**] 03:50PM NEUTS-88* BANDS-1 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-1-22**] 03:50PM PLT COUNT-328
[**2121-1-22**] 03:50PM PT-14.2* PTT-27.2 INR(PT)-1.3*
[**2121-1-22**] 01:33PM O2 SAT-58
[**2121-1-22**] 12:22PM LACTATE-1.1
[**2121-1-22**] 12:00PM GLUCOSE-119* UREA N-54* SODIUM-139
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
[**2121-1-22**] 12:00PM LD(LDH)-231 CK(CPK)-78
[**2121-1-22**] 12:00PM CK-MB-3 cTropnT-0.13*
[**2121-1-22**] 12:00PM IRON-13*
[**2121-1-22**] 12:00PM calTIBC-134* VIT B12-757 FOLATE-13.3
HAPTOGLOB-431* FERRITIN-293* TRF-103*
[**2121-1-22**] 12:00PM WBC-13.7* RBC-2.68* HGB-8.5* HCT-25.8* MCV-96
MCH-31.6 MCHC-32.8 RDW-13.6
[**2121-1-22**] 12:00PM NEUTS-88* BANDS-1 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2121-1-22**] 12:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL STIPPLED-OCCASIONAL
[**2121-1-22**] 12:00PM PLT SMR-NORMAL PLT COUNT-264
[**2121-1-22**] 12:00PM RET AUT-1.1*
[**2121-1-22**] 10:31AM LACTATE-1.3
[**2121-1-22**] 08:05AM GLUCOSE-132* UREA N-57* CREAT-1.3* SODIUM-138
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-31 ANION GAP-10
[**2121-1-22**] 08:05AM CK-MB-NotDone cTropnT-0.10* proBNP-[**Numeric Identifier 62826**]*
[**2121-1-22**] 08:05AM ALT(SGPT)-22 AST(SGOT)-110* CK(CPK)-53
[**2121-1-22**] 08:05AM CALCIUM-6.5* MAGNESIUM-2.2
[**2121-1-22**] 08:05AM CORTISOL-27.7*
[**2121-1-22**] 08:05AM CRP-117.1*
[**2121-1-22**] 08:05AM WBC-13.0* RBC-2.59* HGB-8.0* HCT-25.2* MCV-97
MCH-30.8 MCHC-31.6 RDW-14.6
[**2121-1-22**] 08:04AM LACTATE-1.6
[**2121-1-22**] 06:40AM TYPE-ART PO2-225* PCO2-63* PH-7.35 TOTAL
CO2-36* BASE XS-7 COMMENTS-BIPAP
[**2121-1-22**] 06:40AM LACTATE-2.3*
[**2121-1-22**] 06:40AM freeCa-1.07*
[**2121-1-22**] 06:27AM COMMENTS-GREEN TOP
[**2121-1-22**] 06:15AM WBC-15.8* RBC-3.26* HGB-10.3* HCT-31.7*
MCV-97 MCH-31.4 MCHC-32.4 RDW-14.3
[**2121-1-22**] 06:15AM PT-12.6 PTT-26.0 INR(PT)-1.1
.
TTE [**2121-1-22**]:
The left atrium is mildly dilated. There is symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular systolic function appears grossly preserved but
views are technically suboptimal. Due to suboptimal technical
quality, a focal wall motion abnormality 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 moderately thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
CHEST, ONE VIEW: There are no comparisons. The evaluation is
markedly
limited due to patient positioning. There is thoracic scoliosis.
There is elevation of the left hemidiaphragm. The right lung is
clear. There may be a left lower lobe infiltrate as well as a
small pleural effusion.
.
EKG: afib with RVR at rate of 75-150, nl axis, poor R wave
progression with ?reverse Q waves in anterior leads (?prior
posterior MI)
Brief Hospital Course:
A/P: [**Age over 90 **] yo female with a PMH of CVA, MI, L Breast CA, PUD, CHF,
Parkinson's with dementia, who presented with respiratory
distress, fever, and hypotension.
.
1. Septic shock/hypotension:
Pt had temp of 104.8 with SBP down to the 70s in the ED,
unresponsive to fluids. Only revealing source was dirty UA (so
possible urosepsis) as well as ? L sided PNA. Lactate down to
1.1 after fluids (was 2.3 on admission). Pt was covered broadly
initially with vancomycin and ceftazidime both UA and
pseudomonal/MRSA coverage given pt lives in an [**Hospital1 599**]. She was
given multiple NS boluses. She was able to come off pressors on
HD#2. However, the bp remained low normal and did drop again
into the low 80's. Over the next several days, the pt did
periodically require that phenylephrine be added back on for bp
support. However an accurate bp [**Location (un) 1131**] was difficult to obtain.
There was no arterial line and the pt had poor upper extremitity
pulses. The bp measurements were obtained by noninvasive cuff on
the lower extremity. It was ultimately determined to tolerate bp
in the 80's without the addition of pressors and assess
perfusion using other surrogates such as urine output and warmth
of extremities. By these measures, there was good perfusion and
no need to continue pressors. The culture data remained negative
and the pt was treated for a presumed PNA given the infiltrates
on chest imaging.
.
2. Respiratory Distress:
The pt's initial presentation was for respiratory distress,
which required NRB to maintain oxygenation at Rehab. She
required BiPAP in the ED. This was assessed to be
multifactorial. Pulmonary edema was considered to be a major
contributor initially given infiltrates on CXR and a BNP of
27,000 as well as the rapid afib in the ED. The pt was diuresed
and put on BiPAP and did show some improvement although the BP
dropped. However the pt was febrile to 104.8 and found to have a
lactate of 2.3 and there was a suspicion for PNA as well as a
source of the respiratory distress. Ceftaz and vanc were
initiated. She was given nebulizer treatments.
Over the course of the hospital stay, the respiratory status
failed to improve significantly. There was a waxing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 688**]
with the pt having episodes of worsening desaturation requiring
that she be put back on 100% by facemask. A CXR [**1-28**] showed new
nearly complete L lung opacification, atelectasis vs PNA, likely
with CHF contributing. The pt clinically remained in clear
respiratory distress over the following week. She had periods of
apnea and appeared to use accessory muscles to some degree.
Discussions were held with the daughter that the pt would
likely not be able to keep up this state of respiratory
distress. There was discussion regarding the long-term plan and
what interventions the pt would want. The pt had been DNR/DNI
since admission. The pt's status was changed from DNR/DNI more
toward comfort care. PRN morphine was to be used for comfort.
The pt did maintain the labored breathing for several days,
although she demonstrated little alertness or awareness and did
not appear uncomfortable. She was called out of the MICU to a
medical floor on [**2121-1-31**]. Shortly thereafter she was found to
have ceased spontaneous respirations and had no pulse. She was
pronounced deceased.
.
3. Afib with RVR:
No records indicate a prior history. Likely related to
sepsis/infection. Pt was intermittently in NSR and Afib. TTE
revealed symmetric LVH, preserved LV systolic function (possibly
falsely presevered due to MR), moderate [**Last Name (un) 6879**]; no new WMA. Use of
nodal blocking agents was limited by blood pressure. The plan
was to load with amiodarone given that pt seems to do worse when
she is in afib with RVR from cardiac standpoint. She continued
to have paroxysmal AF.
.
4. CHF:
Likely systolic and diastolic dysfxn, though poor quality echo.
The pt was periodically diuresed as necessary, although this was
limited by hypotension. She continued metop 25 tid
.
5. Presumed PNA:
Had temp of 104.8, WBC to 15, with question of LUL infiltrate on
CXR in addition to CHF, abx started empirically in ED for code
sepsis, though hypotension was likely [**1-2**] CHF, rapid AF and
lasix/metoprolol that was given. Vanc/ceftaz x 7 days.
.
6. FEN: continued tube feeds
#Parkinsons: continue sinemet and entacapone
.
#CAD: Per daughter, pt has h/o prior MI. LDL 70. h/o hemorrhage
so not an ASA.
-continue BB.
.
#Hypothyroidism: TSH 4.8. continued levothyroxine.
.
#. PPX: SC heparin, colace, protonix, SSI for tight glucose
control
#. Access: PICC placed [**1-23**], infusing after t-PA [**1-27**].
#Contact: Daughter, [**First Name4 (NamePattern1) **] [**Name (NI) 2405**] [**Telephone/Fax (1) 62828**]
Code status was discussed with daughter, was originally DNR/DNI,
although this was later amended towards comfort care.
Medications on Admission:
Amiodoarone 400 mg twice daily
Tylenol prn
Ceftazadime 2 gm [**Hospital1 **]
Vancomycin 1 gm daily
Colace 100 mg [**Hospital1 **]
Heparin 5000 u TID
SSI QID
Atrovent nebs prn
Lansoprazole 30 mg daily
Metoprolol 25 mg TID
Morhpine prn
Senna [**Hospital1 **] prn
Levothyroxine 125 mcg qd
Levsin 0.25 mg G tube q6hr
Sinemet 25/100 2 tab [**Hospital1 **]
Entacapone 200 mg qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
Discharge Condition:
NC
Discharge Instructions:
none
Followup Instructions:
none
|
[
"518.82",
"486",
"427.31",
"785.52",
"412",
"428.0",
"401.9",
"V66.7",
"593.9",
"V10.3",
"438.82",
"244.9",
"995.92",
"V44.1",
"276.4",
"294.10",
"331.82",
"584.9",
"038.9",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11390, 11399
|
6002, 10938
|
283, 289
|
11453, 11458
|
2146, 5979
|
11511, 11518
|
1563, 1614
|
11361, 11367
|
11420, 11432
|
10964, 11338
|
11482, 11488
|
1629, 2127
|
223, 245
|
317, 1243
|
1265, 1455
|
1472, 1546
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,712
| 111,440
|
31725
|
Discharge summary
|
report
|
Admission Date: [**2136-4-10**] Discharge Date: [**2136-4-21**]
Date of Birth: [**2069-9-8**] Sex: M
Service: MEDICINE
Allergies:
Methadone / Dilaudid
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
elective toe amputation and ulcer debridement
Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED:
1. Amputation of the first and second digits of the right
foot.
2. Debridement of right lower extremity anterior ulcer.
.
PICC line Placement
History of Present Illness:
66 yo M with ESRD on HD, CHF, COPD and severe PVD originally
admitted for right 1st and 2nd toe amputation with pre-op
pneumonia, and post-op loculated pleural effusions and a fib
with RVR.
.
The patient initially was admitted to the [**First Name3 (LF) 1106**] surgery
service for right 1st and 2nd toe amputations as well as right
lower leg ulcer debridement with VAC dressing placement on
[**2136-4-11**] On pre-op testing the patient was found to have a right
middle lobe pneumonia. Subsequent CT chest on [**2136-4-11**] revealed
bilateral loculated pleural effusions and pneumonia. He received
multiple antibiotics including nafcillin, clindamycin,
vancomycin and levofloxacin. The patient had a CT guided
thoracentesis with pigtail catheter placement on [**2136-4-13**].
Cultures on this fluid to date are without growth. Sputum
culture has growth only from [**2136-4-11**] with moraxella. The
patient was transitioned to vancomycin and zosyn and is now on
approximately day 6 of an expected 10 day course of zosyn
monotherapy.
.
On post-op day #2 the patient developed a fib with RVR with a
rate to the 130-150's. He developed hypotension to the systolic
70-80's and required transfer for the medical ICU. The patient
transiently required pressors. He was started on an amiodarone
load on [**2136-3-18**].
.
On the day of transfer from the ICU to the floor, the patient
underwent PICC line placement which failed and ended in midline
placement. He is scheduled to undergo revision by IR tomorrow.
In addition, he made his code status DNR/DNI by ICU team report.
.
Currently the patient complains of persistent shortness of
breath and lower extremity pain.
Past Medical History:
ESRD on HD (on Tue-Thurs-Sat schedule)
PVD
HTN
CHF sys/diastolic(EF 55%)
COPD
Crohn's
chronic anemia
hyperlipidemia
CAD/MI/PCI in [**2097**]'s
Paroxysmal AFib
.
PSH: left axillary-bifem bpg [**7-/2128**] (rest pain), L BKA [**12-24**] trauma,
L AKA for ischemia gangrene, right AVF with revision, right
CFA-BK [**Doctor Last Name **] with NRSVG in [**7-29**] with 4 compartment fasciotomy in
[**7-29**], appendix, rotator cuff repair, bladder surgery
Social History:
see previous d/c summeries
Family History:
Mother died of gastric cancer in her 80's. Father died at
85 from ESRD. # siblings, one died of liver disease. Married
with
4 children.
Physical Exam:
In ICU:
Vitals: 95.8 84/50 68 20 95% 2L NC
GEN: NAD, appearing older than stated age
HEENT: EOMI, PERRL. MM dry.
Lungs: Diffuse rhonchi with bronchial breath sounds in the R
middle lung field.
Heart: RRR S1, S2, no MRG
Abdomen: soft NT, ND, L-sided axillary-fem bypass palpable
[**Month/Year (2) **] AKA
[**Month/Year (2) **] 2+ edema at ankle, necrotic [**11-23**] toes, open wound of dorsal
foot, open wound with moderate purulence of anterior shin
.
On transfer from the ICU:
PE 95.6-96.2 68-104 84-110/40-60 13 99% 2L NC I/O: +315 in 24
hrs, 6.5L length of stay
Gen: NAD, comfortable.
HEENT: PERRL.
CV: Systolic ejection murmur loudest at the right sternal
border. Regular rate and rhythm.
Pulm: Coarse crackles in bilateral lung fields.
Abd: Soft, nontender, no organomegaly.
Ext: S/p Left BKA, VAC dressing in place in right shin. Surgical
wound dressing in place over right 1st and 2nd toes. Large [**Month/Day (2) **]
bullae.
.
Pertinent Results:
[**2136-4-10**] 05:45PM BLOOD WBC-12.2* RBC-3.54* Hgb-8.9* Hct-29.0*
MCV-82 MCH-25.1* MCHC-30.6* RDW-17.8* Plt Ct-300
[**2136-4-12**] 12:04AM BLOOD WBC-10.6 RBC-3.32* Hgb-8.4* Hct-27.8*
MCV-84 MCH-25.2* MCHC-30.1* RDW-16.5* Plt Ct-226
[**2136-4-13**] 03:52AM BLOOD WBC-23.6*# RBC-4.30* Hgb-10.4*#
Hct-38.5*# MCV-89 MCH-24.1* MCHC-26.9* RDW-16.1* Plt Ct-388#
[**2136-4-14**] 04:20AM BLOOD WBC-39.5*# RBC-3.86* Hgb-9.2* Hct-33.0*
MCV-86 MCH-24.0* MCHC-28.0* RDW-16.6* Plt Ct-296
[**2136-4-15**] 04:52AM BLOOD WBC-23.5* RBC-3.78* Hgb-9.2* Hct-32.4*
MCV-86 MCH-24.3* MCHC-28.4* RDW-16.8* Plt Ct-302
[**2136-4-17**] 04:09AM BLOOD WBC-9.3 RBC-3.52* Hgb-8.6* Hct-30.8*
MCV-88 MCH-24.4* MCHC-27.8* RDW-17.0* Plt Ct-222
[**2136-4-18**] 06:50AM BLOOD WBC-10.4 RBC-3.63* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.1* MCHC-29.7* RDW-18.9* Plt Ct-250
[**2136-4-19**] 06:00AM BLOOD WBC-9.7 RBC-3.75* Hgb-9.3* Hct-32.3*
MCV-86 MCH-24.7* MCHC-28.7* RDW-17.9* Plt Ct-254
[**2136-4-20**] 06:30AM BLOOD WBC-10.3 RBC-3.69* Hgb-9.3* Hct-31.2*
MCV-85 MCH-25.2* MCHC-29.8* RDW-19.8* Plt Ct-281
[**2136-4-21**] 04:07AM BLOOD WBC-14.3* RBC-3.61* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.3* MCHC-29.8* RDW-19.7* Plt Ct-347
[**2136-4-10**] 05:45PM BLOOD Neuts-84.9* Lymphs-7.6* Monos-5.8 Eos-1.6
Baso-0.2
[**2136-4-13**] 03:52AM BLOOD Neuts-83* Bands-0 Lymphs-13* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-4-19**] 06:00AM BLOOD Neuts-70 Bands-0 Lymphs-13* Monos-9 Eos-2
Baso-1 Atyps-0 Metas-2* Myelos-3*
[**2136-4-12**] 08:33PM BLOOD PT-16.4* PTT-45.2* INR(PT)-1.5*
[**2136-4-20**] 06:30AM BLOOD PT-18.6* PTT-34.5 INR(PT)-1.7*
[**2136-4-21**] 04:07AM BLOOD PT-15.2* PTT-32.3 INR(PT)-1.3*
[**2136-4-10**] 05:45PM BLOOD Glucose-142* UreaN-26* Creat-4.7* Na-141
K-3.7 Cl-98 HCO3-28 AnGap-19
[**2136-4-12**] 07:01PM BLOOD Glucose-108* UreaN-19 Creat-3.6*# Na-141
K-4.0 Cl-105 HCO3-22 AnGap-18
[**2136-4-21**] 04:07AM BLOOD Glucose-88 UreaN-21* Creat-4.9*# Na-140
K-4.3 Cl-100 HCO3-29 AnGap-15
[**2136-4-21**] 04:07AM BLOOD ALT-31 AST-17 LD(LDH)-172 AlkPhos-277*
TotBili-0.7
[**2136-4-14**] 04:20AM BLOOD Lipase-58
[**2136-4-19**] 06:00AM BLOOD GGT-238*
[**2136-4-11**] 01:10AM BLOOD CK-MB-NotDone cTropnT-0.79*
[**2136-4-11**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.74*
[**2136-4-18**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.38*
[**2136-4-18**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.40*
[**2136-4-19**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2136-4-12**] 09:48AM BLOOD TotProt-6.1* Albumin-3.0* Globuln-3.1
[**2136-4-14**] 04:20AM BLOOD TotProt-6.1* Albumin-2.9* Globuln-3.2
Calcium-9.4 Phos-7.5* Mg-2.0
[**2136-4-19**] 06:00AM BLOOD Albumin-2.9* Calcium-10.1 Phos-4.6*
Mg-1.7
[**2136-4-21**] 04:07AM BLOOD Calcium-10.0 Phos-4.6* Mg-1.6
[**2136-4-20**] 07:00AM BLOOD ANCA-PND
[**2136-4-17**] 04:09AM BLOOD Vanco-13.8
[**2136-4-14**] 04:20AM BLOOD Vanco-5.2*
[**2136-4-12**] 07:01PM BLOOD HoldBLu-HOLD
[**2136-4-14**] 10:37PM BLOOD Lactate-1.4
Imaging:
PREOP PA AND LATERAL CHEST, [**2136-4-10**]
IMPRESSION:
1. Dense right middle lobe consolidation, new since [**8-28**],
likely pneumonic.
2. CHF with interstitial edema; new small right pleural effusion
may relate to either process.
.
CT CHEST W/O CONTRAST [**2136-4-11**] 4:23 AM
IMPRESSION: Bilateral loculated pleural effusions, right more
than left. Right lower lobe and middle lobe _____ pneumonia.
Moderate apical emphysema. Moderate mediastinal adenopathy.
.
IMPRESSION:
CT THORACENTESIS W/TUBE PLACMENT [**2136-4-13**] 2:49 PM
1. Successful CT-guided subcutaneous catheter drainage
placement.
2. Incidental 6 mm right middle lobe pulmonary nodule and
emphysema.
_____ catheter care and findings of this _____ pulmonary nodule
discussed with Dr. [**Last Name (STitle) **] at 4:30 p.m. on [**2136-4-13**].
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2136-4-14**] 8:20 PM
IMPRESSION:
1. Ascites and pulsatile flow within the portal vein which may
relate to congestive heart failure.
2. Extensive sludge within the gallbladder (which may relate to
the patient's overall clinical status), but no evidence of acute
cholecystitis.
.
CHEST (PORTABLE AP) [**2136-4-14**] 7:03 AM
IMPRESSION: New right-sided chest tube. No evidence of
pneumothorax. Interval improvement in right pleural effusion
with residual small amount of fluid remaining in the right major
fissure.
.
CHEST (PORTABLE AP) [**2136-4-16**] 3:22 AM
Portable AP chest radiograph was compared to [**2136-4-14**],
obtained at 2:18 p.m.
The pigtail catheter inserted in the upper pleural space in the
right upper lobe is unchanged. There is no interval change in
small amount of intrafissural pleural fluid on the right as well
as there is no change in the right basal areas of atelectasis.
There is interval progression of the [**Year (4 digits) 1106**] engorgement in the
left perihilar area which may represent mild volume overload
with asymmetric distribution due to patient's position.
Bibasilar retrocardiac atelectasis are unchanged. No
pneumothorax or left effusion is demonstrated.
.
ECG: Study Date of [**2136-4-10**] 9:28:38 PM
Sinus rhythm. Left ventricular hypertrophy with secondary ST-T
wave changes although myocardial ischemia cannot be ruled out.
Compared to the previous tracing of [**2135-9-15**] left ventricular
hypertrophy is more prominent and ST segment depressions in the
lateral leads are also more prominent. TRACING #1
.
ECG: Study Date of [**2136-4-12**] 9:45:50 AM
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy. ST segment depression in leads V4-V6 which may be
related
to ischemia in the setting of left ventricular hypertrophy.
Clinical
correlation is suggested. Compared to the previous tracing of
[**2136-4-11**]
atrial fibrillation persists with a slightly slower ventricular
response.
.
ECG:Study Date of [**2136-4-18**] 1:06:08 PM
Atrial fibrillation with rapid ventricular response
Slight nonspecific intraventricular conduction delay
Nonspecific ST-T abnormalities
Since previous tracing of [**2136-4-12**], precordial QRS voltage less
prominent and ST-T wave changes decreased
Brief Hospital Course:
.
#Pneumonia: Patient found to have consolidation on admission,
with CT scan demonstrating loculated pleural effuions. Sputum
cultures grew moraxella. Patient was started on zosyn in house.
Pig-tail catheter was placed to drain pleural effusion, and
cultures sent, but were without growth. Moraxella felt to be an
unlikely pathogen, and patient was clinically improving on
zosyn, so was continued on this regimen for plan of full 14 day
course. Pig-tail catheter was pulled on the floor after several
days and consultation with thoracics. CXR following removal
demonstrated no pneumothorax, or significant reaccumulation of
fluid. Plan to complete course of zosyn via picc as directed
below for full 14 days.
- Patient should have repeat CXR in [**1-24**] weeks time to document
resolution of his infiltrate.
- Please remove PICC upon completion of antibiotics.
.
#Atrial Fibrillation: Patient with A. Fib with RVR. During
initial presentation did not tolerate this rhythm well and was
hypotensive requiring ICU stay. As a result, patient was loaded
with amiodarone with goal of maintaining sinus rhythm. Patient
tolerated amio load well and converted to sinus rhythm prior to
call-out from the ICU. Did have [**11-23**] recurrence of A. Fib with
RVR on the floor that second of which required IV diltiazem to
break. Patient was then started on low dose oral diltiazem for
rate control and remained in sinus rhythm for the remainder of
his hospital stay and 48 hours prior to discharge. Plan to
continue amiodarone and diltiazem and f/u with outpatient [**Month/Day (2) 3390**]
for further management. [**Month (only) 116**] not require long term amiodraone
for rhythm control and would consider discontinuation once his
pneumonia resolved. Patient was not anticoagulated given he his
only indication was history of CHF.
.
#Hypotension: In setting of A. Fib with RVR and pneumonia.
Consistent with sepsis and unstable tachycardia. Improved with
IVF's and rhythm control of his A. Fib. Recommend monitoring
blood pressures by mentation, and L-forearm given AV fistula on
R-arm and picc proximal on the left.
.
#Amputation: Patient had successful 1st/2nd toe amputation with
debridement of his arterial ulcer. Patient followed closely by
[**Month (only) 1106**] surgery in house who recommended outpatient follow-up
on discharge. continue current wound-care and wound vac with
changes as directed.
.
#ESRD: Continued on HD in house. Last session on day of
discharge - Saturday. Continue T/H/Sat dialysis.
.
#Sacral Wound: Seen by wound care nurse in-house. continue
dressing changes as directed.
.
#Coagulopathy: Mild coagulopathy in house on antibiotics.
Thought [**12-24**] to abx and nutriotional status. Given PO vitamin K
with subsequent improvement.
.
#Transaminitis/Liver: Developed in-house. Thought [**12-24**] to
hypotension/shock liver. Normalized prior to discharge. If
recurs would consider amiodarone toxicity. Patient with
persistent Alk Phos elevation and GGT confirming it to be
hepatic and not from recent amputation. Liver USD with biliary
sludge but no e/o cholecystitis/ductal dilation or other acute
pathology. Would consider outpatient ERCP/MRCP in future given
h/o Crohn's disease and elevated alk phos - concern for PSC.
Sent P-ANCA in house - pending at time of discharge.
.
#Crohn's Disease: Continued on outpatient regimen. No diarrhea.
#Leukocytosis: Mild new leukocytosis on day prior to discharge.
Vitals stable, afebrile, and without e/o infection. If develops
diarrhea would have concern for C. Diff in this hospitalized, HD
patient on zosyn.
.
#Lung nodule: Patient had several CT scans in house. On one
occasion a scan found a 6 mm right middle lobe pulmonary nodule.
Recommend repeat evaluation w/ CT scan of this nodule as an
outpatient once acute pneumonia has resolved to better ascertain
size of nodule and assess for interval change.
# Chronic anemia. Stable, likely anemia of chronic disease.
# CAD s/p MI with PCI in the [**2097**]'s. No signs of active
ischemia. ST depressions on EKG correlated with A. Fib w/ RVR
and enzymes stable. Troponin mildly elevated but [**12-24**] to ESRD
and demand from rapid rate.
- Continue aspirin, nitroglycerin PRN.
.
# Psych. Continue buspirone and sertraline. Stable.
# Prophylaxis. Heparin subcutaneously, PPI. Antiemetics PRN.
# Access: Tunnelled line, midline. Please remove midline after
completion of antibiotics.
# Code: DNR/DNI
.
Medications on Admission:
Oxygen 2L/min
Carvedilol 25 [**Hospital1 **]
Omeprazole 20 [**Hospital1 **]
Asacol 1200 tid
Phoslo 3 caps tid
Alprazolam [**Hospital1 **]
Buspar [**Hospital1 **]
Zoloft qhs
EC-ASA 325 qd
Nitro 0.4 sl prn
Fe pills
.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: through [**4-23**], and then begin reduced dose
prescription.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
to start on [**4-24**] after completion of loading phase.
15. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours): hold for SBP < 100.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
17. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q12 () for 5 days: through [**2136-4-26**]
for total of 2 weeks.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
1st and second toe amputation
arterial ulcer
atrial fibrillation with rapid ventricular response
Pneumonia
Sepsis
End stage renal disease
Transaminitis
Sacral Ulcer
Discharge Condition:
Stable, non-weight bearing.
Discharge Instructions:
You were admitted to the hospital for a toe amputation. On
admission it was found that you had a pneumonia. Your amputation
was performed successfully and your leg ulcer was surgically
debrided. You were then treated for your pneumonia.
.
You also developed an irregular heart rate known as atrial
fibrillation and required the intensive care unit for monitoring
and control of your heart rate. You were started on 2 new
medications for control of this heart rate - Amiodarone and
diltiazem. You should discuss these with your doctor as you may
not need to take them long term. In the short term however,
please take all new medications as directed upon leaving the
hospital.
.
Please call your physician should you develop any new lower
extremity pain, chest pain, palpitations, shortness of breath,
fever > 101 or any other symptom concerning to you.
.
You must take the following medications:
1. Piperacillin/tazobactam - for total of 2 weeks through [**4-26**] [**2135**]
2. Amiodarone - 400mg twice daily and then 200mg daily
thereafter. Please do not discontinue this medication without
discussing it with your doctor.
3. Diltiazem 15mg by mouth every 6 hours. Please do not
discontinue this medication without discussing it with your
doctor.
4. Please continue all other medications as directed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2136-5-1**] 12:30 on the [**Location 74518**] [**Hospital Ward Name 121**] building,
Chest Disease Center, [**Location (un) 453**], [**Hospital1 **] building. You will
see the NP [**Location (un) 1439**] or [**Female First Name (un) **]
Report to the [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology
for a Chest X-Ray 45 minutes before your appointment.
..
Provider: [**Name10 (NameIs) **] Surgery -> [**2136-5-2**] at 11:45AM, with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**], [**Hospital Unit Name **] 110 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 5c,
([**Telephone/Fax (1) 14585**]
.
Provider: [**Name10 (NameIs) 3390**], [**Name11 (NameIs) 4392**],[**Name12 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 74519**], please call for an
appointment in the next 1 month.
|
[
"038.9",
"428.42",
"V49.76",
"428.0",
"707.13",
"496",
"707.03",
"995.92",
"440.24",
"285.21",
"511.9",
"272.4",
"486",
"585.6",
"785.52",
"555.9",
"V45.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"84.11",
"86.22",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
16693, 16763
|
9909, 14364
|
326, 495
|
16972, 17002
|
3837, 9886
|
18363, 19370
|
2727, 2865
|
14629, 16670
|
16784, 16951
|
14390, 14606
|
17026, 18340
|
2880, 3818
|
241, 288
|
523, 2190
|
2212, 2666
|
2682, 2711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,497
| 100,150
|
29273
|
Discharge summary
|
report
|
Admission Date: [**2175-8-10**] Discharge Date: [**2175-8-22**]
Date of Birth: [**2148-2-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Right flank pain, fever
Major Surgical or Invasive Procedure:
embolization of bleeding artery under IR
History of Present Illness:
27 F here for 2 days of right flank pain, sharp, worsened by
deep breaths. No similar pains on past. Associated fatigue and
fevers x 2 days. No dysuria, hematuria or any other urinary
symptoms. Chronic tingling in the right foot (since she was
diagnosed with cord compression many months back. No headache.
ER course - given Abx as below. Temp 103.9
ROS:
Constitutional: Fatigued, weight loss in past 5 weeks. Fever and
associated chills as above. Also anorexic.
Neuro: No confusion, numbness of extremities, dizziness or
light-headedness, vertigo, weakness of extremities, confusion,
tremor. Parasthesias-as above
Psychiatric: no depression, suicidal ideation
Eyes: No blurry vision, diplopia, loss of vision, photophobia.
Wears glasses.
ENT: No dry mouth, oral ulcers, bleeding nose, gums, tinnitus,
sinus pain, sore throat
Cardiac: no chest pain, DOE, syncope, PND, orthopnea,
palpitations, peripheral edema
Pulmonary: No shortness of breath, hemoptysis, pleuritic pain.
Has chronic coung for many weeks
GI: Had some nausea and vomiting. No diarrhea, constipation,
hematemesis, melena, hematochezia. Abd pain as above.
Heme: no easy bleeding, bruising, lymphadenopathy
GU: no dysuria, hematuria, increased frequency, urgency or
incontinence
Endocrine: Lost hair since starting chemo. No skin changes, heat
or cold intolerance
Skin: no rash or pruritis
Musculoskeletal: no myalgias, arthralgias, back pain
Allergy: no seasonal allergies- NKDA.
.
[x] All other systems negative on detailed review except as
noted.
Past Medical History:
- Hepatocellular carcinoma - metastasis to bone, lung, abdomen
-Had been receiving weekly 5-FU leucovorin after having
progressed on the weekly doxorubicin. She previously was
treated with gemcitabine, Cisplatin, and Avastin.
- Pulmonary embolism and SVC clot - on anticoagulation.
-R ovarian cyst-She affirms increasing abdominal girth [**2168**],
feeling increased bloating, presented to the ED found to have a
right ovarian cyst, was resected.
- [**2155**] (7yrs old) hospitalized for 6 months for fever/cough,
weakness, unclear source of infection, did require blood
transfusions.
- Gyn- no menstrual periods for the past year
Social History:
Social History: Lives with her sister and brother. Recently
relocated from [**Country 3587**] [**12-21**] - speaks Creole and Portugese.
Denies stds, denies etoh, ivdu, smoking.
Family History:
1 sister age 27, with question of R leg mass resected 4 yrs ago.
Brother had liver problems as a child.
Father - HTN
Denies other cancer history
Physical Exam:
VS T 99.6 P 123/min, BP 104/68 RR 16 100% RA
Gen - Thin female appears chronically sick. Not in acute
distress.
Eyes - pale, not jaundiced
ENT - moist mucosae, no thrush, ulcers or erythema
Neck - supple, no LAD, JVP normal
CV - S1, 2 - normal, No murmurs or rubs, or gallops. Tachycardia
RS - no crackles or wheezing
Abd - rt UQ abd pain, no RT or distenstion. Liver edge palpable.
Rt CVA tenderness
Extremeties - no edema
Skin - no rash
GU - no catheter
Neuro - Alert and oriented x3, Cr n [**3-27**] normal. Motor - [**5-20**] UE
and LE bilaterally equal, prox and distal. Sensory normal to
crude touch bilaterally. Plantars flexor bilaterally. No
pronator drift. Fluent speech.
Psychiatric - not anxious. Calm. Not depressed
Heme/lymph - no cerv LAD, thyroid normal.
Pertinent Results:
CXR - IMPRESSION: No acute cardiopulmonary process. Multiple
pulmonary masses present at the lung base is better evaluated on
the CT examination of [**2175-7-26**]
CT abdomen, pelvis - IMPRESSION:
1. Significant interval worsening of metastatic disease as
described above.
2. Interval increase in size of the left adnexal dermoid.
3. Unchanged appearance of osseous metastasis
.
.
Brief Hospital Course:
# acute blood loss anemia/hemoperitoneum: Likely bleeding from
hepatic tumors, however, angio did not identify obviously
bleeding lesions, so no embolization performed initially. Pt
then had increased abdominal distension and pain; repeat CT scan
did not show demonstrable change in hemoperitoneum, but could
not rule out continued oozing from liver lesions. R hepatic
artery was therefore embolized with Gel-foam to prevent
further/future bleeding. Following procedure, patient had a
stable hematocrit, and did not require additional transfusions.
.
# Fevers: No clinical signs that would indicate current
infection, as pt w/o cough, SOB, dysuria, or diahrea. Serial
blood cultures were without crowth. Fevers believed to be
secondary either to diffuse cancer or blood in peritoneum.
.
# Pain: Pt swtiched from PCA to MS contin w/ diluadid PRNs.
While patient was significantly uncomfortable on admission, pain
ins well controlled at time of discharge. Pain due to
carcinomatosis of abdomien.
.
# hepatocellular carcinoma: HepB +, widely metastatic. last
chemo over 2 weeks ago. As pt has failed multiple
chemotherapeutic regimens, felt that would not gain advantage
from additional treatment. Pt seen by palliative care, and their
assistance is most appreciated. Patient discharged with home
hospice.
Medications on Admission:
LOVENOX 60MG subcutaneously [**Hospital1 **]
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: [**1-17**] mL PO q 1 hour
as needed for discomfort/respiratory distress.
Disp:*4 syringes* Refills:*0*
2. Wheelchair Misc Sig: One (1) Miscellaneous once a day.
Disp:*1 * Refills:*0*
3. hospital bed
please provide pt w/ one hospital bed
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4
Hours) as needed for Pain.
Disp:*150 Tablet(s)* Refills:*2*
8. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*240 Tablet Sustained Release(s)* Refills:*2*
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*1*
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VistaCare
Discharge Diagnosis:
Metastatic liver cancer
hemoperitoneum
Discharge Condition:
Stable
Discharge Instructions:
You are discharged after an admission due to bleeding in your
belly. This bleeding was from one of your liver tumors. You
had the blood suppy to that tumor blocked so that it won't
bleed. Because of these bleeding tumors, you are no longer a
canidate for the serafinib treatment. Unfortuantly all the
chemotherapy we normally use to treat liver cancer has not
proven successful. You are now being discharged home, and
arangements are being made to give you the support to remain
comfortable.
Followup Instructions:
Call your Dr. [**Last Name (STitle) **] you develop severe abdominal pain, confusion,
difficulty breathing, vomiting.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"285.1",
"197.0",
"453.2",
"155.0",
"197.7",
"780.6",
"112.0",
"198.5",
"568.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
6793, 6833
|
4161, 5470
|
339, 382
|
6916, 6925
|
3754, 4138
|
7470, 7717
|
2798, 2945
|
5565, 6770
|
6854, 6895
|
5496, 5542
|
6949, 7447
|
2960, 3735
|
276, 301
|
410, 1929
|
1951, 2585
|
2617, 2782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,966
| 127,285
|
12748
|
Discharge summary
|
report
|
Admission Date: [**2161-9-17**] Discharge Date: [**2161-10-9**]
Date of Birth: [**2108-1-21**] Sex: M
Service: MEDICINE
Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**9-23**]: Placement of right-sided PICC line by IV nurses
[**9-24**]: Bedside placement of chest tube by Interventional
Pulmonology
[**9-26**]: Removal of chest tube by Thoracic Surgery
[**10-1**]: VATS/decortication by Thoracic Surgery
[**10-3**]: Removal of chest tubes by Thoracic Surgery, Removal of
PICC line
History of Present Illness:
53yoM with indwelling R arm picc x 2 weeks and very complicated
surgical and medical history including gastric bypass and
multiple other abdominal surgeries, chronic TPN with indwelling
PICC lines, cachexia, and multiple admissions to the intensive
care units for PICC line sepsis, who presents with fever of 102
and tachycardia as well as a feeling of malaise, which he
associates with episodes of line sepsis.
In the ED, initial VS were: 100.1 120 129/81 20 97% 2L.
Patient given 1L NS bolus with no resolution of tachycardia.
Patient also c/o anxiety and given 1mg PO ativan with little
effect. Motrin 600 mg and Morphine 4mg IV resolved patient's
headache. WBC 18.9 w/ 88.5% neutrophils. Patient covered for
unknown source of SIRS with vanc/zosyn/gent. 2 peripheral BCx
sent and 1 BCx of of PICC sent. UCx sent, but clean U/A. CXR
wnl. Transfered to the ICU for tachycardia and SIRS with
possible sepsis.
Past Medical History:
1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines
Social History:
Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.
Family History:
Significant for CAD in his father and a sister w/ SLE
Physical Exam:
Admission Labs:
Vitals: T: 100.9 BP: 120s/80s P: 110-120s R: 18 O2: 98-99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: tachycardic with normal rhythm, normal S1 + S2, I/VI
systolic murmur heard best @LLSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: extensive surgical scarring, soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2161-9-17**] 09:15PM WBC-18.9* RBC-3.76* HGB-11.9* HCT-35.6*
MCV-95 MCH-31.6 MCHC-33.4 RDW-16.3*
[**2161-9-17**] 09:15PM NEUTS-88.5* LYMPHS-7.9* MONOS-1.1* EOS-2.2
BASOS-0.3
[**2161-9-17**] 09:15PM PLT COUNT-437
[**2161-9-17**] 09:15PM GLUCOSE-85 UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2161-9-17**] 09:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2161-9-17**] 09:24PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2161-9-17**] 09:26PM LACTATE-1.9
Studies:
[**2161-9-17**] CXR: Low lung volumes; however, no focal acute pulmonary
process
identified.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2161-9-30**]
12:44 PM
IMPRESSION:
1. Slight interval increase in fluid component of large left
hemopneumothorax.
No source of active extravasation identified.
2. Left upper lobe consolidation could represent infection.
Recommend CT
follow up after resolution of acute symptoms.
3. Scattered ground-glass opacity in the right lung compatible
with infection.
Brief Hospital Course:
53 year old male with multiple GI surgeries including Roux-en-Y
gastric bypass surgery with bile duct injury, total gastrectomy,
distal pancreatectomy, and splenectomy, was initially admitted
with malaise and fevers, found to have PICC line sepsis; during
this admission, patient had a fall from bed with subsequent rib
fractures and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation. This
hospitalization was also complicated by anemia, UTI, delirium
and thrombocytosis.
.
Active Issues:
# PICC line sepsis: The patient met SIRS criteria on admission
with fevers to 102, WBC 19 and tachycardia, along with a
confirmed site of infection in his PICC line. He was initially
admitted to the MICU, but transferred to the floor after he was
determined to be hemodynamically stable. The patient's right
PICC line was removed. Blood cultures from the PICC line grew
E. coli, Enterococcus and Stenotrophomonas. A new left-sided
PICC was placed on [**9-23**] for prolonged delivery of IV
antibiotics, and it was removed after antibiotics finished on
[**10-3**]. The patient was treated with meropenem, vancomycin and
levofloxacin. TTE showed no valvular vegetations. Serial blood
cultures were subsequently negative.
.
# Hemothorax: The patient fell out of bed on [**9-24**] and sustained
9th and 10th rib fractures, complicated by a hemothorax. The
Interventional Pulmonology team inserted a chest tube for
drainage on [**9-24**], and it was subsequently removed by the
Thoracic Surgery team on [**10-3**]. Chest tube placement and removal
was complicated by a minimal pneumothorax. After removal of the
tube, the patient continued to have intermittent fevers and
periods of hypotension that were responsive to IV fluid boluses.
On follow-up imaging of the chest, he was noted to have
reaccumulation of his effusion with loculations, unable to be
drained by IP. He was taken to the OR on [**10-1**] for a
VATS/decortication by Thoracic Surgery. There was minimal blood
loss during the surgery. The patient felt that his breathing
and pain was much improved following the surgery
.
# Nutrition/cachexia: Ongoing problem for this patient secondary
to his prior gastrectomy. During this admission, the patient
tolerated PO diet well along with nutritional supplements.
However, out of concern for his malnutrition, per his outpatient
providers, the patient was further supplemented with TPN for ten
days, while he had an indwelling PICC for antibiotic therapy.
TPN was discontinued when his PICC was removed on [**10-3**]. He was
followed by the Surgical Nutrition team and they recommended
high protein content supplements and patient followup as an
outpatient to ensure he maintains his weight and nutritional
status. There was extensive discussion among his outpatient care
providers, and the decision was made not to place another PICC
line for TPN. He is also not a candidate for J-tube placement.
.
# Anemia: Over the course of this admission, the patient
experienced slowly downtrending hematocrit from continued bleed
into his left pleural space. He required three units of PRBCs
over the course of his stay. Hematocrit sunsequently stabilized
in the mid-20s.
.
# UTI: Patient was noted to have a UA positive for 111 WBC,
without any growth on culture, along with increased frequency of
urination. He was treated empirically for a UTI with seven days
of levofloxacin.
.
# Delirium: The patient was at times tangiential in thought
processes and sleepy. This was attributed to acute medical
issues and pain medications. He tended to be more delirious in
response to IV Dilaudid. Lithium level was WNL; he was not
hypoglycemic during episodes of delirium. After treatment of
bacteremia completed and the patient underwent
VATS/decortication, his mental status improved and subsequently
remained stable.
.
# Thrombocytosis: Thrombocytosis to peak of ~ 1.5 million was
thought to be an acute reaction in response to his infection and
hemothorax. Hematology was consulted and recommended no
interventions at this time. JAK2 sent off for possible
myeloproliferative disorder, as he has also had chronic
leukocytosis and anemia. Results are pending.
.
Chronic issues:
# Anxiety/BPD/ADHD: Documented history of these problems. The
patient was extremely anxious during this admission, likely
secondary to multiple medical problems. [**Name (NI) **] was continued on his
home medications, including amphetamine-dextroamphetamine,
clonazepam, diazepam, dronabinol, lithium carbonate,
mirtazapine, oxycodone, Ramelteon, tramadol, venlafaxine,
zolpidem and zonisamide.
.
.
Transitional issues:
1.) Code: Full (but does not want to be intubated if it means he
will never be able to come off the vent), confirmed with patient
and his HCP (sister)
2.) Emergency contact: sister [**Name (NI) **] (HCP) [**Telephone/Fax (1) 39334**]; [**Name (NI) **]
[**Name (NI) 39335**] (girlfriend) [**Telephone/Fax (1) 39336**]'
3) JAK2 and ristoceiting cofactor sendout pending. Please
followup
Medications on Admission:
AMPHETAMINE-DEXTROAMPHETAMINE - 10 mg Capsule, Ext Release 24 hr
- 2 Capsule(s) by mouth twice a day
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for anxiety
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1 ml IM
once a month
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
prn
DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release (E.C.) - 2
Tablet(s) by mouth twice a day as needed for pain
DRONABINOL [MARINOL] - 10 mg Capsule - 1 Capsule(s) by mouth
twice a day start with once a day for 1 week, then increase if
no
ill effect
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FOOD SUPPLEMENT, LACTOSE-FREE BOOST - - Liguid (vanilla,
strawberry, chocolate) 3 cans per day dx: anemia, Vitamin B12
deficiency, osteoporosis, depression, basilar migraines, tardive
dyskinesia, chronic pain
LEVOMEFOLATE CALCIUM [DEPLIN] - 15 mg Tablet - 1 Tablet(s) by
mouth am
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 3 Capsule(s) by mouth
three
times a day
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth
three
times a day
LITHIUM CARBONATE - 450 mg Tablet Extended Release - one
Tablet(s) by mouth daily
MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime
ONDANSETRON [ZOFRAN ODT] - 8 mg Tablet, Rapid Dissolve - 1
Tablet(s) by mouth three times a day as needed for nausea
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 3
Tablet(s) by mouth once a day
OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth every eight (8)
hours as needed for pain
PHYSICAL THERAPY - - please evaluate and treat for general
deconditioning, L hip pain, ankle fracture
RAMELTEON [ROZEREM] - 8 mg Tablet - 3 Tablet(s) by mouth at
bedtime
SYRINGES - - for b12 shots for b12 shot every day
TETRABENAZINE [XENAZINE] - (Prescribed by Other Provider) (Not
Taking as Prescribed) - 12.5 mg Tablet - 1 Tablet(s) by mouth
twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth prn headache
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Ext Release 24 hr - 2
Capsule(s) by mouth in AM
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bed time as
needed for sleep
ZONISAMIDE - 100 mg Capsule - 3 Capsule(s) by mouth at bedtime
ASPIRIN [ADULT LOW DOSE ASPIRIN] - (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
CALCIUM CITRATE-VITAMIN D3 - 315 mg-250 unit Tablet - 3
Tablet(s)
by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FISH OIL-DHA-EPA [FISH OIL] - 1,200 mg-144 mg Capsule - 4
Capsule(s) by mouth twice a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] - Liquid - 1 by mouth
[**Hospital1 **]
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - 2 Tablet(s) by
mouth once a day
PSEUDOEPHEDRINE-GUAIFENESIN [MUCINEX D] - Dosage uncertain
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL - (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth daily
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL - 250 mg Tablet - 1 Tablet(s) by mouth once a day
VITAMIN E - (OTC) - Dosage uncertain
Discharge Medications:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QHS (once a day (at bedtime)).
10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig:
Three (3) Tablet Extended Rel 24 hr PO once a day.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
13. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO twice a day.
14. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
21. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a
day.
22. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three
(3) Tablet PO twice a day.
23. Centrum Silver Tablet Sig: Two (2) Tablet PO once a day.
24. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
25. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
mL PO Three Times a Day with Meals.
Disp:*QS 1 month supply* Refills:*2*
26. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 1
months.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 1 weeks: Do not drink alcohol or operate
heavy machinery while on this medication. .
Disp:*QS 1 week supply* Refills:*0*
28. Outpatient Lab Work
Please check a CBC and Chem 7 on [**2161-10-12**] and [**2161-10-19**]. Please
fax the results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**] @ [**Telephone/Fax (1) 3382**]. His office
phone number is [**Telephone/Fax (1) 250**]. Please also fax the results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. His office phone number is [**Telephone/Fax (1) 22**].
Discharge Disposition:
Home With Service
Facility:
Primary Home Care Specialty
Discharge Diagnosis:
Primary diagnosis:
PICC line sepsis
moderate malnutrition
.
Secondary diagnoses:
Hemothorax
Left 9th and 10th rib fractures
Loculated pleural effusion
reactive thrombocytosis
depression/ anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 39278**],
.
It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted with a fever
and overall malaise, and were found to have bacteria in your
bloodstream from your indwelling peripherally inserted central
catheter (PICC) line. You were found to have three bacteria
growing in your blood: Escherischia coli, Entercoccus and
Stenotrophomonoas. You were treated with intravenous fluids and
antibiotics (vancomycin, meropenem and levofloxacin). Your
urine was also positive for an infection, which was covered by
these medications as well. A new peripherally-inserted central
catheter line was placed for treatment with these antibiotics
and for delivery of total parenteral nutrition. This was
removed on Saturday [**10-3**].
.
Additionally, on Thursday [**9-24**], you fell out of bed and
sustained fractures of your left 9th and 10th ribs. These
fractures caused blood to accumulate in the space surrounding
your left lung. The Interventional Pulmonology team drained
this blood with a chest tube, but it reaccumulated and developed
fibrotic pockets, which required surgical treatment. On
Thursday [**10-1**], you had a video-assisted thoracic surgery to
clear out the space around your left lung. You did very well
during the surgery with minimal blood loss. Afterwards, your
breathing and pain improved.
.
Please note, the following changes have been made to your
medications:
.
START taking the following medications:
1. START taking ProSTAT 30 cc by mouth three times a day with
meals. This is a protein supplement that was recommedned by Dr.
[**Last Name (STitle) **]. The supplement will be delivered to your home on
[**2161-10-12**].
2. START using a Lidocaine patch as needed for rib pain. Apply
one patch daily for twelve hours and then remove. Please allow
for 12 hours between patches.
.
STOP taking the following medications:
- STOP taking Aspirin 81 mg by mouth daily until you follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
CHANGE THE DOSE of the following medications:
1. Clonazepam was reduced from 1 mg by mouth twice a day as
needed for anxiety to 0.5 mg by mouth twice a day as needed for
anxiety.
2. Diazepam was reduced from 5 mg by mouth three times a day as
needed for anxiety to 2 mg three times a day as needed for
anxiety.
3. Mirtazapine was reduced from 60 mg by mouth at bedtime to 30
mg by mouth at bedtime.
4. Sennosides (Senna) was increased from 8.6 mg by mouth daily
for constipation to 8.6 mg by mouth twice daily for
constipation. You do not need to take this medication if you are
having loose stools.
5. Tetrabenazine (Xenazine) was not placed on your medication
list. Please clarify the dose and administration of this
medication with your primary care physician or prescribing
provider.
6. Your dose of Oxycodone has temporarily been increased from 5
mg by mouth every eight hours as needed for pain to 5 mg by
mouth every six hours as needed for pain. You have been given a
prescription for a week's worth of pain medications. If you feel
that you will need more, please discuss this with Dr. [**First Name (STitle) 3535**]. If
you feel that your pain has improved, you may return to your
original home regimen. Please do not drink alcohol or operate
heavy machinery while on this medication.
.
Of note, many of the medication changes were made as there was
concern that your mental status was intermittently affected by
many of the sedating medications that you were taking.
Followup Instructions:
Please keep all follow-up appointments as below:
.
It is recommended you follow up with [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 39337**] in
Nutrition Services at ([**Telephone/Fax (1) 7026**]. Please call them once you
are home to make an appt within 1 week of discharge.
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2161-10-14**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please contact your insurance and change your Dr [**Last Name (STitle) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3535**]. Failing to do so could result in you receiving [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and
your referral for Hematology/Oncology will not be able to be
processed**
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-10-20**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], 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 Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2161-10-12**]
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17,505
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Discharge summary
|
report
|
Admission Date: [**2170-8-14**] Discharge Date: [**2170-8-22**]
Date of Birth: [**2089-12-10**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Cyclosporine / Clindamycin / Meropenem /
Metronidazole
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o female with h/o MDS transformed to AML tranferred from
[**Hospital Unit Name 153**] following an admission for SOB.
.
Presented to the ER [**8-14**] with SOB. Patient was found to have a BP
of 220/80. She was given 40mg PO lasix and [**12-11**] inch of
nitropaste, which quickly brought her BP down to 100/50. Her VS
at the time were notable for a temp 97.8, HR 96, and a RR of 44
(O2 sats were not documented). She then became tachycardic, with
a HR of 136. She was given 0.5mg ativan PO for anxiety which
then caused her BP to drop further to 80s/50s. Her pulse
gradually slowed, down to 96 and then down to 62. However, her
BP remained 80s/50s. Ms. [**Known lastname 60949**] appeared diaphoretic and
continued to be tachypneic, with RR in the 40s. O2 sats dipped
down to 86% but then came up to 94% on 6L O2.
.
In the ER, no temp was checked, but pt was 89% on RA on arrival,
with a RR of 18. Sats improved to 93-94% on 3L by nc (is on 2L
at home). BP was 84-129/40-58 and HR 62. Her PAC was accessed
for blood draw. She was given lasix 40mg IV x1 and a foley was
placed to monitor UOP. She was also started on a nitro gtt at
10mcg/min. She was started on BiPAP with improvement in her
tachypnea. By the time she was transferred to the [**Hospital Unit Name 153**], her BP
was in the 120s/80s and her RR was 17.
.
Of note, the pt's functional status has been slowly declining
over the recent months. Per her daughter, the patient has even
mentioned stopping transfusions at times because they seem to be
causing her to develop more episodes of CHF. At her baseline the
patient can walk a few steps with a walker but must stop [**1-11**]
fatigue and dyspnea. She is essentially limited to movements in
her room at [**Hospital 100**] Rehab (gets up to commode, up to the chair,
etc).
.
in the [**Hospital Unit Name 153**] the patient was briefly on BIPAP and then weaned to
NC. She was given lasix for presumed CHF flare. When she was
stable off BIPAP she was transferred to the floor for further
management.
Past Medical History:
Past Medical History:
Onc history: Mrs. [**Known lastname 60949**] was diagnosed with MDS
in [**2169-9-9**] after a greater than 6 year history of anemia
treated with iron supplementation. In [**7-14**] [**Known firstname **] became more
fatigued and irritable and was noted to be pancytopenic. Bone
marrow biopsy at that time showed: hypercellular for age bone
marrow erythroid hyperplasia, moderately dysplastic
granulopoiesis, mildly increased myeloblasts, megaloblastic and
dysplastic erythropoiesis, abundant megakaryocytes wtih frequent
small hypolobate dysplastic forms, decreased stainable iron, no
ring sideroblasts seen, and mild to focally moderatley increased
bone marrow reticulin. Her biopsy and aspirate were consistent
with a myelodysplatic disorder. Cytogenetics show multiple
abnormalities including a deletion of the long arm of chromosome
5 and trisomy 8. She has been receiving blood product support
now
for several months requiring transfusions 1-3 times weekly of 1
bag of platelets and [**12-11**] units PRBC. She last received blood
products on [**2170-7-20**] of 1 bag of platelets.
.
PAST MEDICAL HISTORY:
AML- supportive tx only (no chemo/radiation)
s/p fall [**12/2169**] sustaining a right trimalleolar fracture
CHF- [**2170-4-9**]
Paroxysmal Afib
bradycardia
Colon Cancer- no radiation or chemotherapy
Depression
UTI [**5-15**]
Urinary urgency/incontinence
Stoma bleeding- [**2170-4-9**]
.
PAST SURGICAL HISTORY
s/p colectomy with colostomy [**2163**]
s/p pacer placement for bradycardia [**5-14**]
s/p insertion of port-o-cath [**3-15**]
Social History:
[**Known firstname **] was born in Moldova but for a period of her childhood her
family was in exhile in Siberia. She emigrated to [**Country **] in
[**2143**] and then to the USA in [**2159**]. She continued to spend [**1-12**]
months a year in [**Country **] until this past winter. She worked for
about 50 yrs in both [**Country 532**] and [**Country **] as a math teacher. She
speaks [**Hospital1 100**] and Russian fluently. She does not speak English.
She never smoked or drank alcohol.
Family History:
[**Known firstname 60950**] father is deceased- died in [**2105**] in Russian
concentration
camp with kidney problems. [**Name (NI) **] mother died of a stroke in [**2127**].
She has two children: a son and a daughter who are both alive
and
well.
Physical Exam:
VS - T 99.3 P 67 BP 140/60 RR 30 O2sat 95% 5L NC
Gen: Elderly female, Russian only speaking, thin female, in mild
resp distress.
HEENT: Sclera anicteric, MMM. Neck supple, no evidence of JVD.
Lungs: Crackles [**12-11**] way up lungs bilaterally, no wheezes, poor
resp. effort
CV: RR, normal S1 and S2, no m/r/g.
Abd: Soft, NTND. + hernia around ostomy site. Colostomy bag in
place, no stool currently. + quiet BS. No masses, no HSM
appreciated.
Ext: no edema, 2+ PT/radial pulses
Pertinent Results:
Labs on admission:
[**2170-8-14**] 03:30AM BLOOD WBC-12.6*# RBC-3.29* Hgb-10.0* Hct-27.5*
MCV-84 MCH-30.5 MCHC-36.5* RDW-14.7 Plt Ct-13*#
[**2170-8-14**] 03:30AM BLOOD Neuts-4* Bands-0 Lymphs-6* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-3* Blasts-81*
[**2170-8-14**] 03:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-8-14**] 03:30AM BLOOD Plt Smr-RARE Plt Ct-13*#
[**2170-8-14**] 03:30AM BLOOD Glucose-97 UreaN-41* Creat-1.7* Na-131*
K-3.8 Cl-93* HCO3-27 AnGap-15
[**2170-8-14**] 03:30AM BLOOD CK(CPK)-26
[**2170-8-14**] 03:30AM BLOOD cTropnT-0.07*
[**2170-8-14**] 03:30AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0
[**2170-8-14**] 09:07AM BLOOD Type-ART pO2-141* pCO2-41 pH-7.47*
calTCO2-31* Base XS-6.
.
[**2170-8-14**] CXR - A pacemaker overlies the left chest, with leads
overlying right atrium and right ventricle. There is a right
internal jugular central venous catheter in place, with the tip
in the proximal right atrium. The cardiac and mediastinal
contours are unchanged, with aortic calcifications.
Moderate-to-severe congestive failure persists. There is likely
a left effusion. No pneumothorax. IMPRESSION: Persistent
moderate-to-severe congestive failure. An underlying pneumonia
cannot be excluded
Brief Hospital Course:
80 yo f with MDS recently tranformed to leukemia presented from
[**Hospital 100**] Rehab after acute onset SOB likely due to CHF
exacerbation with possible PNA as well.
.
On admission the patient had evidence of volume overload on CXR
an on exam. However, PNA couldn't be excluded either. It was
thought that there may also have been a component of
leukocytosis contributing to her resp distress as well given her
CBC showing 80% blasts. The patient's SOB was very responsive to
nitropaste so she was started on 1 inch q6h with good effect.
She was also given lasix IV boluses as needed for SOB. For her
possible leukocytosis she was given hydrea, 500mg x1 and 1000mg
x1. Although she responded to diuresis, given her refractory
leukemia she remained transfusion dependent and unfortunately
with transfusion would become overloaded with worsening
respiratory status. She continued to complain of SOB and she
began to require morphine IV to make her breathing more
comfortable. She was continued on Nitropaste and given morphine
as needed for comfort. When it became clear that the patient
would continue to require more and more transfusion support and
her respiratory status was not improving, a family meeting was
arranged to discuss the goals of care. She had elected not to
pursue any aggressive treatment up to this point. It was
explained to the patient and the family that the patient would
continue to need transfusion support which would likely worsen
the patient's respiratory status and make it difficult for her
to return to her nursing home. After a long discussion, the
patient elected to stop getting transfusion support with goal of
comfort only. She was made CMO and was continued on IV morphine
and nitropaste as needed. Her daughter and grandson were at the
bedside most of the time. When she became CMO her antibiotics
were discontinued and labs were no longer checked. She passed
away on the morning of [**8-22**] with her daughter and grandson
present.
Medications on Admission:
tylenol 650mg PO Q4prn
amiodarone 200mg PO QD
docusate 100mg PO BID
heparin flushes to port
latanoprost 0.005% 1drop OU QHS
lorazepam 0.5mg PO TID prn
pantoprazole 40mg PO QD
valerian 1mg PO QHS
senna 1tab PO BID prn
MOM 30mL PO QD prn
lasix 20mg IV prn
benadryl 25mg q6 PO prn
melatonin 3mg PO QHS
trazadone 50mg PO QHS prn
hydrocortisone 2.5% CR appy to affected area [**Hospital1 **]
venlafaxine XR 75mg PO QD
metoprolol tartrate 25mg PO BID
hydralazine 10mg PO TID
isosorbide mononitrate 30mg PO QD
anzemet 12.5mg IV Q8
lasix 40mg PO QD
levofloxacin 250mg PO QD (start [**8-9**] -> [**8-16**])
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
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"518.81",
"428.0",
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"V10.05",
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"V44.3",
"401.9",
"486",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9312, 9321
|
6648, 8635
|
337, 343
|
9384, 9394
|
5284, 5289
|
9446, 9452
|
4519, 4768
|
9284, 9289
|
9342, 9363
|
8661, 9261
|
9418, 9423
|
4783, 5265
|
294, 299
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371, 2391
|
5303, 6625
|
3547, 3986
|
4002, 4503
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,734
| 100,579
|
36796
|
Discharge summary
|
report
|
Admission Date: [**2125-10-17**] Discharge Date: [**2125-10-26**]
Date of Birth: [**2058-6-10**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Bronchoscopy, PICC line placement
History of Present Illness:
67 year old man 1 month s/p AVR, MVR, and CABG x 3, now with
fever to 100.7, WBC 18.7, and erythema at superior aspect of
wound. Pt recently had a long hospitalization following CABG and
MVR/AVR([**Date range (3) 83151**]), which was complicated by post-op
CVA, aflutter/afib with unsuccessful cardioversion, and a
HA-pna. The pt was discharged with a trach to [**Hospital3 **],
due to his inability to manage secretions. The pt did well at
rehab, until [**2125-10-4**], when he developed a low-grade fever and
CXR showed a new left lung base consolidation. He continued to
have temps to 99, and on [**10-14**] pt was started on ceftriaxone 1g
q24h. On [**10-15**] the pt was also started on vancomycin 1g q12h. Per
rehab reports the pt developed confusion and RR in the high
30's. The pt was thought to be in volume overload, and was given
lasix 20mg IV once on [**10-17**]. Gram stain of sputum from [**10-14**] showed
1= GPCSputum culture from [**10-14**] grew 2+ E. coli that was
pansensitive. Cdiff from that date was also negative. Blood
cultures from [**10-15**] showed no growth on [**10-16**].
In the ED, the pt's triage VS were: T100.7, P71 BP 185/73, RR
20, 99%. Pt had a non-con CT Chest that showed: soft tissue
stranding anterior to sternum, soft tissue stranding and fluid
posteriorly (4cm x 07.cm) adjacent to pericardium which may be
thickened. Tmax in ED 100.9, pt received tylenol. Pt was seen by
CT [**Doctor First Name **] which thought that CT findings were post-op changes, and
recommended continuing vanc/ctx for presumed pna versus
cellulitis. Pt admitted to MICU for further eval.
Past Medical History:
Coronary artery disease s/p CABG
- [**8-23**] Had NSTEMI, cath showed 3VD.
- [**2125-9-12**] - CABGx3(Left internal mammary artery->Left anterior
descending artery, Saphenous vein graft->Obtuse marginal artery,
Saphenous vein graft->Posterior descending artery)/Aortic Valve
Replacement(25mm [**Doctor Last Name **] Pericardial)/MV Repair(St. [**Male First Name (un) 923**] 32mm
saddle ring)
- hospital course c/b aflutter/afib, s/p cardioversion x2, coag
pos staph and GNR in sputum, pt got 8 day course of vancomycin
and zosyn stopped [**10-1**], [**9-13**] frontal CVA
Mitral Regurgitation s/p mitral valve repair
Aortic Insufficiency s/p AVR
CVA: right frontal infarction [**9-13**]
Atrial fibrillation/flutter
Failed swallow with signs aspiration s/p [**2125-9-19**] PEG placement
Inability to manage secretions s/p [**2125-9-26**] Tracheostomy #8
Portex
Social History:
Lives with sister. [**Name (NI) **] alcohol since [**2092**] though was a heavy
drinker prior to this. He has smoked at least a pack a day for
50 years. Works in finance managing stock portfolios.
Family History:
[**Name (NI) 2320**] (Mother)
Ca (grandparents)
Physical Exam:
VS: P73, BP 114/60, RR 13, POx 98% on A/C FiO2 50%, TV 500,
RR14, PEEP 8
Gen: Elderly man with trach, in NAD
HEENT: EOMI, PERRLA, fair dentition
CV: RRR, 3/6 systolic murmur at apex
Pulm: CTAB anteriorly, no wheeze, trying to cough, responds to
suctioning
Chest: Erythema over sternal notch, incision site well healed
near clavicle, steri-strips in place along bottom of incision
site. No e/o purulent discharge, no tenderness.
Abd: Soft, NT/ND, no organomegaly, G-tube in place, minimal
erythema surrounding tube site, no tenderness at tube site
Extr: Warm, trace pedal edema, DP+ b/l, left forearm in brace,
right UE PICC
Neuro: A+Ox3, low volume d/t trach
CN: EOMI, PERRLA, left lower facial droop
Motor: 0/5 strength left UE and 3/5 strength in L LE, [**6-19**]
strength R UE and LE.
Pertinent Results:
[**2125-10-17**] 02:44PM BLOOD WBC-18.7* RBC-3.29*# Hgb-10.0*# Hct-30.9*
MCV-94 MCH-30.3 MCHC-32.2 RDW-14.9 Plt Ct-171
[**2125-10-24**] 04:25AM BLOOD WBC-12.8* RBC-2.81* Hgb-8.4* Hct-26.3*
MCV-94 MCH-29.8 MCHC-31.9 RDW-15.2 Plt Ct-194
[**2125-10-17**] 02:44PM BLOOD PT-17.6* PTT-33.9 INR(PT)-1.6*
[**2125-10-24**] 04:25AM BLOOD Plt Ct-194 PltClmp-1+
[**2125-10-24**] 04:25AM BLOOD PT-20.7* PTT-31.3 INR(PT)-1.9*
[**2125-10-17**] 02:44PM BLOOD Glucose-138* UreaN-26* Creat-0.9 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
[**2125-10-24**] 04:25AM BLOOD Glucose-128* UreaN-15 Creat-0.8 Na-135
K-4.8 Cl-100 HCO3-31 AnGap-9
[**2125-10-19**] 6:09 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-10-22**]**
GRAM STAIN (Final [**2125-10-19**]):
THIS IS A CORRECTED REPORT [**2125-10-20**].
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
PREVIOUSLY REPORTED AS [**2125-10-19**].
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (CC7D) ON [**2125-10-20**] AT
15:06.
RESPIRATORY CULTURE (Final [**2125-10-22**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ESCHERICHIA COLI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- 16 I <=1 S
CEFTAZIDIME----------- 16 I <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ 8 I <=1 S
MEROPENEM------------- =>16 R <=0.25 S
PIPERACILLIN---------- R <=4 S
PIPERACILLIN/TAZO----- 64 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CT Chest:
IMPRESSION:
1. Post-surgical stranding in the anterior mediastinal space. No
fluid
collection.
2. Tracheostomy tube is 7.6 cm from the carina.
4. Right PICC loops superiorly, malpositioned; consider
readjustment.
5. Mitral and aortic valve replacement.
6. Left moderate-sized pleural effusion and bibasal atelectasis.
7. Gynecomastia.
CXR [**2125-10-24**]
Portable AP chest radiograph was reviewed in comparison to
[**2125-10-22**].
The tracheostomy tip is 6.5 cm above the carina. The
cardiomediastinal
silhouette is stable. The replaced mitral valve is in place.
There is
bilateral pleural effusion and right lower lobe opacity that
might represent a combination of atelectasis and infectious
process. The left retrocardiac atelectasis has also progressed
and might represent an additional source of infection as well.
Brief Hospital Course:
67 year old man 1 month s/p AVR, MVR, and CABG x 3, now with
fever to 100.9, WBC 18.7 admitted with possible pneumonia and
cellulitis, rule out mediastinitis.
# Fever/Pseudomonal pneumonia: Pt had CT chest that indicated
some stranding around sternum, but thoracic surgery did not
think CT was consistent with mediastinitis, but that changes
were characteristic of post-op changes. No evidence of
cellulitis on exam, and although PICC line appeared normal, it
was removed for concern for line infection. Pt found to have new
ventilator-associated pneumonia, and had bronchoscopy that
showed copious secretions. Sputum grew multi-drug resistant
pseudomonas. During the admission the pt was thought to have had
a ceftriaxone allergic reaction (morbilloform drug rash) and
ceftriaxone was added to allergy list. Pt was discharged to
rehab on tobramycin with plan to complete a 14 day course, that
will be complete on [**2125-11-4**]. He will need his tobra level
checked every 3 days to see if his dose needs adjustment. Renal
function should be checked q3 days while on the tobra to ensure
proper dosing.
# Cardiovascular: EKG improved from prior. No chest pain.
Continued amiodarone, coumadin, statin, aspirin and restarted
beta blocker at a lower dose.
# H/o CVA: Left hemiparesis improved as L LE now has some
strength. He was continued on his statin, aspirin, and coumadin.
# FEN/GI: Continue home Jevity.
# GERD: was continued on home ranitidine
# Access: new PICC line was placed during his admission, old
PICC was removed and had a negative culture.
# Communication: With sister [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 83152**], and
patient
# CODE STATUS: FULL CODE
Was tranfered to rehab for continued care.
Medications on Admission:
Atorvastatin 80 mg daily
Docusate Sodium 10mg [**Hospital1 **]
Aspirin 81 mg daily
Amiodarone 200 mg daily
Lisinopril 10 mg DAILY
Metoprolol Tartrate 50 mg TID
Temazepam 15 mg HS as needed for insomnia.
Norvasc 10 mg once a day
Ranitidine HCl 15 mg/mL Syrup DAILY
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day): while mechanically
ventilated.
Regular insulin Sliding Scale
Warfarin 2 mg Tablet
Mucinex 600mg [**Hospital1 **]
CTX 1 g q24 Day 1= [**10-14**]
Vanco 1g q12 Day 1= [**10-15**]
Lasix 20mg once
MVI daily
Tylenol 650 supp q6h prn fever
Trazodone 50mg qhs prn
Tylenol Elixir
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a
day).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
dyspnea, wheeze.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Apply to groin.
13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for mucus.
17. 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.
18. 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.
19. Tobramycin Sulfate 40 mg/mL Solution Sig: Six Hundred (600)
mg Injection Q24H (every 24 hours) for 10 days.
20. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
22. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomina.
23. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO HS (at bedtime) as needed for pain/cramping.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Healthcare associated pneumonia
Secondary:
Coronary artery disease
Atrial fibrillation on coumadin
Hx of cerebrovascular accident
Discharge Condition:
Good, vital signs stable
Discharge Instructions:
You were admitted to the hospital with fevers and found to have
a pneumonia. We started you on a two week course of antibiotics.
You should complete your course of tobramycin on [**2125-11-4**].
Followup Instructions:
Follow up with your primary care doctor in [**3-20**] weeks.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2125-11-1**] 1:45
|
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icd9cm
|
[
[
[]
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] |
[
"96.72",
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icd9pcs
|
[
[
[]
]
] |
12320, 12394
|
7472, 9211
|
279, 314
|
12577, 12603
|
3942, 7449
|
12847, 13036
|
3068, 3118
|
10061, 12297
|
12415, 12556
|
9237, 10038
|
12627, 12824
|
3133, 3923
|
234, 241
|
342, 1951
|
1973, 2837
|
2853, 3052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,954
| 154,974
|
4511
|
Discharge summary
|
report
|
Admission Date: [**2145-5-30**] Discharge Date:
Date of Birth: [**2088-9-16**] Sex: F
Service: OMED
CHIEF COMPLAINT: Neck swelling.
HISTORY OF PRESENT ILLNESS: This is a 56 -year-old white
female with a history of multiple myeloma diagnosed in [**2142**],
hypertension, amyloid of tongue, who recently returned from
felt left ear fullness. She developed worsening sinus
congestion over the past four days with increasing rhinorrhea
but without purulence. She has noted upper teeth soreness
over the past two days, as well as a sore throat for the past
four days. Over the past 24 hours, the patient noted a large
midline mildly tender submandibular mass. She feels that her
voice is becoming hoarse. She has a sensation of narrowing
PAST MEDICAL HISTORY:
1. Multiple myeloma, stage 3, diagnosed in [**2142**] with
dentistry radiographs, treated with Melphalan and prednisone
with minimal response, status post Vincristine, Doxorubicin,
and Dexamethasone, status post ablative bone marrow
transplant in [**2143-3-25**], status post nonablative
allogeneic bone marrow transplant in [**2143-11-25**].
2. History of deep venous thrombosis in [**2142**], left jugulars,
left superficial femoral, left popliteal DVD.
3. Skin and subcutaneous skin necrosis secondary to VAD
extravasation.
4. Hematuria.
5. Hypertension.
6. Amyloid deposition.
PAST SURGICAL HISTORY: The patient had tonsillectomy as a
child.
FAMILY HISTORY: Notable for hypertension. There is no
family history of diabetes mellitus, coronary artery disease,
or cancer.
SOCIAL HISTORY: The patient is married with two children.
She denies use of tobacco or alcohol. She is a retired law
firm manager.
REVIEW OF SYSTEMS: Negative for fever or chills, headache,
visual changes, nausea or vomiting, rash, arthralgia,
myalgia, dysuria, and cough.
PHYSICAL EXAMINATION: Vital signs: temperature 98.2 F, heart
rate 106, blood pressure 148/80, respiratory rate 20, oxygen
saturation 98% on room air. Generally, a middle aged woman
resting comfortably, positive for hoarse voice. Head, eyes,
ears, nose, and throat: normocephalic, atraumatic, pupils are
equal, round, and reactive to light and accommodation,
negative purulent sinus drainage, negative sinus tenderness,
bilateral erythema to his tympanic membranes, negative
discharge, very large tongue noted, a 6.0 cm fluctuant
midline submandibular mass which is warm.
Neck: shoddy anterior and posterior cervical lymphadenopathy,
supple, no evidence of stridor. Lungs are clear to
auscultation bilaterally, no wheezes. Cardiac: regular rate
and rhythm, S1, S2, without S3 or S4, III/VI holosystolic
ejection murmur, carotid pulses without bruits. Abdomen:
soft, nontender, nondistended, no masses, active bowel
sounds. Extremities: negative clubbing, cyanosis, or edema.
Central nervous system: alert and oriented times three, [**5-29**]
motor strength in upper extremities and lower extremities
bilaterally.
ADMISSION LABORATORY DATA: White blood cell count 7.3,
platelets 249,000. Sodium 136, potassium 6.5 (specimen
hemolyzed), repeat potassium under 5.0, chloride 103,
bicarbonate 23, BUN 11, creatinine 0.7. Albumin 3.5, ALT 23,
AST 50, LDH 631, alkaline phosphatase 101, total bilirubin
0.6. Beta microglobulin pending.
ALLERGIES: The patient has no known drug allergies.
ADMITTING MEDICATIONS: Verapamil 180 mg po q day.
HOSPITAL COURSE:
1. Ear, Nose, and Throat and Pulmonary: With the patient's
worsening ear, nose, and throat and upper respiratory
symptoms, there was immediate concern for a rapidly expanding
soft tissue infection in her neck. On the day of admission,
the patient underwent ear, nose, and throat evaluation by the
Ear, Nose, and Throat service at [**Hospital3 **] - [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **], who noted a supraglottitis with lingular
tonsillitis.
No evidence of airway compromise was noted, but because of
the inflammation in the area, the Ear, Nose, and Throat
service recommended close monitoring in an Intensive Care
Unit for continuous O2 saturation monitoring. The patient
was then transferred to the Medical Intensive Care Unit. The
patient was begun on Decadron 10 mg IV q six hours as well as
empiric antibiotics therapy with IV Unasyn.
Throughout her stay on the Medical Intensive Care Unit, the
patient's oxygen saturation remained well above 95% on room
air. The patient experienced considerable clinical
improvement with IV steroids and IV antibiotics. A decrease
in the size of the patient's mass was noted. The patient's
voice, as per her report, returned to [**Location 213**] and her
sensation of throat fullness considerably diminished. The
patient's Decadron was discontinued in the Intensive Care
Unit.
2. Infectious Disease: Throughout her stay, the patient
remained afebrile and hemodynamically stable. Multiple blood
cultures and throat swab cultures were negative. However
nasopharyngeal washing noted heavy gram negative rods which
were felt by the microlab to be hemophilus. After
approximately 48 hours of IV Unasyn, the patient was changed
to po Augmentin and recommended to complete a ten day course
of po Augmentin by the Ear, Nose, and Throat service.
3. Pulmonary: The patient required no supplemental oxygen
throughout her stay in the Medical Intensive Care Unit. On
the day prior to discharge, the patient was transferred to
the OMED floor.
4. Oncology: Multiple myeloma: stable in near CR
5. Heme: s/p Allo BMT.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Supraglottitis.
2. Tonsillitis.
3. Airway compromise.
4. Multiple myeloma
5. BMT
DISCHARGE MEDICATIONS: Verapamil 180 mg po q day and
Augmentin 875 mg po bid times ten days.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 3878**] of
Ear, Nose, and Throat. The phone number is [**Telephone/Fax (1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**]
Dictated By:[**Last Name (NamePattern1) 9280**]
MEDQUIST36
D: [**2145-6-1**] 14:01
T: [**2145-6-1**] 15:38
JOB#: [**Job Number 19259**]
|
[
"401.9",
"203.00",
"277.3",
"V42.0",
"529.0",
"463",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5527, 5576
|
1455, 1568
|
5597, 5684
|
5708, 5779
|
3412, 5505
|
1395, 1438
|
5791, 6208
|
1869, 3395
|
1722, 1846
|
137, 153
|
182, 761
|
783, 1371
|
1585, 1702
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 162,426
|
4821
|
Discharge summary
|
report
|
Admission Date: [**2103-6-22**] Discharge Date: [**2103-6-28**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 y/o male with HTN, CAD (nstemi in [**2101**]), COPD (fev1 20%, home
o2 4L, chronic steroids; intubated x2) who complaining of acute
onset shortness of breath on the day of admission. He has
recently been discharged from [**Hospital1 18**]. He states that he felt a
burning sensation on both sides of his lower back (which is
chronic) and he became acutely dyspneic after this happened. He
reports that he usually becomes SOB when he has back pain. This
time, he could not catch his breath and called EMS immediately.
Of note, the patient also complains of severe burning with
urination which has been chronic x 2 years. He reports that this
has been worsening in severity over the last 6 months. Was on
cipro in the past which helped relieve his symptoms transiently.
Patient is not currently sexually active (has not been for 3
years). No hematuria. No h/o kidney stones.
.
In the [**Name (NI) **], pt was tried on BiPAP but did not tolerate this well.
He improved with Albuterol/atrovent nebs x 3 and IV solumedrol.
He denies fever, chills, cough, nausea, vomiting, hematuria,
diarrhea, or melena/BRBPR.
Past Medical History:
1. COPD on 4 L O2 at home and s/p multiple admissions and
intubations for flares-FEV1/FVC 35%
2. Hypertension
3. Hyperlipidemia
4. CAD s/p NSTEMI ([**2101**])
5. Chronic low back pain L1-2 laminectomy from accident at work
6. Steroid induced hyperglycemia
7. Left shoulder pain for several months
8. Cataract
9. GERD
Social History:
Married with six children. Lives at home in [**Location (un) 16174**] with wife.
Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint.
Former smoker. Quit 25 years ago. 20 pack year history.
Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use.
Activity limited due to prior spine and current shoulder
problems
Family History:
Mother with asthma and [**Name (NI) 2481**]
Father with [**Name2 (NI) 499**] cancer
Physical Exam:
Vitals: 96 - 100/59 - 16 - 100% on 4L
Gen - AA man, appears comfortable, Speaking in full sentences.
Breathing with pursed lips.
HEENT - Anicteric sclera. MMM.
NECK- no JVD. No bruits.
CV- RRR. Faint but audible S1, S2. No MRG
Pulm - good air movement. + crackles at LLL. Scatterered
expiratory wheezes. No ronchi, rales.
Abd - NABS, Soft, non distended. Mild epigastic tenderness.
Ext - No cyanosis, edema. Warm and dry. Reduced skin turgor.
Nails - No clubbing. No pitting/color changes/indentations
Neuro - AOx3. CN intact, no focal motor/sensory deficits
Pertinent Results:
[**2103-6-22**] 12:40PM WBC-16.9* RBC-4.71 HGB-12.7* HCT-39.7* MCV-84
MCH-27.0 MCHC-31.9 RDW-15.0
[**2103-6-22**] 12:40PM NEUTS-80.3* LYMPHS-13.4* MONOS-4.9 EOS-1.3
BASOS-0.2
[**2103-6-22**] 12:40PM PLT COUNT-306
[**2103-6-22**] 12:40PM GLUCOSE-73 UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-15
[**2103-6-22**] 12:40PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2103-6-22**] 12:40PM PT-11.7 PTT-25.9 INR(PT)-0.9
[**2103-6-22**] 12:40PM CK(CPK)-46
[**2103-6-22**] 12:40PM CK-MB-NotDone cTropnT-<0.01
[**2103-6-22**] 12:40PM D-DIMER-429
.
CHEST (PORTABLE AP) [**2103-6-22**] 5:54 PM
No significant change since the prior study.
Brief Hospital Course:
.
.
1) DYSPNEA: The patient intitially presented complaining of
acute onset shortness of breath at home. This most likely
represented the patient's typical COPD flare, for which the
patient has been admitted with several times in the past. There
was no evidence of pneumonia on CXR; however, he was started on
ceftriaxone and azithromycin initially. These were stopped
after a short peroid of time since there was no evidence of
pneumonia. A few days into his admission, the patient acutely
decompensated with desats into the 80's and low blood pressure
(80-90's systolic). He was transferred to the MICU for a 24
hour period, at which time he received BiPAP and more frequent
nebs. He stabilized and was transferred back to the floor.
While back on the floor, he continued to have episodes of acute
SOB requiring frequent nebs (often Q1H). With nebs, his O2 sats
stabilized in the mid 90's, and he did not require further ICU
level of care. He was started on doxycycline for coverage of
possible bronchitis. Blood cultures still pending without
growth to date, and sputum culture obtained was not a good
sample.
.
2) DYSURIA: Mr. [**Known lastname 19017**] also complained of significant dysuria
on this admission, requiring catheterization. UA was negative.
He was also noted to have significant urinary retention after
catheterization, suggesting significant BPH. He was started on
Flomax and Proscar this admission. His dysuria could also be
due to chronic prostatitis since UA was found to be negative.
He was not started on antibiotic therapy for this possibility
during this admission. He should see urology as an outpatient
for these issues.
.
3) BACK PAIN: He continued to complain of significant back pain
during this admission, consistent with his musculoskeletal pain
related history of L1-2 laminectomy from an accident he had at
work many years ago. This pain made him anxious and
occasionally precipitated shortness of breath. It was well
controlled with oxycodone prn.
Medications on Admission:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 1 doses.
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
15. Prednisone taper
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
3. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
[**Known lastname **]:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
15. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: One (1)
INH Inhalation twice a day.
16. Medication
Pyridium 200 mg PO TID x 3d, take after meals
17. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 6 days.
[**Known lastname **]:*12 Capsule(s)* Refills:*0*
18. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*2*
19. Prednisone 10 mg Tablet Sig: as per taper Tablet PO once a
day for 30 days: days [**1-10**] take 60 mg;days [**6-15**] take 50 mg;day
[**11-20**] take 40 mg;day 16-20 take 30 mg;day 21-25 take 20 mg;day
26-30 take 10 mg.
[**Month/Year (2) **]:*105 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) COPD flare
2) Coronary artery disease
3) Hypertension
Discharge Condition:
stable, improved from the time of admission
Discharge Instructions:
Please call your doctor or return to the ER if you experience
difficulty breathing, chest pain, fever, or chills. Take your
medications as prescribed and follow up as scheduled below.
Please see your PCP
Followup Instructions:
1) UROLOGY APPOINTMENT on [**7-17**] at 10am with Dr. [**Last Name (STitle) 4229**] in the
[**Hospital Ward Name 23**] Building on the [**Location (un) **] in the Surgical Specialties
Area.
2) PULMONARY BREATHING TESTS Where: [**Hospital6 29**] PULMONARY
FUNCTION LAB, Phone:[**Telephone/Fax (1) 612**], Will contact you regarding
appointment
4) [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: [**Hospital1 7975**]
INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2103-7-10**] 9:00
3) Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY (NB) Where: OR EYE
SURGERY (NB) Date/Time:[**2103-7-18**] 3:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"414.01",
"401.9",
"724.2",
"530.81",
"412",
"V46.2",
"272.4",
"788.1",
"723.1",
"600.01",
"285.9",
"491.21",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9014, 9072
|
3537, 5539
|
292, 298
|
9173, 9218
|
2831, 3514
|
9472, 10293
|
2150, 2236
|
6937, 8991
|
9093, 9152
|
5565, 6914
|
9242, 9449
|
2251, 2812
|
233, 254
|
326, 1436
|
1458, 1778
|
1794, 2134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,683
| 156,394
|
34665
|
Discharge summary
|
report
|
Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-30**]
Date of Birth: [**2106-3-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2187-7-15**] Aortic Valve Replacement(32mm CE tissue), Coronary
Artery Bypass Graft x 2 (SVG to LAD, SVG to OM), Aortic
Endarterectomy
History of Present Illness:
This 81 year old patient with severe aortic stenosis and CAD has
been experiencing daily episodes of chest pain for the last 10
days. His symptoms occur with activity such as taking a shower,
doing yard work or after he eats dinner. He has some associated
shortness of breath. The patient has a history of a cardiac
catheterization done at [**Hospital1 2025**] in [**2176**] due to unstable angina which
revealed a right dominant system with an 80% discrete OM1 artery
and a discrete 50% RCA lesion. EF 65%. An aortoiliac angiogram
was also done which revealed marked tortuosity, right greater
than left and a mild fusiform aneurismal dilation of the distal
aorta. (Of note, there is no indication on the cath report that
any coronary intervention was done).
Past Medical History:
Coronary Artery Disease, Hypertension, Hypercholesterolemia,
Rheumatic Fever (as child), RBBB, Gastroesophageal Reflux
Disease, Chronic Renal Insufficiency, s/p TURP, s/p Carpal
tunnel release bilaterally, s/p Benign tumor removed from chest
wall removed 50 years ago
Social History:
Quit smoking 1 month ago/previously smoked 1 pack per week/40+
yr smoking history. Married, lives at home with his wife.
Alcohol- 1-2 drinks per day. Retired.
Family History:
Father died at age 74 from heart disease. Mother died from
[**Name (NI) **]??????s lymphoma. One brother died at age 9 from congenital
heart disease
Physical Exam:
VS - T 96.9 BP 139/78 HR 73 RR 22 95% RA
Gen: NAD. Mood, affect appropriate. Answers questions
appropriately. Lying flat after cardiac catheterization
HEENT: NCAT. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
Neck: Supple with flat JVP.
CV: very soft S1S2, III/VI systolic murmer at RUSB and LUSB,
gallarvadin murmur at apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB in anterior lung
fields.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: DP dopplerable b/l
Pertinent Results:
[**7-13**] Cardiac Cath: 1. Selective coronary angiography revealed 2
vessel disease within the left coronary arterial anatomy and
presumed RCA disease. The LAD had 70% proximal stenosis. The
LCX had a proximal long segment of 80% stenosis. The OM1 had a
proximal long segment of 80% stenosis. The RCA was not
selectively cannulated, but presumed likely to be totally
occluded as left to right collaterals were visulalized. 2.
Limited resting hemodynamic assessment revealed elevated
systemic arterial pressure with an aortic pressure of 157/76.
The aortic valve
was evaluated with careful pullback from LV to aorta as well as
simultaneous measurement of LV pressure and femoral artery
pressure. The mean gradient was 28.12 mm Hg, consistent with a
calculated aortic valve area of 1.02 cm2. The PCWP was normal
at 12 mm Hg. The cardiac index was below normal at 2.36.
[**7-15**] Echo: Prebypas: Very limited TEE examination as unable to
advance TEE probe beyond 35 cms. Very poor image quality. Dr
[**Last Name (STitle) **] informed re very limited TEE exam. 1. No atrial
septal defect is seen by 2D or color Doppler. 2.Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %). No trans gastric
images obtained. Very poor quantification of ejection fraction.
3.The ascending aorta is mildly dilated. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
4. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen. 5. The mitral valve leaflets are
mildly thickened. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2187-7-15**] at 1500 hours. Post Bypass: 1. Very
limited views. Unable to comment on post bypass findings.
Brief Hospital Course:
Mr. [**Known lastname 66958**] was electively admitted for a cardiac cath. Cath
revealed severe three vessel coronary artery disease and
moderate to severe aortic stenosis. Please see report for
details. Cardiac surgery was consulted and he underwent usual
pre-operative work-up. On [**7-15**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 2 and
aortic valve replacement. Please see operative report for
details. Mr. [**Known lastname 66958**] was transferred to the CVICU for invasive
monitoring in stable condition. In initial post-op course he
required multiple Inotropes for hypotension, along with multiple
blood transfusions and Amiodarone for Atrial Fibrillation. He
required aggressive diuresis and DCCV x 2 on post-op day two for
AF. Also on this day bilateral chest tubes were placed d/t
pleural effusion. Renal service was consulted d/t renal failure.
On post-op day five Heparin was started d/t continued episodes
of Atrial Fibrillation. His Inotropes were slowly weaned off
over time. Mr. [**Known lastname 66958**] required prolonged intubation d/t
difficulty with oxygenation. He was eventually weaned from
sedation and was extubated on post-op day nine. Chest tubes were
eventually removed. Vancomycin had to be restarted d/t
bacteremia. The patient was transfered to the floor on POD 12
where he continued to progress. By the time of discharge on POD
15, the pt was ambulating with assistance, the sternal wound was
healing and pain was controlled with oral analgesics. He was
discharged in good condition to [**Hospital3 **].
Medications on Admission:
Diovan 320mg daily in the am, Felodipine 10mg daily in the am,
Metoprolol succinate 25mg daily in the am, Aspirin 81mg daily in
the am
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Hospital3 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
3. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q2H (every 2 hours) as
needed.
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Toprol XL 100 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q 8H
(Every 8 Hours).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
11. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM: Hold for INR > 3, MD to dose daily based on INR goal [**2-4**] for
A-fib.
13. Furosemide 10 mg/mL Solution [**Month/Day (3) **]: One (1) Injection TID (3
times a day).
14. Vancomycin 750 mg IV Q 24H
15. Heparin Flush (10 units/ml) 2 mL IV PRN
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. Diovan 80 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] hospt
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Hypertension, Hypercholesterolemia, Rheumatic Fever (as
child), RBBB, Gastroesophageal Reflux Disease, Chronic Renal
Insufficiency
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. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 5686**] in [**2-4**] weeks
Dr. [**Last Name (STitle) **] in [**1-3**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2187-7-30**]
|
[
"427.31",
"V15.82",
"272.0",
"511.9",
"V12.09",
"V17.49",
"998.0",
"997.1",
"707.12",
"440.0",
"518.5",
"278.00",
"584.9",
"496",
"458.29",
"530.81",
"V16.7",
"414.01",
"041.11",
"287.5",
"682.6",
"274.0",
"401.9",
"V19.5",
"424.1",
"998.59",
"426.4",
"997.3",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.64",
"89.68",
"99.04",
"88.53",
"88.56",
"00.40",
"38.93",
"89.64",
"36.12",
"96.72",
"37.22",
"38.14",
"39.61",
"38.91",
"88.72",
"34.04",
"96.6",
"99.62",
"96.04",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
8044, 8093
|
4474, 6065
|
283, 422
|
8378, 8385
|
2518, 4451
|
8896, 9161
|
1693, 1843
|
6250, 8021
|
8114, 8357
|
6091, 6227
|
8409, 8873
|
1858, 2499
|
233, 245
|
450, 1210
|
1232, 1501
|
1517, 1677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,973
| 163,462
|
8395
|
Discharge summary
|
report
|
Admission Date: [**2148-7-10**] Discharge Date: [**2148-7-16**]
Date of Birth: [**2075-4-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina, SOB
Major Surgical or Invasive Procedure:
cabg x5/Maze/stapling of left atrial appendage [**2148-7-10**]
(LIMA to LAD, SVG to diag, sequenced to OM, SVG to PDA, SVG to
PL)
History of Present Illness:
73 yo male with + stress test first admitted on [**6-18**] for cardiac
cath. This showed 90% LAD, 90% diag 1, 80% OM1, 100% RCA. Prior
stress echo showed EF 15-20%. Pt returns for cabg with Dr.
[**Last Name (STitle) 914**].
Past Medical History:
CAD, s/p anterior wall STEMI in [**8-9**] stents to proximal and
mid LAD
CHF, EF 20% (TTE [**2146**])
Hypertension
Hyperlipidemia
Chronic renal insufficiency, baseline Cr ~2.0
GI bleed in setting of elevated INR [**9-9**]
Bipolar disorder
Paroxysmal afib
ICD placed [**12-9**]-has never fired
cholecystectomy
appendectomy
tonsillectomy
hiatal hernia
[**12/2132**] MVA right leg trauma
mild pancreatitis d/t Tegretol
nephrogenic diabetes insipidus
L4-5 disc fusion
Social History:
lives alone. Former ETOH abuse, stable with AA. Former smoker
(35 years/<1ppd). No children.
Family History:
(+) FHx CAD: both parents had MI's in their 70's.
Physical Exam:
HR 60 RR 15 137/76 5'[**52**]" 104.3 kg
skin/HEENT unremarkable
neck full ROM with no bruit appreciated
CTAB
RRR no murmur
abd soft, NT, ND, + BS
extrems warm and well-perfused with no edema
right fem cath site, left fem NP
2+ bilat. DP/radials
PTs non-palp.
no varicosities
neuro grossly intact
Pertinent Results:
[**2148-7-15**] 03:30PM BLOOD WBC-11.0 RBC-3.12* Hgb-9.6* Hct-26.9*
MCV-86 MCH-30.9 MCHC-35.9* RDW-14.6 Plt Ct-200
[**2148-7-16**] 09:00AM BLOOD PT-18.3* INR(PT)-1.7*
[**2148-7-15**] 03:30PM BLOOD Plt Ct-200
[**2148-7-11**] 03:04AM BLOOD Fibrino-224
[**2148-7-15**] 03:30PM BLOOD Glucose-111* UreaN-40* Creat-2.1* Na-138
K-5.1 Cl-106 HCO3-25 AnGap-12
[**2148-7-10**] 10:22PM BLOOD ALT-38 AST-93* AlkPhos-72 Amylase-125*
TotBili-0.3
[**2148-7-11**] 12:39AM BLOOD Lipase-51
[**2148-7-15**] 03:30PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.6
FINAL REPORT
INDICATION: Evaluate for infiltrate or effusion.
COMPARISON: [**2148-7-11**].
TECHNIQUE: PA and lateral chest.
FINDINGS: Since the previous examination, the mediastinal
drains, left-sided
chest tube, endotracheal tube, nasogastric tube, right internal
jugular venous
access sheath and pulmonary artery catheter has been removed.
There is stable
postoperative widening of the cardiomediastinal silhouette.
Small right
pleural effusion is unchanged and small left pleural effusion is
slightly
increased. There is no pneumothorax.
IMPRESSION: Bilateral pleural effusions, increased on the left.
Status post
removal of multiple lines and tubes. No pneumothorax.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 8913**] R.M. SUN
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2148-7-15**] 11:09 AM
Procedure Date:[**2148-7-15**]
Brief Hospital Course:
Admitted [**7-10**] and underwent cabg x5/Maze/stapling of left atrial
appendage.Transferred to the CSRU in stable condition on
epinephrine, phenylephrine and propofol drips. Off all drips on
POD #1 after corrected acidemia and 3 units PRBCs overnight.
Extubated that afternoon and coumadin/amiodarone started for
post-Maze. EP consulted , chest tubes removed,and pt.
transferred to the floor to begin increasing his activity
level.Pacing wires removed without incident on POD #3.Amiodarone
decreased per EP recs. He continued to make good progress on the
floor while waiting for his INR to rise.Cleared for discharge to
home with VNA services on POD #6. He is to have first blood draw
on Th. [**7-18**] and coumadin dosing/INR follow up with Dr. [**First Name (STitle) **] as
per discharge instructions.
Medications on Admission:
ASA 81 mg daily
plavix 75 ng daily
diovan 80 mg daily
metoprolol 50 mg [**Hospital1 **]
zocor 80 mg daily
lasix 20 mg daily
lithium 150 mg daily
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:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*2 MDI* Refills:*1*
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
2 days: 3 mg on [**7-16**] & [**7-17**], then INR to be drawn, results
called to Dr. [**First Name (STitle) **] for continued Coumadin dosing .
Disp:*120 Tablet(s)* Refills:*0*
12. 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*
13. Aerobid 250 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
Disp:*1 MDI* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD
Afib
MI
CHF
prior coronary stents
elev. chol
CRI
prior GI bleed
HTN
ICD
bipolar disorder
s/p ORIF left leg
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
first blod draw.Thurs [**7-18**] with INR to be called to Dr. [**First Name (STitle) **]
at [**Telephone/Fax (1) 29643**];fax [**Telephone/Fax (1) 7531**] ; daily coumadin dosing per
Dr.[**First Name (STitle) **]
Followup Instructions:
first blood draw Thursday, [**2148-7-18**] with coumadin dosing per
Dr.[**First Name (STitle) **]
follow up with Dr. [**Last Name (STitle) **] in [**1-8**] weeks
follow up with Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2148-7-17**]
|
[
"585.6",
"428.0",
"296.80",
"427.31",
"414.8",
"414.01",
"403.91",
"V45.02",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"99.04",
"37.34",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
5944, 5995
|
3240, 4046
|
331, 463
|
6150, 6159
|
1718, 3217
|
6631, 6980
|
1331, 1382
|
4241, 5921
|
6016, 6129
|
4072, 4218
|
6183, 6608
|
1397, 1699
|
280, 293
|
491, 716
|
738, 1204
|
1220, 1315
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,775
| 132,153
|
43404
|
Discharge summary
|
report
|
Admission Date: [**2164-8-8**] Discharge Date: [**2164-8-28**]
Date of Birth: [**2099-7-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Bactrim / Simvastatin
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
shortness of breath, heartburn
Major Surgical or Invasive Procedure:
[**2164-8-8**]
OPERATION:
1. Laparoscopic reduction of giant paraesophageal hernia.
2. Closure of diaphragm with pledgeted sutures.
3. Pexy of stomach to diaphragm.
[**2164-8-11**]
OPERATION:
1. Repeat laparoscopy and revision of hiatal hernia repair.
2. Endoscopy.
History of Present Illness:
Ms. [**Known lastname 85502**] is a pleasant 65 year old female who was initially
seen
by us in consultation for her hiatal hernia a couple months ago.
She was first told she had a hernia when giving birth 44 years
ago, when she was worked up after having hematemesis. She was
not
followed, but told when she had chest xrays done sporadically
for
URI's, that she had a large hiatal hernia. She did not have
anything done, but over the past five years she has become
increasingly more symptomatic with dyspnea on exertion at a few
steps, weekly heartburn, and food sticking in her esophagus. She
denies regurgitation, odynophagia, nausea, or vomiting.
Past Medical History:
-left lumpectomy- benign 15-20 years ago.
-left leg rod from MVA 44 yrs ago
-HTN-controlled with medication
-L rotator cuff 8.09
-? hyperlipidemia with reaction to medication- not on meds
Social History:
Homemaker, lives alone. Has four children with a supportive son.
20 pk yr hx of smoking, quit 7 years ago. Denies ETOH.
Family History:
Mother-died brain aneurysm 51
Father-DM, [**Name2 (NI) 11964**] died age 77
Siblings: sister died of lung cancer, brother died of MI in
early
50's
Offspring- epilepsy
Physical Exam:
Vital signs on discharge:
T: 99.3, HR 87, BP 107/60, RR 22, O2 sats 94% on 3LNC
Physical Exam:
General: pleasant, Alert and Oriented x 3, without focal
deficits. At times sleepy upon waking up and with slight
confusion but orients once awake.
Lungs: decreased LLL, clear t/o
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND. lap sites C/D/I
Ext: trace BLE edema. warm t/o
R PICC line to 50cm intact and covered with dry, sterile
dressing.
Pertinent Results:
[**2164-8-27**] 06:55AM BLOOD WBC-11.3* RBC-2.97* Hgb-8.1* Hct-24.7*
MCV-83 MCH-27.3 MCHC-32.8 RDW-14.9 Plt Ct-542*
[**2164-8-26**] 07:40AM BLOOD WBC-11.5* RBC-2.98* Hgb-8.1* Hct-24.9*
MCV-84 MCH-27.3 MCHC-32.7 RDW-15.0 Plt Ct-608*
[**2164-8-19**] 01:35AM BLOOD PT-13.3 PTT-23.8 INR(PT)-1.1
[**2164-8-27**] 06:55AM BLOOD Glucose-112* UreaN-14 Creat-0.9 Na-141
K-3.9 Cl-103 HCO3-26 AnGap-16
[**2164-8-23**] 07:50AM BLOOD Glucose-113* UreaN-17 Creat-0.8 Na-141
K-4.2 Cl-103 HCO3-29 AnGap-13
[**2164-8-11**] 01:54PM BLOOD ALT-54* AST-47* AlkPhos-59 TotBili-0.5
[**2164-8-27**] 06:55AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2164-8-23**] 07:50AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.4
Chest xray [**2164-8-23**]:
Impression:
IMPRESSION: Marked unchanged left hemidiaphragm elevation.
Bilateral pleural effusions, greater on the right than the left,
which remain unchanged in size when accounted for the technical
differences between the current upright view and prior
semi-erect view. There is also better aeration of bilateral
upper lobes, consistent with patient positioning.
Brief Hospital Course:
Ms. [**Known lastname 85502**] was admitted to [**Hospital1 18**] on [**2164-8-8**] where she underwent
repair of a giant hiatel hernia by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **].
She required reoperation on [**2164-8-11**] for revision of hiatal
hernia repair, laparoscopically again by Dr. [**First Name (STitle) **] and Dr.
[**Last Name (STitle) **]. The patient was on the floor postoperatively but due
to acute respiratory distress and intussusception of the stomach
at the level of the repair, the patient required the above
mentioned reoperation and was mechanically ventilated. She
remained in the ICU for respiratory failure until [**2164-8-22**], when
she stabilized then transferred to the floor. Her hospital
course is below by systems.
Neuro: The patient was sedated initially while mechanically
ventilated, but weaned off, with slow but appropriate mental
status. She had anxiety and some delirium which resolved in part
by zyprexa (new to her), seroquel(on at home) and prn
benzodiazepines. She has had back pain relieved with tylenol.
Respiratory: She required transfer to SICU with reintubation on
[**2164-8-10**], where she was found to have intussusception of the
stomach at the level of the repair requiring reoperation. She
was difficult to wean initially off the ventilator but was
extubated on [**2164-8-19**], after diuresis. She had a left pleural
effusion which IP felt was unsafe to do bedside thoracentesis.
IR felt this could be drained, but by this time the patient was
extubated and was mentally intact refusing such procedure. She
was weaned to nasal cannula with aggressive pulmonary toilet.
Cardiovascular: The patient had postoperative atrial
fibrillation which resolved early on with diltiazem and quiesced
the rest of her stay with betablockers.
GI/GU: The patient was kept NPO following her surgery, and then
once extubated initially failed swallow. She pulled out her NG
tube, therefore was initiated on TPN [**2164-8-20**]. By [**2164-8-22**] she
passed her swallow, was placed on thin liquid with puree diet,
which she tolerated. She was advanced to a soft mechanical
diet, which she tolerated but takes in small quantities due to
poor appetite.
She was diuresed for volume overload, which she responded to,
electrolytes repleted, and foley was discontinued on [**2164-8-22**]. An
ecoli UTI was adequately treated to sensitive ciprofloxacin.
Abdominal incisions healed well with sutures removed on [**2164-8-27**].
Her last bowel movement was [**2164-8-26**].
ID: The patient developed leukocytosis, fever and started on
broad spectrum antibiotics. Ecoli was found in the blood, urine
and left thrombophlebitis all sensitive and treated with
ciprofloxacin and zosyn on [**2164-8-14**] for seven days. She had a
left PICC line in which was removed during this time, but a left
subclavian placed. This was discontinued on [**2164-8-22**] and she
developed a fever, therefore cipro was reinitiated that evening
with decreased fever, and she was cultured. The left subclavian
triple lumen was dc'd on [**2164-8-23**]. Formal infectious disease
consult was initiated on [**2164-8-24**], when we added vancomycin and
switched cipro to IV. Coagulase negative staph resistant to
oxacillin resulted in the blood on [**2164-8-27**]. ID felt the patient
would be safely treated with five more days of IV cipro and
vanc- last day [**2164-9-1**]; without need for labs. A right sided
PICC line with confirmed placement was then placed on [**2164-8-27**] at
50 cm.
Medications on Admission:
sertraline
xanax 2-3x /day
lisinopril
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Large hiatel hernia s/p repair.
Prolonged ICU course for respiratory failure- resolved.
Enterococcus bactermia, and UTI treated.
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:
Discharge to rehab.
-Call Dr. [**First Name (STitle) **] if you experience fevers greater than 101.5,
chills, shakes, shortness of breath, nausea, vomiting, stomach
pain, constipation, diarrhea, or any concerns.
-Call if your incisions open, drain, become red.
Completed by:[**2164-9-4**]
|
[
"553.3",
"041.11",
"401.9",
"451.82",
"530.81",
"790.7",
"997.4",
"458.29",
"293.0",
"512.1",
"750.4",
"276.6",
"511.9",
"518.5",
"278.01",
"999.31",
"285.9",
"599.0",
"560.0",
"E879.8",
"041.4",
"427.31",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.68",
"99.15",
"96.6",
"96.04",
"53.83",
"96.72",
"33.24",
"34.84",
"44.64"
] |
icd9pcs
|
[
[
[]
]
] |
7017, 7068
|
3402, 6928
|
351, 620
|
7241, 7241
|
2307, 3379
|
1665, 1834
|
7089, 7220
|
6954, 6994
|
7417, 7707
|
1944, 2288
|
1875, 1929
|
281, 313
|
648, 1300
|
7256, 7393
|
1322, 1512
|
1528, 1649
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
727
| 181,317
|
24425
|
Discharge summary
|
report
|
Admission Date: [**2201-5-18**] Discharge Date: [**2201-5-23**]
Date of Birth: [**2124-8-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
transfer for evaluation of tamponade
Major Surgical or Invasive Procedure:
Pericardial drain placement, ICD lead revision
History of Present Illness:
76 yo F with s/p DDD pacer/ICD placement (? for av block) on
[**5-6**], presented to [**Location (un) **] today w/ complain of SOB and chest
pain for the past 2-3 days, as welll as LH amd weakness, worse
w/ exertion. Had a bedside echo which showed pericardial
effusion with RA and RV diatolic collapse suggestive of
tamponade. Pt was sent to [**Hospital1 18**] for pericardial drain. At cath,
found to have RA and pericardial pressure of 10 mmHG--> 200 cc
of loculated effusion drained with decompession of pericardium
(pressure of 2). During cath pt had an episode of a flutter.
Also, suspected intramyocardial V-lead during procedure--> EP
consulted for evaluation of possible RV perforation; plan to go
to EP lab in am for lead revision.
On ROS: no fevers/chills; + dyspnea, LH, chest pressure before
cath; some chest dyscomfort (reprodusible on exam) after cath;
denies lifting heavy weights or doing maneuvers that could have
dislodged V lead.
She had a nl colonoscopy last year and nl mammogram (up to date
on cancer screening)
Past Medical History:
HTN
arthritis
2:1 AVB
Social History:
no etoh/tobacco
Family History:
cad, PVD in mother; PUD father; no cancers
Physical Exam:
afebrile 60-90 123/56 rr12 96% 2L NC
Gen: NAD
Neck: jvd 7 cm
Pulm: cta b
CVS: rrr; s1/2; [**1-18**] holosystolic murmur at L mid sternal border
without radiation; pericardail drain in place; no ICD pocket
hematoma
Abd: + BS; soft; nt/nd
Ext: non pitting edema
Pertinent Results:
Labs: Cr 1.1; INR 1.0; AST 83; ALT 78
Trop <0.04
TTE w/ large pericardial effusion; no valvular dz
Brief Hospital Course:
76 yo F with 2:1 AVB; s/p ICD placement 10 days ago, p/w low
pressure tamponade; s/p drainage and pericardial drain
placement.
1. Tamponade: Pt was watched in CCU for HD stability post
percardial drain placement. ? RV perf as found to have
intramyocardial V lead during the case. Mrs. [**Known lastname **] was given IV
hydration o/n and antihypertensives were held. Per EP, no RV
perf. Percocet for pain post procedure but most prominent pain
is actually her chronic sciatic and L shoulder pain exacerbated
by ICD placement. Drain was successfully d/ced with no evidence
of reaccumulation on TTE. Follow up fluid micro/cytology and
cell counts. Percocet for pain post procedure (limit to 2 g
tylenol/ day as unclear etiology of transaminitis).
2. ? intramyocardial V lead: EP consulted. Lead revision was
without complications.
3. Rhythm: episode of aflutter during drain placement. DDD
interrogated: underlying 2:1 AVB. cont tele. no anticoagulation
at this time given recent pericardial effusion. Pt will follow
up with Dr. [**Last Name (STitle) 1911**] in one week and will rediscuss
anticoagulation at that time.
4. Transaminitis: unclear etiology. check hepatitis panel.
consider RUQ U/S. repeat LFTs in am. outpt workup.
5. Lines: groin swan (in IVC) was d/ced after EP procedure
tomorrow. PIV
6. FEN: gentle hydration was administered and serial crits were
followed.
7. Proph: po diet; sq heparin was used
8. full code throughout hospital stay
Medications on Admission:
Meds: Evista; ASA 81; Hyzaar 100-25
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*20 Tablet(s)* Refills:*2*
2. Sotalol HCl 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary Diagnosis:
1. Cardiac tamponade s/p pericardial drain
2. Paroxysmal Atrial fibrillation
Secondary Diagnosis:
1.HTN
2.2:1 AV block
3. arthritis
Discharge Condition:
Good
Discharge Instructions:
Please call your PCP or return to the emergency department if
you develop chest pain, shortness of breath, weakness,
dizziness, or other worrisome symptom.
Followup Instructions:
Please call neurology at [**Telephone/Fax (1) 1690**] to adresse your memory
problems.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 902**] His office will
call you to schedule a follow-up appointment within 1 week at
his [**Location (un) **] office. At that time, he should discuss with you the
possibility of starting anticoagulation for your atrial
fibrillation.
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2201-7-9**] 4:30
|
[
"427.32",
"715.90",
"996.72",
"564.00",
"423.9",
"790.4",
"719.41",
"427.31",
"426.12",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"89.45",
"37.75",
"37.0",
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
4009, 4077
|
2026, 3489
|
352, 401
|
4273, 4280
|
1902, 2003
|
4484, 5057
|
1563, 1607
|
3575, 3986
|
4098, 4098
|
3515, 3552
|
4304, 4461
|
1622, 1883
|
276, 314
|
429, 1468
|
4216, 4252
|
4117, 4195
|
1490, 1514
|
1530, 1547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,665
| 135,934
|
22032
|
Discharge summary
|
report
|
Admission Date: [**2172-8-18**] Discharge Date: [**2172-8-24**]
Service: MEDICINE
Allergies:
Wheat Starch
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Decreased Urine Output, Hypotension
Major Surgical or Invasive Procedure:
L subclavian central line
History of Present Illness:
Mr. [**Known lastname **] is an 86 year old Male with chronic overflow
incontinence and diabetic neurogenic bladder who was recently
discharged to [**Hospital1 18**] on [**2172-8-15**] for urinary incontinence. He
returned to the ED for poor urine output, with foley in place
and lethargy. Of note pt also on narcotics, neurontin and
antidepressants. Bladder scan at NH showed no residual urine. Pt
sent to ED for further evaluation.
.
ED COURSE: Initial VS T 97.9 BP 81/49 HR 97 95%RA, a bladder
scan revealed no urine in the bladder with the foley functioning
normally with flushing. UA consistent with UTI and a lactate of
3.6. The patient was given Cefepime. His SBP was initially in
the 80s subsequently rose to the 90s but back down to 80s
despite 4LNS. Pt admitted to ICU for urosepsis, closer
monitoring despite DNR/DNI status. Per PCP ok for central lines
and pressors. ED unsucessful at placing central line, 3
attempts, R-IJ, SCV-failed.
.
ROS: Pt confused, answered yes to all questions, poor historian
despite history taken in Spanish.
Past Medical History:
#. Pseudomonas, Enterobacter cloacae UTI
#. Neurogenic Bladder with overflow incontinence chronically
catheterized
#. Gram + Sepsis
#. Cervical spondylolisthesis with myelopathy
#. neurodegenerative disorder
#. h/o CVA with right sided hemiparesis
#. DM-2
#. Chronic anemia
#. seizure disorder on Dilantin
#. schizo-affective disorder
#. History of DVT
#. Hypothyroidism
#. Left leg ischemic gangrene with ulcerations s/p Left AKA for
gangrene in [**8-27**] course c/b sepsis
#. Celiac disease
#. CHF-?EF
#. Dementia
#. B12 Deficiency
Social History:
-Spanish speakin only, nursing home resident. Family situation
unclear, called numbers-both disconnected. Per social worker,
no family members available. [**Name2 (NI) **] had step children involved in
care years ago but they left for [**Male First Name (un) 1056**] and have never
returned. He has no health care proxy and no family/relatives.
Family History:
unable to assess
Physical Exam:
VS: T 97.0 HR 81 BP 79/42 RR 18 95% 2LNC
GEN: Confused elderly gentleman lying comfortably in bed
HEENT: Dry MM, EOMI, PERRL, adentulous, R sided facial droop
RESP: CTABL, no crackles or wheezing
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft ND/NT +BS
EXT: L AKA, stumpt without lesions, RLE-[**1-25**]+ pitting edema, b/l
thigh edema, scrotal edema
NEURO: Confused, oriented to self only, unknown baseline MS,
follows some commands
Pertinent Results:
MICRO:
[**2172-8-18**] 8:00 pm BLOOD CULTURE SET #2.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Final [**2172-8-21**]):
REPORTED BY PHONE TO [**Female First Name (un) 13194**] [**Doctor Last Name **] AT 2140 ON [**8-19**]..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
.
[**2172-8-20**] 6:33 am URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
.
[**2172-8-20**] 6:33 am URINE Source: Catheter.
**FINAL REPORT [**2172-8-21**]**
URINE CULTURE (Final [**2172-8-21**]):
GRAM NEGATIVE ROD #1. ~4000/ML.
GRAM NEGATIVE ROD #2. ~[**2164**]/ML. SECOND MORPHOLOGY.
.
[**2172-8-20**] 8:34 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2172-8-21**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2172-8-21**]):
REPORTED BY PHONE TO LANSOM CAROLIN [**2172-8-21**] 8:20AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Lactate
[**2172-8-21**] 04:12PM 7.4
[**2172-8-20**] 05:13PM 7.9*
[**2172-8-19**] 07:21PM 5.8*
[**2172-8-19**] 02:00AM 3.0*
[**2172-8-18**] 11:04PM 3.6
Brief Hospital Course:
AP: 86 yo M with neurogenic bladder and chronic indwelling
catheter presenting with poor PO intake, low UOP, UTI consistent
with urosepsis given elevated lactate, poor UOP, hypotension and
source.
.
1)Urosepsis/Shock: Overflow incontinence from neurogenic
bladder, chronic indwelling catheter presents with multiple drug
resistant UTI, hypotension refractory to IVF. He was initially
treated with cefepime given previous sensitivities, add vanco
given h/o Gram + sepsis and refractory hypotension. His foley
was changed, Urine cultures here grew GNR, he had [**12-26**] blood
cultures with coag neg staph. He had diarrhea which was C-Diff
posisitve. He was treated for C-Diff with flagyl, his Abx course
was changed from cefepime to meropenem based on sensitivities,
his Vanco IV was d/c'd and continued on PO Flagyl for C-diff.
His lactate was elevated and increased to 7.4 on [**8-21**] despite
11L IVF. His pressors were changed from Neo to Levophed for
persistently elevated lactate despite IVF, ECHO did not show
wall motion abnormalities which suggested infectious process as
opposed to cardiogenic shock.
Patient's lactate continued to rise without any improvement with
maximal therapy. Given his overall poor prognosis, decision was
made to make patient CMO on medical grounds.
Patient passed away on [**2172-8-24**] at 8AM. Attending was notified. No
post-mortem was performed since patient had no next of [**Doctor First Name **].
Medications on Admission:
Medications: Discharge Medications [**2172-8-15**]
-Pantoprazole 40 mg daily
-Hexavitamin once cap daily
-Docusate 100mh PO bid
-Calcium Carbonate 500 mg PO bid
-Tramadol 25 mg PO tid
-Ferrous Sulfate 325mg daily
-Levothyroxine 75 mcg daily
-Fluoxetine 20 mg daily
-Penicillin V Potassium 500 mg q 8 hours through [**8-22**]
-Furosemide 20 mg daily
-Mirtazapine 7.5mg qhs
-Acetaminophen 325 mg PO q6hr PRN
-Gabapentin 600mg PO bid
-Cefpodoxime 200 mg PO daily through [**8-18**]
-Dilantin 200mg Po bid
.
NH MEDS:
-Vit B12 Injections qmonth
-Prozac 20mg daily
-Lasix 20mg daily
-Levoxyl 150mcg daily
-KCL 20 MEQ daily
-Prilosec 20mg daily
-Colace 100mg [**Hospital1 **]
-Neurontin 600mg [**Hospital1 **]
-Oyst-Cal-1gm [**Hospital1 **]
-Dilantin 300mg [**Hospital1 **]
-Cefpodoxime 200mg [**Hospital1 **] until [**8-18**]
-Pen VK 500mg TID until [**8-22**]
-Mirtazapine 7.5mg HS
-MOM
-Tylenol 650mg prn
-Oxycodone 5mg q8hrs
Discharge Disposition:
Expired
Discharge Diagnosis:
c. diff colitis
urosepsis
cardiac arrest
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2172-8-24**]
|
[
"579.0",
"345.90",
"V49.76",
"038.9",
"295.70",
"995.92",
"276.2",
"276.51",
"008.45",
"244.9",
"785.52",
"428.0",
"438.20",
"596.54",
"599.0",
"250.60",
"266.2",
"996.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6512, 6521
|
4098, 5540
|
254, 281
|
6605, 6610
|
2777, 2839
|
6662, 6696
|
2298, 2316
|
6542, 6584
|
5566, 6489
|
6634, 6639
|
2331, 2758
|
179, 216
|
3211, 4075
|
2869, 3176
|
309, 1360
|
1382, 1918
|
1934, 2282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,998
| 151,422
|
9581
|
Discharge summary
|
report
|
Admission Date: [**2154-2-4**] Discharge Date: [**2154-2-7**]
Date of Birth: [**2077-12-28**] Sex: M
Service: MEDICINE
Allergies:
Roxicet / Morphine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Scheduled admission for pre-cath hydration prior to carotid
angioplasty
Major Surgical or Invasive Procedure:
catheterization [**2154-2-6**]
History of Present Illness:
76 yr old male c/pmhx carotid stenosis, RAS s/p stent, CKD (cr
4.0), dyslipidemia, htn, tongue ca, spinal stenosis presents to
have percutaneous revascularization with Dr [**First Name (STitle) **] requiring
pre-cath hydration. Patient reports that that carotid stenosis
was noted on ultrasound and that he has been asymptomatic
without sxs of CVA or TIA. He denies CP, SOB, abd pain, cough,
f/c, orthopnea, pnd, ankle edema, change on bowel movements,
weight loss, amarousis fugaux, weakness, dysarthria, presyncope
or syncope. He does note symptoms of claudication after walking
[**12-14**] block, which is relieved by rest.
Diagnostic tests perfomred at outside provers include:
TTE [**5-20**] - LVEF 60%. No AS. Trace mr, tr. Mild septal
hypertrophy.
.
Carotid u/s- [**2154-1-24**]
Elevated peak systolic velocity in proximal RCA consistent with
severe 80-99% stenosis with peak systolic velocity 457 and
diastolic 147. LCA reveals [**Last Name (un) **] systlolic 216 and diastolic 54.
.
Carotid Cath [**2154-2-6**] - RCCA normal. [**Country **] has tubular 80% lesion
at previous CEA site. ICA fills the ipsilateral MCA and PCA
without noted filling of the ACA.
Past Medical History:
1. Supraglottic squamous cell carcinoma, extending to the base
of
the tongue, stage T2, N0, M0.
2. Malignant melanoma, status-post definitive excision in [**Month (only) 205**]
[**2143**], in the left posterior auricular area.
3. RIGHT carotid endarterectomy, several years ago (although
some past notes report LEFT CEA)
4. Hypertension
5. Hypercholesterolemia
6. Depression
7. History of L4-L5 surgery in [**2136**]
8. Left femoral angioplasty in [**2133**] and [**2152**].
9. Right femoral angioplasty in [**2140**] and [**2152**].
10. Left hip prosthetic replacement in [**2137**].
11. Face lift in [**2133**].
12. Laminectomy in [**2144-6-11**].
13. History of Tonsillectomy
14. Gastroesophageal reflux disease
15. Barrett's esophagus, noted on EGD during PEG placement in
[**2145-12-13**]. On gross appearance--no tissue biopsy taken.
16. Diffuse esophageal thickening and a 1 cm right paratracheal
lymph node noted on CT in 8/[**2144**]. There was noted to be some
difficulty with peristalsis as well on a barium swallow study of
[**7-/2145**], as well as a questionable stricture in the distal
esophagus.
17. Chronic renal insufficiency/RAS s/p angioplasty and stent
[**2152**]
18. Hypothyroidism
.
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: no cabg
.
Percutaneous coronary intervention: no pci
.
Pacemaker/ICD: no pacer
Social History:
The patient has a 135 pack year tobacco history. He quit in
[**2132**]. He also has a history positive for alcohol for 30 years
and reports quitting in [**2131**]. He
worked as a custodian for the city of [**Location (un) 86**] until [**2126**]. No
IVDU. He
lives alone and is widowed x2. Lives in senior housing in
[**Location (un) **]
Family History:
Significant for a brother and a sister with myocardial
infarction both in their 50s. He has two maternal aunts with
[**Name2 (NI) 499**] cancer. His sister had lung cancer. No h/o dm.
Physical Exam:
On admission-
VS - 97.6, 125/71, 64 bpm, 20 RR, 98% RA
Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no JVP appreciated. Carotid bruit appreciated
bilaterally.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
=========
Labs
=========
[**2154-2-6**] 06:20AM BLOOD WBC-6.7 RBC-3.23* Hgb-10.9* Hct-31.8*
MCV-99* MCH-33.9* MCHC-34.4 RDW-13.8 Plt Ct-172
[**2154-2-5**] 06:50AM BLOOD WBC-6.6 RBC-3.39* Hgb-11.2* Hct-33.5*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.8 Plt Ct-180
[**2154-2-4**] 03:31PM BLOOD WBC-6.1# RBC-3.04* Hgb-10.0* Hct-29.7*
MCV-98# MCH-32.8* MCHC-33.6 RDW-13.9 Plt Ct-169
[**2154-2-4**] 03:31PM BLOOD PT-12.9 PTT-24.9 INR(PT)-1.1
[**2154-2-6**] 06:20AM BLOOD Glucose-77 UreaN-43* Creat-3.8* Na-141
K-5.0 Cl-109* HCO3-22 AnGap-15
[**2154-2-5**] 06:50AM BLOOD Glucose-72 UreaN-42* Creat-3.9* Na-142
K-4.8 Cl-108 HCO3-29 AnGap-10
[**2154-2-4**] 03:31PM BLOOD Glucose-108* UreaN-41* Creat-4.2*# Na-140
K-5.4* Cl-107 HCO3-27 AnGap-11
[**2154-2-4**] 03:31PM BLOOD ALT-8 AST-13 AlkPhos-48 TotBili-0.2
[**2154-2-6**] 06:20AM BLOOD calTIBC-243* VitB12-248 Folate-14.6
Ferritn-89 TRF-187*
.
==========
Cardiology
==========
C. Cath [**2-6**]
COMMENTS: 1. Access was via 6F sheath in RFA. Initial BP
219/95
with HR 63. Blood pressure came down to systolic 140 with IV
tng.
2. Imaging of aortic arch and left carotid deferred in order to
preserved dye.
3. The right common carotid artery was imaged with a Berenstein
catheter selectively showing patent Right common with a right
internal
with a 80% tubular lesion at prior CEA site. The right carotid
filled
the right MCA and a fetal origin PCA but not the right ACA. The
right
external had a moderate lesion.
4. We elected to proceed to right internal carotid stenting.
We placed
the Berenstein in the right external and exchanged over a
SupraCore wire
for a 6F Shuttle sheath after giving Heparin (ACT 265). We then
crossed
the internal carotid lesion with a Prowater and exchanged for a
6mm
Spider filter. We predilated with a Quantum Maverick 2.5x20 at
8atm and
stented with a Protege 8-6x40mm tapered self-expanding stent.
We posted
the stent with a Quantum Maverick 4.5x20 at 18 atm. The patient
tolerated the procedure well with minimal hypotension as status
post
CEA. He remained neurologically intact during the procedure and
immediately after. Post intervention angiography showed no
complications and the right carotid now filled the right ACA.
5. Groin closure with Mynx.
FINAL DIAGNOSIS:
1. Stenting of right internal carotid for restenosis after CEA
Brief Hospital Course:
#. Carotid stenosis/PVD: Carotid ultrasound consistent with
severe RCA disease and moderate LCA disease. Patient is already
s/p CEA. Patient asymptomatic on admission denying any numbness,
tingling, or weakness. Patient underwent cardiac catheterization
on [**2-4**] with stenting of right internal carotid for restenosis
after CEA. Patient underwent hydration with mucomyst and bicarb
were administered prior to cardiac catherization. Patient was
continued on asa, plavix and statin. Patient given Rx for
aspirin and plavix.
.
# HTN: Patient has had two episodes of HTN urgency. No signs of
end organ ischemia. Patient felt this was likely [**1-14**] to anxiety.
Improved with hydralazine prn on the medicine floor. In the CCU,
BP elevated to 160 improved to 140s once restarted outpatiet
beta blocker.
.
#. CKD: Baseline Cr. per report around 4. Patient as an
outpatient not on HD, and patient has not had discussions with
nephrologist about this in the past. Renal team initiated
discussion re: HD and are following along. Cr improved with
gentle hydration. Patient aware of high likelihood of needing
dialysis post-cath. Patient recieved pre-catherization
hydration. Creatinine after catherization was stable at previous
baseline. Patient informed to follow up with his outpatient
nephrologist Monday after discharge.
.
#. Anemia: Unknown baseline Hct. Macrocytic. Likely secondary to
renal dysfunction. Awaiting PCP notes for baseline Hct. Iron
studies showed TIBC 243 (low), iron 82, b12 248, folate 146,
ferritin 89, transferrin 187 (low).
.
#. Psych: Continued SSRI and Wellbutrin
.
#. GERD: Continued ppi
.
# Hypothyroidism: Continued synthroid
.
#. PPx: PO diet. SQH. PPI.
.
#. Code: Full code confirmed with patient
Medications on Admission:
Citalopram 40 mg po daily
Levothyroxine 0.125 mg daily
Bupropion 75 mg po BID
Simvastatin 20 mg po daily
Metoprolol Tartrate 25 mg po daily
Omeprazole 20 mg po bid
Plavix 75 mg po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
9. Basic metabolic panel Sig: One (1) weekly for 3 weeks:
please draw Basic metabolic panel [**2154-2-11**]. Please make sure
results are sent to Dr. [**Last Name (STitle) 32496**] as well as Dr. [**Last Name (STitle) **]. [**Last Name (STitle) 17590**] B Hazar
.
Disp:*1 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Carotid artery stenting
.
Secondary: 1. Supraglottic squamous cell carcinoma, extending to
the base of the tongue, stage T2, N0, M0.
2. Malignant melanoma, status-post definitive excision in [**Month (only) 205**]
[**2143**], in the left posterior auricular area.
3. Left carotid endarterectomy, several years ago.
4. Hypertension
5. Hypercholesterolemia
6. Depression
7. History of L4-L5 surgery in [**2136**]
8. Left femoral angioplasty in [**2133**] and [**2152**].
9. Right femoral angioplasty in [**2140**] and [**2152**].
10. Left hip prosthetic replacement in [**2137**].
11. Face lift in [**2133**].
12. Laminectomy in [**2144-6-11**].
13. History of Tonsillectomy
14. Gastroesophageal reflux disease
15. Barrett's esophagus, noted on EGD during PEG placement in
[**2145-12-13**]. On gross appearance--no tissue biopsy taken.
16. Diffuse esophageal thickening and a 1 cm right paratracheal
lymph node noted on CT in 8/[**2144**]. There was noted to be some
difficulty with peristalsis as well on a barium swallow study of
[**7-/2145**], as well as a questionable stricture in the distal
esophagus.
17. Chronic renal insufficiency/RAS s/p angioplasty and stent
[**2152**]
18. Hypothyroidism
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted to the hospital for carotid artery stenting.
You tolerated the procedure well without complication. You are
being discharged home on your regular medications. It is very
important that you follow up with your nephrologist this week
and have your electrolytes checked as the dye that was used for
the procedure may worsen your renal function. You were cleared
by renal and neurology as well as Dr. [**First Name (STitle) **] to be discharged
home.
.
Medication changes:
1) You were started on a full strength aspirin for which you are
being given a prescription. You should continue to take your
plavix as well. These two medications are extremely important
given your new carotid stent. You should not stop taking these
medications prior to talking to a cardiologist.
.
You should call Dr. [**First Name (STitle) **] if you experience any neurologic
symptoms such as dizziness, lightheadedness, numbness or
tingling in your fingers or toes or loss of motor coordination.
YOu should come to the ER if you experience any chest pain,
shortness of breath, or severe abdominal pain. It has been a
pleasure taking care of you at [**Hospital1 **].
Followup Instructions:
Please follow up with your nephrologist preferably early next
week. We have called to make you a follow up appointment but no
one answered the phone and there was no message machine. Please
call to schedule ([**Telephone/Fax (1) 32497**] with Dr. [**Last Name (STitle) 17590**] B Hazar at your
convenience. If you cannot see your nephrologist within the week
then you should see your primary care doctor instead and have
your electrolytes. You can call his office at ([**Telephone/Fax (1) 32498**].
In addition, you should follow up with Dr. [**First Name (STitle) **] at his new
location of [**Hospital3 **] within 1 month of discharge.
Completed by:[**2154-2-8**]
|
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10978, 11446
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3552, 4333
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|
239, 312
|
410, 1581
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2993, 3334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,303
| 101,499
|
20404
|
Discharge summary
|
report
|
Admission Date: [**2191-5-21**] Discharge Date: [**2191-5-29**]
Date of Birth: [**2154-7-26**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 36-year-old male with
a nonsignificant history was admitted 3 days ago from an
outside hospital. According to his wife, the patient was in
normal state of excellent health until a week-and-a-half ago,
before his admission, when he noted the onset of left flank
pain a few days after his return from a golf trip to [**State 108**].
The patient notes that the day before his admission, he had
developed gross blood in his urine. However, despite this
symptom, his wife reports that he went to work the morning of
his admission, returned around noon, seemingly to be in
normal health. He was found by a neighbor around 8 p.m., on
the day of admission incoherent and crawled up in a fetal
position in his front lawn, he was very agitated, but highly
confused leading the neighbor to contact the EMS and police.
Police noted that he was agitated, combative, and confused
resulting in his transport to [**Hospital 1474**] Hospital. While at
this outside hospital, he was initially alert and oriented
times 3, but due to his combative behavior, he was given 60
mg of IV Ativan. By report, he was found to have a fever of
103 degrees, a negative head CT and EKG showing [**Street Address(2) 4793**]
elevation from leads V1 through V4, and troponin level of 13.
The urine toxic screen positive for benzodiazepines and
cocaine. He was given IV Rocephin, aspirin, nitroglycerin,
and an amp of D50, was intubated. He was transported by Med
flight to [**Hospital1 18**] for emergent cardiac catheterization. At
presentation to [**Hospital1 18**] ER, he was found to have a blood
pressure of 205/101, a heart rate of 123, saturations at 99
percent on FiO2 of 0.6.
His labs were significant for a white blood cell count of
13.6, platelets of 114, creatinine 2.7, serum glucose of 31,
and ABG of 7.21 per pH, PCO2 41, PO2 134. He received
bedside echocardiogram, which revealed normal LV function and
no valvular disease with a question of apical hypokinesis.
He was sent emergently to the cardiac catheterization lab,
which did not reveal any evidence of coronary artery disease.
His wedge was 22 mmHg, the cardiac output of 8 liters a
minute and cardiac index of 4.2; however, his CK level
increased from 450 at the outside hospital to 3835 on
admission to [**Hospital1 18**] leading to suspicion of rhabdomyolysis.
Following catheterization, the patient was admitted to the
MICU.
PAST MEDICAL HISTORY: Genital herpes.
Muscle spasms on muscle relaxants at home.
OUTSIDE MEDICATIONS:
1. Muscle relaxant that the patient cannot remember the name
of.
2. Xanax p.r.n.
HOSPITAL MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Flagyl 500 mg p.o. b.i.d.
3. Levofloxacin 250 mg p.o. q. 48h.
4. Sevelamer 800 mg p.o. t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He lives with his
wife and a 1-year-old child. Child was left locked inside
when Mr. [**Known lastname 12967**] was found outside forcing police to break
down the door. VSS is involved in this case. The patient
works as an occupational therapist. His wife denies the
patient had any previous tobacco history or history of
alcohol use or recreational drug use. However, the patient
admits to having used cocaine for a total of 6 times as well
as a red pill and [**First Name8 (NamePattern2) **] [**Location (un) 2452**] pill, which he is unable to
mention the names of.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature maximum 99.6 degrees,
blood pressure 99-145 systolic over 60-74 diastolic. Heart
rate 75 to 97, respiratory rate 13 to 28. Oxygen saturation
91 to 95 percent on room air. The patient was overall 15
liters positive upon transfer to the medicine service.
Generally: Well-appearing, no apparent distress. HEENT:
Normocephalic, atraumatic. Head, no pharyngeal erythema or
exudate. Sclera anicteric. Neck: No JVD or
lymphadenopathy. Cardiac: Normal. Pulmonary: Normal.
Abdomen: Normal. Skin: No clubbing, cyanosis or edema.
Neurologically: Alert and oriented, mildly delayed recall
process. Cranial nerves intact. Visual fields full to
confrontation. No pronator drift. Negative Romberg's.
Rapid alternating movements intact. Touch and proprioception
intact. Motor strength 5/5 in all extremities.
LABORATORY DATA: From admission, white blood cell count
17.1, hematocrit 32.1, platelets 68. PTT 41.8, INR 3.7,
fibrinogen 106, haptoglobin less than 20. Chemistry profile
notable for a BUN of 15, creatinine is 7.9, glucose 104,
calcium 7.4, phosphorous 7.2, magnesium 1.8. LFTs notable
for an ALT of 2508, AST of 1871, LDH 1802, CK 6751, alkaline
phosphatase of 81, T-bili 1.2.
MICU course was complicated by persistent hypoglycemia
requiring 4 amp's of D50. He developed hypotension requiring
a Levophed infusion. His hematologic parameters continued to
degrade with his hematocrit dropping to 33.6 from 44, and his
platelets dropping to a low of 36,000 requiring a platelet
transfusion. His thrombocytopenia was complicated by the
development of coagulopathy with his INR increasing to a high
of 3.5. His fibrinogen dropping to 63 and D-dimer level
greater than 10,000, that was considered that this could be
TTP/HUS, given the initial fever, mental status change, acute
renal failure, and thrombocytopenia. However, the absence of
a microangiopathic process on blood smear argued for the
diagnosis of DIC instead. Chest radiograph showed evidence
of patchy opacities in the right upper lobe and left lower
lobe consistent with aspiration pneumonia. Infectious
Disease was consulted while in the ICU. He was placed on
Flagyl, vancomycin, and levofloxacin for presumed aspiration
pneumonia and Acyclovir for HSV meningitis given his acute
mental status changes. Additionally, renal consult and GI
consults were obtained while the patient was in the ICU and
as he had put out guaiac positive diarrhea and had rapidly
progressed to acute renal failure.
HOSPITAL COURSE WHILE ON FLOOR: Cardiac. The patient ruled
in for myocardial infarction by cardiac enzymes and by his
EKG changes consistent with that. However, his
catheterization was unrevealing in terms of evidence for
cardiac ischemia. The likely explanation was that this was
mostly likely a cocaine induced vasospasm causing myocyte
ischemia and death. His LV function was preserved according
to the echocardiogram.
Rhabdomyolysis. Given the patient's enormous increase in his
CK, the patient had evidence of heme-positive urine. Again,
this was mostly likely attributed to cocaine induced
rhabdomyolysis. Other possible etiologies could have been
virally induced or possibly related to the patient's status
of being found down. The patient's CK slowly began to trend
down with aggressive IV fluid hydration.
Acute renal failure. The patient had nonoliguric acute renal
failure. There was evidence of bloody-brown casts seen in
his urine, which is characteristic of ATN. The patient
maintained adequate urinary output without requiring
dialysis.
Liver dysfunction. The patient had evidence of hepatic
involvement to his multisystem organ failure. This is mostly
likely attributed to shock liver given his known development
of DIC and profound hypertension during his first hospital
day.
Coagulopathy. It is most likely attributed to DIC.
Hematology was consulted to assist in the management. There
is no evidence of schistocytes on peripheral smears.
Mental status changes. Although, the patient's mental status
changes seemed highly likely to be solely to his cocaine use.
It was also attributed to delirium and the onset of fever and
possible sepsis. This improved after antibiotic treatment
and IV fluid hydration. Uremia may have also contributed to
his mental status decline.
Hypoglycemia. The patient's initial metabolic derangements
were noted in the ICU, the thought was that the patient may
have had an adulterated form of cocaine with quinine, which
is apparently common and can cause protracted hypoglycemia.
Infectious disease. The patient was febrile without any
obvious source of infection, felt that this may be attributed
to the patient's atelectasis versus cytokine response to
muscle or liver necrosis. The patient although was
maintained on antibiotics for aspiration pneumonia.
DISCHARGE DIAGNOSES: Acute myocardial infarction with
cardiac catheterization showing no occluded coronary
arteries.
Acute nonoliguric renal failure.
Disseminated intravascular coagulopathy.
Rhabdomyolysis.
Hepatitis consistent with shock liver contributing diagnosis
include cocaine abuse.
CONDITION ON DISCHARGE: The patient is stable without oxygen
requirement, tolerating POs, mentating clearly.
DISCHARGE STATUS: The patient would be discharged to home.
MAJOR SURGICAL OR INVASIVE PROCEDURES PERFORMED: The patient
had cardiac catheterization. He was intubated and he had a
central line placement.
FOLLOW UP: The patient will follow-up with his PCP [**Name Initial (PRE) 176**] 1
week. The patient will also follow-up with gastroenterology
for an elective colonoscopy given his history of bloody
diarrhea as an inpatient. Additionally, the patient will
follow-up with intensive outpatient treatment program for
substance abuse. The patient will have a follow-up renal
ultrasound and follow-up with Dr. [**Last Name (STitle) 4883**] nephrology to
monitor his renal function.
DISCHARGE MEDICATIONS:
1. Amlodipine 5 mg p.o. q.d.
2.
Protonix 40 mg p.o. q.d.
3. Ciprofloxacin 500 mg p.o. q.d. for 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**]
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2191-8-3**] 14:52:19
T: [**2191-8-4**] 10:17:06
Job#: [**Job Number **]
|
[
"728.88",
"507.0",
"970.8",
"518.81",
"E854.3",
"410.71",
"305.60",
"584.5",
"286.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.56",
"38.93",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
3563, 3581
|
8456, 8731
|
9554, 9929
|
9062, 9531
|
3604, 8434
|
164, 2553
|
2576, 2929
|
2946, 3546
|
8756, 9050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,196
| 143,821
|
17868
|
Discharge summary
|
report
|
Admission Date: [**2186-4-19**] Discharge Date: [**2186-5-1**]
Date of Birth: [**2136-7-4**] Sex: M
Service: [**Hospital1 **]/MEDICINE
HISTORY OF PRESENT ILLNESS: This 49 year old man is
transferred from [**Hospital Ward Name 12573**] Intensive Care Unit to the [**Hospital Ward Name 12053**] for further management of aspergillomas. The patient
has a two to three year history of pulmonary problems
secondary to sarcoidosis and aspergillomas. His original
symptoms were dyspnea and cough. His chest CT revealed
interstitial lung disease and mediastinal lymphadenopathy.
The patient has received several bronchoscopies with
transbronchial biopsy and pathology revealed necrotizing
granulomas. He also had an open resection of an aspergilloma
from his right lung. When the original diagnosis of
sarcoidosis was made, the patient received a course of
corticosteroids, with symptomatic improvement of his dyspnea.
In [**2185-11-20**], the patient was prescribed Itraconazole for
aspergillus infection. He started on his medication but was
unable to refill his prescription because of financial
limitation.
The patient has been seen at [**Hospital6 **] for
evaluation of aspergilloma resection. He was not felt to be
a good surgical candidate and therefore did not receive
resection.
The patient presented to [**Hospital6 6689**] on
[**2186-4-18**], with a large amount of hemoptysis (several cups).
A bronchoscopy revealed left upper lobe bleeding source.
Interventional radiology embolization procedure was attempted
but the arterial bleeding source was not identified. The
patient was hemodynamically stable and he ceased bleeding on
his own. He was transferred to [**Hospital1 188**] for further evaluation.
The patient was admitted to the [**Hospital Unit Name 153**]. Throughout his stay in
the [**Hospital Unit Name 153**], he had small amounts of hemoptysis, coughing up
sputum streaked with blood. He received two doses of
Solu-Medrol for sarcoidosis in the [**Hospital Unit Name 153**]. He was transferred
to the [**Hospital Ward Name 517**] for possible interventional pulmonary
procedure.
At the time of transfer, the patient describes stable
shortness of breath, as well as large and small joint
polyarthralgias. He has no other complaints at this time.
PAST MEDICAL HISTORY:
1. Pulmonary sarcoidosis as suggested by interstitial lung
disease, mediastinal lymphadenopathy, and necrotizing
granulomas on transbronchial biopsy. The patient has had an
extensive negative tuberculosis workup.
2. Bilateral aspergillomas, upper lobes.
3. Hepatitis B.
4. Ethanol abuse.
5. Cocaine use.
6. HIV negative.
7. Pancytopenia, status post bone marrow biopsy which
revealed normal bone marrow.
8. Cholecystitis.
MEDICATIONS ON TRANSFER:
1. Itraconazole 200 mg once daily.
2. Percocet.
3. Dextromethorphan.
4. Valium per CIWA scale.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a contractor. He does not
currently work secondary to illness. He formerly smoked
fifteen pack years. He was also in prison for a period of
time. He denies intravenous drug use.
FAMILY HISTORY: The patient has a sister with leukemia.
PHYSICAL EXAMINATION: On transfer, temperature is 97.6,
heart rate 100, blood pressure 122/79, oxygen saturation 100%
in room air. In general, a thin black man, hoarse, no acute
distress. Head, eyes, ears, nose and throat examination -
Sclera anicteric. The pupils are 3.0 millimeters and light
reactive. The oral mucosa is moist. Neck examination is
negative for supramandibular, cervical, axillary, posterior
auricular lymphadenopathy. Lung examination is clear to
auscultation bilaterally and resonant to percussion. Heart
is regular rate and rhythm, normal S1 and S2, no S3, no
murmurs, rubs or gallops. Abdomen - decrease bowel sounds,
soft, nontender, nondistended. Extremities - no edema.
LABORATORY DATA: On transfer, white blood cell count was
9.7, hematocrit 24.5, platelet count 222,000. INR 1.1,
partial thromboplastin time 28.3. Sodium 140, potassium 4.2,
chloride 110, bicarbonate 23, blood urea nitrogen 13,
creatinine 0.6, glucose 227.
CT of the chest [**2186-4-20**], bilateral aspergillomas, left upper
lobe dominant lesion with ground glass surrounding it
consistent with hemorrhage. Mediastinal lymphadenopathy
likely sarcoid.
Pulmonary function tests revealed FVC 59% of predicted, FEV1
79% of predicted, FEV1/FVC 135% of predicted, total lung
capacity 69% of predicted, residual volume 24%, RV/TLC 106%,
DLCO 55%.
Electrocardiogram on [**2186-4-19**], showed normal sinus rhythm,
rate 113 beats per minute, peaked T waves, normal axis,
normal intervals, borderline left ventricular hypertrophy by
voltage.
HOSPITAL COURSE: The patient was transferred to the [**Hospital Ward Name 12053**] for further management of his pulmonary issues. The
infectious disease service was consulted and recommended
increasing his Itraconazole to a dose of 200 mg p.o. twice a
day given with acidic fluids. The interventional pulmonary
service was involved in the patient's care and recommended a
trial of intralesional Amphotericin B for treatment of the
patient's aspergillomas. An attempted placement of the
pigtail catheter in the left upper lobe aspergilloma was
unsuccessful because the catheter kinked when it came into
contact with the aspergilloma material. A needle was
inserted into the cavity and a specimen sent for culture and
pathology.
After the procedure, the patient developed acute onset left
sided pleuritic chest pain, decreased oxygen saturation,
chills, and rigors. A stat radiograph was obtained and ruled
out the presence of tension pneumothorax. The patient was
placed on broad spectrum antibiotics (Vancomycin,
Levofloxacin, and Metronidazole). He was given a single dose
of Meperidine and his symptoms and oxygen saturation
subsequently improved. A radiograph obtained in the evening
after the procedure revealed the presence of a small left
apical pneumothorax. This remained stable on several repeat
chest radiographs.
The patient was felt to be at continued risk of massive
hemoptysis as a result of his left upper lobe aspergilloma.
The air crescent in this aspergilloma was deemed to be too
small to accommodate even a smaller size catheter, resection
was considered to be the most reasonable option for treatment
of the aspergilloma. The thoracic surgery service was
consulted and evaluated the patient. A consensus opinion
among the three services consulting on this patient was that
he would benefit from further treatment for possible invasive
bronchopulmonary aspergillosis followed by definitive
aspergilloma resection and intercostal muscle flap placement
in the residual cavities to prevent further growth. The
patient was loaded with 400 mg of Voriconazole twice a day on
[**2186-4-29**], and 200 mg twice a day on [**2186-4-30**]. The patient
was discharged with instructions to continued Voriconazole at
200 mg twice a day and follow-up with surgery in two weeks
for discussion about aspergilloma resection. A social work
consultation insured that the patient would be able to obtain
his medications despite the patient's limited resources and
the expense of the medication.
DISCHARGE DIAGNOSES:
1. Bilateral aspergillomas, status post recent massive
hemoptysis from left upper lobe aspergilloma.
2. Pulmonary sarcoidosis.
3. Anemia and leukopenia of undetermined etiology.
4. Symmetrical large and small joint polyarthralgias of
undetermined etiology.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: The patient was discharged to home.
FOLLOW-UP: He is to have weekly liver function tests, blood
urea nitrogen and creatinine checked. He has an appointment
to follow-up with Dr. [**Last Name (STitle) 952**] of cardiothoracic surgery on
[**2186-5-18**].
MEDICATIONS ON DISCHARGE:
1. Voriconazole 200 mg p.o. q12hours.
2. Dextromethorphan p.r.n. cough.
3. Percocet one to two tablets q12hours p.r.n.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2186-5-2**] 19:19
T: [**2186-5-6**] 14:56
JOB#: [**Job Number 49545**]
|
[
"288.0",
"517.8",
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"276.1",
"512.1",
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icd9cm
|
[
[
[]
]
] |
[
"33.93"
] |
icd9pcs
|
[
[
[]
]
] |
3145, 3186
|
7265, 7527
|
7861, 8263
|
4749, 7244
|
3209, 4731
|
181, 2297
|
2776, 2914
|
2319, 2751
|
2931, 3128
|
7552, 7835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,895
| 138,962
|
47032
|
Discharge summary
|
report
|
Admission Date: [**2116-11-6**] Discharge Date: [**2116-11-11**]
Date of Birth: [**2054-2-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
chest pain and Signs of alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
On presentation to the medical ICU:
62 y/o male w/ Medical history of untreated Hep C, COPD, chronic
alcholism, HTN, CAD s/p MI in [**3-/2116**] w/ stenting who presents
with chest pain and withdrawal. The patient has had multiple
admissions most recently 2 in [**Month (only) 216**] [**2116**]. In [**3-/2116**] he had an
NSTEMI with stent placement. In [**6-/2116**] he had a stress MIBI with
a wall motion abnormality and small, reversible, anterolateral
perfusion defect. In [**7-24**], he was r/o for MI with enzymes,
EKGs. Cardiac cath was not recommended. Pt was to be optimized
on medications, but continues to drink to excess and not take
cardiac medications. He was also found to have depression and
alcohol withdrawal and was encouraged to go into therapy, but
declined last minute. He was readmitted from [**Date range (1) 45402**] for
chest pain again where cath was deferred given his continued
drinking and non-compliance with medications.
.
The patient presented again to the ED on the day of admission
with chest pain and concern over his drinking. He reports that
he lost his health insurance and so has not been able to take
his medications for the past 3-5 days (was taking half pills
prior to that). This made him anxious so he started drinking
more than usual. He reports usually drinking 1 quart of vodka
daily, with his last drink being yesterday. He has chest pain
2-3x daily for which he usually sits down and rests, which
dissipates his pain. The patient also had a fall a few days
prior from a sitting position where he fell forwards and hit his
nose on a table, denied LOC, loss of bowel/bladder function,
tongue biting.
.
In the ED, initial VS were: 98.0 110 154/114 18 100% 15L nrb.
Labs showed bicarb of 12 with anion gap of 26, normal CBC,
lipase of 93, EtOH of 69, normal LFTs, and trop < 0.01. He was
given 3L NS, plavix 75mg, metoprolol tartrate 100mg, and a total
of ativan 8mg IV for withdrawal. Per ED report, did have
hallucinations. On transfer vitals were 90 185/115 RR: 30 O2:
99%RA
.
On arrival to the MICU, the patient states he is feeling better
than on admission.
.
GENERAL MEDICINE ACCEPT NOTE (From medical ICU)
62yo man with history of NSTEMI [**3-/2116**] s/p BMS to prox LAD,
untreated Hepatitis C, COPD, alcoholism, HTN, anxiety presents
with chest pain and in alcohol withdrawal. He has been admitted
12 times this year, numerous times for chest pain, most recently
twice in [**2116-8-24**]. His last admission was for chest pain;
he was considered for catheterization but decision was made at
that time to hold off due to his medication noncompliance and
continued alcohol abuse. He has been getting chest pain at rest
as well as with minimal exertion (walking [**11-12**] feet), which
subsides with rest. He reports history of hallucinations with
previous alcohol withdrawal but denies prior seizures. However
he did fall from seated position into a table and sustained a
nasal laceration, but denied LOC, urinary incontinence.
.
He presented to the ED on [**2116-11-7**] with chest pain and anxiety.
He stated that he had not been taking his medications since he
recently lost his Mass Health insurance. He stated that his
lack of insurance and inability to take his medications made him
anxious, so he consumed roughly 1 quart of alcohol per day which
seemed to ease his anxiety.
.
In the ED, his initial VS were: 98.0 110 154/114 18 100% 15L on
NRB. CE's negative, EtOH: 69, bicarbonate: 12, anion gap: 26,
lipase: 93. He was given 3L NS, plavix 75mg, metoprolol tartrate
100mg, and 8mg of IV ativan for ithdrawal.
.
He was transferred to the MICU for stabilization, where he has
placed on the CIWA scale and given 50mg valium overnight and
10mg during the day on [**2116-11-7**]. He was also given isosorbide
with improvement in his hypertension and tylenol for his
headaches. He [**Date Range 20003**] out for MI with enzymes negative x3 and EKG
has been unchanged.
.
He was then transferred to the floor. Before transfer out, he
complained of chest pain, shortness of [**Date Range 1440**], and weakness.
EKG was performed which showed evidence of old infarct but no
acute changes. He was given Valium and by re-evaluation was
sleeping and when awoken had no complaints of pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. All other systems negative.
Past Medical History:
- CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
- CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- NSTEMI in [**3-/2116**] with BMS to proximal LAD
- Stress mibi in [**6-/2116**] showing reversible, small moderate
severity perfusion defect involving the LAD (diagonal) territory
and normal LV cavity size, mid-anterior HK with preserved EF 56%
- Last admission in [**8-/2116**] he was considered for catheterization
but this was deferred given persistent pattern of medication
non-compliance and alcoholism
.
- OTHER PAST MEDICAL HISTORY:
- HCV - genotype 2; last VL [**2116-1-10**] was 3,230,000
- Anxiety
- CKD stage III baseline Cr 1.3-1.9
- COPD
- s/p hernia repair
- longstanding alcoholism
- tobacco use
- diastolic dysfunction on Echo in '[**13**]
- hyperparathyroidism - persistently elevated PTH - has not
undergone further work-up
- numerous admissions for alcohol withdrawal, chest pain,
anxiety
Social History:
Adapted from OMR:
-Heavy drinker since his 20s. Most recently has been drinking 1
quart of vodka per day x 3 days. Before that was drinking about
1 pint vodka per day. Has smoked cigarettes/cigars since his
20s; currently smoking [**2-27**] cigars per day.
- h/o blackouts, DTs, hallucinations during withdrawal, unsure
about seizure but thinks so
- Multiple detox treatments, including Addiction Treatment
Center ([**Location (un) 583**]), [**Location (un) 86**] City, [**Hospital1 882**], [**Last Name (un) 5112**], [**Hospital1 10551**]
- Past heroin abuse x 30 years, stopped 10 years ago (used to
shoot [**1-26**] bags/day) and went to methadone clinic.
- Experimented with LSD, MJ, crack cocaine in past
- Smoked 1.5ppd, smoked for 20 [**Month/Day (2) 1686**]
- Divorced for [**11-3**] [**Month/Year (2) 1686**], keeps in touch with 30 y/o daughter
and is on good terms with ex-wife.
- Lives in rooming house in [**Location (un) **] for last 3-4 years; lives
alone
- Denies h/o physical/sexual abuse
- Educated through 3 years college
- Employment: Worked as mechanical engineer until fired for
alcoholism in [**2099**]. Later worked as a magician, lost job when
store closed in [**2112-2-5**]. Laid off from work for [**Location (un) 86**] Trolley
on [**Holiday 1451**] [**2114**].
Family History:
Mother is alive, has DM, father died of HF and kidney disease at
86 y/o. Denies psychiatric family history. No h/o early MI or
sudden cardiac death.
Physical Exam:
On admission to the MICU:
97.6 88 185/111 32 96 2L
General: Alert, oriented, appears chronically ill
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: distant heart sounds with decreased air movement, no
wheezes
Abdomen: soft, obese but non-tender, bowel sounds present, no
organomegaly
GU: no foley, violaceous rash on left anterior thigh
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, finger to nose slow but intact, gait
deferred but patient able to sit up at edge of bed to use urinal
without diffculty
ON DISCHARGE:
Unchanged except less ill-appearing, NAD, conversant, gait slow
but intact; occasionally complaining of chest pain or shortness
of [**Year (4 digits) 1440**]
Pertinent Results:
LABS ON ADMISSION:
[**2116-11-6**] 04:20PM BLOOD WBC-9.6 RBC-5.32# Hgb-14.7# Hct-45.7#
MCV-86 MCH-27.7 MCHC-32.2 RDW-17.4* Plt Ct-252
[**2116-11-6**] 04:20PM BLOOD Neuts-83.5* Lymphs-12.2* Monos-3.2
Eos-0.3 Baso-0.8
[**2116-11-6**] 04:20PM BLOOD PT-11.3 PTT-21.9* INR(PT)-0.9
[**2116-11-6**] 04:20PM BLOOD Plt Ct-252
[**2116-11-6**] 04:20PM BLOOD Glucose-89 UreaN-24* Creat-1.5* Na-139
K-4.7 Cl-101 HCO3-12* AnGap-31*
.
PERTINENT LABS:
[**2116-11-6**] 04:20PM BLOOD ALT-21 AST-32 AlkPhos-68 TotBili-0.6
[**2116-11-6**] 04:20PM BLOOD Lipase-93*
[**2116-11-6**] 04:20PM BLOOD cTropnT-<0.01
[**2116-11-6**] 09:55PM BLOOD cTropnT-0.01
[**2116-11-7**] 07:06AM BLOOD cTropnT-<0.01
[**2116-11-7**] 12:32AM BLOOD Calcium-9.1 Phos-1.7* Mg-1.5*
[**2116-11-6**] 04:20PM BLOOD Osmolal-312*
[**2116-11-6**] 04:20PM BLOOD ASA-NEG Ethanol-69* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2116-11-7**] 12:24AM BLOOD Lactate-1.1
.
LABS ON DISCHARGE:
[**2116-11-10**] 06:20AM BLOOD WBC-9.0 RBC-4.38* Hgb-12.4* Hct-38.6*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.7* Plt Ct-164
[**2116-11-10**] 06:20AM BLOOD Plt Ct-164
[**2116-11-10**] 06:20AM BLOOD Glucose-96 UreaN-22* Creat-1.5* Na-135
K-4.1 Cl-102 HCO3-24 AnGap-13
[**2116-11-10**] 06:20AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.9
.
MICROBIOLOGY:
MRSA SCREEN (Final [**2116-11-9**]): No MRSA isolated.
.
DIAGNOSTICS:
--ECG [**2116-11-9**] Since the previous tracing the rate is slower.
Otherwise,
findings are unchanged.
--CHEST (PA & LAT) Study Date of [**2116-11-9**] 3:28 PM Heart size and
mediastinum are stable. Lungs are essentially clear except for
bibasilar linear opacities, most likely consistent with
atelectasis. No interval development of pleural effusion or
pneumothorax is seen. Hyperinflation is appreciated better on
the lateral views.
Brief Hospital Course:
62 y/o w/ PMHx untreated Hep C, COPD, chronic alcholism, HTN,
s/p NSTEMI in [**3-/2116**] with BMS to proximal LAD who presents with
chest pain, found to be in alcoholic hallucinosis, now treated
for alcohol withdrawal.
.
ACTIVE ISSUES THIS ADMISSION:
# Alcoholic hallucinosis - Patient is unsure if he has ever
seized before. Looking through past [**Hospital1 18**] admits, he has had
hallucinations before, but no documented seizures. He reported
not drinking since 1 day prior to admission ([**2116-11-5**]). He
was started on an aggressive CIWA scale for valium 10mg PO q1hr
prn. He was started on thiamine, folate, and MVI supplements.
He was weaned off the CIWA scale after several days without
issue and hallucinosis resolved, he appeared less tremulous, and
overall was feeling much better. He was extensively counseled
regarding his alcohol abuse, and encouraged to get back to AA.
He will be discharged to a rehab facility where he can continue
sobriety and try to get back on his feet.
.
# Angina - Patient has had repeated admissions over past few
months for chest pain, most recently twice in [**2116-8-24**].
Decision was made not to recath at that time as patient has not
been compliant with his medications and was felt that cath would
bring more harm than benefit. Had intermittent symptoms of
[**2115-1-27**] chest pain, often sharp and midline, throughout his
hospitalization and was seen to have EKG's unchanged from prior,
and pt had [**Date Range 20003**] out for MI with cardiac enzymes. His chest pain
was likely related to his anxiety but possibly from hypetension
as well, for which his Imdur was increased to 90 mg daily. He
was restarted on his home cardiac regimen that he should have
been taking including ASA, Plavix, statin, [**Last Name (un) **], beta blocker,
Imdur. Should he continue to have chest pain at the rehab, would
give sublingual nitroglycerins, check blood pressure and if
elevated consider giving an extra Metoprolol; also consider
relaxation techniques given self reported anxiety.
.
# Shortness of [**Last Name (un) 1440**]: As above, likely a large component of
anxiety; however pt also with COPD at baseline. His CXR appeared
unchanged and consistent with COPD.
.
# Hypertension - Was hypertensive in ED, likely secondary to
withdrawal as well as rebound from beta-blocker and nitrate
therapy. The patient antihypertensives were restarted on
admission (see above). His Imdur was increased from 60mg to
90mg per day. His blood pressure should be followed up and
consider titrating his medications; his Valsartan could
potentially be uptitrated. He also needs to quit drinking
alcohol which will likely benefit his blood pressure.
.
CHRONIC ISSUES:
# COPD - Had distant [**Last Name (un) 1440**] sounds and tachypneic on admission
but was later saturating well on RA by the time of discharge. He
was started on standing albuterol/ipratropium nebs with
albuterol prn and was intermittently complaining of shortness of
[**Last Name (un) 1440**] especially on exertion, which was improved by rest and
nebulizer treatments.
# Anxiety - pt self reported severe GAD and this was likely the
cause of his intermittent mild chest pain and shortness of
[**Last Name (un) 1440**]. Initiation of an SSRI was discussed but not able to be
fully explored before discharge, as this would require close
outpatient follow up which was not able to be secured by
discharge.
.
TRANSITIONAL ISSUES:
-*patient may be a candidate for anti-depressant or anti-anxiety
treatment, which may help with his medication compliance, severe
anxiety, and alcoholism*
- continue working with community social worker and
rehabilitation facility to continue abstaining from alcohol,
continue to encourage alcohol abstinence and compliance with AA
A brief verbal signout was given to the [**Hospital3 2558**] about the
pt's course and active issues just before discharge.
Of note, it was learned after pt was discharged that he was seen
to be drinking mouthwash in the bathroom. Our hospital mouthwash
is reportedly non-alcoholic.
Medications on Admission:
Medication list from last discharge:
1. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*4*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual Take 1 under your tongue every 5 minutes up to 3 as
needed for chest pain: If you have continued pain after 3,
please stop and return to the ER.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*4*
11. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
4. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-2**]
MLs PO Q6H (every 6 hours) as needed for cough.
5. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q3H (every 3 hours).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob, wheeze.
17. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)
Tablet PO DAILY (Daily).
18. Maalox prn for heartburn
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chest Pain
.
SECONDARY DIAGNOSIS:
Alcohol Withdrawal
Anxiety
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:
Mr. [**Known lastname **],
.
It was a pleasure taking care of your in your hospital stay at
[**Hospital1 69**]. As you know you were
admitted for chest pain and alcohol withdrawal. You were
admitted into the Intensive Care Unit, and you were given
medication to prevent you from going into alcohol withdrawal.
Your heart was monitored as well and it was determined that you
should continue on your current medications in order to optimize
your cardiac status.
.
Please note the following change to your medications:
.
Please START taking the following medications:
Guaifenesin as needed for cough
Maalox as needed for heartburn
.
Please note the following CHANGE to your medications:
Imdur (isosorbide mononitrate) dosage increased from 60mg per
day to 90mg per day
.
Please continue taking the medications you were prescribed
before your hospitalization.
.
Followup Instructions:
Please call [**Hospital3 **] at [**Telephone/Fax (1) 1247**] to establish a
primary care doctor. The patient has not been seen in a very
long time because he missed too many appointments.
Completed by:[**2116-11-12**]
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7,282
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43708
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Discharge summary
|
report
|
Admission Date: [**2196-8-4**] Discharge Date: [**2196-8-13**]
Service: MEDICINE
Allergies:
Penicillins / Fosamax
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
shortness of breath, cough, fatigue, lightheadedness for 3 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 93940**] is an 83 y/o M w/PMH significant for lung CA who
presents w/gradually progressing SOB, cough, fatigue and
lightheadedness over the past 3weeks. Per daughter & patient: Pt
was in his usual state of health and able to perform ADLs until
3 wks ago when he suddenly became SOB though pt cannot recall
exact moment he became SOB. Pt describes feeling as not being
able to breathe in enough air/oxygen. SOB is persistent, occurs
w/slightest movement. SOB only relieved when pt is sitting up
and not moving. SOB is worse at night and pt has been sleeping
w/three large pillows to elevate himself to almost a seating
position. Pt can no longer lie flat on back w/o becoming SOB.
Around this time, pt also has been experiencing lightheadedness,
dizziness and worsening cough w/yellow-whitish sputum. Pt has
been unable to perform ADLs and his 4 children have been
assisting him with activities he would normally do on his own
such as bathing and eating. His daughter also states he has has
had a depressed mood, decreased motivation and has also been
confused, not able to recall the date or what he ate for
breakfast. He has had one episode of syncope during these three
weeks, though he cannot recall when and how long he was
unconscious. Episode of syncope occurred while he was sitting,
he did not fall or hit his head. Pt also admits to cold
intolerance, LOA and constipation but denies CP, fevers/chills,
diaphoresis, n/v, diarrhea, incontinence, dysuria, urinary
frequency, black or dark stools, blood in stool and hematuria.
.
This AM, pt went for scheduled appointment w/Dr. [**Last Name (STitle) **] at
[**Hospital1 18**] for his lung CA. Dr. [**Last Name (STitle) **] was concerned when he saw
pt and sent him to [**Hospital1 18**] ED.
Past Medical History:
PMH:
1. Squamous cell lung cancer
1. NIDDM: diet controlled ?????? in records but daughter denies
2. RCC: diagnosed [**2183**]; s/p partial R nephrectomy [**2-/2184**]
3. Prostate CA: s/p XRT [**2182**]
4. CAD: s/p catheterization & stent??????2; other blockages said to
be seen in [**1-/2195**]
5. HTN
6. GERD
7. Basal cell CA of skin: on maxilla bilat; not excised
8. Asthma
9. Arthritis
Social History:
Mr. [**Known lastname 93940**] was born in [**Country 532**] and immigrated to the Unites
States in [**2179**]. He has four children. His daughter who lives
nearby accompanies him today. He is a widow and currently lives
in a [**Location (un) 448**] apartment alone. His family visits very often.
He is a former smoker, smoking one pack a day for at least 40
years. He quit approximately 20 years ago. He is a retired
engineer but denies any occupational or environmental exposures.
Family History:
Mr. [**Known lastname 93941**] mother died at the age of 68 from complications
of hypertension. His father died in his 70s from a blood
infection. He has two brothers, one of whom has diabetes.
Physical Exam:
T: 96.8 HR: 68 BP: 118/68 RR: 22 O2Sat: 99%2L
General: elderly man of avg wt; slightly cachectic; appears
fatigued; NAD
Skin: nml temp & consistency; +seborrhaic keratoses & cherry
angiomata on abdomen
HEENT: MMM; no supraclavicular or cervical LAD; no thyromegaly;
no JV elevation
Chest: +diffuse coarse breath sounds/rhonchi; intermittent
crackles in LL & ML bilat; no wheezes; +use of accessory muscles
Cardiac: distant HS; RRR
Abd: difficult to appreciate BS; soft; nontender; nondistended;
no splenomegaly or hepatomegaly
Ext: no LE edema; +good DP pulses bilat
Neuro: CNII-XII intact; no asterixis; no pronator drift;
strength 5/5 in major muscle groups of arms & legs
Pertinent Results:
[**2196-8-4**] 11:45AM GLUCOSE-79 UREA N-36* CREAT-1.9* SODIUM-142
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2196-8-4**] 11:45AM CK(CPK)-29*
[**2196-8-4**] 11:45AM CK-MB-NotDone
[**2196-8-4**] 11:45AM WBC-6.9 RBC-4.83 HGB-13.1* HCT-41.0 MCV-85
MCH-27.1 MCHC-31.9 RDW-15.9*
[**2196-8-4**] 11:45AM NEUTS-67.5 LYMPHS-23.7 MONOS-7.5 EOS-1.1
BASOS-0.2
[**2196-8-4**] 11:45AM HYPOCHROM-1+ MICROCYT-1+
[**2196-8-4**] 11:45AM PLT COUNT-430
[**2196-8-4**] 11:45AM PT-12.9 PTT-28.9 INR(PT)-1.1
.
.
Radiology:
[**2196-8-4**] CHEST (PA & LAT)
1) Right perihilar opacity/mass; it is unclear per given
history, whether this represents the site of the patient's
primary lung cancer. If not, this may represent a pneumonic
infiltrate; correlate clinically.
2) Multiple small nodules and cavitary lesions seen on the prior
chest CT are not appreciated on the current chest x-ray.
.
[**2196-8-4**] CTA CHEST W&W/O C
1. No evidence of pulmonary embolism. 2. Increased right-sided
effusion.
3. Diffuse bronchial wall thickening. 4. Increase in size of
multiple lung lesions, some of which again demonstrate cavitary
transformation and peripheral wedge-shaped appearance. The
overall appearance is most concerning for progression of
metastatic disease with differential diagnosis again including
typical and atypical infectious processes.
Brief Hospital Course:
Patient is an 83 y/o M w/PMH significant for lung CA who
presented w/gradually progressing SOB, cough, fatigue and
lightheadedness over the past 3weeks w/CXR concerning for PNA or
worsening lung CA. CT performed for further eval also revealed
unilateral pleural effusion and increased pulmonary lesions
concerning for worsening CA or infection. Differential
diagonisis on presentation included advancing malignancy, CHF,
pneumonia. The patient after admission became hypotensive and
additionally was requiring increasing oxygen support. The
patient was transferred to the [**Hospital Unit Name 153**] for ongoing care. In the
[**Hospital Unit Name 153**] he was started on Levofloxacin and Flagyl for possible
pneuominia, with ceftriaxone additionally added as well later.
The patient had large O2 requirements, requiring a
non-rebreather to maintain O2 sats > 90. However, as the patient
was DNR/DNI without presssors, therapies offered in the [**Hospital Unit Name 153**]
were limited. The patient was tried on a trial of CPAP to held
decrease the associated work of breathing but found the CPAP too
uncomfortable and preferred not to use it. The patient therefore
was trasnferred back to the floor for ongoing care. The
patient's prognosis was known to be poor which the patient and
his family were aware of. Therefore, priority was shifted
towards comfort which was guided by the patient's family. As the
patient was lucid and interactive, although markedly tachypnic,
he and his family preferred not to use any narcotics for comfort
initially. However, as the patient's course progressed over a
course of days and he became more tired and confused, the
patient's family guided the use of morphine until a point when
the patient was on a morphine drip titrated to comfort. All
supportive measures including medications, fluids, and lab
checks were discontinued and the patient was allowed to pass
away with his family present. The patient passed away from
respiratory arrest on [**2196-8-13**].
Medications on Admission:
Atenolol 25mg po QD
Ambien 5mg po QHS
Robitussin A-C 2tsp po QHS
Lipitor 10mg po QD
Imdur 30mg po QD
Albuterol Sulfate 17gm IH 2puffs QID
Protonix 40mg po QD
Advair Diskus 500-50mcg IH 1puff [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Squamous Cell Lung Cancer
Secondary:
Squamous cell lung cancer
Diabetes Mellitus: diet controlled ?????? in records but daughter
denies
Renal Cell Carcinoma: diagnosed [**2183**]; s/p partial R nephrectomy
[**2-/2184**]
Prostate cancer: s/p XRT [**2182**]
Coronary artery disease: s/p catheterization & stent??????2; other
blockages said to be seen in [**1-/2195**]
Hypertension
Gastro-esophageal Reflux disease
Basal cell Cancer of skin: on maxilla bilat; not excised
Asthma
Arthritis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
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"428.0",
"493.90",
"414.01",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7605, 7614
|
5316, 7317
|
293, 299
|
8153, 8163
|
3944, 5293
|
8216, 8223
|
3032, 3228
|
7576, 7582
|
7635, 8132
|
7343, 7553
|
8187, 8193
|
3243, 3925
|
189, 255
|
327, 2099
|
2121, 2513
|
2529, 3016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,046
| 187,977
|
10450
|
Discharge summary
|
report
|
Admission Date: [**2129-4-29**] Discharge Date: [**2129-5-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 34537**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old woman with history of Afib for which she is on
Coumadin who this past monday realized that she felt her right
arm was weak and that she was leaning toward the right. She
currently resides at a nursing home and today her nurse felt she
should be evaluated so she was sent to an OSH. While there a
head CT showed a 2cm x 2.5 cm right cerebellar hemorrhage. Her
INR was 3.4 the day prior to admission, and approximately 2 at
the OSH. Per report, she was reversed with FFP, vitamin K and
factor IX complex.
.
She was transferred to [**Hospital1 18**] for further management. Her INR was
2.0 for which she received FFP, Vitamin K, and Propylene IX in
the emergency department. She denies headache, is blind in her
right eye secondary to macular degeneration but has good vision
with her left eye. She is listing to her right when entering
the room. She is interactive.
Past Medical History:
Atrial fibrillation/flutter on warfarin
Hypertension
Type 2 DM
Dyslipidemia
Right eye blindness secondary to macular degeneration
Glaucoma
Cataracts
Uterine prolapse with urinary incontinence, prior hx of pesary
Spinal stenosis with radiculopathy
Osteoporosis
Depression
Social History:
Smoked <[**12-18**] ppd x 10 yrs, quit in [**2125**]
Denies EtOH and recreational drugs
Lives at nursing home.
Living brother and sister [**Name (NI) 382**] and two nieces are very involved
in her care.
Widowed for 7 years, has a daughter in [**Name (NI) 108**] who is not
involved.
She previously worked as an xray technician and helped
physicians do house calls in the [**Location (un) 34538**] area.
Family History:
Brother with diabetes and eye problems.
Denies cardiac or pulmonary disease.
Physical Exam:
O: T:98.1 BP: 180/111 HR:88 R 18 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT Pupils: R blind/clouded over, L 3mm/2mm EOMs full
without nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to self and hospital
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils Right blind/clouded over secondary to cataracts and
macular degeneration. Left 3mm to 2mm. Visual fields are full to
confrontation with left eye
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Right pronator drift, RUE is not weak but is
uncoordinated. Normal bulk and tone bilaterally. No abnormal
movements, tremors. Strength full power [**4-20**] throughout.
.
Sensation: Intact to light touch and proprioception bilaterally
.
Toes downgoing bilaterally
.
Coordination: Finger to nose uncoordinated with Right, good with
left, normal heel to shin
Pertinent Results:
[**2129-5-6**]
142 101 19 156
3.8 33 1.1
Ca: 9.9 Mg: 1.5 P: 3.1
WBC 13.9 HCT 42.4 Plt 321
[**2129-5-5**]
141 101 19 175
3.8 32 1.2
Ca: 9.7 Mg: 1.5 P: 3.2
WBC 9.0 HCT 44.7 Plt 356
Hand x-ray [**2129-5-4**]
Degenerative changes of osteoarthritis, without evidence of
fracture.
Left upper extremity US [**2129-5-5**]
Occlusive thrombus seen within the left cephalic vein. No deep
vein thrombosis seen within the remainder of the veins of the
left arm.
URINE CULTURE (Final [**2129-5-5**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2129-5-3**] 05:51a
Source: Catheter
Negative for urobil, bili, leuk, protein
Mod bld, sm nitr, 150 glu, tr ket, 15 RBC, 0-2 WBC, >50 bact,
mod yeast, mod epi
.
[**2129-5-3**] 5:40a
141 101 17 144
4.1 31 1.1
Ca: 10.0 Mg: 1.6 P: 3.1
WBC 10.7 HCT 42.2 Plt 311
.
[**2129-4-29**] 06:00AM
GLU 201* UREA N-14 CREAT-1.0 Na-142 K-3.8 Cl-104 CO2-29
CALCIUM-9.3 PHOSPHATE-2.7 MAGNESIUM-1.8
WBC-10.0 HCT-39.5 MCV-83 PLT COUNT-298
PT-13.8* PTT-27.7 INR(PT)-1.2*
.
[**2129-4-29**] 01:17AM
GLU-161* UREA N-13 CREAT-1.0 Na-141 K-3.7 CH-101 CO2-30
cTropnT-<0.01
WBC-10.6 HCT-45.1 MCV-84 PLT COUNT-334
NEUTS-75.7* LYMPHS-15.6* MONOS-5.1 EOS-3.1 BASOS-0.4
PT-18.5* PTT-27.7 INR(PT)-1.7*
.
CXR ([**5-2**]): Right sided hiatal hernia, cardiomegaly, no apparent
pneumonia or CHF.
.
CT head ([**5-1**]): Stable inferior right cerebellar hematoma with
vasogenic edema; no evidence of obstructive hydrocephalus, and
stable slight cerebellar tonsillar herniation.
.
CT HEAD W/O CONTRAST [**2129-4-29**]
1. Right cerebellar intraparenchymal hemorrhage causing mass
effect on the
right lateral ventricle occipital [**Doctor Last Name 534**]. No evidence of
herniation. In the
absence of comparison, direct interval change is not assessed.
2. Mild perihemorrhagic edema and effacement of the fourth
ventricle with
mass effect on the medulla. No evidence of tonsillar herniation.
.
CT HEAD W/O CONTRAST [**2129-4-29**]
Overall stable appearance of the right-sided inferior cerebellar
hematoma and surrounding hypodensities due to edema and
associated mass effect. No new hemorrhage seen. No
hydrocephalus.
.
EKG ([**4-28**]): Aflutter with variable response (79bpm), poor R wave
progression, prolonged QTc, inferior Q waves.
Brief Hospital Course:
Pt presented with right-sided weakness secondary to right
cerebellar hemorrhage. She received vitamin K, FFP and profiline
9 to reverse the coumadin and decrease her INR. In the ICU, her
exam was stable, so no interventions were performed. On [**4-30**],
INR was 1.5 and 1 unit FFP was given. She was transferred to
medicine for step-down care. She had an asymptomatic episode of
atrial flutter with higher degree of AV block and bradycardia
likely caused by over blockade. It resolved with decreased doses
of her beta and calcium blockers. She was monitored on
telemetry with no acute events. Her blood pressure was kept
below 160 systolic for her recent intracranial bleed. She has
been stable with no events on her current doses of long-acting
diltiazem and metoprolol. Her oxygen requirement resolved with
incentive spirometry. She was found to have a UTI shown on
culture to be pan-sensitive E coli, so she was started on 3d
course of Bactrim. Of note, her WBC increased one day after
treatment, but patient remained asymptomatic, so please repeat
urine analysis after completion of antibiotics to confirm
clearance. During this hospitalization, her hand became
ecchymotic and edematous and she complained of severe pain. Work
up was significant for occlusive cephalic venous thrombus, which
is likely causing her symptoms. Given her recent cerebellar
hemorrhage, neurosurgery advised that she not be therapeutically
anticoagulated for this, although SC heparin for DVT prophylaxis
is acceptable and appropriate. Her hand is being managed with
elevation, physical therapy, and pain control with Tylenol.
She will need to follow up with neurosurgery. This was
scheduled.
The patient confirmed her full code status this admission.
Medications on Admission:
Acetaminophen 1g [**Hospital1 **]
Lacri-lube gtt qhs
Alphagan 0.2% daily
Tums 3 tabs daily
Diltiazem 360mg daily
Cosopt 2-0.5% [**Hospital1 **]
Vitamin D2 50,000 units daily
Gabapentin 300mg qhs
Heparin flush
Xalatan 0.005% eye drops qhs
Metoprolol succinate 112.5 mg daily
Remeron 15mg tab qhs
KCl 20 meq daily
Senna 2 tabs qhs
Tramadol 25mg [**Hospital1 **]
Trazodone 25mg qhs
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
4. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Three (3)
Tablet PO once a day.
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a day.
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed for pain.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Five (5) Tablet Sustained Release 24 hr PO DAILY (Daily).
16. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
Discharge Disposition:
Extended Care
Facility:
Newbridge on th echarles{ [**Hospital 100**] Rehab} [**Doctor Last Name 34539**]
Discharge Diagnosis:
Cerebellar hemorrhage
Bradycardia
AV block
Atrial flutter/atrial fibrillation
Hypertension
Atelectasis
Cephalic vein thrombosis
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 for right-sided weakness, and found to have a
brain bleed. We stopped your coumadin. You had an episode of
slow heart rate, which resolved with a change in your heart
medication. You were also found to have a urinary tract
infection, for which we began treatment with an antibiotic. Your
left hand started hurting and was swollen, which is likely
caused by a blood clot in a superficial vein in your arm.
Because of your brain bleed, we cannot thin your blood anymore
than the heparin shots you get three times a day. It will
resolve on its own.
??????DO NOT RE-START YOUR COUMADIN UNTIL CLEARED BY THE NEUROSURGEON
Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????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, or
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), prior
to your injury, you may safely resume taking this AFTER YOU ARE
CLEARED TO DO SO IN THE [**Hospital **] CLINIC.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-6-9**] 10:15
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2129-6-9**] 11:15
Completed by:[**2129-5-6**]
|
[
"729.89",
"431",
"E942.4",
"276.52",
"369.60",
"041.4",
"426.10",
"E934.2",
"790.92",
"733.00",
"427.32",
"453.81",
"518.0",
"V58.67",
"276.8",
"362.50",
"788.30",
"293.0",
"781.3",
"401.9",
"E941.3",
"427.31",
"599.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9786, 9893
|
6048, 7789
|
283, 290
|
10065, 10065
|
3325, 6025
|
11994, 12266
|
1928, 2006
|
8218, 9763
|
9914, 10044
|
7815, 8195
|
10241, 11971
|
2021, 2195
|
223, 245
|
318, 1198
|
2441, 3306
|
10080, 10217
|
1220, 1492
|
1508, 1912
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,757
| 159,160
|
678
|
Discharge summary
|
report
|
Admission Date: [**2149-2-2**] Discharge Date: [**2149-2-6**]
Service: SURGERY
Allergies:
Golytely / Morphine
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Nausea and Vomiting
Inability to speak x minutes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83F with h/o seven prior strokes, HTN, NIDDM, vertigo, Bell's
Palsy who reports a one day history of nausea and vomiting
complicated by a brief episode of weakness/altered
responsiveness and inability to speak while sitting on toilet.
This was witnessed by her daughter.
Past Medical History:
history of CAD< s/p LAD stent in [**2145**]
DM 2 x 25 year
hypercholesterolemia
hypertension
history of CVA x3
Social History:
60 pack year smoking history but quit smoking about 40 years
ago; denies etoh; currently living w/ one of her daughter
Family History:
history of ulcer disease; father died of MI at 69; mom died of
MI at age of 66; 1st brother died of CAD , brain hemorrhage at
the age of 63; 2nd brother died of CVA at the age of 59
Physical Exam:
Admission Physical Exam - [**2149-2-1**]
96.7 56 139/49 18 99%RA
NGT with 500 nonbilious drainage
Abd: soft, mildly tympanitic, ND, hypoactive BS
Pertinent Results:
Admission Labs
--------------------
[**2149-2-1**] 06:00PM BLOOD WBC-15.3*# RBC-4.29 Hgb-13.5 Hct-38.8
MCV-91 MCH-31.5 MCHC-34.8 RDW-13.6 Plt Ct-257
[**2149-2-1**] 06:00PM BLOOD PT-12.0 PTT-21.9* INR(PT)-1.0
[**2149-2-1**] 06:00PM BLOOD Glucose-168* UreaN-28* Creat-0.8 Na-135
K-5.0 Cl-101 HCO3-19* AnGap-20
[**2149-2-1**] 06:00PM BLOOD CK(CPK)-57
[**2149-2-1**] 06:00PM BLOOD Phos-4.6* Mg-2.2
[**2149-2-2**] 01:14PM BLOOD Phenyto-14.4
[**2149-2-1**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs
--------------------
[**2149-2-5**] 05:15AM BLOOD WBC-8.6 RBC-3.23* Hgb-10.9* Hct-29.7*
MCV-92 MCH-33.7* MCHC-36.7* RDW-13.2 Plt Ct-189
[**2149-2-5**] 05:15AM BLOOD Plt Ct-189
[**2149-2-5**] 05:15AM BLOOD Glucose-97 UreaN-9 Creat-0.4 Na-137 K-3.8
Cl-105 HCO3-18* AnGap-18
[**2149-2-5**] 05:15AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.1
[**2149-2-5**] 04:08PM BLOOD Phenyto-11.6
Abdomen/Pelvis CT
CT ABDOMEN WITHOUT CONTRAST: The visualized lung bases are
clear. There are extensive coronary artery and mitral annular
calcifications. There are multiple fluid-filled dilated loops of
small bowel measuring up to 3 cm in maximal transverse dimension
consistent with small bowel obstruction. A likely transition
point is seen in the right lower abdominal quadrant (series 2,
image 60) with proximal fecalization of small bowel contents and
collapsed loops of ileum seen distally. There is no evidence of
free intraperitoneal air or fluid. The unenhanced liver
demonstrates decreased attenuation in segment IV consistent with
focal fatty infiltration. There is no intra- or extra- hepatic
biliary ductal dilatation. The pancreas, spleen, and right
adrenal gland appear normal. Again noted in the left adrenal
gland is a 2.1 x 2.4-cm myolipoma, unchanged in size and
appearance from the prior exam. The right adrenal is normal.
Within the left kidney, there are numerous well-defined
hypodense small cysts, the largest in the lower pole measuring
2.2 x 2.0 cm. The right kidney is unremarkable. The
gastrojejunostomy anastomosis is intact and appears
unremarkable. There is no mesenteric or retroperitoneal
lymphadenopathy. The abdominal aorta and its branches are
heavily calcified.
CT PELVIS WITH IV CONTRAST: A Foley catheter is seen in a
partially distended bladder. Calcified fibroids are identified.
There are numerous sigmoid diverticula without evidence of
surrounding inflammation. No free pelvic fluid or
inguinal/pelvic lymphadenopathy is identified.
BONE WINDOWS: No osseous findings suspicious for malignancy are
identified.
CT RECONSTRUCTIONS: Coronal reconstructions were essential for
delineating the anatomy and presence of small bowel obstruction
with transition point in the right lower abdominal quadrant.
IMPRESSION:
1. Small bowel obstruction with a transition point involving the
distal ileum. No evidence of perforation, obstructing mass, or
abscess.
2. Stable left adrenal myolipoma.
3. Multiple simple left renal cysts.
4. Fibroid uterus.
5. Numerous colonic diverticula without evidence of
diverticulitis.
6. Stable focal fatty infiltration in segment IV of the liver.
CT Head [**2-1**]
---------------
TECHNIQUE: Non-contrast head CT.
FINDINGS: No hemorrhage, mass, hydrocephalus,or shift of
normally midline structures. No major vascular territorial
infarct is apparent. [**Doctor Last Name **]-white matter differentiation is
preserved. Areas of low attenuation are seen in the
periventricular white matter, likely reflecting chronic
microvascular ischemic changes. An old lacunar infarct is seen
in the left thalamus, as well as a hypodense focus in the left
paramedian pons, corresponding to the region of diffusion
abnormality noted on the MRI from [**2144-5-16**]. Paranasal
sinuses and mastoid air cells are normally aerated. Dense
vascular calcifications are noted in the cavernous carotid.
IMPRESSION: No acute intracranial process.
CT HEAD W/O CONTRAST [**2149-2-2**] 3:43 AM
TECHNIQUE: Non-contrast head CT.
FINDINGS: There has been interval development of a moderate
high-density extra-axial collection layering over the right
frontal convexity consistent with subdural hematoma. There is
moderate leftward subfalcine herniation and compression of the
adjacent right lateral ventricle. No major vascular territorial
infarct is identified. There is an old lacunar infarct in the
left thalamus as well as an area of encephalomalacia in the left
paramedian pons. Dense vascular calcifications are noted in the
cavernous carotid. No fracture is identified on bone algorithm
windows. A mucous retention cyst is seen in the left maxillary
sinus.
IMPRESSION:
1. Right-sided acute subdural hematoma causing subfalcine
herniation. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
immediately upon completion of the study. The need for urgent
neurosurgical consultation was discussed.
CT HEAD W/O CONTRAST [**2149-2-2**] 11:22 AM
NON-CONTRAST HEAD CT: Comparison with [**2149-2-2**], 5:18
a.m. Again seen is an extraaxial subdural hematoma outlining the
right frontal, temporal, and parietal cerebral convexities. It
is similar in appearance and size, with some mass effect exerted
on the underlying cerebral cortex. The study is somewhat limited
by motion, however, there is no evidence of intraparenchymal
hemorrhage, acute major vascular territorial infarct. The degree
of subfalcine herniation is approximately the same. The bony
structures are unchanged. Imaged sinuses and mastoid air cells
are clear.
Small amount of blood is again seen in lateral ventricles. A
small focus of hemorrhage is also again noted in septum
pellucidum.
IMPRESSION: Continued appearance of right cerebral convexity
subdural hematoma. No new findings.
CT HEAD W/O CONTRAST [**2149-2-3**] 1:08 AM
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again identified is a high attenuation extra-axial
subdural hematoma layering over the right frontotemporal and
parietal cerebral convexities. It is similar in size to the
prior study and exerts mild mass effect exerted on the adjacent
lateral ventricle. No new areas of hemorrhage are identified.
The degree of subfalcine herniation has decreased over the
interval. The bony structures are unchanged. Imaged paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: Stable appearance of right cerebral convexity
subdural hematoma with decreasing subfalcine herniation. No
evidence of new hemorrhage.
CT ABDOMEN W/CONTRAST [**2149-2-4**] 1:28 PM
INDICATION: 83-year-old female with recent small-bowel
obstruction and new subdural hematoma. Please evaluate status of
small-bowel obstruction.
COMPARISON: [**2149-2-1**].
TECHNIQUE: Continuous MDCT acquired axial images were obtained
from the lung bases to the pubic symphysis after the
administration of 110 cc Optiray intravenous contrast. Oral
contrast was administered. Multiplanar reformatted images were
obtained and reviewed.
CT OF THE ABDOMEN WITH IV CONTRAST: Minor atelectatic changes
are noted at the dependent portions of the lung bases. Coronary
artery and mitral annular calcification is again noted. The
liver enhances homogeneously. Again noted in segment IV of the
liver is an irregular area of slightly lower attenuation than
the surrounding parenchyma, adjacent to the falciform ligament.
This likely represents an area of focal fatty infiltration. The
gallbladder, spleen, pancreas, and right adrenal gland are
within normal limits. Left adrenal myelolipoma is unchanged in
size and appearance from the previous study. Multiple bilateral
renal cysts are again noted, not significantly changed from
previous exam. The kidneys otherwise enhance and excrete
contrast symmetrically. The ureters are normal in appearance,
without evidence of hydronephrosis. The patient is status post
Billroth II, and the gastrojejunostomy anastomosis again appears
unremarkable. Nasogastric tube is seen located within the
stomach. There has been interval resolution of small- bowel
obstruction. No dilated loops of bowel are seen. There is no
evidence of free air, free fluid, or pathologically enlarged
mesenteric or retroperitoneal lymphadenopathy. Extensive
vascular calcifications are again noted within the abdominal
aorta and its branches.
CT OF THE PELVIS WITH IV CONTRAST: The rectum is moderately
distended. Sigmoid diverticulosis is again noted, without
evidence of diverticulitis. Uterine fibroids are present, some
of which have calcified. A Foley catheter is present within a
partially decompressed bladder. No free fluid is seen within the
pelvis, and there is no evidence of abnormal pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic bony lesions are
identified.
IMPRESSION:
1. Interval resolution of small-bowel obstruction.
2. Unchanged appearance of left adrenal myelolipoma.
3. Unchanged appearance of multiple left renal cysts.
4. Unchanged appearance of fibroid uterus with calcification.
5. Diverticulosis, without evidence of diverticulitis.
6. Unchanged appearance of focal fatty infiltration of segment
IV of the liver.
Brief Hospital Course:
[**Known lastname 5086**] was evaluated in the emergency department at [**Hospital1 18**] on
[**2149-2-1**]. WBC count was elevated at 15.3. Abdominal/Pelvic CT
scan showed a small bowel obstruction with a transition point
involving the distal ileum. Neurology exam noted not focal
deficits. Head CT showed no acute intracranial process.
Baseline chest xray was negative. She was admitted to the
hospital. She was made NPO, IV fluids were started and an NG
tube was inserted for decompression.
At HD 1 she was found on the floor for unwitnessed fall. There
was no change in mental status and no evidence of injury.
Repeat head CT scan showed a right-sided acute subdural hematoma
causing subfalcine herniation. She was transferred to SICU for
further monitoring. Dilantin was started.
At HD 2 the patient was stable and doing well. NGT output was
low at 200ml over 24 hours. KUB showed no sign of obstruction.
Repeat head CT showed stable appearance of right cerebral
convexity subdural hematoma with decreasing subfalcine
herniation, with no evidence of new hemorrhage. EEG showed no
seizure activity.
At HD 3 she was afebrile. WBC count was 12.8. She remained NPO
with IV fluids while we awaited bowel function. Repeat
abdominal/pelvic CT showed resolution of the bowel obstruction.
At HD 4 she had return of bowel function. Her diet was advanced
to sips. Dilantin was continued. Neurology/Neurosurgery
continued to follow.
At HD 5 she was discharged to [**Hospital **] Health Care in good
condition. At discharge her dilantin level was 11.6. She was
to continue Dilantin for 4 weeks until follow up in [**Hospital 4695**]
clinic with Dr. [**Last Name (STitle) 548**]. She was to restart her Plavix and ASA
tomorrow. She has an appointment with Dr. [**Last Name (STitle) **] on [**2149-2-25**].
She has a repeat head CT scheduled on [**2149-3-12**] and an
appointment with Dr. [**Last Name (STitle) 548**] after the scan.
Medications on Admission:
Lopressor 50 [**Hospital1 **]
Glucotrol XL 5 [**Hospital1 **]
Cozar 50 QD
Vytorin 10/40 QD
Plavix 75
Nitro 0.3 PRN
ASA 81
Cosopt
Xalatan
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
4 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 4 weeks.
Disp:*84 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO BID (2 times a day).
7. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
1) subdural hematoma
2) abdominal pain
Discharge Condition:
Stable
Discharge Instructions:
return to ER if
- persistent temp > 101.4
- severe abdominal pain or pelvic pain
- persistent nausea, vomiting, or diarrhea
Completed by:[**2149-2-6**]
|
[
"414.01",
"272.0",
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"401.9",
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"276.51",
"V45.82",
"V12.59",
"E849.7",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13382, 13471
|
10374, 12318
|
272, 278
|
13554, 13563
|
1236, 6212
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867, 1050
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12344, 12482
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13587, 13741
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1065, 1217
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184, 234
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306, 579
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6221, 10351
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601, 714
|
730, 851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,846
| 122,715
|
3083
|
Discharge summary
|
report
|
Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-11**]
Date of Birth: [**2100-7-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
- Upper endoscopy [**2137-7-5**]
- Right heart catheterization [**2137-7-8**]
- Left heart catheterization [**2137-7-8**]
History of Present Illness:
Mr. [**Known lastname 14637**] is a 36 M with a history of HIV not on HAART,
non-ischemic dilated cardiomyopathy with EF of [**10-17**]%, and
chronic transaminitis who presents with worsening dyspnea on
exertion. He states that since his last hospitalization
(discharged [**2137-6-18**]), he has been taking his medications as
prescribed. However, while he has felt occasionally well for
days at a time, every 3-4 days he has a "bad" day where he feels
very ill, though the nature of symptoms on bad days has varied.
On this occasion, he began feeling poorly on Saturday, when he
had decreased energy and also developed non-productive cough. He
is not aware of having had fever at home, and no chills. He
noted worsening DOE over this time interval as well, though he
is now fairly limited at baseline in terms of what he is able to
tolerate in the way of activity (has had to scale back his
dog-walking business). He was out with his dogs today when one
ran away, and he was forced to [**Male First Name (un) **] it. When he caught up with
the dog, he was nauseous and vomited x 1. He also felt extemely
weak and SOB. As he had also noticed that his weight has
increased by 3.5 lbs since Friday, he called Dr. [**Last Name (STitle) **] who
instructed him to come into the ED for evaluation.
.
In the ED, initial vitals were T 100.3, HR 129, BP 100/80, RR
18, 100% on RA . He was given mg IV furosemide given his history
of heart failure. D-dimer returned positive, so CTA was done but
negative for PE. Abdominal CT and CXR did not reveal acute
pathology. He received morphine for pain control (atypical chest
pain, abdominal pain). During his time in the ED, he was
tachycardic to 100s-130s and tachypneic to 40s. He was evaluated
by the cardiology fellow and started on nitro gtt before
transfer to the CCU. At the time of transfer, vitals were T
97.4, HR 121, BP 95/78, RR 42, SaO2 100% 3L NC.
.
On arrival to the floor, he remains dyspneic and also nauseous,
though says his breathing is slightly better than on
presentation. He has continued chest/abdominal pain which was
slightly improved by morphine in the ED.
.
On review of systems, he endorses chest pani (chronic/constant,
"tightness" in center chest) and abdominal pain (worst in the
epigastrum, associated with belching and a sensation of
bloating, feels like "a knot or something hard....like after you
get punched") which is brought on by palpation but not present
at rest. He also reports pain in his right calf since earlier
today. He has had episodes of orthopnea at home, to the point
where a few nights ago he was forced to sleep in a chair because
it was the only way he could feel comfortable. He reports
diarrhea with up to [**6-4**] bowel movements per day, yellowish, no
blood, of varying volumes. He is awakened from sleep by the
diarrhea. 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 though
does get occasional nightsweats. He denies exertional buttock or
calf pain. Cardiac review of systems is notable for absence of
ankle edema, palpitations, syncope or presyncope. All of the
other review of systems were negative.
Past Medical History:
- HIV (diagnosed [**2122**], CD4: 627, VL: 2,880 copies/ml in [**4-/2137**];
initially on HAART but stopped several years ago when insurance
ran out)
- Non-ischemic dilated cardiomyopathy with EF of [**10-17**]%
(etiology unknown, but felt secondary to HIV vs. crystal meth
abuse)
- Chronic transaminitis (HCV vs. congestive hepatopathy)
- Hepatitis C virus positive
- Depression
- HPV
Social History:
Social History: Lives alone, MSM with 1 male partner.
[**Name (NI) 1403**] as dog walker.
Tobacco: Denies ever using tobacco.
EtOH:Denies drinking any ETOH recently, No h/o of abuse, drinks
socially 1-2x/month.
Illicit Drugs: amphetamine and IV crystal meth user, denies
since discharge ([**2137-5-9**]). No cocaine or heroin.
Family History:
- Mother and many relatives of mother: Diabetes
- Father: CVA
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T=97.6 BP=97/70 HR=118 RR=24 O2 sat=100% on 2L
GENERAL: Thin young man tachypneic at rest, worse with speech,
appearing uncomfortable. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to just above clavicle
CARDIAC: PMI displaced, distant S1/S2, +2/6 systolic murmur over
the LLSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were rapid and shallow. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, TTP over epigastrum, no rebound/guarding. Belly
firm but not tense. Hepatosplenomegaly. No abdominal bruits.
EXTREMITIES: No c/c/e. TTP of posterior left calf, though no
erythema or enlargement.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Initially dry, but later markedly diaphoretic on repeat exam
PULSES: 2+ DP pulses
.
On Discharge:
Tmax: 37.4 ??????C (99.4 ??????F)
Tcurrent: 37.2 ??????C (98.9 ??????F)
HR: 99 (99 - 131) bpm
BP: 100/58(68) {88/44(55) - 110/80(85)} mmHg
RR: 25 (16 - 35) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 71.6 kg (admission): 79 kg
Height: 70 Inch
JVP: 8 cm H2O
Lungs: trace crackles at bases bilaterally, fair air movement
Cardiac: Tachycardic, RR, summation gallop, no murmur heard
today
Abdomen: hepatosplenomegaly, reduced fluid wave compared to
previous exams
Extremities: warm and well perfused, 1+ DP/PT with no edema
bilaterally
Left calf non-tender to palpation with reduced erythema compared
to previous exams. No cords felt.
Groin and right radial site: clean/ dry/ intact
Pertinent Results:
Basic Admission Labs:
[**2137-7-2**] 06:55PM BLOOD WBC-8.1 RBC-5.27 Hgb-13.6* Hct-41.9
MCV-80* MCH-25.9* MCHC-32.5 RDW-16.9* Plt Ct-298
[**2137-7-2**] 06:55PM BLOOD PT-19.5* PTT-28.1 INR(PT)-1.8*
[**2137-7-2**] 06:55PM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-126*
K-4.7 Cl-97 HCO3-14* AnGap-20
[**2137-7-2**] 06:55PM BLOOD ALT-623* AST-588* AlkPhos-103
[**2137-7-2**] 06:55PM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
.
Other Significant Labs:
[**2137-7-6**] 05:40PM BLOOD UreaN-47* Creat-1.8* Na-118* K-6.7*
Cl-90* HCO3-16* AnGap-19
[**2137-7-2**] 06:55PM BLOOD proBNP-8715*
[**2137-7-2**] 07:50PM BLOOD D-Dimer-7827*
[**2137-7-2**] 06:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-7-2**] 11:22PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
[**2137-7-2**] 11:22PM URINE AMPHETAMINES, GC/MS-Positive
[**2137-7-3**] 04:06AM BLOOD TSH-2.1
[**2137-7-6**] 09:20PM BLOOD Cortsol-15.7
Discharge labs:
[**2137-7-11**] 05:53AM BLOOD WBC-7.6 RBC-5.28 Hgb-13.7* Hct-42.1
MCV-80* MCH-26.0* MCHC-32.6 RDW-16.7* Plt Ct-302
[**2137-7-11**] 05:53AM BLOOD PT-13.5* PTT-29.5 INR(PT)-1.1
[**2137-7-11**] 09:01AM BLOOD Na-134 K-4.5 Cl-97
[**2137-7-11**] 05:53AM BLOOD Glucose-95 UreaN-16 Creat-1.1 Na-130*
K-6.0* Cl-93* HCO3-29 AnGap-14
[**2137-7-11**] 09:01AM BLOOD ALT-138* AST-70* LD(LDH)-330* AlkPhos-99
TotBili-1.7*
[**2137-7-11**] 09:01AM BLOOD Albumin-3.5
[**2137-7-11**] 05:53AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3
.
Microbiology:
Blood cultures: [**7-2**] x2, [**7-3**], and [**7-4**] x2 all no growth
Urine cultures: [**7-2**] and [**7-4**] both no growth
.
Imaging:
ECG ([**7-2**]): Sinus tachycardia. Non-specific ST-T wave
[**Month/Day (1) 14638**].
.
CXR ([**7-2**]): Marked cardiomegaly, similar compared to the prior
study, without pulmonary edema.
.
CT Chest/Abd/Pelvis ([**7-2**]): 1. No central pulmonary embolism.
Evaluation of the subsegmental pulmonary arterial branches
particularly within the lung bases is limited due to poor bolus
timing secondary to underlying cardiac dysfunction.
2. Marked cardiomegaly with dilated main pulmonary artery
measuring 3.8 cm,
findings suggestive of underlying pulmonary hypertension.
3. Moderate intra-abdominal ascites, similar compared to prior.
4. Stable hyperdense lesion in interpolar region of the left
kidney, possible hemorrhagic cyst, but not completely
characterized on this single phase examination. Further
evaluation with renal ultrasound is recommended
non-emergently.
5. Gallbladder wall thickening likely secondary to cardiac
dysfunction and
third spacing. Correlation with clinical signs and symptoms and
liver
function tests is recommended.
6. Heterogeneous enhancement of the liver compatible with
passive congestion from cardiac dysfunction.
.
LLE U/S ([**7-4**]):
Deep vein thrombosis seen in the left tibial veins extending
into
the popliteal, lesser saphenous and the inferior portion of the
left femoral
vein.
.
Renal U/S ([**7-4**]):
IMPRESSION:
1. Exophytic partially thin-walled mass in the interpolar region
of the left kidney appears stable in size over eight years. Some
through transmission may be present and consequently this may
represent a cyst; however, this cannot be fully characterized
with ultrasound. This structure could be followed for stability
with ultrasound or MRI.
2. Trace of ascites.
3. Incidentally noted, the liver is diffusely echogenic
consistent with fatty infiltration. Other forms of liver disease
and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
.
Upper GI Endoscopy ([**7-5**]):
Congestion and abnormal vascularity in the whole stomach
compatible with Portal gastropathy. Possible small grade I varix
in the gastroesophageal junction
.
Cardiac cath ([**7-11**]):
COMMENTS:
1. Seletive coronary angiography of this right dominant system
demonstrated no angiographically apparent coronary disease.
2. Resting hemodynamic measurements revealed elevated left and
right
sided filling pressures with RVEDP 14mmHg and wedge pressure of
14mmHg.
There was mild pulmonary arterial systolic hypertension with
PASP of 37
mm Hg. The cardiac index prior to milrinone initiation was low
at
1.8mL/min/m2.
3. With a bolus of milrinone (50 mcg/kg) followed by a drip at a
rate of
0.375 mcg/kg the cardiac index improved from 1.8 to 2.3 and the
wedge
pressure improved from 20mm Hg to 15 mmHg.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe systolic ventricular dysfunction.
3. Improvement in ventricular function with milrinone
initiation.
4. Mild pulmonary arterial hypertension
.
Echo Report [**7-9**] (on milrinone drip):
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated. There
is severe global left ventricular hypokinesis (LVEF = 15%). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Markedly dilated left ventricle with severe systolic
dysfunction, c/w noncoronary cardiomyopathy. Dilated and mildly
hypokinetic right ventricle. Mild mitral regurgitation. Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2137-6-15**],
severity of mitral regurgitation has decreased. LV cavity is
slightly larger. The other findings are similar.
Brief Hospital Course:
Pt is a 36yo male with Hep C, HIV not on HAART, dilated
cardiomyopathy of unclear etiology with an EF of [**10-17**]%, and
transaminitis who presented with worsening shortness of breath
likely due acute on chronic heart failure.
.
ACTIVE ISSUES
.
# Dilated Cardiomyopathy: Etiology of pt's cardiomyopathy is
unclear. Possibly related to his HIV status or chronic
amphetamine use. Dr. [**First Name (STitle) 437**] was consulted and he felt a right
heart catheterization would be helpful to better evaluate the
severity and etiology of patient's heart failure. Right heart
catheterization showed no angiographically apparent coronary
disease, but elevated left and right sided filling pressure with
RVEDP 14 mmHg and wedge pressure of 14 mmHg, as well as mild
pulmonary systolic hypertension with PASP of 37 mmHg. A
milrinone drip was started then patient loaded on oral digoxin.
Significant improvement in left ventricular function was noticed
with improvement of cardiac index from 1.8 to 2.3 mL/min/m2 and
wedge pressure from 20 to 15 mmHg.
.
# Acute exacerbation of chronic heart failure: Given his history
of dilated cardiomyopathy (EF 10%), weight gain, and elevated
BNP, patient's acute dyspnea was thought to be secondary to a
CHF exacerbation. Possible triggers include illicit drug use
given patient's positive urine tox (though patient denies) or
medication non-compliance/undermedication. PE also possible
given patient's complaint of pleuritic chest pain and his
asymmetric calf swelling later found to be a DVT. Patient was
aggressively diuresed, initially on a lasix gtt then later on
oral torsemide. Pt was initially started on a nitro gtt as well
to improve pulmonary vascular congestion which was quickly
weaned off. The efficacy of diuresis was significantly
improvement since the initiation of milrinone drip, with the net
fluid balance of negative 9.5 liter in 3 days. His beta-blocker
was held in the setting of his acute exacerbation and an ACE was
held in the setting of his elevated creatinine. Pt was felt to
be stably diuresing on oral torsemide at the time of his leave.
OUTPATIENT ISSUES
- Patient was instructed to take torsemide 20 mg daily
- Patient will need close monitoring of electrolytes, especially
Cr given the newly started diuresis regimen
- On discharge, patient has a dry weight of 71.6 kg . He was
instructed to measure his weight daily.
- Upon discharge, patient taking oral digoxin, torsemide,
lisinopril
.
# Left lower extremity DVT: On presentation patient was
complaining of left calf pain. Ultrasound showed a large DVT
extending into the thigh. Patient was started on heparin gtt for
anticoagulation. Hepatology performed an EGD in this patient to
determine whether pt had any contraindications to
anticoagulation and found only a small grade I varix and signs
of portal gastropathy. They recommended that coumadin therapy be
initiated in this patient with an INR goal of 2.5-3 given
patient's baseline liver dysfunction and elevated INR. Lovenox
bridge was provided while awaiting patient's INR to reach
therapeutical range.
OUTPATIENT ISSUES:
- Started Lovenox 80 mg injection twice daily for blood clots
- Started warfarin 4 mg po qd
- Patient was instructed to start routine INR check through
[**Hospital3 **] at [**Hospital1 18**].
.
# Pleuritic chest pain: Pt intermittently complains of
right-sided chest pain located near the apex and sometimes
traveling to the back of his shoulder. Pain unlikely to be
cardiac in origin given patient's repeatedly negative EKGs.
Though CT PE on admission was negative for PE, the study was
somewhat limited given patient's poor EF and the incorrect
timing of the contrast. However, further studies have thus far
been deferred as patient is currently being appropriately
anticoagulated for his confirmed DVT. Further discussion will
need to occur about whether patient would benefit from an IVC
filter.
.
# Hepatopathy/Transaminitis: Pt has had elevated liver enzymes
for the past several admissions, possibly related to his
recently discovered Hep C viral load or congestive hepatopathy
from his cardiac dysfunction. There are clear signs of portal
hypertension on EGD and other imaging has shown some ascites and
a diffusely echogenic appearance of the liver that cannot rule
out cirrhosis. Patient will likely require an outpatient liver
biopsy to better characterize the extent of his liver disease if
his LFTs do not completely recover with decreased volume load
OUTPATIENT ISSUES
- Patient has an appointment with Dr. [**Last Name (STitle) **] on [**8-16**] for
hepatology follow-up.
- Patient need recheck of LFT prior to the hepatology
appointment
.
# Kidney Cyst: Noted on CT imaging. Found to be stable for the
past eight years on follow-up ultrasound, so likely requires no
further work-up.
.
# Hyponatremia: Patient's sodium has been low early in
admission, likely a hypervolemic hyponatremia given patient's
cardiac and liver disease. In addition to his ongoing diuresis,
patient was started on 1000cc fluid restriction though there is
some question as to his compliance with this. Upon admission to
the CCU with close monitoring of I/O and relaxation of fluid
restriction to 1500 mL/day, Na recovered to 134 on discharge.
.
# [**Last Name (un) 6055**]-[**Doctor Last Name **] Respirations: Pt was noted to have a
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiratory pattern while sleeping and
occasionally while awake as well. Pt might benefit from BiPap or
CPap though he has tolerated this poorly in the past.
Pulmonology was consulted and pt will be set up with a sleep
study as an outpatient.
OUTPATIENT ISSUES
- Sleep studies have been discussed with patient. Patient is
aware that this could be set up through his primary care doctor.
.
# Abdominal Pain: Etiology unclear; possibly there is a
component of GERD given epigastric tenderness, belching.
Possibly relates to transaminitis/hepatic congestion or his
portal gastropathy. Could also be due to pressure secondary to
ascites.
.
# Acute Kidney Injury: Patient's creatinine has been elevated
throughout this admission. Appears to be pre-renal based on his
urine lytes so likely due to poor forward flow. His creatinine
was much improved since the initiation of milrinone drip. Upon
his leave of hospital, his serum creatinine returned to 1.1.
.
CHRONIC ISSUES
.
# HIV: Off of HAART, though last CD4/VL showed reasonable
control. Patient need follow-up with ID as an outpatient to
better follow his disease progression.
.
# Substance Abuse: Patient denies recent methamphtamine use but
his urine tox screen is confirmed positive for amphetamines by
GC/MS. [**Name13 (STitle) **] social work, patient is hesitant to seek treatment
for his addiction and becomes defensive when asked about his
drug use.
.
TRANSITIONAL ISSUES
.
# Patient left AMA due to difficulty with his business/ dogs
living at his house and not having anyone to help feed/ clean
the dogs. We attempted to have Social Work help with the issue
with the dogs, but patient refused.
# Please contact [**Name (NI) **] [**Name (NI) 805**]/ social work team early if patient
re-admitted.
# Patient expressed to social work a frustration with what he
views as poor communication on the part of the medical staff.
Special attempts should be made to make sure patient is always
informed and updated about his plan, including minute details
about test results and medication changes.
# Patient has cardiology followup with Dr. [**Last Name (STitle) **] on [**7-25**]
for furhter evaluation of his congestive heart failure. Patient
on 2.5mg lisinopril, could not tolerate 5mg previously, although
up titration could be considered.
# Patient will also follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and diuresis
clinic for weight and possible Lasix IV (patient weighed 71.6 kg
at discharge).
# Patient has infectious followup with Dr. [**Last Name (STitle) 6137**] on [**8-7**] for further evaluation of his HIV and hepatitis C and
possibly starting antiretroviral therapy as we believe that his
cardiomyopathy is more likely infectious in etiology than due to
his IVDA.
# Patient has hepatology followup with Dr. [**Last Name (STitle) **] on [**8-16**] for
further evaluation of his transaminitis and hepatitis C.
# Patient has a scheduled followup with his primary care doctor
Dr. [**First Name (STitle) 3535**] at [**Hospital3 **] at [**Hospital1 18**] on [**7-17**] and [**9-6**] for
to weight the patient and check electrolites/ renal function/
Liver function since patient started digoxin, torsemide,
lisinopril and we would like LFTs prior to his Liver
appointment. His sleep studies shall be arranged through Dr.
[**First Name (STitle) 3535**]. Patient should have aggressive electrolyte monitoring.
Medications on Admission:
- Metoprolol succinate 25 mg PO daily
- Furosemide 10 mg PO daily
- Spironolactone 12.5 mg PO daily
- Ambien PRN
- Tylenol PM PRN
Discharge Medications:
1. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
2. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*14 syringe* Refills:*2*
6. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Systolic heart failure (ejection fraction 15%)
- Deep vein thrombosis
- Portal gastropathy
- Congestive hepatopathy
- Acute renal failure
- Hyponatremia
SECONDARY:
- Amphetamine abuse
Discharge Condition:
Stable although high likelyhood of re-admission as patient
leaving AMA and not fully diuresed. Patient still with
summation gallop upon discharge, as well as mild crackles at
bases. Blood chemistries/ liver function tests improving but
not at baseline.
Discharge Instructions:
Dear Mr. [**Known lastname 14637**],
You were admitted with shortness of breath that was most likely
due to your heart failure and extra fluid in your system. You
were treated with medications to help remove fluid with
significant improvement in your symptoms. While you were here,
you were also found to have blood clots in your left leg and
were started on blood thinning medications. You had an EGD
study to evaluate your abdominal pain and for dilated veins in
the esophagus, and you were found to have irritation of the
stomach likely related to liver dysfunction from your heart
failure (veins in the esophagus were near-normal). You were
noted to have periods of apnea (stopped breathing) while you
were sleeping, and you were seen by the pulmonary team who
recommend an outpatient sleep study.
Your shortness of breath and chronic chest and abdominal pain is
likely all related to your heart failure and the buildup of
fluid in your system. Therefore, it is VERY IMPORTANT that you
take your medications as prescribed, keep all of your doctors
[**Name5 (PTitle) 4314**], and monitor your fluid intake. You should weigh
yourself at home every morning and call Dr.[**Name (NI) 14643**] office if
your weight increases by more than 3 lbs (weigh yourself as soon
as you get home for a baseline on your home scale). You should
monitor your fluid intake (beverages and liquid foods) and try
to limit yourself to 1500 ml (1.5L) of fluid daily. Finally, it
is VERY IMPORTANT that you stop using crystal meth or other
amphetamines, as these may be the cause of your heart failure
and can worsen your condition. You did not want further
information about support for quitting during this admission,
but if you change your mind please speak to Dr. [**First Name (STitle) 3535**] or one of
your other physicians as there are many resources available to
assist you with staying clean.
As you know, it was our recommendation that you remain in the
hospital for further medical care. You have elected to be
discharged against medical advice. Please call Dr. [**Last Name (STitle) **] or
Dr. [**First Name (STitle) 3535**] if you experience a recurrence of symptoms right away,
as this may help to keep you out of the hospital.
We have made the following changes to your medication regimen:
- BEGIN TAKING Lovenox 80 mg injection twice daily for blood
clots
- BEGIN TAKING warfarin 4 mg by mouth daily for blood clots
- BEGIN TAKING lisinopril 2.5 mg by mouth daily for your heart
failure
- BEGIN TAKING digoxin 0.125 mg by mouth daily for your heart
failure
- BEGIN TAKING torsemide 40 mg by mouth daily for your heart
failure (this is a diuretic to help decrease fluid)
- BEGIN TAKING omeprazole 20 mg by mouth daily for your stomach
pain
- STOP TAKING furosemide (this will be replaced by torsemide)
Followup Instructions:
1. PRIMARY CARE
Department: [**Hospital3 249**]
When: WEDNESDAY [**2137-7-17**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*You need to call your insurance to list Dr. [**First Name (STitle) 3535**] as your PCP
before this appointment.
*You will need to have your electrolytes checked at this
appointment.
2. CARDIOLOGY
Department: CARDIAC SERVICES
When: THURSDAY [**2137-7-25**] at 10:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
3. [**Hospital **] CLINIC
When: THURSDAY [**2137-7-25**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
4. [**Hospital3 **]
Through [**Hospital3 **] at [**Telephone/Fax (1) 250**]. You have already
been contact[**Name (NI) **] regarding follow up blood tests on Monday. Please
arrange to have your INR checked then.
5. INFECTIOUS DISEASE
Department: [**Hospital3 249**]
When: WEDNESDAY [**2137-8-7**] at 12:00 PM
With: [**Last Name (NamePattern5) 14644**], MD, PHD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
6. LIVER
PROVIDER: [**Name10 (NameIs) **],[**Name11 (NameIs) 640**] [**Name Initial (NameIs) **] (LIVER CENTER)
DATE: [**2137-8-16**]
TIME: 08:00a
LOCATION: LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
|
[
"V08",
"428.0",
"416.8",
"428.23",
"584.9",
"572.3",
"453.42",
"276.1",
"786.52",
"537.89",
"070.54",
"276.2",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.54",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
21983, 21989
|
12148, 20932
|
299, 423
|
22229, 22485
|
6353, 6359
|
25334, 27132
|
4507, 4686
|
21112, 21960
|
22010, 22208
|
20958, 21089
|
10783, 12125
|
22509, 25311
|
7322, 10766
|
4701, 4701
|
5629, 6334
|
240, 261
|
451, 3737
|
6375, 7305
|
4715, 5615
|
3759, 4146
|
4178, 4491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,753
| 140,266
|
15846
|
Discharge summary
|
report
|
Admission Date: [**2188-8-25**] Discharge Date: [**2188-9-2**]
Date of Birth: [**2123-3-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cephalosporins / Protamine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
DOE/angina
Major Surgical or Invasive Procedure:
AVR ([**Street Address(2) 6158**]. [**Male First Name (un) 923**] Epic porcine) / cabg x3 (LIMA to LAD, SVG to
DIAG, SVG to OM) [**2188-8-25**]
History of Present Illness:
65 yo male with longstanding hx of murmur. Echo in [**6-8**] showed
moderate to severe AS which has progressed since [**11-7**]. He was
originally noted to have only AS, and the severity of it was
noted just prior to undergoing planned robotic CABG at [**Hospital1 2177**].
Presents for AVR/CABG.
Past Medical History:
CAD/AS
prior RF ablation for right kidney mass
hyperlipidemia
HTN
CRI ( base 3.2-3.7)
IDDM
mild anemia
? hyperparathyroidism
right knee bursitis
? gout
sleep apnea- CPAP
hernia
Social History:
works for US Dept. of Labor
lives with wife in RI
no tobacco since [**2150**]
rare ETOH
Family History:
brother with CABG x4 at age 63
Physical Exam:
6'1" 223#
HR 58 SB RR 18 right 128/60 left 130/62
NAD
skin warm, dry, no c/c large atypical nevus on scalp
NCAT, PERRL, sclera anicteric, OP benign, teeth in fair repair
neck supple, full ROM, no JVD
left carotid bruit; right transmitted murmur vs. bruit
CTAB
RRR, nl S1 S2
soft, NT, ND, + BS, left herniorrhaphy scar
warm, well-perfused, 1+ BLE edema
no varicosities
alert and oriented x3, gait [**Last Name (LF) 4374**], [**First Name3 (LF) 2995**] [**5-5**] strengths
2+ bil fems
Pertinent Results:
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Good LV systolic fxn. There is mild symmetric left ventricular
hypertrophy.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The [**Month/Day (1) 8813**] valve leaflets are severely thickened/deformed. There
is severe [**Month/Day (1) 8813**] valve stenosis (area <0.8cm2). Trace [**Month/Day (1) 8813**]
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Patient is -Paced, on no infusions.
Normal biventricular systolic fxn.
Trace MR.
[**First Name (Titles) 6**] [**Last Name (Titles) 8813**] valve prosthesis is well-seated and functioning. No
leak, no AI.
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) **] [**2188-8-25**] 12:30
[**Known lastname **],[**Known firstname 177**] [**Medical Record Number 45551**] M 65 [**2123-3-25**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-8-25**]
10:29 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2188-8-25**] SCHED
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN [**Name Initial (PRE) 7417**] # [**Clip Number (Radiology) 45552**]
Reason: tamponade
[**Hospital 93**] MEDICAL CONDITION:
65 year old man s/p CABG
REASON FOR THIS EXAMINATION:
tamponade
Final Report
AP CHEST 10:40 P.M. ON [**8-25**]:
HISTORY: Status post CABG.
IMPRESSION: AP chest compared to [**8-25**] at 12:15 and 1:48
p.m.
Edema is cleared from the left lung, left lower lobe atelectasis
has worsened
appreciably and there is new atelectasis at the right lung base.
Cardiomediastinal silhouette has a normal postoperative caliber,
decreased
since earlier in the day. Pneumomediastinum is now evident but
not clinically
significant. Tip of the ET tube above the upper margin of the
clavicles, 6 cm
above the carina and 2 cm above optimal placement. Tip of the
Swan-Ganz
catheter projects over the region of the pulmonic valve.
Nasogastric tube
passes into the stomach and out of view. Midline drains still in
place.
Findings discussed by telephone with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38136**] at the time
of dictation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2188-8-26**] 12:35 PM
Imaging Lab
?????? [**2183**] CareGroup IS. All rights reserved.
[**2188-8-29**] 02:54AM BLOOD WBC-8.7 RBC-2.81* Hgb-8.8* Hct-24.7*
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.6 Plt Ct-166
[**2188-8-25**] 10:06PM BLOOD PT-13.4 PTT-31.9 INR(PT)-1.2*
[**2188-8-29**] 02:54AM BLOOD Glucose-127* UreaN-92* Creat-4.8* Na-135
K-4.2 Cl-101 HCO3-26 AnGap-12
[**2188-8-26**] 03:03AM BLOOD Glucose-133* UreaN-80* Creat-3.6* Na-140
K-6.1* Cl-112* HCO3-20* AnGap-14
[**2188-8-25**] 12:16PM BLOOD WBC-12.9*# RBC-2.90*# Hgb-9.0* Hct-25.8*#
MCV-89 MCH-30.9 MCHC-34.7 RDW-13.0 Plt Ct-230
Brief Hospital Course:
Admitted [**8-25**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred
to the CVICu in stable condition on amiodarone, insulin and
propofol drips. Extubated on POD #1. [**Last Name (un) **] consult done due to
protamine reaction. Recommended lantus and humalog SS. Renal
also consulted due to CKD and rising creatinine.Chest tubes
removed on POD #2. Renal diet also started. Amiodarone restarted
for AFib, and converted to SR. Low dose beta blcoakde titrated.
Transferred to the floor on POD #4 to begin increasing his
activity level. The remainder of his postoperative course was
essentially unremarkable.His kidney function improved with good
diuresis and creatnine back to baseline. Glucose levels well
controlled on the new Lantus and Humalog regiment. On POD#8
Mr.[**Known lastname 11679**] was discharged to home with VNA follow up. He was
instructed on all neccessary follow up visits.
Medications on Admission:
ASA 81 mg daily
diovan 160 mg [**Hospital1 **]
hectoral 1 mcg daily
imdur 60 mg daily
lasix 80 mg qAM, 40 mg qPM
SL NTG 0.4 mg prn
novolin N 20 units SQ QHS
novolog 20 units SQ at supper
novolog mix 70/30 16 units qAM
phoslo 667 mg TID with meals
toprol XL 100 mg daily
zocor 80 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 * Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
13. lantus Sig: One (1) 50 Injection once a day: with
breakfast.
Disp:*1 50* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: One (1) based on
glucose level Subcutaneous ACHS for daily doses.
Disp:*qs based on glucose level* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Last Name (un) 45553**] Island
Discharge Diagnosis:
CAD/AS s/p AVR/cabg x3
prior RF ablation for right kidney mass
hyperlipidemia
HTN
CRI ( base 3.2-3.7)
IDDM
mild anemia
? hyperparathyroidism
right knee bursitis
? gout
sleep apnea- CPAP
hernia
postop A Fib
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100, redness or drainage
no driving for one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 45554**] in [**1-2**] weeks
see Dr. [**Last Name (STitle) 45555**] in [**2-3**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2188-9-2**]
|
[
"427.31",
"997.5",
"276.7",
"272.4",
"403.90",
"250.40",
"E878.2",
"428.0",
"997.1",
"585.9",
"424.1",
"327.23",
"588.81",
"414.01",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.21",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7917, 7988
|
4945, 5858
|
303, 449
|
8239, 8246
|
1652, 3224
|
8528, 8748
|
1096, 1128
|
6196, 7894
|
3264, 3289
|
8009, 8218
|
5884, 6173
|
8270, 8505
|
1143, 1633
|
253, 265
|
3321, 4922
|
477, 775
|
797, 975
|
991, 1080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,377
| 164,400
|
39101
|
Discharge summary
|
report
|
Admission Date: [**2123-12-13**] Discharge Date: [**2123-12-15**]
Date of Birth: [**2071-5-15**] Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
hypotension, GI bleed
Major Surgical or Invasive Procedure:
PRBC transfusion
History of Present Illness:
Mr. [**Known firstname 1806**] [**Known lastname 86651**] is a 52 year old man with history of
metastatic esophageal adenocarcinoma to the liver s/p esophageal
stenting ([**2123-6-3**]) who presents from oncology clinic with
upper GI bleed and hypotension SBP 80s, admitted to [**Hospital Unit Name 153**] [**12-13**],
transferred to OMED [**12-14**].
.
Patient reports recurrent pattern of nausea, hematemesis and
dark stools during his chemotherapy cycles. He reports these
symptoms restarted less than a week after starting his most
recent cycle. His symptoms and hematocrit are closely monitored
by Dr. [**Last Name (STitle) 3274**] in his outpatient oncology clinic. On [**2123-12-3**]
he started his seventh cycle of EOX. In clinic he received 2
units of pRBC for Hgb 7.9/Hct 24 in anticipation of blood loss
with repeat Hgb 9.8/Hct 29.4. He returned to Dr.[**Name (NI) 3279**]
office on [**2123-12-10**] for follow up and Hct/Hgb remained low
7.7/22.4. At this time he received 3 units of pRBC with
inappropriate bump to 9.0/26.2. He stopped taking his
chemotherapy on [**2123-12-10**] and had his last episode of hematemesis
on the morning of [**2123-12-12**]. He presented to clinic [**12-13**] for
follow up and though feeling much better he was found to have
Hct 24.7 and systolic blood pressures in the 80s. Given concern
for hemodynamic instability he was sent to the ED for further
evaluation.
.
In the ED, initial vs were: T 98.6 P 71 BP 93/54 R 16 O2 sat
100% RA. Patient received pantoprazole continuous drip, zofran 4
mg IV, 1 u pRBC, and 1 L NS. He was transferred to [**Hospital Unit Name 153**] for
concern of ongoing upper GI bleed and hypotension with SBP in
the 90s.
.
In the [**Hospital Unit Name 153**], he denied any dizziness, shortness of breath, or
chest pain. He had not had any hematemesis or bowel movements in
over 24 hours. The patient denied significant concern about
these symptoms as he had similar GI symptoms with his prior
cycle of chemotherapy which resolved with ending the
chemotherapy cycle. He was transfused 2 units blood and 1 unit
plts, and Hct was stable prior to transfer to floor. CT showed
stent embedded in stomach.
.
He denies use of alcohol, NSAIDS, antiplatelet therapy or
anticoagulation. He reports good compliance to current regimen
of prilosec [**Hospital1 **], Tagamet (cimetidine), and occasional antacid.
.
He currently reports no complaints. Denies pain and nausea.
Eager to eat "normal" food for dinner. Has not had a BM since
admitted. currently refusing EGD but willing to discuss further
in AM
Past Medical History:
- Metastatic esophogeal cancer to the liver, tissue diagnosis
[**6-4**] Poorly-differentiated carcinoma with neuroendocrine
differentiation
- s/p esophagogastroduodenoscopy with esophageal stent
placement [**2123-6-3**]
- chemotherapy, s/p cycle 7 of EOX (q21d): epirubicin,
oxaliplatin and xeloda d1-14
- History of torn R ACL- not repaired
- left leg > right leg varicose veins which is chronic since
remote skiing accident
- history of RUE DVT in the setting of PICC line ([**6-/2123**])
- osteoarthritis
Social History:
- technology officer to guide engineers, now on long term
disability
- Tobacco: None
- Alcohol: None (socially, none since [**5-/2123**])
- Illicits: None
Family History:
- "everyone lives to the 90s"
- denies cancer, heart disease, diabetes, clotting or bleeding
diseases
Physical Exam:
Vitals: 97.6 602 98/56-102/55 16 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, decreased bowel sounds, no rebound
tenderness or guarding, + epigastric pain with deep palpation.
GU: no foley
Ext: warm, well perfused, no cyanosis or edema.
Skin: multiple scattered excoriation throughout the body, dry
skin
Pertinent Results:
[**2123-12-13**] 11:20PM HCT-23.9*
[**2123-12-13**] 11:20PM PLT COUNT-96*
[**2123-12-13**] 07:49PM GLUCOSE-88 UREA N-8 CREAT-0.5 SODIUM-130*
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-8
[**2123-12-13**] 07:49PM CALCIUM-7.8* PHOSPHATE-3.8 MAGNESIUM-1.8
[**2123-12-13**] 07:49PM WBC-3.7* RBC-2.70* HGB-8.5* HCT-25.3* MCV-94
MCH-31.4 MCHC-33.5 RDW-17.0*
[**2123-12-13**] 07:49PM PLT COUNT-72*
[**2123-12-13**] 10:30AM UREA N-9 CREAT-0.6 SODIUM-129* POTASSIUM-4.0
CHLORIDE-96 TOTAL CO2-29 ANION GAP-8
[**2123-12-13**] 10:30AM estGFR-Using this
[**2123-12-13**] 10:30AM ALT(SGPT)-30 AST(SGOT)-52* ALK PHOS-239* TOT
BILI-0.5
[**2123-12-13**] 10:30AM CALCIUM-8.4
[**2123-12-13**] 10:30AM PT-12.5 PTT-29.5 INR(PT)-1.1
[**2123-12-13**] 09:07AM WBC-4.1 RBC-2.60* HGB-8.3* HCT-24.7* MCV-95
MCH-32.1* MCHC-33.8 RDW-17.5*
[**2123-12-13**] 09:07AM PLT SMR-LOW PLT COUNT-85*
[**2123-12-13**] 09:07AM GRAN CT-2930
Brief Hospital Course:
Mr. [**Known firstname 1806**] [**Known lastname 86651**] is a 52 year old man with history of
metastatic esophageal adenocarcinoma to the liver s/p esophageal
stenting ([**2123-6-3**]) who presents from oncology clinic with
upper GI bleed and hypotension SBP 80s, admitted to [**Hospital Unit Name 153**] [**12-13**],
transferred to OMED [**12-14**].
.
# GI Bleeding. Likely bleeding from esophageal adenocarcinoma
post chemo from sloughing vs bleeding from migrated stent. CT
abdomen shows local increase in the size of tumour, in
particular at the proximal aspect of the stent in the esophagus
and posterior mediastinum as well as of the large mass centered
in the stomach. Hcts stable. No further bleeding. Tolerating
diet. Thoracic [**Doctor First Name **] input: currently no surgical intervention.
Patient refusing EGD. F/u with oncology and rad-onc.
.
#Fevers: Spiked to 102 overnight [**Date range (1) 25029**]. [**Month (only) 116**] be related to
underlying malignancy. No leukocytosis. No evidence for
infection. CXR shows no evidence of PNA. Blood and urine cx
pending at discharge.
Medications on Admission:
- CAPECITABINE [XELODA] - (Prescribed by Other Provider) - 500
mg
Tablet - Tablet(s) by mouth 2tablets in am and 3 tablets in pm
Take for ONLY 14 days during each chemotherapy cycle
- CITALOPRAM - 10 mg Tablet - 1 Tablet(s) by mouth once a day
- LORAZEPAM - 0.5 mg Tablet - [**2-6**] Tablet(s) by mouth q 6-8 h prn
as
needed for prn anxiety/nausea
- ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by
mouth
q 8-12 h as needed for nausea/vomiting
- OXYCODONE - 5 mg Tablet - 2 Tablet(s) by mouth q4-6
- OXYCODONE [OXYCONTIN] - 10 mg Tablet Sustained Release 12 hr -
3
Tablet(s) by mouth every twelve (12) hours
- PANTOPRAZOLE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
- ZOLPIDEM - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime prn
- Tagamet almost daily prn
- Mylanta [**Hospital1 **] prn
- dilaudid prn, unclear dosage
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety/insomnia.
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
5. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO twice a day.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Mylanta Oral
9. Dilaudid Oral
10. capecitabine Oral
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed, likely secondary to tumor.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for GI
bleeding and low blood pressure. You were given IV fluids and
your blood pressure improved. You were transfused blood and
your hematocrit remained stable. You decided against having an
endoscopy.
Please continue your home medications.
Followup Instructions:
The following appointments have been made for you:
Department: RADIOLOGY
When: THURSDAY [**2123-12-23**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2123-12-28**] at 9:30 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2123-12-28**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"780.60",
"698.9",
"197.7",
"458.9",
"530.82",
"276.1",
"300.4",
"150.9",
"285.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8120, 8126
|
5270, 6378
|
301, 319
|
8206, 8206
|
4314, 5247
|
8666, 9601
|
3649, 3753
|
7354, 8097
|
8147, 8185
|
6404, 7331
|
8356, 8643
|
3768, 4295
|
240, 263
|
347, 2921
|
8221, 8332
|
2943, 3457
|
3473, 3633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,065
| 182,889
|
44776
|
Discharge summary
|
report
|
Admission Date: [**2197-2-21**] Discharge Date: [**2197-2-24**]
Date of Birth: [**2121-5-21**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
dizziness, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 95808**] is a 75-year-old woman with a history of
hypertension who presents with dizziness, nausea, and confusion.
She was in her USOH until 1 pm this afternoon when she developed
sudden-onset dizziness and nausea. The dizziness she has trouble
describing, but it was not lightheadedness, not room-spinning,
and not trouble walking straight. She does note that she was
watching TV and at the same time noticed that she could suddenly
not see the right side of the TV - or anything else on the
right,
for that matter. She lay down for two hours and awoke at 3 pm.
She felt better, in that her dizziness and nausea had resolved,
but she still had a headache and her vision was blurry. She
tried
to call her friend [**Name (NI) **], but could not remember her phone number.
She did manage to call her daughter (whose number was
pre-programmed in her phone), and her daughter found her to be
confused: she couldn't remember her last name, or her date of
birth, or her doctor's name. Her daughter came over to her house
at 7:15 pm and thought she looked quite pale and was still
confused. She took her to [**Hospital1 **] [**Location (un) 620**].
There, her initial blood pressure was 208/134. She was started
on
a labetalol gtt and she showed some improvement in her confusion
according to her daughter. A non-contrast head CT showed
hypodensity in the left occipital lobe in the distribution of
the
left PCA. She was transported to [**Hospital1 18**]. Here, her initial blood
pressure was 174/87, still on the labetalol gtt.
Ms. [**Known lastname 95808**] still complains of a mild headache, but denies loss
of vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech. Denied focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denied difficulty with gait.
On review of systems, she denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied cough,
shortness of breath. 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. Denied rash.
Past Medical History:
HTN
Hypercholesterolemia
CAD s/p MI with 2 stents and angioplasty [**2190**]
s/p hysterectomy for fibroids
"borderline" DM
Social History:
Denies tobacco, alcohol, and illicit drug use. Lives
in [**Location 745**], retired bookkeeper.
Family History:
Mother died at 61 of an MI. Diabetes in MGM. Father
with COPD and died at 83 with septicemia.
Physical Exam:
Physical Exam:
Vitals: T: 98.1 P: 72 R: 18 BP: 154/50 (on labetalol gtt) SaO2:
99%3L
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (not to date - [**2173-2-20**]).
Able to relate history without much difficulty. Attentive, able
to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent
with
intact repetition and generally intact comprehension though she
requires frequent clarification of requests, which her children
say is not normal. Normal prosody. There were no paraphasic
errors. She was able to name high frequency objects but had
trouble with low frequency. She could not read, nor even name
letters, though she said she knew what they were. Writing was
intact. Speech was not dysarthric. Able to follow both midline
and appendicular commands. She was able to register 3 objects
and
recall [**3-13**] at 5 minutes. She had neglect of the right side when
asked to bisect lines: she did get lines on the right of
midline,
but missed the lines on the farthest right, and she also
intersected the left-sided lines well to the left of the center
of the line. She also neglected the right side of the
cookie-theft picture. She had evidence of apraxia when asked to
demonstrate slicing bread and hammering nails (she made
appropriate motions with her right hand for slicing and
hammering, but didn't use the left to hold the bread or the
nail). She had poor visuospatial (figure copying) skills. She
had
finger agnosia (could not show second or pointer finger or 5th
or
pinky fingers on either hand, but did get left thumb correct).
She had dyscalculia (5 quarters in $2.25). She was easily able
to
learn go/no go. No right-left confusion. Anosognosic.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 3mm and brisk. Right homonymous hemianopia.
Funduscopic exam revealed no papilledema or hemorrhages, but
fundi were not well visualized due to patient incooperation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right NLF flattening and droop.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue appears to protrude to the right, but I believe this
is midline when corrected for the facial droop.
-Motor: Normal bulk throughout. Increased tone in left LE. No
pronator drift bilaterally. No adventitious movements noted. No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, short stride and arm
swing.
Romberg absent.
Pertinent Results:
[**2197-2-21**] 10:22AM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-182
CK(CPK)-103 ALK PHOS-80 AMYLASE-53 TOT BILI-0.8
[**2197-2-21**] 10:22AM LIPASE-28
[**2197-2-21**] 10:22AM CK-MB-4 cTropnT-<0.01
[**2197-2-21**] 10:22AM ALBUMIN-4.0 CHOLEST-252*
[**2197-2-21**] 10:22AM TRIGLYCER-181* HDL CHOL-55 CHOL/HDL-4.6
LDL(CALC)-161*
[**2197-2-21**] 10:22AM TSH-1.3
[**2197-2-21**] 10:22AM CRP-7.3*
[**2197-2-21**] 05:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2197-2-21**] 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2197-2-21**] 03:57AM GLUCOSE-197* UREA N-16 CREAT-0.9 SODIUM-134
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2197-2-21**] 03:57AM CK-MB-NotDone cTropnT-<0.01
[**2197-2-21**] 03:57AM CK(CPK)-97
[**2197-2-21**] 03:57AM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.9
CHOLEST-240*
[**2197-2-21**] 03:57AM %HbA1c-6.9*
[**2197-2-21**] 03:57AM TSH-1.6
[**2197-2-21**] 03:57AM TRIGLYCER-148 HDL CHOL-53 CHOL/HDL-4.5
LDL(CALC)-157*
[**2197-2-21**] 03:57AM CRP-6.7*
[**2197-2-21**] 03:57AM WBC-11.9* RBC-4.01* HGB-11.5* HCT-32.6*
MCV-81* MCH-28.5 MCHC-35.1* RDW-14.1
[**2197-2-21**] 03:57AM PT-12.3 PTT-21.8* INR(PT)-1.0
[**2197-2-21**] 03:57AM SED RATE-25*
[**2197-2-20**] 10:40PM GLUCOSE-256* UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2197-2-20**] 10:40PM CK-MB-5 cTropnT-<0.01
[**2197-2-20**] 10:40PM CK(CPK)-114
[**2197-2-20**] 10:40PM WBC-11.4* RBC-4.77 HGB-13.3 HCT-37.4 MCV-79*
MCH-27.9 MCHC-35.6* RDW-13.8
[**2197-2-20**] 10:40PM NEUTS-88.2* LYMPHS-9.5* MONOS-1.9* EOS-0.2
BASOS-0.2
[**2197-2-20**] 10:40PM PT-11.9 PTT-21.8* INR(PT)-1.0
Brief Hospital Course:
Pt with stable neurologic exam during stay in MICU. Initially,
SBPs brought down to 140-160. After it was determined that she
had a PCA stroke, she was allowed to autoregulate to 180.
MRI/A was performed which demonstrated: [**2-21**]:
IMPRESSION: Acute left PCA infarct. Slightly diminished flow
signal in the left posterior cerebral artery, otherwise normal
MRA of the head.
With PCA infarct, likely cardioembolic origin, echo was
performed which demonstrated:
Echo [**2196-2-22**]: Mild symmetric LVH with preserved regional and
global systolic function. Evidence of elevated LV filling
pressures. No ASD by color Doppler or bubble study. Moderate
pulmonary hypertension. Mild aortic stenosis. Compared with the
report of the prior study (images unavailable for review) of
[**2190-9-15**], LV function now appears normal. The severity of mitral
regurgitation is reduced. Estimated PA pressures are elevated.
Mild aortic stenosis is now present.
Labs with elevated FLP, elevated A1c. pt was contined on RISS
to maintain euglycemia and statin was started initially at 40mg
QDay and increased to 80 QDay with elevated LDL.
With stable neurologic exam and stable BPs, pt was transferred
to floor for further management.
Physical therapy did not feel that the patient required a
rehabilitation admition.
The patient was put on aggrenox, lipitor, metoprolol and benicar
as a medication regimen at the time of discharge.
Medications on Admission:
Benicar 20 mg daily
Toprol XL 50 mg daily
ASA 81 daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO twice a day: Take one tablet by mouth on
[**1-16**], and [**2-26**]. Take one tablet [**Hospital1 **] thereafter.
Disp:*60 Cap(s)* Refills:*2*
4. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left occipital infarction
Discharge Condition:
Vital signs stable. The patient has a stable right homonymous
hemianopsia. She is also somewhat inattentive.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
Please return to the hospital if you should develop any
concerning symptoms. These include but are not limited to
changes in vision, slurred speech, or a weak limb.
Please do not drive your car until your vision has been
reassessed.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2197-3-27**] 3:00
Please make an appointment to see your primary care doctor in
the next two weeks. [**Last Name (LF) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2197-2-24**]
|
[
"414.01",
"250.00",
"272.0",
"434.11",
"401.0",
"412",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10449, 10507
|
8391, 9820
|
305, 311
|
10577, 10690
|
6627, 8368
|
11079, 11525
|
2887, 2982
|
9926, 10426
|
10528, 10556
|
9846, 9903
|
10714, 11056
|
5146, 6608
|
3012, 3540
|
245, 267
|
339, 2611
|
3555, 5129
|
2633, 2758
|
2774, 2871
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,298
| 169,527
|
36141
|
Discharge summary
|
report
|
Admission Date: [**2162-1-4**] Discharge Date: [**2162-1-8**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Lethargy, altered mental status
Major Surgical or Invasive Procedure:
Upper endoscopy x 2, [**2162-1-4**] and [**2162-1-5**]
History of Present Illness:
[**Age over 90 **] year-old Russian speaking only male with a history of
prostate cancer, ?CAD, and questionable prior MI presenting to
the ED for altered mental status. As patient is Russian
speaking only, history obtained from his son [**Name (NI) **] who
accompanies the patient at the bedside.
Last night the patient was in his usual state of health. This
morning, [**Doctor First Name **] went to check on his father, and he was confused,
with his feet hanging off the bed and not responding
appropriately. Ambulance was called. At that time, the patient
was having difficulty ambulating/staying on his feet. Per
report, by the time he arrived to the ED, he was alert,
oriented, and able to communicate he was at the hospital, but
still per the son was not appropriate saying somewhat confused
statements.
In the ED inital vitals were T 97.2 F, HR 92, BP 120/100, RR 22.
No oxygen saturation was recorded. He had dried blood around
mouth with pale conjunctiva. Patient had NG lavage which showed
dark red blood with clots, and NG tube was placed to
intermittent suction with dark red blood/coffee grounds. He
was stool guiac positive. He received 80 mg IV Protonix as well
as 8mg /hr Protonix drip. CXR initially concerning for possible
free air under the diaphragm, but repeat CXR did not show
evidence of free air. Labs showed anemia with HCT 17.2
(baseline of mid 20's in [**2159**]), WBC 16.5 with 92.8 percent PMN's
and 4.1 percent lymphocytes. Coag panel showed PT: 13.0 PTT:
27.8 INR: 1.2. LFTs were WNL. Lipase at 146. UA had trace
blood and WBC's but otherwise unrevealing. CMP signficant for
ARF with creatinine of 1.8 (baseline 1.0 in [**2159**]). BUN of 133.
Hypernatremic to 147. The patient was bolused with 2 L IV NS,
and was in the midst of having 1 U of PRBC's hanging prior to
transfer. Vitals prior to transfer BP 94/52 HR 91 sinus.
100% RA Afebrile.
On arrival to the ICU, patient is sleeping with NGT in right
nostril. Able to communicate with son, but falls asleep easily.
Denies any pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Prostate cancer, s/p TURP in ~[**2151**], treated intermittently with
hormonal therapy, no treatment for past several years, staging
unknown.
Urinary incontinence
Chronic constipation
Coronary artery disease, ? previous MI per PCP, [**Name10 (NameIs) **] no
supporting evidence and patient denies
COPD
Compression fracture of L-spine
Social History:
Ambulates with walker past 8 years. No smoking/ alcohol/drugs.
Lived with his wife who is 88, but she is currently in hospice
care at [**Hospital 100**] Rehab. Son checks in on patient 2-3x per day via
telephone communciation. Patient used to be chief financial
officer of corporation in [**Location (un) 4551**]. Immigrated to US from [**Location (un) 4551**]
25 years ago. Has history of BCG vaccination. His wife passed
away at the [**Hospital 100**] Rehab on [**2162-1-6**] (patient is currently
unaware, but son will tell him when he thinks it is the right
time).
Family History:
Mother died of heart disease at age of 82. Father died of shock
at age of 52. No history of colon cancer, stomach cancer, liver
disease, pancreatic disease, or bleeding dyscrasias.
Physical Exam:
Admission exam:
BP 94/52 HR 91 sinus. 100% RA Afebrile.
General: Lethargic but in NAD. Very pale.
HEENT: Sclera anicteric, pale conjunctiva. Dry mucous membranes
with dried blood caked around lips. Posterior oropharynx with
dried blood but otherwise cleared. Right lid lag.
Neck: supple, flat neck veins. No LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, crescendo/decrescendo murmur in
aortic region with carotid radiation. No rubs or gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: clear urine with foley in place
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: Lethargic but AOX3. Can follow commands (with Russian
interpretation). MAE. EOMI. PERRLA. Right lid lag.
Symmetric smile. [**5-21**] grip strength. [**5-21**] plantar flexion, [**4-21**]
dorsiflexion of feet. 1+ bilaterall patellar reflexes,
symmetric.
Discharge exam:
VS: T 96.0, BP 110/58, HR 58, RR 18, O2 97% on room air
PAIN: none
GEN: NAD
CV: RRR
CHEST: CTAB
ABD: Soft, nontender, nondistended, normal bowel sounds
NEURO: Alert, conversive, ambulates with walker and assistance
PSYCH: Calm, appropriate
Pertinent Results:
Admission labs:
[**2162-1-4**] 10:00AM BLOOD WBC-16.5*# RBC-1.69*# Hgb-5.6*#
Hct-17.2*# MCV-102*# MCH-33.3* MCHC-32.7 RDW-17.1* Plt Ct-261
[**2162-1-4**] 10:00AM BLOOD Neuts-92.8* Lymphs-4.1* Monos-2.9 Eos-0.1
Baso-0.1
[**2162-1-4**] 12:47PM BLOOD PT-13.0* PTT-27.8 INR(PT)-1.2*
[**2162-1-4**] 10:00AM BLOOD Glucose-142* UreaN-133* Creat-1.8*
Na-147* K-4.1 Cl-114* HCO3-22 AnGap-15
[**2162-1-4**] 10:00AM BLOOD ALT-14 AST-18 AlkPhos-56 TotBili-0.4
[**2162-1-4**] 10:00AM BLOOD Lipase-146*
[**2162-1-4**] 04:11PM BLOOD Calcium-7.9* Phos-3.4 Mg-2.2
[**2162-1-4**] 10:00AM BLOOD VitB12-1051* Folate-14.8
Discharge labs:
[**2162-1-8**] 06:35AM BLOOD WBC-7.0 RBC-2.45* Hgb-8.2* Hct-24.2*
MCV-99* MCH-33.5* MCHC-33.9 RDW-18.5* Plt Ct-159
[**2162-1-8**] 06:35AM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-143
K-3.4 Cl-111* HCO3-28 AnGap-7*
Imaging:
CXR [**1-4**]
IMPRESSION: Curvilinear opacity in the right lung base, most
likely
represents an area of plate-like atelectasis and less likely
subdiaphragmatic free air within diaphragmatic eventration;
either way, attention on abdominal exam is recommended, and if
clinical concern for surgical abdomen exists, abdominal CT may
be considered. These findings were discussed with, [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **],
at 10:36 a.m. on [**2162-1-4**] by [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone.
CXR [**1-4**]:
FINDINGS/ IMPRESSION: There has been interval placement of an
endogastric
tube with the side port projecting over the gastric bubble.
Again is seen a
curvilinear density projecting over the right lower lung with
lucency beneath it, but lung markings are also noted beneath it.
Examination of prior exams shows no diaphragmatic eventration,
and this likely represents an area of atypical atelectasis as
opposed to subdiaphragmatic free air. Otherwise, there has been
no change from prior exam.
EGD [**1-4**]:
Esophagus: Normal esophagus.
Stomach:
Contents: A large amount of old blood and clots were seen in the
stomach fundus which was thick and difficult to suction through
the endoscope. No active bleeding was seen.
Duodenum: No ulcers seen in the duodenal bulb or second portion
of the duodenum.
Impression:
Blood in the stomach
No ulcers seen in the duodenal bulb or second portion of the
duodenum.
Otherwise normal EGD to second part of the duodenum
EGD [**1-5**]:
Esophagus: Normal esophagus.
Stomach:
Contents: Old blood that was seen on prior endoscopy was no
longer seen in the stomach likely due to erythromycin which the
patient received prior to the procedure. Excavated Lesions Two
cratered ulcers with visible vessel and stigmata of recent
bleeding were seen in the cardia of the stomach. Two endoclips
were successfully applied to one ulcer and one endoclip was
applied to the second ulcer in the cardia for the purpose of
hemostasis. 2 cc.of Epinephrine 1/[**Numeric Identifier 961**] was injected into the
base of each ulcer with successful hemostasis.
Duodenum: Normal duodenum.
Impression:
Gastric ulcer (endoclip, injection)
Blood in the stomach
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
[**Age over 90 **] year-old man presents with lethargy and altered mental
status. He was found to be profoundly anemic with HCT 17. He had
evidence of recent upper GI bleed with dried blood around his
oral mucosa and oropharynx. NG tube lavage revealed blood in
stomach. Pt did not have melena, but did have guaiac positive
stools. He was admitted to the ICU and intubated for airway
protection. 4 units of PRBC transfused with HCT going from
17-->28 and stabilizing to 24-25. EGD revealed blood in stomach
and multiple gastric ulcers, but no active bleeding. Two
endoclips were placed and epinephrine was injected into sites
that were suspected to be the source of bleeding. Patient was
extubated without complication. His mental status improved
after treatment including blood transfusion. PPI was given IV
BID in ICU and transitioned to PO once on the floor. Patient
remained alert and with stable hematocrit for several days after
transfer from ICU to the floor. Of note, we received word from
the patient's son that his wife passed away at the [**Hospital 100**] Rehab
on [**2162-1-6**].
PROBLEM LIST:
# Acute blood loss anemia from acute upper GI bleed from gastric
ulcers. Hospital course as described above. No biopsies were
obtained. He should continue pantoprazole 40mg [**Hospital1 **] and see [**Hospital **]
clinic as needed. Repeat HCT should be performed 3 days after
discharge. Discharge day HCT was 24.2.
# Acute kidney injury from pre-renal failure from acute GI
bleed: Admission Cr 1.8. Pt was resuscitated with IV fluids and
PRBC transfusion. Discharge day Cr 0.9.
# Hypernatremia: Presented with sodium of 148. Likely etiology
was dehydration from poor PO intake from altered mental status.
Once patient became alert, he took adequate PO fluids and his Na
downtrended to 143 on the day of discharge.
# Lethargy / altered mental status was secondary to profound
anemia. Resolved after treatment of acute GI bleed and blood
transfusion.
# Systolic murmur: Concerning for aortic stensosis. Consider
echo if patient would ever consider surgical intervention.
CHRONIC ISSUES:
# Chronic constipation: Prn Docusate and Senna
# History of compression fracture of lumbar spine: Calcium and
Vitamin D
# History of Prostate Cancer
TRANSITIONAL ISSUES:
- Repeat hematocrit on [**2162-1-11**] to ensure stability
- Consider echo to assess for cardiac valve disease if patient
would be considered a surgical candidate. If patient is an
unlikely candidate for surgery, this may be deferred.
Medications on Admission:
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 po qday
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) 2 po qday prn
Docusate Sodium 100 mg Tablet Sig: 1-2 Tablets PO BID
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn
Acetaminophen 325 mg 2 tabs po q6hrs prn pain
Vitamin D-3 400 unit Tablet 2 po qday
Calcium Carbonate 500 mg Tablet 1 po tid
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever or pain.
5. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Gastrointestinal bleeding from gastric ulcer
- Gastric ulcer
- Anemia from acute gastrointestinal blood loss
- Acute kidney injury from pre-renal failure, resolved
- Hypernatremia, resolved
SECONDARY DIAGNOSES:
- History of prostate cancer
- Chronic constipation
- Compression fracture of lumbar spine
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 with lethargy from home and found to have
bleeding in your stomach from an ulcer. You were started on
treatment for ulcer with an acid reducing medication. Blood
transfus was provided for very low blood count (hematocrit =
17). After blood transfusion, your blood counts stabilized with
hematocrit between 24-25.
MEDICATION INSTRUCTIONS:
- INCREASE DOSE: Pantoprazole 40 mg twice a day (previously once
a day). This is the acid reducing medication for ulcer
treatment.
Followup Instructions:
You may follow-up with your doctor at the rehabilitation
facility.
|
[
"293.0",
"V10.46",
"788.39",
"496",
"276.8",
"V13.51",
"785.2",
"780.79",
"V49.86",
"584.9",
"285.1",
"564.09",
"531.40",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11965, 12031
|
8497, 9597
|
281, 337
|
12398, 12398
|
5317, 5317
|
13094, 13163
|
3845, 4028
|
11420, 11942
|
12052, 12264
|
11046, 11397
|
12580, 12914
|
5935, 8474
|
4043, 5041
|
12285, 12377
|
5057, 5298
|
10784, 11020
|
2433, 2880
|
210, 243
|
365, 2414
|
5333, 5919
|
9611, 10595
|
12939, 13071
|
12413, 12556
|
10611, 10763
|
2902, 3237
|
3253, 3829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,077
| 133,448
|
8363+55935
|
Discharge summary
|
report+addendum
|
Admission Date: [**2151-8-20**] Discharge Date: [**2151-8-26**]
Date of Birth: [**2126-2-16**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 25-year-old female
with a history of acute rheumatic fever at age 3, status post
mitral valve repair with ring angioplasty in [**2150-1-31**],
who was admitted to the Coronary Care Unit after an episode
of sustained ventricular tachycardia. The patient had acute
rheumatic fever. Per OMR note, this was diagnosed when
admitted in [**2149-12-31**] for a motor vehicle accident.
Underwent repair in [**2151-2-1**] with angioplasty ring.
The patient has had follow-up echocardiograms with 3+ mitral
regurgitation, normal ejection fraction, myxomatous thickened
mitral valve leaflets. Latest echocardiogram was done on
[**2151-8-17**]. The patient is followed by cardiologist and
[**Hospital6 733**] primary care physician, [**Name10 (NameIs) **] an ACE
inhibitor.
The patient reported to the Emergency Room on [**8-20**] with a
3-month episodes of lightheadedness, noticed racing heart.
The patient states the episodes occur during work as house
cleaner, lasted one to two minutes, occurred one to two times
per week. She did have a Holter study on [**2151-2-22**],
showing asymptomatic nonsustained ventricular tachycardia.
On the morning of admission the patient had an episode of
palpitations with lightheadedness while working and was
brought to the Emergency Room. Vital signs were blood
pressure 60/40, heart rate of 160s, pulse of 90s, respiratory
rate of 30. The patient was found to be in monomorphic
ventricular tachycardia, started on a lidocaine drip.
In the Emergency Room the patient complained only of a sore
throat. No chest pain or shortness of breath. No nausea,
vomiting or diarrhea.
PAST MEDICAL HISTORY:
1. Acute rheumatic fever at age 3.
2. Motor vehicle accident in [**2149-12-31**], found to have
mitral regurgitation on admission.
3. Mitral valve repair with ring angioplasty in [**2150-1-31**].
4. Gravida 1 para 1; status post cesarean section in [**2147**].
5. History of positive purified protein derivative. The
patient received BCG in [**Country 4194**] growing up.
6. Echocardiogram in [**2150-11-1**] showing stable mitral
regurgitation, normal ejection fraction.
7. Echocardiogram on [**8-17**] revealed 3+ mitral
regurgitation, normal ejection fraction, mitral valve
leaflets thickened and myxomatous.
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION: Zestril 5 mg p.o. q.d. and oral
contraceptive pills.
SOCIAL HISTORY: Moved from [**Country 4194**] in [**2149**]. Lives with
family in [**Last Name (un) 813**]. Works as a part-time house cleaner. No
tobacco. No alcohol.
FAMILY HISTORY: No history of coronary artery disease.
PHYSICAL EXAMINATION ON ADMISSION: Generally, a pleasant
female in no apparent distress. Vital signs were pulse
of 79, blood pressure 101/63, respiratory rate of 12, pulse
oximetry of 100% on 2 liters nasal cannula. HEENT revealed
pupils were equal, round, and reactive to light and
accommodation. Mild erythema on the back of her throat.
Mucous membranes were moist. Neck had no lymphadenopathy.
No jugular venous pressure was noted. No bruits.
Cardiovascular had a regular rate and rhythm, S1/S2, a [**4-6**]
holosystolic murmur at her left lower sternal border
radiating to her axilla. Lungs were clear bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities showed no edema and no calf tenderness.
Neurologic examination revealed the patient was alert and
oriented times three and mentated well.
LABORATORY ON ADMISSION: She had a white blood cell count
of 7.8, hematocrit of 39.4, platelets of 186. INR of 1.2,
PT of 13.2, PTT of 32.3. Chem-7 showed a sodium of 139, a
potassium of 3.8, a chloride of 104, bicarbonate of 22, BUN
of 19, creatinine of 1.1, glucose of 111.
RADIOLOGY/IMAGING: Electrocardiogram on admission revealed
ventricular tachycardia at 190 beats per minute.
Electrocardiogram after lidocaine drip showed normal sinus
rhythm at a rate of 95, right axis deviation, and frequent
premature ventricular contractions.
HOSPITAL COURSE: In the Emergency Room the patient was
started on a lidocaine drip and converted to normal sinus
rhythm out of ventricular tachycardia. The patient was
transferred to the Coronary Care Unit for further management
and telemetry. The patient was started on sotalol 80 mg p.o.
b.i.d. Zestril was continued at 5 mg p.o. q.d. The patient
was also on telemetry, and there was no prolongation of her
QTc interval while on telemetry.
The patient was transferred to the floor on Far Three on
[**2151-8-21**]. She stated she felt well. She had no chest
pain and no shortness of breath. Her sotalol and lisinopril
were continued until [**8-23**] when it was stopped. The
patient was then studied on electrophysiology on Wednesday,
[**8-25**], and had a successful ablation.
The patient was transferred to the floor, put back on
telemetry, and had no more cardiac events. The patient will
need mitral valve replacement in the future.
Gastrointestinal revealed the patient began tolerating a
regular diet. The patient was empirically started on
Protonix for prophylaxis. This was discontinued after she
had begun eating a regular diet for two days.
Hematology revealed the patient had the diagnosis of a
question of anemia. Throughout her stay, the patient's
hematocrit stayed between 38 to 40 range.
CONDITION AT DISCHARGE: Stable.
DISCHARGE FOLLOWUP: The patient was to follow up as an
outpatient with Cardiology and primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE STATUS: The patient had no change in her code
status. The patient is full code.
DISCHARGE DIAGNOSES:
1. Monomorphic ventricular tachycardia, now status post
ablation by electrophysiology study.
2. Mitral regurgitation (3+); the patient will need surgical
replacement of mitral valve in the future.
MEDICATIONS ON DISCHARGE: The patient was sent home on
lisinopril 5 mg p.o. q.d. and enteric-coated aspirin 81 mg
p.o. q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2151-8-25**] 16:37
T: [**2151-8-28**] 09:54
JOB#: [**Job Number 29575**]
Name: [**Known lastname 5166**], [**Known firstname 5167**] Unit No: [**Numeric Identifier 5168**]
Admission Date: [**2151-8-20**] Discharge Date: [**2151-8-26**]
Date of Birth: [**2126-2-16**] Sex: F
Service:
ADDENDUM:
OUTPATIENT MEDICATIONS: 1) Atenolol 25 mg po q day, 2)
Lisinopril 5.0 mg po q day. It was decided that the patient
did not need to be placed on Sotalol and thus no [**Doctor Last Name **] of
Hearts was necessary.
OU[**Last Name (STitle) 5169**]NT APPOINTMENTS:
1. With primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**9-1**], at
10:30 AM.
2. With cardiothoracic surgeon, Dr. [**Last Name (Prefixes) **], Thursday,
[**9-2**], at 10:30 AM.
3. With primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 80**] [**Last Name (NamePattern1) **], [**9-9**], at
01:30 PM.
Th[**Last Name (STitle) 1293**] is deciding when and whether to have mitral valve
repair which she will need at some point in the future. This
is being coordinated with her cardiologist, Dr. [**First Name (STitle) **] and her
cardiothoracic surgeon, Dr. [**Last Name (Prefixes) **], as well as her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 80**] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**], M.D. [**MD Number(1) 298**]
Dictated By:[**Last Name (NamePattern1) 4776**]
MEDQUIST36
D: [**2151-8-26**] 17:30
T: [**2151-8-31**] 21:48
JOB#: [**Job Number 5170**]
|
[
"427.1",
"394.2",
"V45.89",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
2725, 2786
|
5840, 6040
|
6067, 6703
|
2479, 2533
|
4176, 5490
|
6728, 8053
|
5505, 5514
|
5535, 5819
|
161, 1784
|
3639, 4158
|
1806, 2452
|
2550, 2707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,325
| 198,070
|
42147
|
Discharge summary
|
report
|
Admission Date: [**2178-7-22**] Discharge Date: [**2178-8-4**]
Date of Birth: [**2127-10-30**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Cough, SOB, fever, transferred from OSH for respiratory distress
Major Surgical or Invasive Procedure:
Left Subclavian CVL (at OSH)
Intubation / Extubation
CVL insertion ([**Hospital1 18**])
History of Present Illness:
Ms. [**Known lastname **] is a 50F smoker with ?history of COPD, chronic
headaches on narcotics, fentanyl patch has increased to 75
recently. She also has a history of HLD, ?DM, PVD s/p fem-[**Doctor Last Name **].
She presented to [**Hospital3 7571**]Hospital on [**7-18**] with SOB, fever
and chest pain. She was having 1 week of SOB associated with
non-productive cough, pleuritic chest pain, wheezing,
generalized myalgias and fever/chills. She was treated with nebs
high grade E. coli bactermeia and respiratory failure. On
admission she received a CXR, TTE and a CT. CT was consistent
with diffuse nodular ground glass opacities, small bilateral
effusions([**7-19**]). CTA and LENIs negative. TTE on [**7-18**] showed LVEF
55-60%, mild MVP and mod MR, LAE and mild LV dilation. She was
treated with DuoNeb, Xopenex nebs, Solumedrol 60mg IV Q8hrs and
Dilaudid. 4 out 4 BCx positive for Pan-sensitive E.Coli, she was
treated with various ABx including: Ceftazidime, Levaquin([**7-21**]),
Cipro and Azithromycin. On transfer to [**Hospital1 18**] she was on Levaquin
500mg IV QDay and Azithromycin. Urine and LFTs unremarkable.
[**Date range (1) 45402**] she had increased work of breathing requiring BiPAP,
NRB mask and eventually required intubation for worsening
respiratory acidosis (7.23/55/59 on 5L). She received 2 doses of
Pancuronium for agitation, coughing, dysynchrony, desaturations
and elevating PIPs. She has been having minimal secretions and
tracheal aspirations were negative for organisms. She received
20mg IV Lasix x2 and put out 1.6L.
.
[**7-22**] patient CXR showed developing bilateral fluffy bilateral
infiltrates. She was given 20mg IV Lasix for LE edema, elevatged
BNP and elevated CVP after a Subclavian line was placed. CVP
reduced to 12 after Lasix.
Vitals on transfer from OSH: Afberile, sinus rhythm at 109 bpm.
BPs 110-160s on propofol 100mcg. MAPs 70-80s. Vent settings 400
CMV, PEEP 7.5, RR 25, O2%92%. ABG 7.35/46/86.
.
On the floor, she arrived intubated, on Propofol drip, stable.
Her vent settings were FiO2 60% Vt 400, RR 20, PEEP 8 and her VS
were afebrile, HR 114, BP 168/87, O2%99%, RR mid 20s (breathing
over vent).
.
Review of systems:
Patient is intubated and sedated, unable to attain ROS
Past Medical History:
Past Medical History: (Per OSH records)
- ?COPD
- Chronic HAs on Narcotics
- PVD
- ?DM
- HLD
- HTN
- Anemia (unknown etiology, possible UGIB)
Social History:
Social History: (From OSH recods)
- Tobacco: [**12-7**] PPD
- Alcohol: None
- Illicits: None
Family History:
Family History: (From OSH Records)
- NC
Physical Exam:
On admission to MICU from transfer:
Vitals: Afebrile BP:162/83 P:104 R:20s O2:98% 60%FiO2
General: Intubated, Sedated on Propofol drip. Does not appear in
any acute distress.
HEENT: Dry mucous membranes, dried blood around nares and lips
surrounds ET tube.
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior exam is limiting though she has course rhonchi
throuhgout with evidence of crackles worse at bases bilaterally
and with end expiratory wheezes apically.
CV: Tachycardic, S1 S2 clear and of good quality though heart
exam limited by lound rhonchorous breah sounds.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley in placve draining moderate-large amount of light
urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
Vitals-99.6 (tmax 100.2) 124/68 127 20 96% RA
General-Patient appears well and in NAD
Cardiac-RRR, S1 and S2, no m/r/g
Lung-Diffuse crackles and popping sounds. Improves with cough.
Abdomen-Soft, NT/ND, BSx4
Extremeties-No calf swelling or tenderness
Neuro-A&Ox3, CN II-XII intact, moving all extremeties
Pertinent Results:
Lab Results on Admission
[**2178-7-22**] 04:30PM GLUCOSE-157* UREA N-30* CREAT-1.1 SODIUM-141
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2178-7-22**] 04:30PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-2.2
[**2178-7-22**] 04:30PM WBC-22.2* RBC-3.44* HGB-10.8* HCT-31.4*
MCV-91 MCH-31.5 MCHC-34.5 RDW-14.8
[**2178-7-22**] 04:30PM NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2178-7-22**] 04:30PM PT-13.1 PTT-24.5 INR(PT)-1.1
[**2178-7-22**] 07:20PM TYPE-ART RATES-20/0 TIDAL VOL-400 PEEP-8
O2-60 PO2-148* PCO2-49* PH-7.40 TOTAL CO2-31* BASE XS-4
-ASSIST/CON INTUBATED-INTUBATED
[**2178-7-22**] 06:07PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2178-7-22**] 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
ABGs:
[**2178-7-22**] 07:20PM BLOOD Type-ART Rates-20/0 Tidal V-400 PEEP-8
FiO2-60 pO2-148* pCO2-49* pH-7.40 calTCO2-31* Base XS-4
-ASSIST/CON Intubat-INTUBATED
[**2178-7-23**] 03:26AM BLOOD Temp-37.2 Tidal V-400 FiO2-40 pO2-80*
pCO2-46* pH-7.44 calTCO2-32* Base XS-5
[**2178-7-23**] 02:39AM BLOOD Triglyc-888* HDL-10 CHOL/HD-19.2 (on
Propofol drip)
.
Discharge Labs:
[**2178-8-2**] 06:15AM BLOOD WBC-8.4 RBC-2.61* Hgb-8.1* Hct-23.5*
MCV-90 MCH-31.2 MCHC-34.7 RDW-14.1 Plt Ct-398
[**2178-8-2**] 12:45PM BLOOD Hgb-9.0* Hct-26.6*
[**2178-8-1**] 06:35AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-136
K-3.8 Cl-100 HCO3-26 AnGap-14
===========================================
Imaging:
[**7-22**] CXR:
1. Diffuse parenchymal opacification is in keeping with clinical
diagnosis of ARDS.
2. Endotracheal tube in standard position with tip 5.1 cm above
the carina
[**7-22**] CT Abdomen
1. Diffuse patchy opacities within the lung fields along with
wedge-shaped
infarctions along bilateral lung bases, raise the possibility of
septic
emboli.
2. No evidence of intra-abdominal abscess.
3. Numerous renal and liver cystic lesions of various size seen
in polycystic kidney disease.
[**7-23**] CXR: FINDINGS: In comparison with study of [**7-22**], there has
been some decrease in the still prominent diffuse bilateral
pulmonary opacifications. Monitoring and support devices remain
in good position
[**7-27**] CXR: Previously widespread infiltrative pulmonary
abnormality improved
substantially between [**7-25**] and [**7-27**] has not changed,
raising concern for acute pulmonary embolism or other
abnormality not detectable on
conventional radiographs. There is no consolidation or collapse.
No pleural
effusion or pulmonary edema. Heart size is normal. ET tube and
right internal jugular line are in standard placements and a
nasogastric tube passes below the diaphragm and out of view.
[**7-28**] EEG: Abnormal EEG due to diffuse and prolonged slowing in
the delta range with superimposed alpha rhythm, both anteriorly
and posteriorly. The record is consistent with a diffuse mild to
moderate encephalopathy without evidence of focality or of
increased irritability.
[**7-29**] CXR: Single AP view of the chest shows an ET tube 4.2 cm
above the
carina. An OG tube and IJ line are in standard position. Lung
volumes are
low, however, there is no consolidation or collapse. No pleural
effusion or
pneumothorax. Heart size is normal.
[**7-29**] Echo: The left atrium is normal in size. 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. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
[**7-30**] CXR: As compared to the previous radiograph, the lung
volumes have
slightly increased, potentially reflecting improved ventilation.
The
pre-existing atelectasis at the right lung base is unchanged in
extent. No
interval appearance of new parenchymal opacities. Borderline
size of the
cardiac silhouette, no pleural effusion.
[**7-31**] MRI head: 1. No acute infarction. No evidence of other
intracranial abnormalities on non-contrast MRI.
2. Persistent partial bilateral mastoid air cell opacification.
3. Possible mucus retention cyst in the nasopharynx. If
clinically indicated, this may be further assessed by direct
visualization to exclude other possible etiologies.
========================================
MICROBIOLOGY:
OSH BCx Positive in [**3-9**] bottles for pan-sensitive E.Coli
All BCx negative in house
All UCx negative in house
Sputum Cx negative
Fungal culture preliminary negative
Brief Hospital Course:
HOSPITAL COURSE
50yo F PMHx chronic HA on high dose narcotics who initially
presented to OSH w cough, fevers/chills, found to have Ecoli
bacteremia, with worsening respiratory distress [**1-7**] ARDS
requiring intubation, transferred to [**Hospital1 18**], now status post abx
therapy with improvement in respiratory status and extubation.
# E.Coli sepsis: At OSH, patient with multiple blood cultures
positive for pan-sensitive E.Coli. Treated with azithromycin +
levofloxacin at OSH, transitioned to CTX on transfer given
persistant fevers; source of bacteremia thought to UTI with
concern for seeding of newly identified PCKD. Cultures at [**Hospital1 18**]
remained negative and fever curve / leukocytosis resolved. Plan
for 14d coverage with antibiotics and completed on [**8-4**].
# ARDS - at OSH patient developed increasing hypoxia, with
bilateral infiltrates consistent with ARDS, requiring
intubation. Underlying etiology was thought to be Ecoli sepsis.
She was maintained on ARDSnet ventilation protocol with
treatment of underlying bacteremia. Sedation was complicated by
high narcotic and benzo requirements, thought to be [**1-7**] chronic
narcotic usage; patient's respiratory status improved and she
was successfully extubated on [**7-30**]. On discharge her respiratory
status is stable at ~97-98% on RA.
# Tachycardia: Patient has been tachycardic while on the floor
to ~120. Per PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 71168**], baseline is around 80-90. EKG
shows NSR although patient denies any pain aside from her
chronic HA. The tachycardia does not appear related to
dehydration, as the patient is tolerating adequate PO fluids.
Tachycardia believed to be related to deconditiong in the
setting of severe illness and intubation, with likely underlying
lung disease and bronchodilator medications. Patient was
initially started on metoprolol with good effect, but it was
discontinued as she did not have indication for beta-blockade.
TSH was checked and was normal. Her tachycardia has been
asmptomatic; the patient denies any CP or palpitations. The PCP
was updated verbally regarding the need for close follow-up of
this issue.
#Chronic HAs: Patient with chronic HAs being treated with
Fentanyl Patch 75mcg as an outpatient. Fentanyl patch was
stopped in setting of intubation. Patient was initially
transitioned to methadone with prn ultram after extubation in
ICU. On the floor, she was transitioned to MS contin given her
preference of MS Contin to methadone. She was also restarted on
her home amitriptyline. The patient reports her HA pain is
under control and would like to be d/c on her current regimen.
The patient was provided a short supply of her opiate regimen,
enough to reach her follow up appointment with her PCP.
# Polycystic Kidney Disease: Patient with newly identified PCKD
on admission with CTAP showing multiple cysts in her liver. CTA
of head in setting of intubation did not demonstrate large [**Doctor Last Name **]
aneurysms. Patient with normal renal function at this time.
Will follow up with PCP. [**Name10 (NameIs) **] that source of E. Coli sepsis
may be related to cyst seeeding from a UTI as discussed above.
We suggest considering a renal consultation as an outpatient to
clarify this potential diagnosis.
# Hypertension: Held home lisinopril in setting of acute
illness. Patient is being discharged home without lisinopril as
her blood pressure is normotensive at the time.
#. Smoking cessation-Patient has not smoked x16 days. Doing
well on nicotine patch, without break through cravings. Will
continue as o/p and follow-up with PCP.
# GERD: continued home omeprazole.
Medications on Admission:
Medications: (Per OSH recordS)
- Lisinopril 40mg PO QDay
- Albuterol prn
- Zocor 80mg PO QDay
- Prilosec 20mg PO QDay
- Amitriptylline 100mg PO QDay
- Penicillin- since [**7-17**] 500mg PO TID
- Fentanyl Patch 75
- Tramadol ?2 pills [**Hospital1 **]
Transfer from [**Location (un) **] Valler Meds:
- Azithromycin 500 mg IV (Day 1=[**7-20**])
- Levaquin 500mg IV QDay
- Solumedrol 60mg IV Q6hours
- Combivent 4 puffs QID
- Lopressor 25 mg [**Hospital1 **]
- Colace 100 mg [**Hospital1 **]
- Simvastatin 80 mg QHS
- Omeprazole 20mg PO QDay
- Arixtra 2.5 mg SC
- [**Last Name (un) **]
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
5. tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain: please do not take more than 8
tablets per day.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
7. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO every twelve (12) hours as needed for pain:
Please do not drive or operate heavy machinery while taking
this medication.
Disp:*18 Tablet Extended Release(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*10 Patch* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: acute respiratory distress syndrome
Secondary diagnosis: E. Coli sepsis, polycystic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **], it was a pleasure to take care of you at [**Hospital1 1535**]. You were transferred here from
[**Location (un) **] for management of your E. Coli infection and acute
respiratory distress syndrome. You were intubated because of
acute respiratory distress syndrome and your breathing was
helped by the machines. You were treated with antibiotics, and
were extubated when your respiratory status improved. You were
transferred to regular medicine floor and did well.
Please note the following changes to your medicaiton regimen:
1) STOP taking your lisinopril for now because your blood
pressure was normal at the time of discharge. You may need to
restart this medication at later time.
2) STOP using fentanyl patch
3) START MS contin 15 mg twice daily for your headaches. Please
do not drive while you're taking this medication as it can make
you drowsy.
4) CHANGE Zocor to 40 mg daily at bedtime.
5) START Senna 1 tab twice daily as needed for constipation.
6) START 100mg colace twice daily as needed for constipation.
Followup Instructions:
You have an appointment scheduled with Dr. [**Last Name (STitle) 21160**] your Primary
Care Physician fo [**8-13**] at 12:45pm.
Completed by:[**2178-8-4**]
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81,190
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Discharge summary
|
report
|
Admission Date: [**2135-10-28**] [**Month/Day/Year **] Date: [**2135-11-3**]
Date of Birth: [**2107-6-3**] Sex: F
Service: MEDICINE
Allergies:
Imitrex
Attending:[**Attending Info 8238**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Patient is a 28yo female with PMH of
migraine headache and s/p gastric bypass who presents from home
with exertional dyspnea for two weeks, worsening over the past 2
days acutely along with intermittant chest pains. Patient was
last in her usual state of health until [**Month (only) 404**] of this year
when she underwent gastric bypass surgery. Following the
surgery, patient had difficulty taking food PO because of an
esophageal ulcer and went home with TPN via PICC. She had the
PICC for several months at home and experienced a line infection
that led to PICC replacement. A second PICC was placed and
patient continued to receive home TPN, but in [**Month (only) 116**] of this year,
began to not answer her door to nurses that came to visit to
change the dressing. She did this volitionally because she did
not want to interact with them. She continued to self-administer
TPN at home for 2-3 weeks during which time the dressing was not
changed and pus began to ooze from around the PICC site. She
continued to infuse TPN and one night the PICC fell out in her
sleep. She then presented to the hospital where she was found to
have pulmonary embolisms and septic pulmonary emboli. She was
discharged for this and later re-presented from home to outside
hospital in [**Month (only) 216**] of this year where she was found to have
pneumonia and had a large right pleural effusion, drained with
chest tube. She was discharged home and continued on IV
Rocephan. She is followed by Dr. [**Last Name (STitle) **], infectious disease in
[**Hospital1 487**].
At home for the past 2-3 weeks she developed dyspnea on
exertion. Over the past 2-3 days the dyspnea worsened and she
developed fevers at home to 102. She presented to the ED for
evaluation at [**Hospital1 487**].
In the ED, initial VS were: T97.9 HR92 BP122/90 RR15 O2sat:99%
A bedside cardiac echo: Tricuspid valve vegetation, poor right
ventricular filling, no clear strain. She was started on
vancomycin, cefepime, and gentamicin. She had a head CT which
confirmed no brain septic emboli and a chest CTA which showed
the presence of multiple pulmonary septic emboli. She was
started on IV heparin.
On arrival to the MICU, VS T98.4, HR85, BP121/85, RR22, O2sat:
100%RA. She has continued stable chest pain. She is in no acute
distress.
Past Medical History:
Migraine headaches
Achilles tendonitis
S/p RNY gastric bypass
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
- Used to work at a group home but lost that job because the
company could not accomodate her medical needs related to her
current illness. Got her Gastric bypass in an effort to improve
her running time to become a police officer/ do police academy.
- Works at [**Company 96369**] House, Non-Profit Organization as Program
Assistant
- Lives with fiance and two children
Family History:
Diabetes in father
Diabetes in paternal grandparents
HTN in maternal and paternal grandparents
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T98.4, HR85, BP121/85, RR22, O2sat: 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, [**4-19**] mid-peaking
systolic murmur heard best at the LLSB
Lungs: Clear to auscultation bilaterally but decreased breath
sounds at the right base, no wheezes, rales, ronchi, resonant to
percussion throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moves all 4 extremities and ambulates
without difficulty
[**Month/Day (4) 894**] PHYSICAL EXAM:
VS - T 98.0, BP 121/90, HR 82, RR 18, O2 98% RA
GENERAL - AOx3, NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no LAD, no carotid bruits
HEART - RRR, nl S1/S2, 3/6 systolic murmur heard best at the
LLSB
LUNGS - CTAB, no r/rh/wh, no accessory muscle use
ABDOMEN - S/NT/ND, no HSM, no rebound/guarding, laparoscopy
scars
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - CNs III-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout, steady gait
SKIN - No petechiae, splinter hemorr, [**Last Name (un) **] lesions, oslers
nodes
Pertinent Results:
ADMISSION LABS:
[**2135-10-28**] 05:00PM CK-MB-1 cTropnT-<0.01
[**2135-10-28**] 02:40PM PT-12.0 PTT-49.9* INR(PT)-1.1
[**2135-10-28**] 03:30AM GLUCOSE-75 UREA N-8 CREAT-0.2* SODIUM-143
POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2135-10-28**] 03:30AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-69 TOT
BILI-0.1
[**2135-10-28**] 03:30AM LIPASE-10
[**2135-10-28**] 03:30AM cTropnT-<0.01 proBNP-96
[**2135-10-28**] 03:30AM ALBUMIN-3.2*
[**2135-10-28**] 03:30AM WBC-5.4 RBC-3.92* HGB-9.7* HCT-30.2* MCV-77*
MCH-24.8* MCHC-32.3 RDW-14.6
[**2135-10-28**] 03:30AM NEUTS-50.3 LYMPHS-38.6 MONOS-6.5 EOS-4.0
BASOS-0.5
[**2135-10-28**] 03:30AM PLT COUNT-433
[**2135-10-28**] 03:30AM PT-12.4 PTT-150* INR(PT)-1.1
[**2135-10-28**] 04:43AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2135-10-28**] 04:43AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2135-10-28**] 04:43AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2135-10-28**] 04:43AM URINE MUCOUS-MANY
[**2135-10-28**] 04:40AM PT-11.6 PTT-34.7 INR(PT)-1.1
[**2135-10-28**] 04:00AM URINE HOURS-RANDOM
[**2135-10-28**] 04:00AM URINE UCG-NEG
[**Month/Day/Year 894**] LABS:
[**2135-11-3**] 07:20AM BLOOD WBC-5.0 RBC-4.01* Hgb-10.1* Hct-31.5*
MCV-79* MCH-25.2* MCHC-32.0 RDW-16.2* Plt Ct-441*
[**2135-11-3**] 07:20AM BLOOD Neuts-51.3 Lymphs-37.7 Monos-7.1 Eos-3.2
Baso-0.7
[**2135-11-3**] 07:20AM BLOOD Plt Ct-441*
[**2135-11-3**] 07:20AM BLOOD PT-11.8 PTT-38.3* INR(PT)-1.1
[**2135-11-3**] 07:20AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-141 K-3.7
Cl-104 HCO3-30 AnGap-11
[**2135-11-3**] 07:20AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.0
MICROBIOLOGY:
Blood Culture, Routine (Final [**2135-11-3**]): NO GROWTH.
Blood Culture, Routine (Final [**2135-11-3**]): NO GROWTH.
Blood Culture, Routine (Final [**2135-11-3**]): NO GROWTH.
WOUND CULTURE (Final [**2135-10-30**]): No significant growth.
Blood Culture, Routine (Final [**2135-11-3**]): NO GROWTH.
Blood Culture x 7 - pending
Legionella Urinary Antigen (Final [**2135-11-1**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
IMAGING:
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2135-10-28**]
IMPRESSION:
1. Left interlobar artery, superior lingular and left
posterobasal segment embili have a septic embolic apperance.
2. Multifocal nodular opacities in both lungs consistent with
septic emboli.
3. Enlarged right atrium, no right ventricular right heart
strain.
4. Left upper lobe intrapulmonary congenital bronchogenic cyst.
CHEST (PA & LAT) Study Date of [**2135-10-28**]
FINDINGS: No comparison studies. There are multifocal bilateral
nodular
ground-glass opacities. Concurrent CTA of the chest better
evaluates this. The cardiomediastinal shilhouette and hila are
normal. No pleural effusion, no pneumothorax.
CT HEAD W/ CONTRAST Study Date of [**2135-10-28**]
IMPRESSION: No acute process. No evidence of septic emboli.
CHEST (PORTABLE AP) Study Date of [**2135-10-29**]
The appearance of the lungs is similar compared to the study
from the prior day compatible with patient's known history of
endocarditis and septic emboli.
BILAT LOWER EXT VEINS Study Date of [**2135-10-31**]
IMPRESSION: No evidence of deep vein thrombosis in either right
or left lower extremity.
Portable TEE (Complete) Done [**2135-11-1**]
IMPRESSION: Moderate-sized vegetation on posterior cusp of
tricuspid valve with moderate to severe tricuspid regurgitation.
No annular abscess or evidence of infectious involvement with
other valves seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 28 year old woman with a history of tricuspid
endocarditis and septic pulmonary emboli (likely related to a
TPN line following bariatric surgery) who presented on [**2135-10-28**]
with worsening dyspnea on exertion and chest pain.
ACTIVE ISSUES
-------------
#. Endocarditis: The patient has known endocarditis and related
septic emboli diagnosed at [**Hospital6 3105**] in 6/[**2135**].
Her only known (+) culture to date was for Proteus Mirabilis
([**2135-7-17**], Resistant only to tetracycline). She has been treated
previously with ceftriaxone but was non-adherant to her
antibiotic course. Re-presented to [**Hospital3 **] this past
[**Month (only) 216**] and transferred to [**Hospital1 18**] for CT surgery evaluation. At
[**Hospital1 18**], the patient underwent CTA that showed pulmonary emboli
consistent with septic pulmonary emboli. A head CT showed no
cerebral emboli. A bedside echo showed a tricuspid vegitation.
The patient was started on heparin, vancomycin, cefepime and
gentamicin and admitted to the ICU. The patient remained stable
in the ICU and was called out on HOD #1. On the floor the
patient was continued on vancomycin and cefepime. She was seen
by infectious disease who recommended a TEE. The TEE revealed a
1.5cm tricuspid vegitation with moderate-severe TR. There was no
abscess and ECG showed no conduction abnormality. The patient
was seen by CT surgery who declined operative intervention. The
patient's heparin was stopped due to low concern for
thromboembolism and a midline was placed. In discussion with
infectious disease, it was decided that the source of the
patient's infection is likely Proteus bacteremia and she was
discharged on ceftriaxone. Serologies for causes of culture
negative endocarditis (e.g. coxiella, bartonella) were pending
at [**Hospital1 **]. the patient will continue her IV antibiotic
therapy at home and with guidance from the [**Hospital 112489**] clinic.
#. Atrial Fibrillation: The patient reports having episodes of
afib while hospitalized in [**Month (only) **]. On the floor, the patient was
noted to be in afib with RVR to rates of ~140-150. She
complained of chest discomfort but her hemodynamics were stable.
An ECG showed a rapid rate and rate related changes but no signs
of overt ischemia. Troponins were flat. the patient was given
intravenous metorpolol and transitioned to oral metoprolol with
good success. Her rhythym converted to sinus and remained that
was throughout her hospital stay. She will be discharged on
metoprolol succinate 150mg daily. This dose may require further
titration on an outpatient basis.
#. S/p gastric bypass, anemia: The patient was on vitamin
supplementation with B12 and a multi-vitamin during
hospitalization. Iron studies were sent due to a microcytic
anemia but revealed low-normal iron levels and a ferritin of
302. Her reticulocyte count was inappropriately normal making
bone marrow supression in the setting of active infection the
most likely source of her anemia. The patient will follow-up
with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
TRANSITIONAL ISSUES
-------------------
#. Continue IV antibiotic course as directed by the infectious
disease clinic
#. Follow-up coxiella, bartonella, brucella, legionella labs as
outpatient
#. Continue beta-blockade and titrate on an outpatient basis
#. Discuss with primary care physician [**Last Name (NamePattern4) **]: B12 supplementation
and multivitamins
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Vitamin D 50,000 UNIT PO THREE TIMES A WEEK
2. CeftriaXONE Dose is Unknown IV Q24H
3. Omeprazole 20 mg PO BID
4. Zolpidem Tartrate 10 mg PO HS
5. melatonin *NF* 3 mg Oral PRN Insomnia
[**Last Name (NamePattern4) **] Medications:
1. Zolpidem Tartrate 10 mg PO HS
2. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. melatonin *NF* 3 mg Oral PRN Insomnia
6. Omeprazole 20 mg PO BID
7. Vitamin D 50,000 UNIT PO THREE TIMES A WEEK
8. CeftriaXONE 2 gm IV Q12H
[**Last Name (NamePattern4) **] Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
[**Location (un) **] Diagnosis:
Endocarditis
Septic pulmonary emboli
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Location (un) **] Instructions:
It was a pleasure taking care of you at the [**Hospital1 18**]!
You were admitted due to shortness of breath and chest pain, and
we think that this was secondary to an infection involving one
of your heart valves. You received intravenous antibiotics in
the hospital, and your shortness of breath and chest pain have
improved. You were also found to have atrial fibrillation in the
hospital.
Please start the following medications:
- Ceftriaxone 2 grams every 12 hours
- Multivitamins
- Metoprolol
Thank you for allowing us to participate in your care.
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: 500 [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 59250**]
Phone: [**Telephone/Fax (1) 112490**]
Appointment: Tuesday [**2135-11-8**] 2:00pm
*At this appointment please discuss with your primary care
provider about the follow up appointment scheduled with Dr.
[**Last Name (STitle) **] and make sure that appointment will be okay for a
timeframe.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES-RIVERWALK
Department: Infectious Disease
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 21918**]
Phone: [**Telephone/Fax (1) 63259**]
Fax: [**Telephone/Fax (3) 112491**]
Appointment: Tuesday [**11-22**], 1:45pm
Completed by:[**2135-11-4**]
|
[
"300.00",
"346.90",
"397.0",
"280.9",
"278.00",
"795.51",
"V15.81",
"539.89",
"V64.2",
"780.52",
"530.20",
"V12.61",
"415.12",
"E878.8",
"421.0",
"V12.09",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8397, 11893
|
298, 305
|
4756, 4756
|
13611, 14565
|
3208, 3305
|
11919, 12766
|
4075, 4737
|
12798, 12837
|
239, 260
|
12869, 12869
|
13031, 13588
|
361, 2662
|
4772, 8374
|
12884, 12996
|
2684, 2748
|
2764, 3192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,002
| 120,994
|
10602
|
Discharge summary
|
report
|
Admission Date: [**2177-4-20**] Discharge Date: [**2177-5-5**]
Date of Birth: [**2104-10-18**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
fall / hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 10840**] is a 72year old male, with multiple medical
problems, including duodenal resection for adenoidCA in the 4th
portion of his duodenum, in [**3-14**] by Dr. [**Last Name (STitle) **]. He was noted
to have recurrence to mediastinal nodes [**2-14**]. He has two recent
admissions for signs of small bowel and billiary obstruction.
Which were treated and patient was most recently discharged on
[**2177-4-19**] to home as he had refused rehab. He was scheduled to
return to clinic for further chemotherapy, however developed
nausea, vomiting and lightheadedness the day after his
discharge. He had an episode of fall and presented to ED with
hypotension. Given his concerningly low blood pressure he was
admitted to the surgical ICU. His surgical course prior to this
admission is as follows:
[**4-4**]: biliary cannulation not possible as D2 was infiltrated
with tumor. His ERCP was otherwise normal to D3.
[**4-7**] PTC report: External compression of the common hepatic duct
and distal CBD obstruction by duodenal mass. 8 Fr internal and
external drainage tube with its distal tip were positioned at
duodenal third portion.
[**4-8**]: UGI: irregular narrowing of 2nd part duodenum c/w recurrent
tumor
[**4-10**]: Biliary stent: internalized successfully with pigtail
passed and remaining through duodenal obstruction into the
jejunum
[**4-15**]: Cholangiogram: dilated hepatic ducts and patent biliary
drain with terminal pigtail distal to the area of obstruction
[**4-17**] IR metallic stents unsuccessful, still has PTC to gravity
drain
Past Medical History:
PMHx/PSurgHx:
--a fib w/ tachy-brady syndrome s/p pacemaker placement on
[**2174-2-1**] by Dr. [**Last Name (STitle) 284**] @ [**Hospital1 18**]
--AAA s/p endovascular repair by Dr. [**Last Name (STitle) 1111**] [**2-9**] with known
endoleak per records.
--Type II diabetes, insulin-dependent
--Bilateral LE fx s/p fixation 20 yrs ago
--Morbid obesity
--Sleep apnea
--HTN
--diabetic retinopathy
--CHF most likely diastolic as has preserved EF 55%
--Pulmonary artery hypertension
--Hyperlipidemia
--Chronic venous stasis
--Prior syncope
--Arthritis
-- Cardiac Cath [**4-12**] [**2-8**] to abnormal stress which showed no
significanty blockage. One vessel coronary artery disease.
Normal LV systolic function. Mild LV diastolic dysfunction.
No significant subclavian stenosis on the right or left.
Angioseal of right femoral artery.
- Restrictive pattern on PFT's [**3-12**]
Social History:
Social Hx: lives w/ wife, no tobacco for 25 yrs (>100 pack-year
hx), social EtOH, former heavy drinker, retired realtor/salesman
Family History:
non-contributory
Physical Exam:
ON ADMISSION
VS: T 98.7 BP 70/50 HR O2Sat 94%2L
HEENT: COP, MMM, scleral icterus
Heart: RRR
Abdomen: obese, soft, mild tenderness to RUQ palpation
PTC draining bilious fluid
Skin: warm, well perfused
Pertinent Results:
[**2177-4-19**] 02:23AM PLT COUNT-239
[**2177-4-19**] 02:23AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-1+
[**2177-4-19**] 02:23AM NEUTS-86* BANDS-2 LYMPHS-4* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2177-4-19**] 02:23AM WBC-7.8 RBC-3.22* HGB-9.8* HCT-29.8* MCV-93
MCH-30.6 MCHC-33.0 RDW-18.6*
[**2177-4-19**] 02:23AM ALBUMIN-2.2* CALCIUM-7.9* PHOSPHATE-3.5
MAGNESIUM-2.3
[**2177-4-19**] 02:23AM ALT(SGPT)-77* AST(SGOT)-72* LD(LDH)-192 ALK
PHOS-311* AMYLASE-15 TOT BILI-14.2*
[**2177-4-19**] 02:23AM LIPASE-11
[**2177-4-19**] 02:23AM GLUCOSE-283* UREA N-60* CREAT-1.2 SODIUM-133
POTASSIUM-5.7* CHLORIDE-107 TOTAL CO2-15* ANION GAP-17
[**2177-4-19**] 12:59PM SODIUM-130* POTASSIUM-5.1 CHLORIDE-103
[**2177-4-20**] 05:40PM PLT SMR-HIGH PLT COUNT-429#
[**2177-4-20**] 05:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL
[**2177-4-20**] 05:40PM NEUTS-80* BANDS-5 LYMPHS-3* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-3*
[**2177-4-20**] 05:40PM WBC-17.5*# RBC-3.38* HGB-10.1* HCT-31.3*
MCV-93 MCH-29.9 MCHC-32.3 RDW-18.2*
[**2177-4-20**] 05:40PM cTropnT-0.03*
[**2177-4-20**] 05:40PM LIPASE-12
[**2177-4-20**] 05:40PM ALT(SGPT)-112* AST(SGOT)-99* ALK PHOS-317*
TOT BILI-14.7*
[**2177-4-20**] 05:40PM GLUCOSE-133* UREA N-74* CREAT-2.0*
SODIUM-132* POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-14* ANION
GAP-19
[**2177-4-20**] 05:54PM LACTATE-3.6*
[**2177-4-20**] 11:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-NEG
[**2177-4-20**] 11:08PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2177-4-20**] 11:52PM PT-15.5* INR(PT)-1.4*
[**2177-4-20**] 11:52PM PLT COUNT-378
[**2177-4-20**] 11:52PM WBC-20.7* RBC-3.22* HGB-9.5* HCT-29.4* MCV-92
MCH-29.6 MCHC-32.4 RDW-18.4*
[**2177-4-20**] 11:52PM CALCIUM-7.8* PHOSPHATE-5.5*# MAGNESIUM-2.2
[**2177-4-20**] 11:52PM LIPASE-11
[**2177-4-20**] 11:52PM ALT(SGPT)-106* AST(SGOT)-85* LD(LDH)-211 ALK
PHOS-310* AMYLASE-13 TOT BILI-15.9*
[**2177-4-20**] 11:52PM GLUCOSE-106* UREA N-75* CREAT-2.0* SODIUM-134
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-14* ANION GAP-20
Brief Hospital Course:
Briefly, Mr. [**Known lastname 10840**] was readmitted to the [**Hospital1 18**] SICU for signs
of sepsis with increased WBC and hypotension. He is a 72M who
is s/p (4th portion) for adenocarcinoid tumor (duodenal primary
w Lung Mets) and CCY [**3-14**]. He was previously admitted for tumor
recurrence in mediastinal nodes [**2-14**], and biliary obstruction.
During this last admission, to treat this obstruction, he
received a PTC, EGD with failed duodenal stent placement [**4-9**],
PTC internalization [**4-10**], 2 duodenal stents by GI [**4-14**], and failed
metallic stents by GI [**4-17**]. He was discharged after his diet was
advanced and he tolerated PO without any difficulty. However on
the day following his discharge he felt lightheaded and had an
experienced a fall due to weakness, without loosing
consciousness. He was brought to ED, and was found to be
hypotensive. He was transferred to SICU, where he temporally
required pressors ( no intubation) and was treated with multiple
antibiotics for sepsis, presuming his biliary system as the
source of infection. After patient was weaned off pressors, with
stable VS, he was transferred to OMED service for further
management. On the floor patient was intermittently hypotensive
with poor renal and liver function. BP as well as renal function
responded well to volume resuscitation, and during the course pt
was also found to have UTI. Given he already was on Cipro for
his presumed biliary infection, Zosyn was added, which led to a
decrease in pt's WBC and an overall clinical improvement.
Patient was started on chemotherapy on [**2177-5-3**]. Cisplatin was
given. On [**2177-5-4**] Patient presented with worsening cough and
abdominal pain, and later increasingly hypoxic with O2 sats low
80s, 92% on NRB. He subsequently developed worsening mental
status. CXR revealed total white out of left lung likely from
fluid and collapse. Pt was intubated and transferred to ICU. He
was started on three pressors with no improvement in his
hypotension as well as broad spectrum antibiotics. The patient
became increasingly more acidotic. Family was contact[**Name (NI) **] and
informed of his morbid state. After discussion with his family,
the goals of care were transferred to focus on comfort measures.
The patient passed away comfortably.
His hospital course is broken down by systems:
Neuro
His pain has been well controlled, however he developed new
abdominal tenderness prior to transfer to the ICU which was
treated with IV Dilaudid.
Cards
He transiently required the use of neosynephrine and levophed to
maintain his BP in the ICU, was completely weaned off pressors
as of [**4-25**], however was transferred to the floor on PO
Midodrine. Given episodic hypotension he was also started on
Octreotide TID and Albumin [**Hospital1 **] with good response. He was
v-paced without episodes of arrythmia.
Pulm
O2 requirements were weaned during initial ICU stay, on floor
stable oxygenation without O2 requirements however (as above)
sudden desaturation requiring intubation and ventilation.
Unclear etiology but most consistent with ARDS.
FEN/GI
[**4-21**] underwent IR tube study where tube was repositioned and
contrast was visualized in the jejunum. He tolerated this
procedure well without complication. [**4-21**] RUQ US: limited
bedside study demonstrating patent main portal vein with
antegrade flow. CBD not identified. On [**4-30**] biliary drain was
exchanged due to excessive amount of leakage around the drain.
He remained jaundiced with scleral icterus and dark urine. LFTs,
T-[**Female First Name (un) 7925**] improved only mildly during the course. During the
course, his diet was slowly advanced as tolerated from clears,
and he tolerated po's without nausea or vomiting.
Renal: pt developed acute renal failure, which was thought to be
prerenal with possible HRS in he setting of poor liver function,
as well as possible ATN in the setting of hypotension. Renal was
consulted and patient was treated with
Midodrine/Octreotide/Albumin for HRS with improvement of renal
function.
Heme
Given his heparin allergy, pt has been on fondaparinux for the
treatment of DVT at his right UE.
ID
Was empirically placed on vanco/zosyn this admission. On [**4-22**],
flagyl and cipro were added. On [**4-23**], vanco and flagyl were
d/c'd. During the course pt was found to have UTI, and Zosyn
was given renally dosed.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 325', Lopressor 50", NPH 35u qAM, Lasix 20',
Simvastatin 10', Lisinopril 40'
Discharge Disposition:
Expired
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"272.4",
"E934.2",
"038.9",
"428.32",
"278.01",
"197.0",
"518.81",
"428.0",
"V45.01",
"576.2",
"995.92",
"427.31",
"584.5",
"287.4",
"152.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10075, 10084
|
5508, 9917
|
292, 298
|
10129, 10132
|
3211, 5485
|
10182, 10186
|
2957, 2975
|
10105, 10108
|
9943, 10052
|
10156, 10159
|
2990, 3192
|
234, 254
|
326, 1897
|
1919, 2793
|
2809, 2941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,069
| 191,669
|
13621
|
Discharge summary
|
report
|
Admission Date: [**2127-4-23**] Discharge Date: [**2127-4-29**]
Date of Birth: [**2067-8-27**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 59-year-old patient
with a known history of who has previously had angioplasty in
[**2115**]. He has done well until six months prior to admission
where he noticed decrease in exercise tolerance. The patient
had subsequently had a positive exercise tolerance chest and
was admitted to [**Hospital6 256**] on [**2127-4-23**] for carcinoma.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia
2. Hypertension
3. Status post percutaneous coronary interventions as
previously mentioned.
4. Positive family history for coronary artery disease.
5. Anxiety disorder
ALLERGIES: The patient states no known drug allergies.
MEDICATIONS:
1. Aspirin 325 mg po qd
2. Lopressor 25 mg po bid
3. Zestril 5 mg po qd
4. Effexor XR 75 mg qd
5. Cardizem CD 300 mg qd
6. Pravachol 40 mg po qd
ADMISSION LABORATORY VALUES were unremarkable.
PHYSICAL EXAMINATION ON ADMISSION revealed normal sinus
rhythm, heart rate in the 70s. Blood pressure 120/70.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
HOSPITAL COURSE: The patient was taken to the cardiac
catheterization lab where he was found to have multivessel
coronary artery disease which would not likely be amenable to
interventional procedures. A cardiothoracic surgery
consultation was obtained and the patient was taken to the
Operating Room on [**2127-4-24**] where he underwent
coronary artery bypass graft x4 with a left internal mammary
artery to the LAD, a left radial graft to the OM, saphenous
vein to the RCA and saphenous vein to the diag. The patient
was postoperatively transported from the Operating Room to
the cardiac surgery recovery unit in stable condition on
Neo-Synephrine and nitroglycerin intravenous drips. Later on
the day of surgery, the patient was weaned from a mechanical
ventilator and extubated. The following day, the patient
required some Neo-Synephrine for approximately 24 more hours
due to some hypotension.
On postoperative day #2, he was transferred out of the
Intensive Care Unit and he was hemodynamically stable and his
chest tubes had been discontinued. On postoperative day #3,
the patient was begun with cardiac rehabilitation, began
ambulating. His Foley catheter and the central venous line
were removed as were his epicardial pacing wires. The
patient continued to progress and remained hemodynamically
stable, had some hypertension and was begun on beta blockers
which had subsequently been increased. On [**4-29**], today,
postoperative day #5, the patient remains hemodynamically
stable and is ready to be discharged home.
His condition today is as follows: Temperature 98.3??????, pulse
86, blood pressure 124/78, room air oxygen saturation is 93%.
His physical examination is unremarkable. His sternal
incision is well and his leg and his left arm incisions are
clean, dry and intact with Steri-Strips in place.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg po bid
2. Lasix 20 mg po bid x1 week
3. Potassium chloride 20 milliequivalents po bid x1 week
4. Colace 100 mg po bid
5. Zantac 150 mg po bid
6. Enteric coated aspirin 325 mg po qd
7. Imdur 60 mg po qd
8. Effexor 75 mg po qd
9. Pravachol 40 mg po qd
DISCHARGE CONDITION: Stable. He is to be discharged home.
FOLLOW UP: He is to follow up with Dr. [**Last Name (STitle) 1537**] on four weeks
for his postoperative check. He is to follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in three to four weeks or
as needed.
DISCHARGE DIAGNOSES:
1. Coronary artery disease
2. Status post coronary artery bypass graft
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2127-4-29**] 09:58
T: [**2127-4-29**] 10:07
JOB#: [**Job Number 41104**]
|
[
"272.0",
"V45.82",
"414.00",
"401.9",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"88.53",
"88.56",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3373, 3412
|
3697, 4038
|
3072, 3351
|
1232, 3049
|
3424, 3676
|
184, 536
|
558, 1214
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,634
| 174,865
|
16287
|
Discharge summary
|
report
|
Admission Date: [**2167-8-25**] Discharge Date: [**2167-8-30**]
Date of Birth: [**2115-12-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 51-year-old man with a
past medical history of metastatic esophageal cancer and
recent back surgery, who presented with new onset shortness
of breath. Per the family since Sunday, the patient had
becoming increasingly short of breath. He had not been able
to get out of a chair or exert himself secondary to this
shortness of breath. He feels that he is able to take a deep
breath. He also described increasing lower extremity edema.
Four-to-five pillow orthopnea. He has not had any recent
fevers, chills, and cough, but he has been "gurgling" and
sounding congested per his family. He has had no nausea or
vomiting. He has had diarrhea, had three episodes of large
volume loose stool since Sunday. He took Imodium for two
days, and has not had a bowel movement since.
On date of admission, his oxygen saturation was 82%, so the
patient was taken to the Emergency Room. He was found to
have a new pleural effusion, which was drained. The
preliminary results looked like an exudate with 26 atypical
cells likely from a malignancy. The patient feels that his
breathing has improved since the tap.
REVIEW OF SYSTEMS: The patient has not eaten since [**Month (only) 205**]. He
has had a 45 pound weight loss. He has taken occasional sips
of Gatorade, but the patient describes the sense of not being
able to swallow. The family states that he does not cough
while swallowing.
PAST MEDICAL HISTORY:
1. Esophageal cancer.
2. Nephrostomy tube infection. He had started taking Cipro
on [**Month (only) 2974**]. Today is day 4 of 10.
3. Back surgery.
4. Depression.
5. Normocytic anemia likely secondary to anemia of chronic
disease.
6. Hypertension.
7. Hypercholesterolemia.
8. Acute renal failure.
MEDICATIONS:
1. Zoloft 100 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Lisinopril 10 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d.
5. Magnesium two tablets p.o. q.d.
6. MS Contin 15 mg p.o. b.i.d.
7. Nystatin swish and swallow.
8. Calcium carbonate and ergocalciferol 50,000 units q week
being held secondary to hypercalcemia.
9. Sertraline 100 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a former smoker.
FAMILY HISTORY: He has a sister with [**Name (NI) 4278**] disease and a
mother with breast cancer.
PHYSICAL EXAM ON ADMISSION: His vitals: In the Emergency
Room, his temperature was 95.0, heart rate of 110, blood
pressure 102/76, respiratory rate of 20. He was 91% on room
air. He was put on a nonrebreather, given Lasix, and he was
93% on nonrebreather. In general, he was a somnolent white
male lying in bed. HEENT: His oropharynx was clear.
PERRLA. EOMI. He had mild exophthalmus. Mucous membranes
were slightly dry. Neck was supple. He had 9 cm of JVD, no
lymphadenopathy. Heart: He had a loud S1, S2. He had a
regular, rate, and rhythm, no murmurs, rubs, or gallops.
Lungs were clear to auscultation bilaterally except decreased
breath sounds half way up bilaterally. Abdomen was soft,
nontender, nondistended. Bowel sounds were present. He had
bilateral nephrostomy tubes in place. Extremities are warm
and well perfused. He had 3+ pitting edema, 2+ pulses
throughout.
LABORATORY DATA: Significant for a white count of 19.4 on
admission. His Chem-7 was within normal limits. His coags
on admission were significant for a PT of 17.6, INR of 2.1.
His urinalysis showed large blood, moderate leukocyte
esterase, small bilirubin, 100 protein, trace ketones, [**11-12**]
white blood cells, and many bacteria. His LFTs were within
normal limits. His LDH was 390.
EKG showed sinus tachycardia at 100 beats per minute.
STUDIES IN THE EMERGENCY ROOM: He had a CT of the head which
showed no hemorrhage.
A chest x-ray showed increased interval bilaterally and
pleural effusions right greater than left.
A urine culture from [**8-23**] showed Pseudomonas which was
sensitive to ciprofloxacin.
The patient was admitted to Medicine for further workup of
his shortness of breath.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
1. Pulmonary: Shortness of breath. The patient had improved
after paracentesis. It was felt that this was likely a
malignant effusion. He was continued on oxygen by nasal
cannula. The fluid was monitored for growth. It was felt
that it was unlikely to be an empyema, and Interventional
Pulmonology was consulted regarding whether or not his
effusion could be pleurodesed.
However, on the morning after admission, the patient
clinically deteriorated. He became hypoxic, hypotensive, and
tachypneic. He had increasing JVD almost to his ears. He
had a pulsus of 14. A STAT echocardiogram was done which was
negative for tamponade. A chest x-ray was done which showed
increasing right pleural effusion. At this time, the patient
was transferred to the ICU for further treatment.
In the ICU, a chest tube was placed by Interventional
Pulmonology. A central line was also placed for access. The
patient was intubated and placed on a ventilator.
On the 5th, CT was done to rule out pulmonary embolus, which
was negative. On the 6th, his endotracheal tube cuff
ruptured and Anesthesia was consulted, and they replaced the
endotracheal tube and the patient remained on the ventilator
until the time of his demise, at which time the endotracheal
tube was pulled.
2. Oncology: The patient was to have had a restaging CT on
admission. However, this was deferred due to his
deteriorating clinical status.
3. Cardiovascular: Patient had a history of hypertension.
He was initially maintained on his lisinopril for blood
pressure control. However, on the 4th, when he became
hypotensive, he was started on pressors in the unit. He was
initially weaned somewhat, however, he required increased
pressor support on the 7th, at which time, they decided to
call a family meeting, and it was decided at this time that
the patient should be made comfort measures only.
4. ID: Sepsis. While on the Intensive Care Unit blood
cultures grew gram-positive cocci. He was continued on
ciprofloxacin and Zosyn. During his ICU stay, Vancomycin was
added on the 5th as he had spiked a fever.
5. Renal: His creatinine was rising during his ICU stay
possibly secondary to the sepsis, versus hypotension, versus
the dye load from the CTA. He was volume repleted and close
monitoring was made of his renal status.
6. Cardiovascular: Patient had multifocal atrial tachycardia
and frequent ectopy during his unit stay. His electrolytes
were repleted, and they tried to avoid hypoxia.
7. GI: The patient had a nasogastric tube placed. Nutrition
was consulted. The patient received tube feeds during his
unit stay.
A family meeting was held on the 7th to discuss the patient's
deteriorating condition due to septic shock and his poor
prognosis especially given the metastatic esophageal
carcinoma. The family decided at the time to make the
patient comfort measures only. The pressor support was
withdrawn and the endotracheal tube was pulled.
At 7:45 p.m., on [**8-30**], there was no pulse, no
spontaneous respirations, no corneal or pupillary reflexes.
The patient's family was present. The attending was notified
and the family refused a postmortem exam.
DISCHARGE DIAGNOSES:
1. Metastatic esophageal cancer.
2. Nephrostomy tube infection.
3. Back surgery.
4. Depression.
5. Normocytic anemia.
6. Hypertension.
7. High cholesterol.
8. Acute renal failure.
9. Sepsis secondary to gram-positive cocci.
10. Hypoxia, respiratory distress requiring intubation.
11. Cardiac arrhythmias including multifocal atrial
tachycardia.
MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2167-9-18**] 14:57
T: [**2167-9-21**] 06:08
JOB#: [**Job Number 46436**]
|
[
"785.59",
"272.0",
"401.9",
"276.5",
"518.81",
"038.9",
"150.9",
"197.2",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.04",
"34.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2331, 2429
|
7345, 7950
|
4159, 7324
|
1296, 1558
|
157, 1276
|
2444, 4131
|
1580, 2273
|
2290, 2314
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,553
| 188,632
|
49856
|
Discharge summary
|
report
|
Admission Date: [**2184-12-24**] Discharge Date: [**2184-12-26**]
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
lethargy, altered mental status
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous catheter
foley catheter
History of Present Illness:
[**Age over 90 **] yo F from nursing home w/ h/o CAD s/p CABG, CHF, DM was
brought in for lethargy. She had been constipated, decreased UO
and anorexic for past few days prior to admission. On DOA, she
was found to be more lethargic and blood draw showed a potassium
of 7.1.
.
ED: Her rectal temp 101.4 but other VSS. She was somnolent and
her abd was distended and tender. Guaiaic positive stools. Her
lactate=1.6 K=6.3. wbc=23.3, elvation of Trop/CK-MB. A CT abd
showed large pelvic mass, ascites, and nodularity of the
peritoneum with Pelvic USG confirming the same. She was intially
given levo, flagyl but then switched to vanc, cefipime. An IJ
triple lumen was placed. Given tenuous respiratory status with
SaO2 low-mid 90's on NC (ABG normal at 7.38/34/93), she was
intubated. Upon transfer to the ICU, she was found to be
tachycardic to ~140 with BP in the 70s but with palpable carotid
pulses. EKG showed SVT with LBB, ? ST dep in lateral leads. She
got 7 lts of IVF until then and was started on Neo, Levo,
Vasopressin.
Past Medical History:
1. CAD s/p CABG in [**2172**]. TTE in [**2175**] demonstrated EF 40% with
inferolateral hypokinesis.
2. Hypertension
3. Hypercholesterolemia
4. Diabetes Mellitus
5. Colorectal Cancer, s/p resetion in [**2177**] with positive nodes.
Chose to be followed conservatively without chemotherapy.
6. s/p left hemispheric CVA. Pt had left internal capsule and
left occipital infarcts.
7. Gait instability. Patient has had frequent falls due to
instability secondary to knee and hip pain, DJD of spine and old
CVA's (above)
8. s/p L ORIF ([**6-13**])
9. GERD
10. Vitamin B12 deficiency. Patient receives monthly injections.
Social History:
The patient lives at [**Hospital3 2558**]. No history of tobacco or
alcohol use ever. [**Name (NI) **] grandson, [**Name (NI) **], can be reached at
[**0-0-**]. Patient's daughter, [**Name (NI) 440**], can be
reached at [**Telephone/Fax (1) 104171**].
Family History:
CAD
Physical Exam:
97.1, 160, 90/27, 17, 100%/ AC 1/500/14/5
GEN: intubated, sedated
HEENT: left IJ in place
Chest: clear anteriorly
CV: RRR, S1, S2, no m/r/g
Abd: distended abdomen, ? firmness in suprapubic region, could
not ellicit
Ext: trace edema, carotid/fem pulses++, no DPs
Rectal: guaiac positive stools (in ED)
.
Pertinent Results:
[**2184-12-23**] 10:50PM BLOOD WBC-23.3*# RBC-3.08* Hgb-8.3* Hct-26.2*
MCV-85 MCH-26.9* MCHC-31.6 RDW-15.6* Plt Ct-1146*#
[**2184-12-23**] 10:50PM BLOOD Neuts-92* Bands-4 Lymphs-1* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2184-12-23**] 10:50PM BLOOD PT-24.2* PTT-32.5 INR(PT)-2.4*
[**2184-12-23**] 10:50PM BLOOD Plt Ct-1146*#
[**2184-12-24**] 01:45PM BLOOD Fibrino-828*
[**2184-12-24**] 01:45PM BLOOD FDP-80-160*
[**2184-12-25**] 04:15AM BLOOD Fibrino-437*#
[**2184-12-25**] 09:42AM BLOOD Ret Aut-1.8
[**2184-12-23**] 10:50PM BLOOD Glucose-95 UreaN-85* Creat-2.8* Na-139
K-6.3* Cl-100 HCO3-23 AnGap-22*
[**2184-12-23**] 10:50PM BLOOD LD(LDH)-540* CK(CPK)-166*
[**2184-12-25**] 04:15AM BLOOD ALT-1145* AST-9340* LD(LDH)-9800*
AlkPhos-81 TotBili-1.3
[**2184-12-24**] 01:45PM BLOOD Lipase-9
[**2184-12-23**] 10:50PM BLOOD CK-MB-24* MB Indx-14.5*
[**2184-12-23**] 10:50PM BLOOD cTropnT-2.96*
[**2184-12-24**] 04:23AM BLOOD cTropnT-2.64*
[**2184-12-24**] 05:59PM BLOOD CK-MB-66* MB Indx-21.4*
[**2184-12-23**] 10:50PM BLOOD Calcium-11.3* Phos-5.5*# Mg-6.6*
[**2184-12-24**] 01:45PM BLOOD Hapto-570*
[**2184-12-24**] 07:36AM BLOOD FiO2-100 pO2-93 pCO2-34* pH-7.38
calTCO2-21 Base XS--3 AADO2-605 REQ O2-96 Intubat-NOT INTUBA
Comment-NRB
[**2184-12-24**] 10:08AM BLOOD Type-[**Last Name (un) **] Temp-36.5 Rates-12/ Tidal V-500
PEEP-5 pO2-39* pCO2-40 pH-7.22* calTCO2-17* Base XS--10
-ASSIST/CON Intubat-INTUBATED
[**2184-12-24**] 12:22AM BLOOD Lactate-1.6
[**2184-12-24**] 06:17PM BLOOD Lactate-8.7*
CXR [**2184-12-24**]
1. Left IJ catheter terminates at the junction of innominate
veins. No pneumothorax.
2. Left retrocardiac opacity may represent atelectasis,
consolidation, or combination of both. Small left pleural
effusion.
.
Portable Abd [**2184-12-24**]
Findings concerning for small-bowel obstruction
.
CT ABD/PELVIS [**2184-12-24**]
1. Large pelvic mass, ascites, and nodularity of the peritoneum.
These findings are concerning for gynecological malignancy.
2. Mild right hydronephrosis.
3. No evidence of small-bowel obstruction
.
PELVIS USG [**2184-12-24**]
Large complex cystic solid pelvic mass with internal
vascularity, highly suspicious for malignancy.
Brief Hospital Course:
[**Age over 90 **] yo F from nursing home w/ h/o CAD s/p CABG, DM, colorectal ca
presented with septic shock, NSTEMI contributing to cardiogenic
shock and large pelvic mass with abdominal mets.
.
# Shock: septic + cardiogenic etiology in setting of NSTEMI and
PNA/UTI, renal failure, shock liver, improved s/p IVF, digoxin
for cardiogenic etiology, and was able to be weaned off
pressors. Given poor prognosis, family decided to withdrawal
aggressive measures on [**12-26**] and make patient comfort measures
only. Patient was extubated and IVF were stopped.
.
# NSTEMI: differential on admission included massive MI v. heart
responding to shock. ECHO showed massive WMA.
.
# Rhythm: SVT with bundle block; digoxin administered to lower
heart rate.
.
# Pelvic mass: found on abdominal CT scan, underlying etiology
for constipation over the days prior to admission. Prognosis
poor in the setting of septic shock. Family's wishes were to
not pursue further diagnostic procedures.
.
# Acute on chronic renal failure: Believed to be secondary to
dehydration + shock
on admission. There was minimal improvement after IVF
resuscitation. Family did not want to persue hemodialysis.
.
# Access: R Fem art line, LIJ
.
# PPX: patient was maintained pneumoboots, PPI, bowel regimen
until goals of care changed.
.
# Code: Family decided to change goals of care to comfort
measures only on the am of [**12-26**] and the patient was extubated,
placed on a morphine drip, and died at 11:41 PM on [**12-26**] from
respiratory failure.
.
# Communication: daughter- [**Name (NI) 440**], grandson
Medications on Admission:
Insulin
Asrpirin 325 mg
Isosorbide
Levothyroxine 25 mcg
Lidoderm patch
Multivit
tramadol
zetia
fluoxetine
gemfibrozil
metoprolol 12.5 [**Hospital1 **]
hydral
nortryptyline
enulose
senna
colace
milk of mag
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Septic shock
Pelvic Mass
Urinary Tract Infection
acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"785.51",
"486",
"789.59",
"V45.81",
"599.0",
"410.71",
"038.9",
"427.1",
"V10.05",
"250.00",
"785.52",
"272.0",
"276.7",
"995.92",
"584.9",
"428.0",
"570",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6762, 6771
|
4888, 6477
|
297, 361
|
6893, 6903
|
2690, 4865
|
6956, 6963
|
2345, 2351
|
6733, 6739
|
6792, 6872
|
6503, 6710
|
6927, 6933
|
2366, 2671
|
226, 259
|
389, 1420
|
1442, 2060
|
2076, 2329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,346
| 150,219
|
23999
|
Discharge summary
|
report
|
Admission Date: [**2188-6-25**] Discharge Date: [**2188-6-30**]
Date of Birth: [**2121-5-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
R Frontal Lobe metastatic lesion, presumed Renal Cell Carcinoma
(RCC).
Major Surgical or Invasive Procedure:
R craniotomy and resection of R frontal lobe metastatic lession,
presumed RCC.
History of Present Illness:
Mr. [**Known lastname 61106**] is a 67-year-old right-handed man, with a three-year
history of Renal Cell Carcinoma discovered on hematuria workup
in [**2185-5-3**], who is seen in consultation as requested by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**] (Onc) for evaluation of his right frontal
solitary brain metastasis. Following discovery of his L kidney
RCC, Mr. [**Known lastname 61106**] [**Last Name (Titles) **] underwent a left nephrectomy in
____.
Postoperatively, he was enrolled in a randomized Phase III trial
comparing
alpha-interferon versus Sutent; he was randomized to the
alpha-interferon arm. On [**2187-4-11**], he was started on Sutent off
study. He was being screened for the Perifosine trial and he
underwent a gadolinium-enhanced head MRI on [**2188-6-10**]. The MRI
showed a 1.5 cm enhancing mass in the right frontal brain with
surrounding edema. He is completely asymptomatic from it,
without headache, nausea, vomiting, seizure, imbalance, or fall.
Past Medical History:
- Coronary artery disease with an angioplasty and stent implant
in [**2184-5-2**]
- Diabetes
- Hypercholesterolemia
- Hypertension
- Asthma
Past Surgical Hx:
- Colonoscopy and polypectomy w/complication of severe GI
bleeding requiring admission to the hospital and
several-units transfusion of blood.
- Metastatic renal cell cancer s/p nephrectomy,
- R tibia plating [**2187-6-27**]
Social History:
The patient is not currently working. He was previously
employed as a real estate manager. He does not smoke, nor has
he smoked in the past. He does not drink alcohol. He has three
healthy grown daughters.
Family History:
There is a history of cancer, diabetes, and heart disease in the
family.
Physical Exam:
Temperature is 98.8 F. His blood pressure
is 142/68. Heart rate is 72. Respiratory rate is 20. His skin
has full turgor. HEENT is unremarkable. Neck is supple.
Cardiac examination reveals regular rate and rhythms. His lungs
are clear. His abdomen is soft with good bowel sounds. His
extremities do not show clubbing, cyanosis, or edema. He had an
above knee amputation in the right lower extremity
Neurological Examination: His Karnofsky Performance Score is 60.
He is awake, alert, and oriented times 3. There is no right/left
confusion or finger agnosia. His calculation is intact. His
language is fluent with good comprehension, naming, and
repetition. His recent recall is intact. Cranial Nerve
Examination: His pupils are equal and reactive to light, 4 mm to
2 mm bilaterally. Extraocular movements are full; there is no
nystagmus. Visual fields are full to confrontation. Funduscopic
examination reveals sharp disks margins bilaterally. His face is
symmetric. Facial sensation is intact bilaterally. His hearing
is intact bilaterally. His tongue is midline. Palate goes up in
the midline. Sternocleidomastoids and upper trapezius are
strong. Motor Examination: He does not have a drift. His
muscle strengths are [**4-5**] at all muscle groups. His muscle tone
is normal. His reflexes are 0-1 bilaterally. His left knee jerk
is 1+ and left ankle jerk is absent. His left toe is down going.
Sensory examination is intact to touch and proprioception.
Coordination examination does not reveal dysmetria. He needs a
walker to walk and his gait is limited by his amputated right
leg.
Pertinent Results:
[**2188-6-29**] 06:48AM BLOOD WBC-12.3* RBC-3.02* Hgb-10.0* Hct-28.7*
MCV-95 MCH-33.1* MCHC-34.9 RDW-15.4 Plt Ct-163
[**2188-6-25**] 03:50PM BLOOD Neuts-93* Bands-1 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2188-6-25**] 03:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
[**2188-6-29**] 06:48AM BLOOD Plt Ct-163
[**2188-6-29**] 06:48AM BLOOD Glucose-169* UreaN-45* Creat-1.4* Na-141
K-4.8 Cl-109* HCO3-25 AnGap-12
[**2188-6-25**] 10:35AM BLOOD cTropnT-0.02*
[**2188-6-28**] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.5
[**2188-6-25**] 01:18PM BLOOD Glucose-106* Lactate-1.0 Na-134* K-4.6
Cl-108 calHCO3-24
[**2188-6-25**] 01:18PM BLOOD Hgb-8.9* calcHCT-27
[**2188-6-25**] 01:18PM BLOOD freeCa-1.19
Brief Hospital Course:
Mr. [**Known lastname 61106**] was admitted to [**Hospital1 18**] on [**2188-6-25**] for same-day
resection of a R Frontal Lobe metastatic lesion, presumed to be
Renal Cell Carcinoma. He tolerated this procedure well, was
transferred to the PACU post-operatively, and ultimately
transferred to [**Hospital Ward Name 121**] 5 for recovery.
On POD#2 he was found to be quite lethargic a stat head CT was
obtained that showed There is no new hemorrhage identified or
evidence of extension of edema. An MRI was also ordered which
showed a hemorrhage with in bed of resection no new areas of
enhancement. He eventually awoke and would follow ocommands but
was sleepy. He was started on Mannitol and his decadron was
kept at a 4mg Q6.
On POD#3 and 4 he was much improved conversant and [**Location (un) 1131**] a
newspaper. No focal deficits noted. His mannitol was weaned to
off. He had episodes of hiccoughs with no clear explanation on
head MRI to explain. He was cleared by Physical therapy to go
home.
At the time of discharge, the pt. was afebrile, tolerating a
regular diet, at full activity and with good pain control
following his R craniotomy. The wound site is C/D/I with no
erythema or obvious signs of infection. The pt. denies
headache, visual disturbances and agrees with plan for d/c. He
will have his sutures taken out at the PCP [**Name Initial (PRE) 3726**].
Medications on Admission:
20 mg po daily, Singular 10 mg po
daily, Hytrin 10 mg po daily, K-Dur 20 mEq po daily, glipizide
10
mg po daily, Byetta 10 units twice daily, Tricor 145 mg po
daily,
Diovan 320 mg po daily, verapamil SR 360 mg po daily, Lasix 40
mg
po daily, Advair 1 puff daily, Ecotrin 325 mg po daily,
hydralazine 10 mg po daily, Androgel 5 gram apply to skin once
daily, finaseride 5 mg po daily, gabapentin 300 mg po twice
daily, Lexapro 10 mg po daily, and Lunesta 3 mg po daily. HE IS
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
2. Keppra 500 mg Tablet Sig: 1-2 Tablets PO twice a day: Take 2
tablet [**Hospital1 **] until [**7-2**] then 3 tab tid until follow up with brain
tumor clinic.
Disp:*120 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Verapamil 120 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q24H (every 24 hours).
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation DAILY (Daily).
8. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): you
must take this to protect your stomach against ulcer formation
while taking the steroids (dexamethasone).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours:
please do not drive or operate heavy machinery while on this
medication.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic RCC to brain.
Discharge Condition:
Stable
Discharge Instructions:
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
You should be hearing from Dr[**Name (NI) 46464**] office regarding set
up of Cyberknife treatment if no call by Wednesday call
[**Telephone/Fax (1) 9710**]
Have your staples out on [**2188-7-4**] between 0900-1200 at Dr
[**Last Name (STitle) 46463**] office
See your Oncologist as planned
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-7-29**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28268**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-7-29**] 4:00
Completed by:[**2188-6-30**]
|
[
"198.3",
"496",
"272.0",
"V45.82",
"414.01",
"250.00",
"401.9",
"V10.52",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8363, 8369
|
4620, 6007
|
347, 428
|
8438, 8447
|
3823, 4597
|
9782, 10407
|
2123, 2197
|
6533, 8340
|
8390, 8417
|
6033, 6510
|
8471, 9759
|
2212, 3804
|
237, 309
|
456, 1472
|
1494, 1879
|
1895, 2107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,420
| 148,290
|
1693
|
Discharge summary
|
report
|
Admission Date: [**2183-5-24**] Discharge Date: [**2183-5-27**]
Date of Birth: [**2131-7-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Percocet / Lipitor / Fioricet
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
chills, n/v
Major Surgical or Invasive Procedure:
Right IJ
History of Present Illness:
51yo male with a history of HIV and asplenia was admitted from
the ED with fever and weakness. He reported feeling well until
the evening of [**2183-5-23**] when he began to have shaking chills,
temperature 102.7, weakness, and nausea/vomiting. He then
reports feeling lightheaded when walking down the street. He has
noticed on and off tingling of the left fingers and the right
thumb through 3rd finger. The patient's history was signifant
for no SOB, cough, sputum production, sinus pain, diarrhea,
hematuria, dysuria, headache, vision changes, or neck pain. He
does endorse some frequency of urination but this is long
standing. He has two dogs at home, no other pets, occasional
sick contact at work, and no recent travel. His most recent CD4
count was 783 in [**5-8**]. His most recent viral load was 305 in
[**2181**].
.
Upon arrival in the ED, temp 101.6, HR 124, BP 126/78, RR 18,
and pulse ox 97% on room air. His exam was notable for fever to
103.8, hypotension to 68/43. He had a central line placed for
the sepsis protocol. His labs were notable for an elevated WBC
to 13.9 and lactate of 2.8. He had CT chest, abdomen, and pelvis
and CXR performed which demonstrated . . . He received levo, 6L
IVF, cefepime 2g IV x 1, vancomycin 1g IV x 1, azithromycin
500mg IV x 1, morphine 6mg IV x 1, ondansetron, and ibuprofen.
He had a negative UA. Blood cx and urine cx were obtained in the
ED.
Past Medical History:
-HIV (last CD4 on [**3-10**] 500, last viral load on [**10-6**] 305
copies/ml, currently off HAART)
-Emergency splenectomy after assault in [**2168**] (has been
vaccinated with Pneumovax)
-Migraines
-Nephrolithiasis
-Shingles
-Left ankle arthroscopy in [**2182**]
-Arthroscopic ACL repair
-Tonsillectomy
-strep pneumo bacteremia [**3-10**]
-Vasovagal syncope
-Right inguinal hernia repair in [**2173**]
-Obstructive sleep apnea (uses CPAP)
-Hyperlipidemia
-BPH
Social History:
He has two daughters and 4 grandchildren. He is divorced. He
works in nuclear cardiology at [**Hospital1 2025**]. He lives alone with his dogs
and performs all of his ADLs. He has never smoked, he drinks
rarely, no IVDU, only smoked marijuana three times. Not
currently sexually active but is bisexual. He had multiple male
sexual partners in the past and had unprotected intercourse. He
believes he contracted HIV from having unprotected sex with a
partner who has since passed away of AIDS.
Family History:
Paternal grandfather and maternal grandmother - DM2
Maternal grandfather died from MI at age 58
Sister died from ovarian cancer at age 50
Physical Exam:
T 100 HR 119 BP 86/46(56) RR 15 97%
Gen: alert, awake, NAD
HEENT: Clear OP, MMM
NECK: Supple, right sided anterior cervical chain LAD, No JVD
but difficult to access given IJ
CV: tachycardic no m/r/g
LUNGS: CTA, BS BL, No W/R/C
ABD: obese, +bs, soft, NT, ND. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: + coarse scarring on right shin
NEURO: Appropriate. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**1-31**]+ reflexes in UE, unable
to elicit LE reflexes. Gate deferred.
PSYCH: Listens and responds to questions appropriately, pleasant
Brief Hospital Course:
51yo male with history of asplenia and HIV was admitted with
fevers and weakness.
.
1. Strep pneumonia bacteremia with sepsis and septic shock. Mr.
[**Known lastname 9700**] was admitted to the ICU with recurrent septic shock.
Blood cultures from the day of admission were positive for strep
pneumonia. He was started on cefepime and vancomycin. He had a
torso scan and sinus scan negative for sources of bacteremia.
He responded to IV antibiotic treatment and cleared his blood
cultures after the initial positive cultures. He was seen by
ID, and his imaging was reviewed again by radiology for evidence
of mycotic aneurysm, which was negative. He also had
pneumococcal serologies sent which were still pending at the
time of this discharge summary. In addition, strongyloides
antibody was sent. He was discharged on 2 weeks of levofloxacin
after the sensitivities revealed sensitivity to levofloxacin,
and will follow up with his PCP regarding possible immunology
workup for recurrent bacteremia, as despite his asplenia, he has
been vaccinated, and the etiology for recurrent infection is
unclear. Also, he was given a repeat pneumovax booster as well
as meningococcus. Per his PCP, [**Name10 (NameIs) **] has already been vaccinated
for H. Flu.
.
2. HIV. No current evidence for starting ART w/ CD4>500.
Continued outpatient management.
Medications on Admission:
-albuterol
-acyclovir for herpetic outbreak started [**2183-5-21**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Septic shock
Streptococcus pneumoniae bacteremia
Asplenia
HIV
Obstructive sleep apnea
Herpes outbreak
Discharge Condition:
Stable, afebrile, blood cultures negative for 3 days.
Discharge Instructions:
You were admitted with septic shock and bacteremia. This was
the second episode of bacteremia. The cause of the repeat
episode is still being evaluated, and there are outstanding
blood tests. We did not find any other infections in other
parts of your body.
.
Medication changes:
Levofloxacin for 11 more days, ending [**6-6**]
.
Return to the ED if you develop fever or chills again, an
allergic reaction to the antibiotic, cough, chest pain,
palpitations, nausea, vomiting or diarrhea.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 9316**]
Date/Time:[**2183-5-29**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2183-7-3**] 3:30
.
See Dr. [**Last Name (STitle) 9625**] within the next 2 weeks to review outstanding
tests. He might also want to refer you to an immunologist.
|
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icd9cm
|
[
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[]
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[
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icd9pcs
|
[
[
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5558, 5613
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5920, 6129
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261, 274
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2252, 2748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,253
| 131,510
|
2440+55380
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-8-2**] Discharge Date: [**2150-8-17**]
Date of Birth: [**2095-2-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Colovesical fistula.
Major Surgical or Invasive Procedure:
Colonoscopy
Open Colovesical Fistula Takedown, Sigmoid Colectomy
History of Present Illness:
This patient is a 55 year-old, white male, with a known
colovesical fistula. He has been treated appropriately with
antibiotics and rest and now presents for excision of the
diseased colon with primary anastomosis.
In [**Month (only) 956**] the patient experienced significant right lower
quadrant pain with chills and fever. The next morning he felt
better. In [**Month (only) 958**] he experienced the onset of pneumaturia. In
[**Month (only) 116**], he developed significant urinary tract infection and saw
his physician, [**Name10 (NameIs) 12532**] with antibiotics. In late [**Month (only) 116**] he began
to see significant amounts of stool coming out in his urine. At
one
point he stopped having regular bowel movements and was only
passing stool through his urine. He presented to the ED and was
found to have a colovesical fistula.
He was started on Augmentin and referred to Dr. [**Last Name (STitle) 1120**]. He is
actually well-controlled at present, has no significant symptom
other than the pneumaturia. He has lost weight by dieting over
the past several months. CT scan suggests the finding is
related to his extensive diverticulosis.
Past Medical History:
Pneumaturia, hyperlipidemia, hypertension, spinal effusion
cervical spine, knee surgery
PAST GASTROINTESTINAL PROCEDURES: None
Social History:
SOCIAL HISTORY: Married, no children. Smokes 3 to 5 cigars per
day. Social alcohol. Two cups of coffee per day. He is a
retired state police officer retired because of his neck injury
Family History:
FAMILY HISTORY: Diverticulosis
Physical Exam:
WT: 211 pounds HT: 5'[**52**]" PULSE: 68 TEMP: normal R: 12
Constitutional: Well-developed, well-nourished patient in no
distress appearing appropriate age.
Skin: no rashes, ulcers, icterus or other lesions; no clubbing
or
telangiectasias.
Eyes: normal conjunctivae and lids. pupils: symmetrical.
ENT: external: normal external inspection of ears and nose.
Mouth: normal oral mucosa, lips and gums. Normal tongue, hard
and soft palate; posterior pharynx without erythema, exudate or
lesions.
Neck: normal motion, central trachea, thyroid: normal size,
consistency and position.
Respiratory: normal breath sounds; no rubs, wheezes, rales or
rhonchi.
Cardiovascular: Normal rhythm, S1 and S2; no rubs, murmurs or
gallop.
Abdominal: Abdominal aorta, no bruits. Normal bowel sounds; no
tenderness, rebound, guarding or masses.
Hernias: No hernias appreciated.
Liver: normal size and consistency.
Spleen: not palpable.
Rectal: hemoccult/guaiac: negative, no external lesions,
hemorrhoids or tags. palpation: normal anal sphincter tone; no
masses or tenderness. Prostate not enlarged.
Gait: normal gait
Extremities: normal range of motion. No edema, varicosities or
cyanosis.
Lymphatic: axillae: not palpable. groin: not palpable. neck: not
palpable.
Neurologic: no evidence of depression, anxiety or agitation.
orientation: oriented to time, space and person.
Pertinent Results:
[**2150-8-2**] 05:30PM BLOOD WBC-7.6 RBC-4.01* Hgb-11.8* Hct-34.3*
MCV-86 MCH-29.3 MCHC-34.3 RDW-13.6 Plt Ct-319
[**2150-8-4**] 07:20AM BLOOD WBC-6.4 RBC-3.23* Hgb-9.6* Hct-27.9*
MCV-87 MCH-29.7 MCHC-34.3 RDW-13.5 Plt Ct-261
[**2150-8-4**] 07:20AM BLOOD Glucose-128* UreaN-8 Creat-0.8 Na-138
K-4.3 Cl-106 HCO3-27 AnGap-9
[**2150-8-4**] 07:20AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
.
Brief Hospital Course:
This is a 55 year old male with a known colovesical fistula. He
had colonoscopy on [**2150-8-3**] which showed Diverticulosis of the
sigmoid colon and transverse colon with the colovesical fistula
likely arising from diverticulum. He went to the OR on [**2150-8-3**]
for: Repair of colovesical fistula.
Pain: He had a PCA for pain control. Toradol was also added. He
was tolerating the pain. Once back on a diet, he was started on
PO meds.
GI/ABD: He was NPO with IVF. His abdomen was soft and nontender.
He had a JP drain in the LLQ.
He was started on clears on POD ... He diet was slowly advanced
as he had return of bowel function...
GU: During the operation, Dr. [**Last Name (STitle) 1120**] noted a large phlegmon
associated with the back wall of the bladder on its
intraperitoneal surface and was concerned about the
significance of the size of the mass and its potential to be
bladder cancer, which would change the operation.
Upon inspection, the phlegmon, strongly suggested an
inflammatory rather than malignant process. The patient also
apparently was asymptomatic prior to surgery with regard to his
urinary system and a tumor the size of the phlegmon that
I have palpated would have caused marked symptoms. During
surgery also, methylene blue was instilled into the bladder and
no leak was noted.
His Foley will stay for 1 week. He had a retrograde study on POD
... and this showed ... The Foley was subsequently removed the
next day...
Medications on Admission:
[**Doctor First Name 130**] 60 prn, indomethacin 50qhs, glyburide/metformin 5/500',
lisinopril 20', atenolol 50', simvatain 40', augmentin 875''
(finished course [**8-2**] for UTI)
Discharge Medications:
1. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
2. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO at
bedtime.
3. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: One (1)
Tablet PO once a day.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simethicone 60 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain: DO not exceed 8 tablets
in one day. Do not take tylenol while taking this medication.
Disp:*30 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Colovesical Fistula
Diverticulitis
Discharge Condition:
Good
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 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
* Monitor your incision for signs of infection.
* It is OK to shower and wash. No tub baths or swimming. Keep
incision clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1120**] in 2 weeks. Call ([**Telephone/Fax (1) 3378**]
to schedule an appointment.
F/U with Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**0-0-**] PCP
SIGNED BUT NOT READ BY ME
Completed by:[**2150-8-6**] Name: [**Known lastname **],[**Known firstname **] T Unit No: [**Numeric Identifier 1858**]
Admission Date: [**2150-8-2**] Discharge Date: [**2150-8-17**]
Date of Birth: [**2095-2-23**] Sex: M
Service: SURGERY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1859**]
Addendum:
Additional information from East Gen Surgery
Chief Complaint:
Diverticulitis, Colovesicular fistula
Major Surgical or Invasive Procedure:
Colonoscopy
Open Colovesical Fistula Takedown, Sigmoid Colectomy
Surgical rexploration
Retrograde Urethrogram
History of Present Illness:
This patient is a 55 year-old, white male, with a known
colovesical fistula. He has been treated appropriately with
antibiotics and rest and now presents for excision of the
diseased colon with primary anastomosis.
In [**Month (only) 1860**] the patient experienced significant right lower
quadrant pain with chills and fever. The next morning he felt
better. In [**Month (only) 880**] he experienced the onset of pneumaturia. In
[**Month (only) 412**], he developed significant urinary tract infection and saw
his physician, [**Name10 (NameIs) 1861**] with antibiotics. In late [**Month (only) 412**] he began
to see significant amounts of stool coming out in his urine. At
one
point he stopped having regular bowel movements and was only
passing stool through his urine. He presented to the ED and was
found to have a colovesical fistula.
He was started on Augmentin and referred to Dr. [**Last Name (STitle) **]. He is
actually well-controlled at present, has no significant symptom
other than the pneumaturia. He has lost weight by dieting over
the past several months. CT scan suggests the finding is
related to his extensive diverticulosis.
Past Medical History:
Pneumaturia, hyperlipidemia, hypertension, spinal effusion
cervical spine, knee surgery
PAST GASTROINTESTINAL PROCEDURES: None
Social History:
SOCIAL HISTORY: Married, no children. Smokes 3 to 5 cigars per
day. Social alcohol. Two cups of coffee per day. He is a
retired state police officer retired because of his neck injury
Family History:
FAMILY HISTORY: Diverticulosis
Physical Exam:
WT: 211 pounds HT: 5'[**52**]" PULSE: 68 TEMP: normal R: 12
Constitutional: Well-developed, well-nourished patient in no
distress appearing appropriate age.
Skin: no rashes, ulcers, icterus or other lesions; no clubbing
or
telangiectasias.
Eyes: normal conjunctivae and lids. pupils: symmetrical.
ENT: external: normal external inspection of ears and nose.
Mouth: normal oral mucosa, lips and gums. Normal tongue, hard
and soft palate; posterior pharynx without erythema, exudate or
lesions.
Neck: normal motion, central trachea, thyroid: normal size,
consistency and position.
Respiratory: normal breath sounds; no rubs, wheezes, rales or
rhonchi.
Cardiovascular: Normal rhythm, S1 and S2; no rubs, murmurs or
gallop.
Abdominal: Abdominal aorta, no bruits. Normal bowel sounds; no
tenderness, rebound, guarding or masses.
Hernias: No hernias appreciated.
Liver: normal size and consistency.
Spleen: not palpable.
Rectal: hemoccult/guaiac: negative, no external lesions,
hemorrhoids or tags. palpation: normal anal sphincter tone; no
masses or tenderness. Prostate not enlarged.
Gait: normal gait
Extremities: normal range of motion. No edema, varicosities or
cyanosis.
Lymphatic: axillae: not palpable. groin: not palpable. neck: not
palpable.
Neurologic: no evidence of depression, anxiety or agitation.
orientation: oriented to time, space and person.
Pertinent Results:
[**8-7**]; [**8-8**] urine: Pseudomonas
[**8-9**] C.diff: neg
[**8-9**] wound: psuedomonas pansensitive
[**8-10**] wound: G+ R bacteroides beta lactamase positive, G- R
sparse [**Last Name (un) 1862**] P
CXR [**8-12**] - LLL infiltrate
CXR [**8-13**]: cardiomegaly and vascular engorgement but no frank
pulmonary edema is present. There is no interval change in the
left lower lobe consolidation as well as in the right middle
lobe and lower lobe opacity that most likely represent
atelectasis.
echo - no endocard
RUS: no hydronephrosis
.
[**2150-8-12**] 05:15AM BLOOD Glucose-91 UreaN-37* Creat-3.6* Na-142
K-5.0 Cl-108 HCO3-20* AnGap-19
.
[**2150-8-17**]--CT CYSTOGRAM (PEL) W&W/O CONTR
Reason: Retrograde urethrogram study due to colonic-vesicular
fistula
Impression: Leak noted at Anterior aspect of bladder
[**2150-8-15**] 06:20AM BLOOD WBC-10.7 RBC-2.88* Hgb-8.0* Hct-25.3*
MCV-88 MCH-27.7 MCHC-31.5 RDW-14.2 Plt Ct-607*
[**2150-8-15**] 06:20AM BLOOD Glucose-110* UreaN-44* Creat-3.1* Na-141
K-4.7 Cl-109* HCO3-22 AnGap-15
[**2150-8-15**] 06:20AM BLOOD Calcium-7.7* Phos-4.0 Mg-2.6
Brief Hospital Course:
This is a 55 year old male with a known colovesical fistula. He
had colonoscopy on [**2150-8-3**] which showed Diverticulosis of the
sigmoid colon and transverse colon with the colovesical fistula
likely arising from diverticulum.
.
He went to the OR on [**2150-8-3**]
for: Repair of colovesical fistula.He had a PCA for pain
control. Toradol was also added. He was tolerating the pain.
Once back on a diet, he was started on
PO meds.GI/ABD: He was NPO with IVF. His abdomen was soft and
nontender.
He had a JP drain in the LLQ.
He was started on clears on POD ... He diet was slowly advanced
as he had return of bowel function...
GU: During the operation, Dr. [**Last Name (STitle) **] noted a large phlegmon
associated with the back wall of the bladder on its
intraperitoneal surface and was concerned about the
significance of the size of the mass and its potential to be
bladder cancer, which would change the operation.
Upon inspection, the phlegmon, strongly suggested an
inflammatory rather than malignant process. The patient was
asymptomatic prior to surgery with regard to his urinary system.
.
On [**8-8**] Mr. [**Known lastname **] had fevers up to 102 last 36h. Started on
pip/tazo [**8-8**] afternoon for ecoli and pseudomonal UTI. Had a
repeat CT abd which showed no evidence of anastomotic leak.
.
On [**8-9**] Pt was triggered for tachypnea and SBP 80s (down from
120s baseline). Received 1L IVF which improved SBP to 100s.
Transferred to ICU. Upon arrival to ICU, ABG 7.45/29/75 w
lactate 4.2. Noted to have stool coming out of foley. He was
taken back to OR on [**8-9**] and found to have stool in
abd.Subcutaneous skin left open. Then transfered to [**Hospital Unit Name 1863**],
intubated. Started on pressors. Nephrology consulted for non
oliguric renal failure with peak creatinine of 3.6 . PT
resuscitated with IVF. and started on meropenem and vanc. Pt
defervesed.
.
By [**8-11**] he was off pressors and extubated, Cultures revealed
pansensitive pseudomonas in urine .
.
[**8-13**] transfered to 12Reisman. Progressed slowly. Required
reinforcement and encouragment to ambulate. C/O arthritis pain
of knees and elbows. Physical Therapy consulted. Pt declined PT
services on multiple occasions.Unable to treat with NSAIDS due
to elevated Creatinine. Discussed alternate options with
Rheumatology. Started on topical Capsaicin with adequate
response. Able to ambulate more comfortably. Pt continued to be
followed [**Name6 (MD) **] ostomy RN, teaching provided.
.
[**8-14**] Vancomycin discontinued. Cr trended down. Pt started on
sips. Diet advanced as bowel function resumed. Urine output
adequate. COntinued with supplemental oxygen via nasal cannula.
Instructed on importance of ambulation, IS use, and coughing
exercises.
.
[**8-15**] pt given clears and transitioned to PO pain meds. Tolerated
well. Ambulating with minimal assist. Ostomy functioning, stoma
beefy red & viable. Abdominal incision packed with AMD kerlix
and retentions sutures intact.
.
[**8-17**]: Tolerating regular food, and oral pain medications with
pain <[**5-30**]. pt went for retrograde urethrogram which revealed
small leak at anterior aspect of bladder. Foley remained in
place. Patient was education on Foley to leg bag care for
discharge. Follow-up appointment was arranged with Dr. [**Last Name (STitle) 1864**]
on [**2150-8-28**] with CT SCAN prior to visit. Visiting Nursing services
arranged for ostomy care, foley care, and glucose montoring. He
was instructed to HOLD following medications due to elevated
creatinine: Lisinopril, Gyburide/Metformin, and Indomethacin.
Creatinine will be followed per PCP and Urology.
.
Spoke to pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1865**]. Confirmed pt's diagnosis of type
II DM. Instructed to maintain on metformin 500 mg [**Hospital1 **]. Will
follow up with PCP [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
[**Doctor First Name 1866**] 60 prn, indomethacin 50qhs, glyburide/metformin 5/500',
lisinopril 20', atenolol 50', simvatain 40', augmentin 875''
(finished course [**8-2**] for UTI)
Discharge Medications:
1. [**Doctor First Name 1866**] 60 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
2. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: One (1)
Tablet PO once a day: HOLD.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD.
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Simethicone 60 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain: DO not exceed 8 tablets
in one day. Do not take tylenol while taking this medication.
Disp:*30 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
9. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for arthritic pain: Please apply to
affected joints .
10. Medications to be HELD
Please do NOT continue taking your Metformin/Glyburide,
Lisinopril, and Indomethacin until your kidney function has
returned to [**Location 1867**]. This will be managed per Urology and your
Primary doctor.
11. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO at
bedtime: HOLD.
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Please make appointment with Dr. [**Last Name (STitle) 1865**] in 1 week for follow up
with diabetes dosing.
Disp:*60 Tablet(s)* Refills:*0*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for infection for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
Discharge Diagnosis:
Primary:
Colovesical Fistula
Diverticulitis
Anastamotic leak
Sepsis
.
Secondary:
Hyperlipidemia, Hypertension, Spinal effusion cervical spine,
knee surgery, diverticulosis/itis
Discharge Condition:
Good
VSS
Ambulating, tolerating Regular diet and pain well controlled
with PO pain meds.
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 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* 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.
* Continue to ambulate several times per day.
* Monitor your incision for signs of infection.
* It is OK to shower and wash. No tub baths or swimming. Keep
incision clean and dry.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid [**Known lastname 1868**] from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
Incision Care:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Kidney Function/Medications to be HELD:
Please do NOT continue taking your Metformin, Glyburide,
Lisinopril, and Indomethacin until your kidney function has
returned to [**Location 1867**]. This will be managed per Urology and your
Primary doctor.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1869**] in [**1-21**] weeks.
2. Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1865**] [**0-0-**] in 1
week and as needed.
3. Please follow-up with Urology-Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 1870**] on
Date/Time:[**2150-8-28**] 11:00 for management & removal of foley
catheter, and follow-up of your kidney function.
***Please have CAT SCAN first-scheduled for Date/Time:[**2150-8-28**]
10:00,Phone:[**Telephone/Fax (1) 491**].
NEITHER DICTATED NOR READ BY ME
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1871**] MD [**MD Number(2) 1872**]
Completed by:[**2150-8-17**]
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40,701
| 102,803
|
42787
|
Discharge summary
|
report
|
Admission Date: [**2117-3-21**] Discharge Date: [**2117-4-27**]
Date of Birth: [**2045-2-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
radiation to left femur
Femur fracture repair
History of Present Illness:
72 yo M living at nursing facility p/w decline in mental status
during past 8 days, per family, w/ acute worsening between
yesterday and today.
.
Pt was admitted to [**Hospital3 **] on [**2117-3-11**], after 1-2 weeks'
complaint of L sided flank pain, which the patient thought was
secondary to a kidney stone. He was found in the ED to have a
GI bleed, which was thought to be secondary to NSAID use for the
flank pain. Found to have gastroduodenitis w/out ulcer via EGD
there, per report. He required no transfusions. He had a CT
scan that demonstrated moderate to severe central stenosis at
L3-L4, L4-L5,
L5-S1 and mottled appearance of bone, worrisome for MM vs. mets
vs. osteopenia. ? of a multiple myeloma suspicion years ago, per
daughter. Discharged to rehab on [**3-13**]. Patient has been making
non-sensical conversations and today was noted not to recognize
daughter. Apparently patient became unarousable today at rehab
and was rushed to the [**Hospital1 18**] emergency department for further
evaluation.
.
In the ED inital vitals were, 97 82 115/101 18 96%RA.
Labs notable for hypercalcemia and acute kidney injury. Being
treated with IV fluids (NS). Mental status improving. CT head
(negative per ED resident). CT torso (not read yet). Vital signs
on transfer: 138/64 77 15 100%/2L. EEG ordered in ED but not
done yet. Access is 18 and 20.
.
On arrival to the ICU, vitals were: 98.5 82 163/82 13 96%RA.
Patient is alert and oriented x2 (person and month/year). Knew
was in hospital but thought was in [**Hospital1 392**]. Patient with halting
speech. Children around patient and very supportive. Pt denies
urinary incontinence/retention, bowel incontinence, saddle
paresthesia. No fevers, chills per family. No chest pains.
Past Medical History:
-GI bleed: recent admission to [**Hospital1 **]
-Coronary artery disease: per mention of d/c summary. No
history of catheterization or echo in the chart. Apparently MI
3 years ago.
-Vascular insufficiency w/ multiple leg ulcers
-? Multiple myeloma: daughter notes that had a mention of MM
disgnosis [**5-31**] yrs ago, but was not confirmed when pt and
-Hypertension
-Hyperlipidemia
-COPD
-OSH -- on BIPAP at home
-Obesiety
-Diverticulitis
-CHF
-Spinal stenosis
Social History:
Prior to hospitalization, pt used a walker to get around. Able
to do all ADLs including cooking, feeding, cleaning.
- Tobacco: quit smoking 10 yrs ago; 140 pack-year hx
- Alcohol: quit EtOH 23 yrs ago
Pt worked as a substance abuse counselor
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
VITALS: 98.5 82 163/82 13 96%RA
General: alert, oriented to person, month and year, states is in
"[**Hospital6 10353**]"
HEENT: Sclera anicteric, MM mildly dry w/ mucous in back of
throat
Neck: supple, JVP not elevated, no LAD, FROM of neck, no
meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur heard best in RU sternal border
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back: no midline spinal tenderness
GU: foley in place
Ext: no pedal edema b/l, significant bilateral lower extremity
skin changes consistent with chronic venous insufficiency
Neuro: AOx2, CN II-XII w/out focal abnormality, patient
purposefully moving all four extremities, with 5-/5 strength in
lower extremities.
.
DISCHARGE EXAM:
.
Pertinent Results:
admission labs:
[**2117-3-21**] 06:00PM BLOOD WBC-7.1 RBC-2.92* Hgb-10.0* Hct-29.3*
MCV-100* MCH-34.2* MCHC-34.1 RDW-14.7 Plt Ct-274
[**2117-3-21**] 06:00PM BLOOD Neuts-67.1 Lymphs-24.3 Monos-6.5 Eos-1.7
Baso-0.6
[**2117-3-21**] 06:00PM BLOOD PT-12.2 PTT-28.4 INR(PT)-1.1
[**2117-3-21**] 06:00PM BLOOD Glucose-90 UreaN-69* Creat-3.7* Na-136
K-4.2 Cl-96 HCO3-29 AnGap-15
[**2117-3-21**] 06:00PM BLOOD ALT-9 AST-23 AlkPhos-62 TotBili-0.3
[**2117-3-21**] 06:00PM BLOOD Lipase-61*
[**2117-3-21**] 06:00PM BLOOD CK-MB-5
[**2117-3-21**] 06:00PM BLOOD cTropnT-0.19*
[**2117-3-21**] 11:36PM BLOOD CK-MB-5 cTropnT-0.18*
[**2117-3-21**] 06:00PM BLOOD Albumin-3.6 Calcium-13.3* Phos-7.0*
Mg-2.9*
[**2117-3-21**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
other pertient labs:
[**2117-3-23**] 02:49AM BLOOD VitB12-218* Folate-5.7
[**2117-4-6**] 09:15PM BLOOD %HbA1c-5.7 eAG-117
[**2117-4-7**] 05:45AM BLOOD Triglyc-144 HDL-35 CHOL/HD-3.8 LDLcalc-68
[**2117-4-6**] 09:15PM BLOOD Ammonia-34
[**2117-3-21**] 06:00PM BLOOD TSH-5.2*
[**2117-3-22**] 03:59AM BLOOD T4-5.1 T3-86 Free T4-1.1
[**2117-3-22**] 02:26AM BLOOD PTH-22
[**2117-3-22**] 02:26AM BLOOD 25VitD-50
[**2117-4-2**] 03:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2117-3-22**] 02:26AM BLOOD PEP-ABNORMAL B IgG-[**2037**]* IgA-27* IgM-6*
IFE-MONOCLONAL
[**2117-4-1**] 05:30AM BLOOD PEP-ABNORMAL B IgG-[**2110**]* IgA-44* IgM-16*
[**2117-3-23**] 02:49AM BLOOD IgG-3481* IgA-48* IgM-12*
[**2117-3-23**] 05:19PM BLOOD b2micro-4.0*
.
FREE KAPPA AND LAMBDA, WITH K/L RATIO
Test Result Reference
Range/Units
FREE KAPPA, SERUM 3290.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 7.1 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 463.38 H 0.26-1.65
.
PARATHYROID HORMONE RELATED PROTEIN
Test Result Reference
Range/Units
PTH-RP 15 14-27 pg/mL
.
VITAMIN D [**2-17**] DIHYDROXY
Test Result Reference
Range/Units
VITAMIN D, 1,25 (OH)2, TOTAL 24 18-72 pg/mL
VITAMIN D3, 1,25 (OH)2 15
VITAMIN D2, 1,25 (OH)2 9
.
CSF
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-74 Monos-26
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-96
LD(LDH)-15
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
NO OLIGOCLONAL BANDING SEEN
STRONG MONOCLONAL BAND IS SEEN IN GAMMA REGION
SAME BAND IS ALSO SEEN IN SERUM PEP
ALTHOUGH THIS IS LIKELY TO REPRESENT NONSPECIFIC
LEAKAGE OF SERUM MONOCLONAL PROTEIN INTO THE CSF
WE CANNOT EXCLUDE THAT THIS REPRESENTS INTRATHECAL SYNTHESIS
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
.
discharge labs:
.....
.
micro:
all blood cultures during admission with no growth
urine cultures x4 with no growth
[**2117-3-31**] 4:16 pm CSF;SPINAL FLUID Source: LP TUBE#3.
GRAM STAIN (Final [**2117-3-31**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2117-4-4**]): NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Cdifficile negative x2
.
studies
admission
Normal sinus rhythm. Possible left atrial abnormality.
Non-specific
ST-T wave abnormalities. No previous tracing available for
comparison
.
admission CXR: Cardiomegaly, but no definite acute
cardiopulmonary process.
.
CT head [**3-21**]
No definite acute intracranial process. Lytic lesions throughout
the skull compatible with multiple myeloma.
.
CT torso [**3-21**]
1. Ground-glass opacities in the bilateral lung zones may
reflect
atelectasis, though a developing infectious process, possibly
aspiration,
cannot be excluded.
2. Cardiomegaly.
3. 2.2 cm rounded hypodensity in the lower pole of left kidney
may represent hemorrhagic cyst, however cannot exclude
malignancy. No lymphadenopathy evident. Could be further
evaluated with ultrasound.
3. Extensive rounded peripancreatic calcifications of unclear
etiology may
represent combination of calcified cysts, and adjacent
diverticula or
aneurysms.
4. Diverticulosis without diverticulitis.
5. Lytic lesions throughout the axial skeleton, as well as large
femoral neck luceny, consistent with reported history of
multiple myeloma. Large femoral neck lytic lesion increases risk
of pathologic fracture.
6. 8 mm heavily calcified outpouching of the aortic arch likely
represents
stable pseudoaneurysm.
.
ECHO [**3-22**]
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined. The
pulmonic valve leaflets are thickened. There is no pericardial
effusion.
.
Femur AP and lateral
1) High suspicion for a new femoral neck fracture, new since
[**2117-3-21**] torso CT. This is likely a pathologic fx through the
lytic lesion in the proximal femoral neck seen on that torso CT.
2) Large lytic lesion in proximal femoral diaphysis, with
endosteal
scalloping, at increased risk for fx.
.
Hip Xray
Essentially a single view of the left hip was obtained. Detail
is
considerably limited by overlying soft tissues. There is
accentuated varus
angulation of the intertrochanteric proximal left femur,
consistent with a
left basicervical fracture. This is new compared with a torso CT
obtained on [**2117-3-21**].
.
MRI head without contrast
Motion limited study. No definite acute infarct identified.
Brain atrophy and small vessel disease seen. Chronic infarcts in
the
brainstem and right thalamus are identified.
.
routine EEG [**3-30**]
This is an abnormal EEG because of mild to moderate diffuse
background slowing and focal epileptiform discharges in the
right
temporal region. These findings are indicative of a mild to
moderate
diffuse encephalopathy with focal area of epileptogenic
potential in the
right temporal region.
.
CT head without contrast [**4-6**]
No CT evidence for acute intracranial process, though MR would
be
more sensitive for acute infact, particularly given the
extensive background abnormality.
.
CXR [**4-6**]
As compared to the previous radiograph, the esophageal catheter
has
been removed. There is a minimal left pleural effusion.
Unchanged low lung
volumes with persistent mild pulmonary edema. The signs
suggesting previous interstitial edema have improved. There is
no evidence of current pneumonia.
.
ECHO [**4-7**]
The left atrium is elongated. No atrial septal defect (ASD) or
patent foramen ovale (PFO) is seen by 2D, color Doppler or
saline contrast with maneuvers. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy (LVH) with normal cavity size. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Overall, normal
biventricular systolic function. However, due to technical
difficulties, a focal wall motion abnormality cannot be fully
excluded. Mild LVH. Mildly dilated ascending aorta. No ASD or
PFO seen by 2D, color Doppler or saline contrast with maneuvers.
No significant valvular stenosis or regurgitation. Borderline
pulmonary hypertension.
.
CXR [**4-8**]
Mild-to-moderate pulmonary edema is new, and basal opacification
is first
attributable to dependent edema before considering concurrent
pneumonia.
Heart size top normal, unchanged. Small pleural effusions are
presumed. No
pneumothorax. A vascular line ends in the left axilla before
entering the
chest.
.
24 hour EEG [**4-9**]
This telemetry captured no pushbutton activations. The
background was mildly slow throughout suggesting an
encephalopathy.
There was minimal left temporal slowing. There were no clearly
epileptiform features or electrographic seizures.
.
LUE ultrasound [**4-10**]
Thrombosis along the venous catheter within the left cephalic
vein. No thrombosis within the deep veins of the left upper
extremity.
.
-------------
[**2117-4-18**] 07:20AM BLOOD WBC-5.3# RBC-3.07* Hgb-9.6* Hct-30.9*
MCV-101* MCH-31.3 MCHC-31.1 RDW-18.1* Plt Ct-243
[**2117-4-19**] 08:50AM BLOOD WBC-5.3 RBC-3.15* Hgb-10.1* Hct-32.3*
MCV-103* MCH-32.2* MCHC-31.4 RDW-18.4* Plt Ct-256
[**2117-4-20**] 05:50AM BLOOD WBC-6.3 RBC-2.98* Hgb-9.5* Hct-31.0*
MCV-104* MCH-31.9 MCHC-30.6* RDW-18.7* Plt Ct-217
[**2117-4-21**] 06:20AM BLOOD WBC-5.4 RBC-2.83* Hgb-9.0* Hct-29.8*
MCV-105* MCH-31.9 MCHC-30.3* RDW-18.8* Plt Ct-172
[**2117-4-21**] 04:57PM BLOOD WBC-10.8# RBC-2.50* Hgb-8.3* Hct-25.8*
MCV-103* MCH-33.4* MCHC-32.4 RDW-18.7* Plt Ct-183
[**2117-4-21**] 08:45PM BLOOD WBC-11.7* RBC-2.57* Hgb-8.3* Hct-26.7*
MCV-104* MCH-32.2* MCHC-31.0 RDW-18.8* Plt Ct-171
[**2117-4-22**] 06:30AM BLOOD WBC-7.5 RBC-2.32* Hgb-7.7* Hct-23.9*
MCV-103* MCH-33.2* MCHC-32.2 RDW-19.1* Plt Ct-135*
[**2117-4-23**] 07:10AM BLOOD WBC-5.4 RBC-2.34* Hgb-7.7* Hct-24.0*
MCV-102* MCH-32.7* MCHC-32.0 RDW-19.9* Plt Ct-120*
[**2117-4-23**] 08:10PM BLOOD Hct-27.2*
[**2117-4-24**] 08:37AM BLOOD WBC-6.8 RBC-2.83* Hgb-9.5* Hct-27.8*
MCV-99* MCH-33.5* MCHC-34.0 RDW-20.0* Plt Ct-133*
[**2117-4-24**] 05:45PM BLOOD Hct-28.9*
[**2117-4-24**] 05:45PM BLOOD Hct-28.9*
[**2117-4-25**] 07:35AM BLOOD WBC-6.5 RBC-3.13* Hgb-10.0* Hct-31.2*
MCV-100* MCH-32.0 MCHC-32.0 RDW-19.4* Plt Ct-154
[**2117-4-26**] 07:00AM BLOOD WBC-6.5 RBC-3.04* Hgb-9.8* Hct-30.7*
MCV-101* MCH-32.3* MCHC-32.0 RDW-19.0* Plt Ct-191
[**2117-4-22**] 06:30AM BLOOD Glucose-90 UreaN-31* Creat-0.9 Na-137
K-4.5 Cl-105 HCO3-25 AnGap-12
[**2117-4-23**] 07:10AM BLOOD Glucose-90 UreaN-32* Creat-0.9 Na-140
K-4.4 Cl-108 HCO3-26 AnGap-10
[**2117-4-24**] 08:37AM BLOOD Glucose-88 UreaN-24* Creat-0.7 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
[**2117-4-25**] 07:35AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-141
K-4.5 Cl-107 HCO3-28 AnGap-11
[**2117-4-26**] 07:00AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-141
K-5.1 Cl-107 HCO3-27 AnGap-12
[**2117-4-25**] 07:35AM BLOOD ALT-23 AST-13 LD(LDH)-173 AlkPhos-80
TotBili-0.5
[**2117-3-23**] 02:49AM BLOOD VitB12-218* Folate-5.7
[**2117-4-6**] 09:15PM BLOOD %HbA1c-5.7 eAG-117
[**2117-4-7**] 05:45AM BLOOD Triglyc-144 HDL-35 CHOL/HD-3.8 LDLcalc-68
[**2117-3-21**] 06:00PM BLOOD TSH-5.2*
[**2117-3-22**] 03:59AM BLOOD T4-5.1 T3-86 Free T4-1.1
[**2117-3-22**] 02:26AM BLOOD PEP-ABNORMAL B IgG-[**2037**]* IgA-27* IgM-6*
IFE-MONOCLONAL
[**2117-3-23**] 02:49AM BLOOD IgG-3481* IgA-48* IgM-12*
[**2117-4-1**] 05:30AM BLOOD PEP-ABNORMAL B IgG-[**2110**]* IgA-44* IgM-16*
[**2117-4-20**] 05:50AM BLOOD PEP-ABNORMAL B
[**2117-3-23**] 02:49AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2117-4-20**] 05:50AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
Brief Hospital Course:
BRIEF HOSPITAL COURSE: Patient is a 72M with a PMH significant
for coronary artery disease, peripheral vascular disease, HTN,
hyperlipidemia with question of prior MGUS or smoldering myeloma
diagnosis who now presented with altered mental status found to
have severe hypercalcemia of malignancy, diffuse lytic lesions
on imaging and monoclonal immunoglobulin spike on protein
electrophoresis in the setting of acute renal insufficiency
concerning for multiple myeloma. His mental status gradually
improved with treatment of hypercalcemia in the ICU and he was
tranferred to the floor. His course of the floor was complicated
by an episode of acute altered mental status thought to be due
to seizure and he was started on keppra. He started treatment
for his multiple myeloma with good response in his SPEP and IgG
Kappa labs and ultimately decided to undergo surgery to
stabilize his femur fracture on [**4-21**] which was complicated only
by some mild post-operative anemia requiring 4 units of pRBCs
over 3 days. At discharge, his HCT was stable. He is due for
his second cycle of chemotherapy on [**4-30**] of
velcaide/dexamethasone.
# HYPERCALCEMIA OF MALIGNANCY, [**2-25**] MULTIPLE MYELOMA ?????? Patient's
calcium on admission in the 13 range, which downtrended to
normal. Appeared intravascularly depleted on admission and
sustained aggressive volume resuscitation with improvement in
metabolic derangements. Diagnosis most consistent with
hypercalcemia in the setting of myeloma given lytic lesions,
monoclonal Ig spike and renal insufficiency. Responded well to
ECV repletion with IV fluids, IV bisphosphonate therapy and
calcitonin SC. Calcitonin was discontinued and calcium remained
within normal range up to discharge.
# ALTERED MENTAL STATUS ?????? Likely multifactorial toxic or
metabolic encephalopathy based on exam and clinical appearance
on admission. Attempted IV naloxone infusion given opioid use
and renal insufficiency which provided a quick response
initially but did not clear the delirium. Infectious work-up was
negative. TSH and TFTs reassuring. CT head without acute
intracranial process, only skull lytic lesions. MRI also did not
show acute process and LP did not show signs of infection.
Overall mental status improved with hydration and improvement in
electrolyte imbalances. On [**4-6**] patient had episode of acute
altered mental status. Code stroke was called. CT head without
contrast did not show evidence of bleed. Patient declined repeat
MRI. Episode thought to be most likely [**2-25**] to seizure. 24 hr EEG
did not show any epileptiform featurs or electrographic
seizures, however per neuro the decision was made to continue to
treat with keppra 750 mg by mouth [**Hospital1 **]. He was also continued on
ASA and statin. He has plans to follow up with neurology after
discharge.
# Multiple myeloma: Patient started treatment with velcaid on
[**4-9**] and dexamethasone was added on [**4-13**]. Heme path reviewed CSF
which had no evidence of plasma cells. Patient underwent
palliative XRT of lytic lesion in femur on [**4-12**]. Tolerated
cycle 1 well without complication. IgG Kappa and SPEP showed
good response to chemotherapy. Due for second cycle of
velcaide/dex [**4-30**]. Outpatient oncologist will be Dr [**First Name8 (NamePattern2) 85290**]
[**Last Name (NamePattern1) **].
# Left Femoral fracture: Patient found to have pathologic left
femur fracture. Initially the decision was made to hold off on
surgery given altered mental status. However, patient clinically
improved. He underwent palliative XRT of a lytic lesion in his
femur. He then underwent orthopedic surgery on [**4-21**] for repair
and tolerated this well, only complicated by mild anemia
post-operatively requiring 4 units pRBC over 3 days. He will
require extensive physical therapy both for his femur repair as
well as his overall deconditioning (bedbound for ~34 days). He
will follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] of orthopedics.
# ACUTE RENAL INSUFFICIENCY ?????? Creatinine on presentation in the
3.7 range with response to hydration. Secondary to hypovolemia.
Creatinine returned to baseline and remained stable through
duration of admission.
# Fever - patient spiked fever to 101.7 on [**4-8**]. pancultured.
started vanc and zosyn for concern of possible aspiration
pneumonia however CXR concerning for volume overload. UA
negative. Stage 1 decub without evidence of infection. Had RUE
ultrasound which showed clot around the midline in left cephalic
vein which may have caused fever. Line was removed. Abx dc'd on
[**4-12**] and patient continued to remain afebrile.
# CORONARY ARTERY DISEASE, CHF HISTORY ?????? Presented with severe
volume depletion, but no evidence of coronary ischemia. Cardiac
biomarkers elevated slightly in the setting of renal
insufficiency with flat CK-MB. No prior catheterization reports
available. 2D-Echo this admission showing hyperynamic LVEF with
only severe MV annular calcification and no significant valvular
disease. EKG reassuring on admission. ACE/[**Last Name (un) **] held in the
setting of initial renal insufficiency. He was continued on beta
blocker, statin, aspirin, and imdur.
# COPD ?????? Stable. Continued nebs prn.
# OSA - Continued home bipap.
[**Date range (1) 92436**] ICU course:
Patient was admitted with respiratory distress. He was placed on
CPAP and suctioned with removal of large mucous plugs. He was
taken off of narcotics and given IV tylenol. He had good oxygen
saturations on room air at time of discharge from the ICU.
Transitional Issues
- if platelets drop below 50 with active bleeding, or if
platelets drop below 30 without bleeding, please discontinue
lovenox and aspirin
- last day lovenox [**5-12**] for dvt ppx after orthopedic procedure
- follow-up with new providers: [**Doctor Last Name **] for Heme/onc,
[**Location (un) 4223**] for orthopedics, [**Doctor Last Name 1206**]/[**Doctor Last Name **] Haerents for neurology.
- cycle 2 of chemotherapy on [**4-30**]:
Chemotherapy Regimen
?????? Bortezomib 2.9 mg IV Days 1, 4, 8 and 11. (1.3 mg/m2)
Supportive Hydration
?????? Dexamethasone 20 mg PO ASDIR Please give the day before and
day after velcade. Specifically days 1,2,4,5,8,9,11,12
?????? If this patient has central venous access, flush per hospital
policy.
PLEASE SPEAK WITH DR [**Last Name (STitle) **] AT ([**Telephone/Fax (1) 3936**] PRIOR TO
ADMINISTRATION
Medications on Admission:
Metoprolol XL 50 mg PO OD
Imdur 60 mg PO OD
Zocor 40 mg PO OD
MVI 1 tab PO OD
Protonix PO 40 mg [**Hospital1 **]
Flexeril 10 mg TID PRN Muscle spasm (d/c [**3-15**])
Oxycodone 5 mg PO Q 4 hr PRN PAin (recent d/c)
tylenol 650 mg PO q 4 hr PRN fever
Furosemide 40 mg PO OD
spiriva
proair
Discharge Medications:
1. acetaminophen 500 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day).
2. docusate sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Month/Year (2) **]: One (1)
Tablet PO DAILY (Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Toprol XL 50 mg Tablet Extended Release 24 hr [**Month/Year (2) **]: One (1)
Tablet Extended Release 24 hr PO once a day.
7. levetiracetam 750 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
8. simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Year (2) **]: Two (2)
Tablet PO DAILY (Daily).
10. acyclovir 400 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every 8
hours).
11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. Imdur 60 mg Tablet Extended Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Extended Release 24 hr PO once a day.
13. enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 3 weeks: last day [**5-12**].
14. multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
15. senna 8.6 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
16. oxycodone 5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care [**Hospital1 **]
Discharge Diagnosis:
Toxic metabolic encephalopathy
Hypercalcemia
Multiple myeloma
Pathologic left femur fracture s/p repair
Anemia
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted with altered mental status from high calcium.
As part of the workup for the high calcium, we discovered that
you had a cancer known as multiple myeloma. You underwent
chemotherapy and radiation to your leg. You also underwent
surgery for your left thigh fracture, which was repaired.
You will need extensive physical therapy and close oncology
follow-up after discharge.
Medication changes:
START
Tylenol 1g three times per day as needed for pain
Oxycodone 2.5-5mg every four hours as needed for pain
Colace 100mg twice per day
Senna 1-2 tabs as needed twice per day for constipation
Bactrim SS (400/80) 1 tab once per day
Lidocaine patch to area of pain twelve hours on, twelve hours
off
Keppra 750mg twice per day
Vitamin D 400mg once per day
Acyclovir 400mg every 8 hours
Lovenox 30mg syringe subcutaneously twice per day for 3 weeks
after orthopedic procedure (last day [**5-12**])
Senna 1-2 tabs twice per day as needed for constipation
STOP
Flexeril
Lasix
Spiriva
Otherwise take all medications as prescribed.
If your platelet count falls below 50 with bleeding, or below 30
without bleeding, please discontinue aspirin and lovenox.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2117-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], 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: ORTHOPEDICS
When: MONDAY [**2117-5-17**] at 9:15 AM
With: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 92437**] R.
Address: 21 [**Doctor Last Name **] HWY [**Apartment Address(1) 24578**], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 9489**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2117-5-6**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) 610**] [**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: NEUROLOGY
When: FRIDAY [**2117-5-14**] at 2:30 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] HAERENTS [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,556
| 117,719
|
20488+20489
|
Discharge summary
|
report+report
|
Admission Date: [**2103-4-8**] Discharge Date: [**2103-4-14**]
Service:
CHIEF COMPLAINT: Lower gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
gentleman with no significant past medical history except
disc herniation (on nonsteroidal antiinflammatory drugs and
aspirin for the last 10 years) who was sent from an outside
hospital for a lower gastrointestinal bleed.
The patient initially presented to [**Hospital1 **]-[**Location (un) 620**] on [**2103-4-7**] at noon with back and hip pain (the patient has been
treated for years for a ruptured disc - on nonsteroidal
antiinflammatory drug therapy) and also with a complaint of
bright red blood per rectum for the last six days.
The patient was sent to the [**Hospital1 188**] and was found to have a hematocrit decreased from 36
to 34 and a RED to 27. The patient was transfused one unit
of packed red blood cells. In addition, he had a question of
coffee-grounds emesis in the Emergency Department, but a
negative nasogastric lavage performed by Gastroenterology.
The patient continued to have a moderately brisk lower
gastrointestinal bleed with about 300 cc to 400 cc of bright
red blood per rectum every two to three hours. The patient
then had a tagged red blood cell scan performed by angiogram
which showed no extravasation and was a negative study. The
patient's bleeding slowly trickled down. At the time of
transfer to the Medical Intensive Care Unit, the patient had
only three bowel movements with a mild amount of blood in
each bowel movement.
Of note, the patient had a fall on [**2103-4-2**] with
residual hip and back pain. Starting on [**2103-4-2**] he
had several episodes of pain with dark red stools. He also
complained of some lower abdominal discomfort, but no nausea
or vomiting. He has been taking two tablets of ibuprofen and
one aspirin per day for the last 10 years. The patient is
mildly demented and unable to provide a clear and concise
history.
Review of systems was positive for a 10-pound weight loss
over the last seven to eight ears. He denied any fatigue.
He denied any dizziness or lightheadedness at home. No
orthopnea or paroxysmal nocturnal dyspnea. No chest pain or
shortness of breath.
PAST MEDICAL HISTORY:
1. Benign prostatic hypertrophy.
2. Disc herniation (on nonsteroidal antiinflammatory drugs).
3. Hypercholesterolemia.
4. Possible dementia.
5. Right eye cataract surgery.
6. A colonoscopy 10 years ago (per his daughter which was
within normal limits, although the patient states he has
never had a colonoscopy).
7. Gait instability and frequent falls.
MEDICATIONS ON ADMISSION:
1. Aspirin as needed (for pain).
2. Ibuprofen two tablets once per day as needed (for pain).
3. Iron sulfate.
4. Colace.
ALLERGIES:
SOCIAL HISTORY: The patient lives with his wife who has
suffered a cerebrovascular accident, and the patient
apparently takes care of his wife when he is at home. His
daughter is [**Name (NI) **] [**Name (NI) **]. Her telephone number is
[**Telephone/Fax (1) 54836**]. The patient has a remote history of tobacco
use but quit 30 years ago. He use to smoke 60 to 100 pack
years. He denies any significant alcohol use. He is a
retired firefighter.
FAMILY HISTORY: No family history of colon cancer. His
father died of emphysema and lung cancer. His mother died of
a cerebrovascular accident.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 97.8
degrees Fahrenheit, his blood pressure was 151/95, his pulse
was 86, sinus arrhythmia, and his oxygen saturation was 99%
on 3 liters nasal cannula. The patient weighed 69 kilograms.
In general, he was an elderly male sitting comfortably.
Inattentive and in no apparent distress. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light. The extraocular movements were
intact. The mucous membranes were moist. The neck was
supple. The sclerae were anicteric. There was no
lymphadenopathy. The chest was clear to auscultation
bilaterally with a decreased inspiratory effort and decreased
breath sounds throughout. Cardiovascular examination
revealed a regular rate. A 2/6 systolic murmur best heard at
the left lower sternal border with radiation to the apex as
well as the left carotid. The abdomen revealed tenderness to
palpation in the bilateral lower quadrants. Otherwise, there
was no hepatosplenomegaly. There was no rebound and no
guarding. The abdomen was soft with good bowel sounds.
Extremities revealed no lower extremity edema. There were no
rashes. Rectal examination (per Gastroenterology) revealed
maroon stool that was guaiac-positive and an enlarged
prostate. Neurologic examination revealed the patient was
alert and oriented times three. The patient stated his name,
he was at a hospital, and it was [**2103-4-8**]. There was
no midline or spinal tenderness to palpation. He had good
bilateral upper and lower extremity strength at 5/5. There
were no cranial nerve deficits.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 7, his hematocrit on transfer was 34 (on
admission on [**4-7**] was 36, then dropped to 33, then stable
at 27, and then up at 34 status post transfusion of one unit
of packed red blood cells - the patient's baseline hematocrit
is 41), his mean cell volume was 90, and his platelets were
262. Chemistry-7 revealed his sodium was 140, potassium was
3.5, chloride was 106, bicarbonate was 27, blood urea
nitrogen was 22, creatinine was 1.1, and his blood glucose
was 93. Calcium was 8.5, his magnesium was 3, and his
phosphate was 2. Alanine-aminotransferase was 18, his
aspartate aminotransferase was 26, his alkaline phosphatase
was 37, his total bilirubin was 0.4, his amylase was .......,
and his lipase was 22. His INR was 1.3. Partial
thromboplastin time was 27. His creatine kinase was 160.
MB was 4. Troponin was less than 0.01.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was pending.
An electrocardiogram showed a normal sinus rhythm with a rate
of 81. There was right atrial enlargement and left atrial
enlargement. Borderline left ventricular hypertrophy. P-R
prolongation. Poor baseline, but no T wave inversions or ST
changes.
IMPRESSION: This is an 81-year-old gentleman with no
significant past medical history who presented with lower
gastrointestinal bleed.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL BLEED ISSUES: On admission to the
Medical Intensive Care Unit, the patient's gastrointestinal
bleed appeared clinically to be slowing down. He had a
negative tagged red blood cell scan (as mentioned in the
History of Present Illness) and a negative nasogastric
lavage. The patient's hematocrit stable after his
transfusion of one unit of packed red blood cells in the low
30s. He remained hemodynamically stable throughout his
hospital course.
The patient did have a colonoscopy performed which showed
diverticulosis of the entire colon. No obvious colonic
polyps or large masses were seen; however, the colonoscopy
preparation was poor. Therefore, small polyps could have
easily been missed. Gastroenterology suggested that the
patient continue with a normal diet, and if his hematocrit
remained stable for over 24 hours, from a gastroenterology
standpoint, the patient was safe to be discharged from the
hospital. The patient was to avoid taking aspirin,
ibuprofen, or any other nonsteroidal antiinflammatory drugs
and was to take Tylenol instead for pain. The patient should
follow up with his primary care physician for any further
gastrointestinal issues.
The patient was initially placed on Protonix 40 mg
intravenously twice per day prior to colonoscopy, and with
colonoscopy results indicating the likely source of bleed as
a diverticular bleed the patient was maintained on Protonix
40 mg once per day for gastrointestinal prophylaxis.
At the time of this dictation, at discharge, the patient's
hematocrit had been stable at 32. He has had no further
episodes of gastrointestinal bleeding, and he should continue
to hold nonsteroidal antiinflammatory drugs and aspirin.
2. MENTAL STATUS ISSUES: On admission it was evident that
the patient most likely had a mild dementia since he had some
problems with attention during the history taking. At night,
the patient was more combative and required Ativan and
Zyprexa for sedation. Haldol should be avoided in this
patient since the patient has a prolonged Q-T at baseline.
The patient should also not receive benzodiazepines since
Ativan was administered and the patient was quite sedated
after receiving this medication.
At the time of this dictation, the patient was currently
being worked up for other causes of dementia. A vitamin B12,
folate, and rapid plasma reagin were currently pending. The
patient was also to have a head computed tomography performed
to rule out a bleed or possibly a subdural hematoma given his
history of a fall one week ago. The patient currently has no
neurological deficits, and his mental status was alert and
oriented times three (to person, place, and time) currently;
however, his mental status waxes and wanes and is often worse
at night. The patient has required a one-to-one sitter and
restraints at night to avoid falls since he frequently tries
to get out of bed. It was possible that the patient may have
an adjustment reaction secondary to a change in his
environment; although, it was necessary to rule out other
causes given his age and his fall one week ago.
A Discharge Summary Addendum will be added to update this
Discharge Summary regarding these mental status issues.
Currently, we are trying to wean off the sitter and the
restraints.
3. CHEST PAIN ISSUES: The patient had one episode of chest
pain during the nuclear red blood cell tagged scan which
resolved shortly thereafter. It was possible that this may
have been secondary to demand ischemia from his
gastrointestinal bleed.
An electrocardiogram showed no ischemic changes, but it was a
poor baseline. The patient does have a unknown coronary
artery disease history. The patient's enzymes were cycled
and were negative for a myocardial infarction. He was
monitored on telemetry and did not show any signs of
abnormalities. The patient was restarted on a beta blocker
50 mg twice per day for hypertension after he remained
hemodynamically stable. The patient should not receive
aspirin given his gastrointestinal bleed. He was also
started on Lipitor for a history of hypercholesterolemia and
likely coronary artery disease.
4. HYPERTENSION ISSUES: The patient manifested high blood
pressures in the 170s to 180s. It was unclear whether these
hypertensive episodes may have been secondary to agitation
since the patient was frequently agitated during some of his
hospital course. The patient was started on by mouth
Lopressor as well as on captopril, and his blood pressure at
the time of discharge had been under better control. Prior
to discharge, I would favor either titrating up the Lopressor
or changing the captopril to a one time daily dosing
lisinopril prior to discharge for easier use of medication.
5. DECREASED CREATININE CLEARANCE ISSUES: The patient
initially had a decreased creatinine clearance on admission
which resolved and was likely prerenal secondary to blood
loss. The patient had a normal creatinine upon discharge,
and his urine output remained within normal limits.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
restated on a regular diet after his colonoscopy. Initially,
he had poor oral intake. However, at the time of this
dictation, he has had improved oral intake.
7. BENIGN PROSTATIC HYPERTROPHY ISSUES: The patient has a
questionable history of benign prostatic hypertrophy which
was not clear on history or on previous records. This issue
will need to be clarified with his primary care physician.
8. LEFT KNEE PAIN ISSUES: On hospital day two, the patient
began to manifest new left knee pain. An arthrocentesis of
the left knee was consistent with pseudogout. Fluid
examination revealed 32,000 white blood cells and [**Pager number **] red
blood cells (with a differential of 72% neutrophils, 3%
lymphocytes, and 25% macrophages). The fluid was rhomboid
trace positive birefringent consistent with calcium
pyrophosphate crystals. However, the Gram stain did not show
any microorganisms, and the fluid cultures have remained no
growth.
Given the patient's left knee pain, Rheumatology was asked
whether intraarticular steroids would be indicated. They
recommended that the patient's pain would most likely resolve
within one week's time, and he did not require further
steroid therapy. If the patient continued to feel pain, a
repeat arthrocentesis of the knee could be performed to
remove further fluid. In the meantime, nonsteroidal
antiinflammatory drugs are contraindicated given his history
of gastrointestinal bleed. The patient will continue with
Tylenol as needed for pain.
9. CODE STATUS ISSUES: Full.
10. PROPHYLAXIS ISSUES: Pneumatic boots and proton pump
inhibitor.
DISCHARGE DISPOSITION: Pending resolution of the patient's
mental status issues, the patient will likely be suitable for
rehabilitation placement. Physical Therapy has evaluated the
patient and felt that he was appropriate for rehabilitation.
DISCHARGE STATUS: To an extended care facility.
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Zyprexa 5 mg by mouth three times per day as needed (for
agitation).
2. Captopril 12.5 mg by mouth three times per day.
3. Metoprolol 50 mg by mouth twice per day.
4. Atorvastatin 10 mg by mouth once per day.
5. Tylenol 500 mg to 1000 mg by mouth q.4-6h. as needed (for
pain); not to exceed 3 grams per day.
6. Protonix 40 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with his primary care physician (Dr. [**Last Name (STitle) **]
within one to two weeks for if any other issues arise.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2103-4-11**] 16:01
T: [**2103-4-11**] 16:14
JOB#: [**Job Number 54837**]
Admission Date: [**2103-4-8**] Discharge Date: [**2103-4-14**]
Service: Medicine
ADDENDUM: Please see the previously dictated Discharge
Summary dated [**2103-4-12**] for History of Present Illness
and Hospital Course.
SUMMARY OF HOSPITAL COURSE (SINCE PREVIOUS DICTATION):
1. HYPOTENSION ISSUES: On [**2103-4-13**], the patient was
noted to have a blood pressure of 60/palp. The patient
denied lightheadedness, dizziness, chest pain, shortness of
breath, or palpitations and had a heart rate in the 50s. His
blood pressure subsequently increased rapidly to 90 without
intervention. A 500-cc normal saline bolus was given, and
the patient's blood pressure increased to 122/80.
An electrocardiogram obtained showed a sinus rhythm without
ST-T wave changes. The patient had two sets of cardiac
enzymes drawn 12 hours apart which were negative. His blood
cultures and urine cultures drawn at the time were negative,
and the patient was afebrile. The patient's hematocrit was
checked and was completely stable from the day prior, and
there were no evidence on physical examination of acute blood
loss.
The patient's blood pressure remained stable for the
remainder of his hospitalization, and his ACE inhibitor and
beta blocker were held. It was anticipated that these
medications will continue to be held and titrated up if
necessary at his extended care facility.
2. MENTAL STATUS ISSUES: The patient's mental status
continued to improve throughout the remainder of his
hospitalization. Vitamin B12, folate, and
thyroid-stimulating hormone were all normal. A rapid plasma
reagin was negative. As noted previously, blood cultures and
urine cultures were negative at the time of this dictation.
As noted previously, the patient's head computed tomography
was completely negative, and he had a nonfocal neurologic
examination.
It was considered likely that the patient's mental status
changes at night were secondary to sundowning and possibly
related to an adjustment reaction secondary to a change in
his environment.
With the improvement in the patient's mental status, the
sitter and restraints were discontinued, and the patient was
alert and oriented times throughout the remainder of his
hospitalization.
3. CHEST PAIN ISSUES: As noted previously, the patient had
an isolated episode of chest pain during the nuclear red
blood cell tag scan which resolved shortly thereafter. As
noted, his electrocardiogram showed no ischemic changes, and
the patient's cardiac enzymes were negative for a myocardial
infarction.
4. GASTROINTESTINAL BLEED ISSUES: Since the previous
dictation, the patient has had no further episodes of
gastrointestinal bleed and has had a hematocrit that has been
stable.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to an extended
care facility.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Diverticulosis.
3. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg by mouth once per day.
2. Acetaminophen 500-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain); do not exceed 3 grams per day.
3. Atorvastatin 10 mg by mouth once per day.
4. Olanzapine 5 mg by mouth three times per day as needed.
5. Colace 100 mg by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was encouraged
to follow up with his primary care physician (Dr. [**Last Name (STitle) 54838**] in
one to two weeks for any new issues that arise.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 54839**]
Dictated By:[**Last Name (NamePattern1) 4950**]
MEDQUIST36
D: [**2103-4-14**] 12:33
T: [**2103-4-14**] 12:41
JOB#: [**Job Number 54840**]
|
[
"458.9",
"401.9",
"562.12",
"280.0",
"712.36",
"275.49",
"722.10",
"294.8",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"81.91",
"99.04",
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
13155, 13437
|
3263, 6402
|
17169, 17242
|
17268, 17585
|
2654, 2792
|
17620, 18037
|
6437, 13131
|
17062, 17148
|
101, 132
|
161, 2245
|
2267, 2628
|
2809, 3246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,984
| 150,618
|
1211
|
Discharge summary
|
report
|
Admission Date: [**2143-11-2**] Discharge Date: [**2143-11-5**]
Date of Birth: [**2075-9-29**] Sex: F
Service: MEDICINE
Allergies:
Norvasc
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 yo female w/ HTN, CRI (baseline 2.9), p/w SOB for the past
week. She reports this began 3 weeks ago and slowly worsened
until this morning when she felt extraodinarily SOB and
"couldn't breath". She presented to [**First Name4 (NamePattern1) 2251**] [**Last Name (NamePattern1) **], where her BP
222/150. She was given ASA 325, Lopressor 5mg IV x3, Lasix 180mg
IV with 1 Liter UOP. She reported mild chest tightness, EKG with
? evolving ST changes, CK 4.3, Trop 0.05. She was given
morphine, heparin (bolus + gtt) and nitro gtt and transferred to
[**Hospital1 18**].
In ED, she was noted to be severely hypertensive - 200s/145,
T97.7, HR 88, RR 21, 95%5L. Exam with diffuse wet crackles, 2+
edema. CXR done no pulmonary edema or consolidation. Trop 0.06,
CK 132. Started on Lasix gtt and bolus of 120mg. Heparin and
nitro gtt continued in ED prior to arrival in CCU.
Taken from admission note
Past Medical History:
HTN
Chronic renal sufficiency
Borderline personality
Glaucoma
Hyperlipidemia
Gout
Hyperparathyroidism
Social History:
Lives in [**Location 3146**] alone.
-Tobacco history: smokes 1 pack/week
-ETOH: occasional (<1 drink/wk)
-Illicit drugs:denies
Family History:
Pt does not know family history; reports "no family"
Physical Exam:
VS: T=98.6 BP=170/112 HR= 94 RR=12 O2 sat=99%RA
GENERAL: Middle aged AA female in NAD. Oriented x3. Odd affect
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Crackles
at bases bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema at ankles, warm and well perfused
extremities.
SKIN: No stasis dermatitis
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ 2+ DP 2+ PT 2+
NEURO: A&O x3, CN 2-12 grossly intact, Sensation intact
throughout, Strength 5/5 in UE/LE equally
Pertinent Results:
[**2143-11-5**] 06:55AM BLOOD WBC-5.8 RBC-3.77* Hgb-10.3* Hct-32.0*
MCV-85 MCH-27.2 MCHC-32.1 RDW-16.8* Plt Ct-236
[**2143-11-2**] 02:05PM BLOOD PT-13.5* PTT-111.2* INR(PT)-1.2*
[**2143-11-5**] 06:55AM BLOOD Glucose-96 UreaN-87* Creat-5.3* Na-138
K-4.2 Cl-99 HCO3-23 AnGap-20
[**2143-11-2**] 02:05PM BLOOD Glucose-110* UreaN-75* Creat-3.9* Na-132*
K-4.5 Cl-98 HCO3-22 AnGap-17
[**2143-11-2**] 08:58PM BLOOD CK(CPK)-112
[**2143-11-3**] 04:46AM BLOOD proBNP-[**Numeric Identifier 7652**]*
[**2143-11-2**] 08:58PM BLOOD CK-MB-4 cTropnT-0.06*
[**2143-11-5**] 06:55AM BLOOD Mg-1.9
[**2143-11-2**] 08:58PM BLOOD Triglyc-67 HDL-15 CHOL/HD-12.7
LDLcalc-162* LDLmeas-<50
CXR [**11-2**]:
No evidence of pneumonia or CHF. Rounded opacities projecting
over the right hilum may represent vascular structures or
prominent lymph nodes. Lateral chest radiograph is recommended
for further evaluation.
ECHO [**11-4**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with inferior and inferolateral
hypokinesis. Overall left ventricular systolic function is
low-normal (LVEF= 50 %). 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. 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.
IMPRESSION: Mild regional left ventricular dysfunction.
Brief Hospital Course:
68 yo female with history of HTN, hyperlipidemia and CRI who
presented with hypertensive emergency and pulmonary edema.
.
HYPERTENSION: Pt presented with severe HTN, dypsnea and elevated
JVP. Neuro exam non-focal. She appeared to be in volume
overload, and was agressively diuresed with a lasix drip. She
was weaned off nitroglycerin gtt and her labetalol dose was
increased. These interventions brought her blood pressure under
better control. A repeat Echo showed ef of 50% and mild
regional left ventricular dysfunction.
CORONARY ARTERY [**Name (NI) 7653**] Pt was without symptoms of chest pain,
EKG initially concerning for ST elevations/T wave abnl in V1-V3.
Trop 0.06, Ck 132. She was started on heparin, which was then
stopped in light of negative enzymes. She was continued on ASA.
A lipid panel was checked.
Acute on Chronic Renal Failure- baseline appears to be 2.9, and
was elevated to 3.9 on admission. Cr rose to 5.3 on discharge.
Cr elevation though to be related to poor forward flow
#Gout- held allopurinol given renal failure
# Borderline Personality- Continued haldol per home dose
Medications on Admission:
Allopurinol 100 mg once daily
Lasix 80mg daily
benztropine 1 mg b.i.d.
Haldol 0.5 mg b.i.d.
labetalol 200 mg b.i.d.
aspirin 81 mg once daily
Discharge Medications:
1. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Outpatient Lab Work
Please check BUN, creatinine, K on [**2143-11-8**] and call results to
Dr. [**Last Name (STitle) 7654**] Phone: [**Telephone/Fax (1) 1144**] and Dr. [**Last Name (STitle) **]: ([**Telephone/Fax (1) 7655**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive Urgency
Pulmonary Edema
Acute on Chronic Renal Failure
Discharge Instructions:
You had very high blood pressure and fluid in your lungs. You
received more Labetolol to control your blood pressure. Your
kidney function is worse. It is important that you get an appt
with Dr. [**Last Name (STitle) **] to assess your laboratory test results.
.
New medicines:
.We increased your Furosemide to twice daily
.We increased your Labetolol to 600mg twice daily
.
Please keep your follow up appt with Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) **] and
Dr. [**Last Name (STitle) **].
Please stop smoking. Information regarding smoking cessation was
given to you on admission. This is the most important thing you
can do for your health.
Followup Instructions:
Primary Care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 1144**] Date/Time:
[**11-12**] at 11:00am.
.
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 62**] Date.time:
[**11-19**] at 3:20pm.
.
Nephrology:
[**First Name8 (NamePattern2) 7656**] [**Name8 (MD) **], MD Phone:([**Telephone/Fax (1) 7655**] Please call your
nephrologist to schedule an appointment in the next 1-2 weeks.
Completed by:[**2143-11-16**]
|
[
"301.83",
"585.9",
"V65.49",
"365.9",
"403.90",
"272.4",
"584.9",
"428.0",
"252.00",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6026, 6083
|
3994, 5110
|
288, 295
|
2341, 3971
|
6885, 7429
|
1508, 1563
|
5301, 6003
|
6104, 6174
|
5136, 5278
|
6198, 6862
|
1578, 2322
|
229, 250
|
323, 1223
|
1245, 1348
|
1364, 1492
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,764
| 101,338
|
46732
|
Discharge summary
|
report
|
Admission Date: [**2110-3-28**] Discharge Date: [**2110-4-1**]
Date of Birth: [**2026-12-6**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Generalized tonic clonic seizure x2
Reason for MICU transfer: Seizure, PNA, CHF and r/o meningitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 99188**] is an 83 year-old woman with HTN, DM, lupus, CKD and
a history of seizure disorder who presents from home after two
seizures. Patient reports first sizure around 5:30pm with
generalized tonic clonic movements lasting about 4 minutes with
a second seizure lasting a shorter duration. Per daughter,
seizures in the past have been attributed to her lupus (?).
Initial vitals in the ED were 96.7 33 160/84 16 100%RA. Pt was
satting 90% on RA and was put on BiPAP at that time. Labs in the
ED were notable for WBC 9.1 71.9%N, HCT 38.3 (b/l 33) proBNP
2626, Cr 2.4 (b/l 1.4-1.5), Glucose 208, Lactate 2.2 and TropT
0.02. K was 6.6. UA was notable for 6 WBC and few bacteria with
nitr negative. CXR revealed pulmonary edema with suggestion of
LUL consolidation c/f PNA. A head CT scan revealed no acute
process. Given presenting complaint of seizures, meningitis was
considered but LP was deferred. Neurology was consulted and
advised emperic treatment for meningitis and starting keppra.
The patient received 750mg IV levofloxacin originally out of c/f
PNA. This was stopped in favor of azithromycin 500mg IV with the
thought that this had less risk of lowering seizure threshold.
For c/f meningitis, received 2g IV ceftriaxone, 2g IV
ampicillin, 600mg IV acyclovir, 1g IV vancomycin. For seizures
received 750mg IV levetiracetam. Also 10 units IV of regular
insulin for hyperkalemia, and 650mg rectal tylenol. Prior to
transfer pt was off Bipap. Vitals on transfer were
On arrival to the MICU, patient appears comfortable although
still requiring 10% nonrebreather but satting high 90s on this.
Denies pain. States her breathing feels much improved.
Past Medical History:
- Fibular Fx and Tibial Fx s/p ORIF on [**2103-6-25**]. Fell on the
stairs, no LOC. Head CT neg.
- SLE - followed by Dr. [**Last Name (STitle) **] @ [**Hospital1 **]
- Insulin dependent diabetes - followed by Dr. [**Last Name (STitle) 713**] @ [**Last Name (un) **]
- HTN
- Hypercholesterolemia
- s/p MI in [**2077**]
- Rheumatoid arthritis
- Headaches
- Osteoporosis
- Cervical dysplasia
- Bell palsy
- Syphillis s/p penicillin Rx
Social History:
Former book-keeper at a furniture store in [**Country **]. Moved from
[**Country **] in [**2069**]. Denies alcohol & tobacco use
Family History:
Mother - DM, CVA. Daughter - DM
Physical Exam:
Physical Exam on Admission:
Vitals: 98.6 137/38 HR 49 98% on 100% NRB RR 16
GENERAL: pt resting comfortably on nonrebreather
HEENT: Normocephalic, atraumatic, EOMs intact, sclerae and
conjunctivae are noninjected. Oropharynx benign. No oral
ulcers
or thrush.
NECK: No JVD, thyromegaly, or adenopathy.
CARDIAC: slow rate. Revealed normal S1, S2. Harsh 2 or [**1-28**]
systolic
ejection murmur of left sternal border, radiating to the right
upper sternal border. No rub or gallop.
LUNGS: Clear to percussion and auscultation.
ABDOMEN: Soft. No organomegaly or masses appreciated.
EXTREMITIES: No clubbing, cyanosis, edema, rash, nodules, or
purpura.
Pertinent Results:
Labs on Admission
[**2110-3-27**] 11:00PM BLOOD WBC-9.1# RBC-4.11* Hgb-11.6* Hct-38.3
MCV-93 MCH-28.2 MCHC-30.2* RDW-13.9 Plt Ct-195
[**2110-3-27**] 11:00PM BLOOD Neuts-71.9* Lymphs-20.2 Monos-6.7 Eos-0.8
Baso-0.3
[**2110-3-27**] 11:00PM BLOOD PT-10.8 PTT-32.2 INR(PT)-1.0
[**2110-3-27**] 11:00PM BLOOD Glucose-208* UreaN-51* Creat-2.4* Na-135
K-6.6* Cl-101 HCO3-25 AnGap-16
[**2110-3-27**] 11:00PM BLOOD proBNP-2626*
[**2110-3-27**] 11:00PM BLOOD cTropnT-0.02*
[**2110-3-27**] 11:00PM BLOOD Calcium-8.7 Phos-5.4*# Mg-2.8*
[**2110-3-29**] 05:42AM BLOOD Vanco-5.9*
[**2110-3-27**] 11:21PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2110-3-27**] 11:21PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-TR
[**2110-3-27**] 11:21PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-1
[**2110-3-27**] 11:21PM URINE CastGr-36*
[**2110-3-27**] 11:21PM URINE Mucous-RARE
Microbiology:
[**2110-3-29**] URINE Legionella Urinary Antigen -PENDING
INPATIENT
[**2110-3-28**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2110-3-27**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
Brief Hospital Course:
83 y/o F h/o HTN, DM, lupus, CKD and a history of seizure
disorder presents with hypoxia after 2 sequential seizures.
# HYPOXIA -> Patient reports that she occasionally has dyspnea
at home. She has a known history of interstitial lung disease
based on prior chest CTs. On presentation, she reported that
her dyspnea was worse than her baseline. She was initially
found to be febrile to 101, tachypneic to the 30s, with O2 sats
in the low 90s. She was initially started on BiPap in the ED,
and then transitioned to a 100% non-rebreather in the MICU.
Differential for her hypoxia included pulmonary edema given
known history of diastolic heart failure, pneumonia,
interstitial lung disease. Her O2 supplement was weaned from NRB
with antibiotics and additional lasix. Repeat echocardiogram
suggested worsening diastolic heart failure. Chest CT was done
after patient failed to notably improve after significant
diuresis and showed LUL and LLL consolidations as well as
chronic ILD. Patient was continued on IV ceftriaxone and
azithromycin for presumed pneumonia. Other than consolidations
on chest CT, there were no other overt signs of infection;
patient remained afebrile, without elevations in her WBC count.
However, she is chronically on steroids, which may have been
masking a possible infection. Once weaned to 3L NC was called
out of MICU. She continued to do well from respiratory
perspective and was satting in the high 90s on 2L O2. At
transfer, she continued on IV ceftriaxone and azithromycin, and
had been diuresed a total of 3L. On the floor, her antibiotics
were transitioned to PO cefpodoxime and azithromycin. She
received one dose of lasix PO on the floor. She was felt to be
euvolemic at that point (minimal crackles at bases, no JVD, no
LE edema). She was taken off oxygen and was satting in the high
90s on room air. Pulmonary saw her and felt that the
consolidations were most likely due to an aspiration
pneumonitis, not pneumonia. Pulmonary recommended outpatient
pulmonary follow-up for PFTs and follow-up of interstitial lung
disease. She was discharged with one additional day of
azithromycin and 3 more days of cefpodoxime.
# SEIZURES -> She initially presented with seizures, possibly
generalized tonic clonic seizure by description of the family,
with history of provoked seizure and possible epilepsy, although
unclear of the exact diagnosis. Patient was not on AED at home.
She initially had drowsiness, thought to be post-ictal.
Etiology of seizure likely multifactorial with underlying PNA on
chest imaging, and acute kidney injury causing medication
accumulation. LP was attempted but was unsuccessful. Her
clinical presentation was not consistent with meningitis (no
meningeal signs, not sensitive to light, full range of neck
motion without pain, no c/o headache); meningitis antibiotics
were discontinued. Her mental status improved over the course
of her MICU stay. She was started on Keppra 750 mg [**Hospital1 **]. No
further seizure activity was noted. Per neurology, patient
should be maintained on keppra for seizure prophylaxis for at
least two years if seizure free, and likely for life.
# Acute renal failure on CKD. Creatinine increased to 2.4 from
baseline of 1.4-1.5. Thought to be pre-renal in the setting of
cardiac dysfunction, poor perfusion, and possibly decreased oral
intake. Medications were adjusted based on renal function. Her
cre improved with diuresis to 1.1. Once on the floor, she
recieved her home dose of PO lasix, 20 mg, and subsequently had
a bump in her cre to 1.3. Lasix was subsequently held given
clinical euvolemia. Recommend restarting lasix upon discharge.
# Bradycardia. Patient initially had HR in mid 50s. Appears
this is her more recent baseline. Last ECG in [**Month (only) 116**] had HR of 59.
Patient's metoprolol was held temporarily for 1 day and
restarted on [**2110-3-29**]. On the floor, patient was noted to have
episodes of bradycardia down to the 30s. Telemetry showed long
pauses without p waves as well as some variable p wave
morphology, possibly related to sick sinus syndrome. EKG showed
long PR interval consistent with 1st degree AV block. Patient
does report that she often feels dizzy at home, although not
here in the hospital, which is concerning for symptomatic
bradycardia. Metoprolol was held given low HR with good
improvement. HR was in the 60-70s at discharge. Patient
remained asymptomatic relative to bradycardia during her
hospitalization.
# Chest pain -> After several days on the floor, patient
developed some new back pain as well as abdominal pain. EKG was
done and showed prolonged PR interval consistent with first
degree AV block but no ST changes. LFTs were normal. Felt to
be most likely musculoskeletal.
# Hypertension. BP on arrival 160 systolic. Likely [**12-26**]
heightened anxiety/sensation of dyspnea. Possible BP has been
further uncontrolled at home which could have caused flash
pulmonary edema. However, given underlying infection and acute
renal failure, her antihypertensives were held for a day with
the exception of lasix to treat presumed pulmonary edema. Her
amlodipine, enalapril, and metoprolol were restarted on
[**2110-3-29**]. Metoprolol was subsequently discontinued on the floor
due to bradycardia down to the 30s.
# Diabetes, insulin dependent. Patient was initially NPO given
mental status. As her mental status improved, she was restarted
on home NPH with sliding scale. Blood sugars hovered in the
mid-200s to 300s. Sliding scale was increased slightly with
some improvement.
# Lupus. Does not appear to be in acute flare.
Hydroxychloroquine and prednisione were restarted on [**2110-3-28**].
Creatinine improved, therefore, hydroxychloroquine dosage was
not changed as it can potentially lower seizure threshold in
renal failure.
# Anemia, chronic. Hct initially was up to 38.3, thought to be
from hemoconcentration. It returned to her baseline around 33
by [**2110-3-29**]. Remained stable throughout hospitalization.
# Elevated lactate 2.2. No anion gap. Could be elevated in the
setting of seizure. Hemodynamically stable for the MICU stay.
# Hyperkalemia. K of 6.6 on arrival. Received 10u IV insulin
in ED with K down to 4.4. Resolved.
=================================
Transitional issues
1. Outpatient follow-up for thyroid nodule found on chest CT
2. Follow-up with neurology for seizures
3. Follow-up with pulmonology regarding interstitial lung
disease for PFTs
Medications on Admission:
- Amlodapine 10 mg daily
- Enalapril 40 mg daily
- Furosemide 20 mg dialy on Monday, Wednsday, and Friday
- Hydroxychloroquine 200 mg daily
- NPH 15 units QAM and 5 units QPM
- Lidocaine 5 % Adhesive Patch PRN
- Metoprolol succinate 50 mg daily
- Prednisone 5 mg daily
- Simvastatin 10 mg daily
- Solifenacin 5 mg daily
- Terazosin 2 mg QHS
- Aspirin 81 mg daily
- Calcium carbonate 1,250 mg daily
- Cholecalciferol 1,000 unit daily
- Colace 100mg [**Hospital1 **]
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Enalapril Maleate 40 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg daily Disp #*1 Tablet Refills:*0
7. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg twice a day Disp #*12 Tablet Refills:*0
8. NPH 15 Units Breakfast
NPH 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg twice a day Disp #*60 Tablet Refills:*2
10. Calcium Carbonate 1250 mg PO DAILY
11. Furosemide 20 mg PO M,W,F
12. Simvastatin 10 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Generalized Tonic Clonic Seizures secondary to infection
Aspiration Pneumonitis
Pneumonia
Acute decompensation of chronic diastolic heart failure
Bradycardia
Acute on Chronic Kidney Disease
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Last Name (Titles) 99189**],
It was a pleasure participating in your care. You were admitted
to the hospital because you had two seizures. You were seen by
Neurology, who recommended that you take a daily medication to
prevent seizures in the future.
You had difficulty breathing when you came into the hospital.
We did a CT scan of your chest and found some abnormal changes
in your lungs. We also treated you with antibiotics because you
may have an infection in your lungs. We recommend that you
follow-up with your lung doctor (pulmonologist).
We also saw that you had some fluid in your lungs. We gave you
medication and helped remove the fluid from your lungs. This
medication helped improve your breathing.
Several times while you were in the hospital, you developed a
very low heart rate. We stopped your medication, metoprolol, to
help increase your heart rate.
Please continue to take all your home medications as prescribed,
except the following:
1. START taking Keppra (Levetiracetam) 750 mg twice daily
2. START taking Cefpodoxime 400 mg twice daily for 3 days
3. START taking Azithromycin 250 mg once daily for 1 days
4. STOP taking Metoprolol
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2110-4-9**] at 10:20 AM
With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2110-5-26**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are in the process of finding a neurology (seizure
specialist) appointment for you. If someone does not call you
with an appointment within the next several days, please discuss
this further at your primary care appointment on [**4-9**].
|
[
"428.0",
"710.0",
"584.9",
"276.7",
"428.33",
"403.90",
"507.0",
"515",
"714.0",
"272.0",
"345.11",
"427.89",
"733.00",
"412",
"250.00",
"585.9",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12583, 12658
|
4856, 11353
|
379, 385
|
12905, 12905
|
3445, 4833
|
14294, 15153
|
2712, 2746
|
11868, 12560
|
12679, 12884
|
11379, 11845
|
13088, 14271
|
2761, 2775
|
240, 341
|
413, 2093
|
2789, 3426
|
12920, 13064
|
2115, 2549
|
2565, 2696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,054
| 121,298
|
4807+4808
|
Discharge summary
|
report+report
|
Admission Date: [**2136-5-1**] Discharge Date: [**2136-5-11**]
Date of Birth: Sex:
Service: ACOVE
HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old
male with a history of hypertension and squamous-cell carcinoma
of the tongue, who was found down at home by the EMTs on
[**2136-5-1**] after life-line activation. By EMT report,
the patient was found alert, confused, and noted to not be
transferred to [**Hospital 16843**] Hospital, where evaluation revealed
hyponatremia to 127, leukocytosis at 19,000, CK of 14,000
with MB of 85, troponin of 8.81, and right and chronic subdural
hematoma. He was then transferred to [**Hospital1 190**] for further evaluation. In the [**Hospital1 346**] Emergency Room, the patient was seen by
the Neurosurgical Service who recommended no surgical
intervention at this time. They felt that his mental status
changes were more likely to be metabolic in etiology, given the
patient's myoglobinemia and hyponatremia. The patient's vital
signs in the emergency room were as follows: Blood pressure
158/81, heart rate 105, respiratory rate 12, oxygen saturation
98% on room air. The patient was treated with normal saline plus
2 ampules of bicarbonate, and the patient was transferred to the
Medical Intensive Care Unit. Head CT here revealed a small
bilateral subdural fluid collection consistent with acute and
chronic subdural hematomas. Chest x-ray was negative for
infiltrate. EKG revealed ST segment depressions of approximately
1 mm in leads 2 and 3. The [**Hospital 228**] medical Intensive Care Unit
course was notable for improving mental status with correction of
metabolic abnormalities. He was reportedly at his baseline at
the time of transferred to the Acove Unit on [**5-3**].
For the issue of the subdural hematomas, the patient was
followed by the Department of Neurosurgery. The patient had
a troponin elevation of 4.3 on [**5-1**], and the patient was started
on a beta blocker. No old EKGs were available for comparison. No
aspirin was given to the patient given his subdural hematomas.
The CKs demonstrated a downward trend with urine alkalinization
to 3500 on transfer. The patient's hyponatremia remained stable
at 128. The patient was febrile to 101.8 on [**5-1**], but no source
was identified. The patient tolerated a soft mechanical diet on
the day of transfer, thought to be high-aspiration risk.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Squamous-cell carcinoma of the tongue status post
resection in [**2130**].
3. History of falls.
MEDICATIONS ON ADMISSION:
1. Captopril 50 mg p.o.b.i.d.
2. Hydrochlorothiazide 25 mg p.o.b.i.d.
3. Lopressor 50 mg p.o.b.i.d.
MEDICATIONS ON TRANSFER FROM THE MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Protonix 40 mg IV q.d.
2. Lopressor 25 mg IV b.i.d.
3. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient was recently divorced. His son,
[**Name (NI) **], is highly involved with his care. He has no tobacco
or alcohol history. He lives in [**Location 20157**], where he has home
care two days a week.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 97.4; heart rate 116; respiratory rate 19; blood
pressure 120/51; oxygen saturation 94% on room air. GENERAL:
The patient is a chronically, ill-appearing male whose speech
is difficult to understand. He is in no acute distress. He
is laying supine in bed. HEENT: Examination revealed the
forehead to have a macular erythema with diffuse scaling.
Sclerae are clear. He has a clear discharge over his eyes
bilaterally. Right pupil is approximately 3 mm in diameter.
Left pupils is 2 mm. Both are reactive. CARDIOVASCULAR :
Regular rate and rhythm with distant S1 and S2, no murmurs,
rubs, or gallops. LUNGS: Lungs were clear to auscultation
bilaterally with minimal air movement due to poor inspiratory
effort. ABDOMEN: Normoactive bowel sounds. Abdomen is
soft, nontender, and nondistended with no hepatosplenomegaly.
He had positive right inguinal hernia. EXTREMITIES: He has
bilateral hand ecchymoses. Capillary refill is about three
seconds. There was no lower extremity edema or cords. The
patient moves all extremities spontaneously. NEUROLOGICAL:
The patient is alert and oriented to self and [**Hospital1 346**]. Speech is difficult to understand.
He follows simple commands. Cranial nerves II through XII
are grossly intact. Although, the patient is minimally able
to cooperate with the examination. Strength is 4+/5
bilaterally in the upper and lower extremities. Skin is warm
and dry without evidence of rashes.
LABORATORY DATA: Laboratory data revealed the following:
The patient had a white blood cell of 10.2, hematocrit 31.3,
platelet count 208,000. Sodium 128, potassium 3.4, chloride
of 93, CO2 of 29, BUN 9, creatinine of 0.7, glucose of 109.
AST 186, ALT 91, alkaline phosphatase of 41, total bilirubin
of 1.4, CK of 3,529, magnesium of 1.9, phosphate of 1.9 and
free calcium of 1.10. He had a urinalysis on [**5-1**], which
revealed large amount of fluid, trace protein, small
leukocyte Estrace, 15 white blood cells, 28 red blood cells,
few bacteria, less than 1 epithelial cell. Chest x-ray
revealed clear lungs. CT of the head revealed multiple small
bilateral acute and chronic subdural hematomas with no shift
or mass effect.
HOSPITAL COURSE: This is a 79-year-old male with a history
of hypertension and tongue cancer, who was found down and
subsequently found to have rhabdomyolysis, hyponatremia,
troponin leak with EKG changes, in addition to acute and
chronic subdural hematomas.
#1. NEUROLOGICAL: The patient's mental status improved
gradually throughout his hospital stay. He remained oriented
to self and to place. He was able to respond to simple questions
and follow simple commands. He was followed closely the
Neurosurgical Service for his subdural hematomas. They did not
believe that surgical intervention is necessary for this patient
at this time. Instead, they have recommended repeating a CAT
scan of the head in several weeks. The patient was seen by the
Neurology Service, as well, particularly regarding the patient's
history of recurrent falls. They felt that the patient's
presentation could be consistent with a progressive supranuclear
palsy or Parkinson plus type syndrome. They requested MRI to
better evaluate for any structural abnormalities. Incidentally,
the MRI revealed a lesion over C2 that the radiologist felt was
concerning for a potential bony metastases. The patient
subsequently had a bone scan, which was negative for metastatic
disease to the bone. The patient will be followed by the
Neurology Service as an outpatient. The patient, at this time,
may be started on a trial of Sinemet in order to assess for a
potential response. Per the Neurosurgical Service, he will have
a repeat CAT scan of his head in approximately three weeks.
#2. RHABDOMYOLYSIS: During his hospital stay, the patient's
CK levels trended markedly downward. He maintained good
urine output with normal renal function. We held off further
bicarbonate and treated the patient initially with maintenance IV
fluids. He continued to do well from a renal standpoint.
#3. HYPONATREMIA: The patient's hyponatremia was felt to be
most consistent with SIADH. The patient had a urine osmolality
of 589 with a urine sodium of 101, as well as a serum osmolality
of 258 with sodium of 128. The most likely cause of this SIADH
is the bilateral subdural hematomas.
We felt that the patient also had a component of cerebral salt
wasting during his hospitalization as the sodium initially
declined from 128 down to nadir of 122. He was on a fluid
restriction of 1.5 liters, and the downward trend occurred in
spite of this. We treated the patient with gentle volume
repletion with normal saline. The patient had a favorable
response to this and the sodium increased to his initial level of
128. It remained stable, thereafter.
#3. CARDIOVASCULAR: The patient had an echocardiogram on
admission, which revealed 2+ mitral regurgitation and a normal
ejection fraction. The patient was started on an ACE inhibitor
for after-load reduction. He did not have any clear evidence on
the echocardiogram to explain the patient's falls. He remained
stable from the cardiovascular standpoint.
DISPOSITION: We felt that the patient in his current
condition is unable to care for himself in his home. He
would likely do best in a acute level rehabilitation center.
At the time of this dictation, we are currently awaiting
placement.
DISCHARGE DIAGNOSES:
1. Recurrent falls of unknown etiology.
2. Acute and chronic subdural hematomas.
3. Hyponatremia consistent with SIADH.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Captopril 25 mg p.o.t.i.d. This medication is to be
titrated up as tolerated.
2. Protonix 40 mg p.o.b.i.d.
3. Senna two tablets p.o.q.h.s.
4. Colace 100 mg p.o.b.i.d.
DIET: The patient's diet will consist of pureed foods and
thickened liquids.
FOLLOW-UP CARE: The patient will followup with his primary
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2136-5-10**] 14:39
T: [**2136-5-10**] 14:49
JOB#: [**Job Number 20158**]
Admission Date: [**2136-5-1**] Discharge Date: [**2136-5-14**]
Service:
ADDENDUM
HOSPITAL COURSE: On the morning [**5-11**], the patient's initial
anticipated day of discharge, his white blood cell count was
noted to be elevated to 32,000 from 10,000, and his creatinine
doubled from 0.7 to 1.6. The patient remained afebrile and did
not have any focal signs of infection. Subsequently, a straight
catheterization was performed, and he was noted to have over 1 L
of urine retained within his bladder. The patient had a Foley
placed. He then defervesced. His creatinine decreased to 0.8 on
the day of discharge today, and his white blood cell count
decreased back to his baseline of 10,000. The patient was
discussed with the Urology Service, and they recommended leaving
[**Hospital 159**] Clinic within one week. During this time, he will take
Ciprofloxacin 250 mg b.i.d. for prophylaxis against urinary tract
infection given the chronic indwelling Foley catheter.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2136-5-14**] 10:49
T: [**2136-5-14**] 11:15
JOB#: [**Job Number 20159**]
|
[
"584.9",
"401.9",
"E888.9",
"728.89",
"852.21",
"253.6",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8656, 8798
|
8821, 9594
|
2584, 2921
|
9612, 10734
|
3173, 5403
|
2438, 2558
|
2938, 3150
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,542
| 182,237
|
803
|
Discharge summary
|
report
|
Admission Date: [**2183-10-11**] Discharge Date: [**2183-10-24**]
Date of Birth: [**2128-1-16**] Sex: M
Service: MEDICINE
Allergies:
Sudafed
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy on [**2183-10-11**] and [**2183-10-17**]
[**2183-10-11**]: IR embolization of an intercostal/bronchial artery
trunk
supplying the right lower lobe.
[**2183-10-13**] IR Successful embolization of right bronchial artery
[**2183-10-15**]: IR embolization of two right intercostal arteries
supplying lung parenchyma
Intubation
PICC line
History of Present Illness:
Mr. [**Known lastname 5721**] is a 55yo M with history of NSCLC s/p chemo, XRT
and surgery in [**2178**] with post-rad pulm fibrosis, bronchiectasis
and emphysema who presented with hemoptysis. He developed a
cough with frank blood two days prior to admission, and
presented to an OSH for evaluation. There he had stable vital
signs and hematocrit and had a CTA which showed bilateral lower
lobe ground glass opacities, pulmonary herosiderosis vs.
atypical PNA. Patient refused ambulance transfer to [**Hospital1 18**] and
presented to our ED this AM.
.
In the ED, initial vs were: 98.8, 103, 122/100, 20, 100%.
Patient was given ativan for anxiety, approximately one liter of
NS and continued on levaquin which was started on [**10-10**] by his
oncologist. Thoracics was consulted and recommended discussing
his case with IP for possible bronch. Patient had witnessed
hemoptysis of approximately 200cc of frank blood in the ED and
has 4 units crossed. His hematocrit and vitals were stable with
SBP in the 120s and heart rate in the 90s-100s. His EKG was
unremarkable. Thoracics wants on west for OR access if
necessary possibly bronch tomorrow or monday. Had 100-200cc
hemoptysis here and once at home today. 3 total episodes of
large bleeding. Satting 100% on Ra. Got levoflox in ED.
.
On the floor, He denied other complaints.
Past Medical History:
Non-small cell lung cancer: large cell carcinoma (locally
advanced, clinical stage T4 N0-1 M0) in [**2177**].
s/p neoadjuvant chemotherapy (Carboplatin/Taxotere) [**9-13**]
s/p chemoradiation (Radiation + low dose [**Doctor Last Name **]/Taxotere) [**12-13**]
s/p surgical resection [**1-14**] with pathologic stage N0. Only scant
residual tumor noted within lung parenchyma.
Bronchiectasis
Emphysema
Pulmonary fibrosis combined with post-XRT/chemo pulmonary
changes
Social History:
Social History: No tobacco or excessive alcohol. Negative HIV
antibody in [**2180**]. Since [**2177**] he has not smoked
tobacco/cigarretes
- this was confirmed in today's visit (prior 40 pack-year
history
of smoking).
Family History:
N/C
Physical Exam:
Physical Exam:
Vitals: T: 97.7 BP: 149/97 P: 90 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Absent breath sounds in RUL, decreased BS in RLL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2183-10-11**] 09:00AM PT-13.7* PTT-27.9 INR(PT)-1.2*
[**2183-10-11**] 09:00AM PLT COUNT-148*
[**2183-10-11**] 09:00AM NEUTS-55.4 LYMPHS-34.4 MONOS-7.5 EOS-1.4
BASOS-1.1
[**2183-10-11**] 09:00AM WBC-5.1 RBC-5.51 HGB-16.7 HCT-48.2 MCV-87
MCH-30.2 MCHC-34.6 RDW-13.3
[**2183-10-11**] 09:00AM estGFR-Using this
[**2183-10-11**] 09:00AM GLUCOSE-111* UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2183-10-11**] 10:24AM LACTATE-1.8
[**2183-10-11**] 10:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-10-11**] 10:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2183-10-11**] 10:55AM URINE GR HOLD-HOLD
[**2183-10-11**] 02:30PM PLT COUNT-144*
[**2183-10-11**] 02:30PM PLT COUNT-144*
[**2183-10-11**] 02:30PM WBC-5.0 RBC-5.08 HGB-15.5 HCT-43.6 MCV-86
MCH-30.5 MCHC-35.5* RDW-13.5
[**2183-10-11**] 06:21PM TYPE-ART PO2-201* PCO2-44 PH-7.37 TOTAL
CO2-26 BASE XS-0
[**2183-10-11**] 07:42PM HCT-43.4
[**2183-10-19**] 05:00AM BLOOD WBC-8.3 RBC-4.26* Hgb-12.7* Hct-35.3*
MCV-83 MCH-29.8 MCHC-36.0* RDW-14.1 Plt Ct-209
[**2183-10-20**] 03:26AM BLOOD WBC-8.2 RBC-4.25* Hgb-12.7* Hct-36.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-14.0 Plt Ct-224
[**2183-10-21**] 04:30AM BLOOD WBC-6.0 RBC-3.75* Hgb-11.4* Hct-32.7*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.1 Plt Ct-241
[**2183-10-22**] 04:18AM BLOOD WBC-6.7 RBC-3.93* Hgb-11.7* Hct-33.9*
MCV-86 MCH-29.8 MCHC-34.4 RDW-13.8 Plt Ct-238
[**2183-10-23**] 03:36AM BLOOD WBC-5.9 RBC-3.90* Hgb-11.5* Hct-33.4*
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.9 Plt Ct-222
[**2183-10-14**] 03:25AM BLOOD Neuts-89.2* Lymphs-5.6* Monos-4.7 Eos-0.2
Baso-0.2
[**2183-10-17**] 03:10AM BLOOD Neuts-72.9* Lymphs-14.2* Monos-7.7
Eos-4.8* Baso-0.3
[**2183-10-19**] 05:00AM BLOOD Neuts-83.7* Lymphs-7.5* Monos-8.2 Eos-0.2
Baso-0.4
[**2183-10-21**] 04:30AM BLOOD Neuts-78.6* Lymphs-14.9* Monos-5.0
Eos-0.9 Baso-0.6
[**2183-10-23**] 03:36AM BLOOD Plt Ct-222
[**2183-10-23**] 03:36AM BLOOD Glucose-118* UreaN-19 Creat-0.7 Na-137
K-3.4 Cl-108 HCO3-22 AnGap-10
[**2183-10-22**] 03:00PM BLOOD Glucose-112* UreaN-24* Creat-0.9 Na-141
K-3.3 Cl-109* HCO3-24 AnGap-11
[**2183-10-22**] 04:18AM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-146*
K-3.5 Cl-117* HCO3-19* AnGap-14
[**2183-10-21**] 04:30AM BLOOD Glucose-128* UreaN-32* Creat-0.8 Na-144
K-2.9* Cl-116* HCO3-20* AnGap-11
[**2183-10-19**] 05:00AM BLOOD ALT-42* AST-60* LD(LDH)-347* AlkPhos-52
TotBili-2.1*
[**2183-10-18**] 03:03PM BLOOD ALT-39 AST-79* AlkPhos-66 Amylase-75
TotBili-2.7* DirBili-1.2* IndBili-1.5
[**2183-10-15**] 02:30AM BLOOD Amylase-50
[**2183-10-23**] 03:36AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
[**2183-10-22**] 03:00PM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0
[**2183-10-22**] 04:18AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1
[**2183-10-21**] 03:20PM BLOOD Type-ART Temp-37.3 O2 Flow-2 pO2-127*
pCO2-21* pH-7.53* calTCO2-18* Base XS--2 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2183-10-21**] 04:43AM BLOOD Type-ART Temp-37.4 Rates-/22 pO2-108*
pCO2-21* pH-7.54* calTCO2-19* Base XS--1 Intubat-NOT INTUBA
[**2183-10-20**] 08:58PM BLOOD Type-ART Temp-38.1 pO2-109* pCO2-20*
pH-7.55* calTCO2-18* Base XS--1 Comment-O2 DELIVER
Labs on d/c
[**10-24**]: WBC 5.7, HCT 30.1, plt 236
Diff Neuts 78.6, Lymph 14.9, mono 5.0, Eos 0.9, Baso 0.6
Glucose 127, BUN 18, Cr 0.7, Na 140, K 3.7, CL 112, HCO 20,
Ca 7.4, Phos 2.5, Mg 2.1
[**10-23**] ALT 66, AST 43, Alk 59, Tbili 0.7
lipase 389
[**2183-10-17**] 8:05 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2183-10-23**]**
Blood Culture, Routine (Final [**2183-10-23**]): NO GROWTH.
ECG
Study Date of [**2183-10-22**] 9:36:34 AM
Sinus tachycardia. Baseline artifact. ST-T wave abnormalities.
Since the
previous tracing of [**2183-10-19**] the rate is somewhat faster.
BILATERAL LOWER EXTREMITY VENOUS US: Study Date of [**2183-10-20**] 1:34
PM No comparison is available. Bilateral common femoral,
superficial femoral and popliteal veins show normal
augmentation, compressibility and flow. Bilateral calf veins
show normal flow and compressibility. IMPRESSION: There is no
evidence of DVT in the bilateral lower extremities.
[**2183-10-15**] embolization:
IMPRESSION: Successful embolization of two right intercostal
arteries
supplying lung parenchyma.
Arteriography of the right subclavian artery and right imternal
mammary artery
showed predominantly pleural based hypervascularity, but no
significant
pulmonary parenchymal supply.
[**2183-10-17**] Bronch:
This procedure was performed in
the intensive care unit. This was under already obtained
consent of the ICU care. The patient was correctly
identified in the intensive care unit. He was sedated with
Versed, propofol, and some fentanyl. Lidocaine was instilled
through the endotracheal tube. Next, the currently present
#39 double-lumen endotracheal tube was unsecured from his
face. The cuffs were deflated, and an 11-French Cook
catheter was threaded through the bronchial lumen into the
left main-stem, after which the tube was withdrawn, followed
by replacement with a single-lumen #8 endotracheal tube. It
was secured at 24 cm at the lip. The patient maintained
saturation at 100% during this portion.
Next, a flexible bronchoscope was introduced through the
single-lumen endotracheal tube and advanced forward, and as
we approached the carina, we noticed that there was
significant distortion from the previous operation. There
was a very obtuse angle at the carinal bifurcation, and the
bronchus to the middle lobe was slit-like and had some
secretions, which were suctioned out. Then, the right lower
lobe bronchus was examined. There was some clot, which was
very carefully suctioned. There was no evidence of active
bleeding. After that, we performed aggressive suctioning of
the left main-stem as well as the left upper and left lower
lobes. All the visible clot on the left side was removed.
At the end of the procedure, everything appeared very patent.
The patient was saturating above 95% during the entire
procedure. Once we were satisfied with the result, the
bronchoscope was withdrawn. The patient tolerated the
procedure well.
.
[**2183-10-22**]: MRI T spine:
The alignment of the thoracic spine is preserved. The vertebral
body height is preserved. There is no prevertebral soft tissue
edema. There
is no evidence of abnormal signal within the cord.
There is multilevel T2-hypointense signal in the intervertebral
disc
suggesting multilevel disc dehiscence seen in setting of
degenerative changes.
At multiple levels including T4-T5, T5-T6, T6-T7 and T7-T8,
there is minimal
disc bulging; however, there is no spinal canal or neural
foraminal narrowing.
IMPRESSION:
1. Normal signal in the spinal cord.
2. Minimal multilevel degenerative changes in the thoracic
spine, with no
evidence of spinal canal or neural foraminal narrowing.
.
[**2183-10-21**]: FINDINGS: Right basilic PICC line is seen with its tip
in the distal superior vena cava. There are unchanged
postoperative changes in the right upper lung fields with volume
loss. Otherwise, there is no acute change in comparison to the
prior.
IMPRESSION:
1. Right basilic PICC line within the distal superior vena cava.
2. No additional acute changes compared to prior radiograph.
.
[**10-19**] RUQ US:
. No evidence of acute cholecystitis.
2. Small echogenic foci dependently within the gallbladder may
represent non-
shadowing stones versus small polyps.
3. GB adenomyomatosis.
4. Small hepatic hemangioma adjacent to the gallbladder fossa.
Brief Hospital Course:
55 y/o with h/o NSCLC s/p chemo / XRT with resulting pulmonary
fibrosis and bronchiectasis presents with hemoptysis.
#Hemoptysis: On the day of admission ([**10-11**]) bronchoscopy
demonstrated a rapid bleed in the RLL, but they were unable to
visualize due to the briskness of bleeding. He was intubated
and taken to to IR (details below). This temporarily controlled
the bleeding, but Mr. [**Known lastname 5721**] has repeated episodes of
agitation and coughing which led to further episodes. On [**10-13**]
he hemoptysized another 75cc and returned to IR for repeat
embolization. He rebled on the evening of [**10-14**] and returned for
embolization on [**10-15**]. On [**10-17**], interventional pulmonology took
him to the OR and removed a large residual clot. No further
bleeding was noted. While in MICU he was extubated on [**10-18**]. By
discharge he had no oxygen requirement.
IR:
[**10-11**]: R CFA access- R intercosto-bronchial art with late
communication w/pulm art noted- embolized with 300-500 um
embospheres; good angiographic result; no other ikely bleeding
source identified; hemostasis by manual compression.
[**10-12**]: R CFA site no hematoma, palpable distal pulses; no
apparent hemoptysis but Hct 48 --> 43 (0207) --> 36 ([**2198**])
[**10-13**]: recurrence of hemoptysis--> repeat bronchial arteriogram
and embolization(with 500-700 micron embospheres) of a large R
bronchial art; abnormal arterial blush was noted and there was
no spinal contribution; good angiographic result achieved; R CFA
access- hemostasis by digital compression.
#Sedation/withdrawal: During the initial week of hospitalization
Mr. [**Known lastname 5721**] required heavy sedation to remain comfortable while
intubated. This included large doses of midazolam. After
extubation he became autonomically unstable with tachycardia,
hypertension and tremors. He was treated with q1h CIWA scales
and initially required frequent valium dosing. His agitation
eventually improved, and he became less tachycardic. His blood
pressure also improved.
#Neurological deficits. He was noted to have a left leg motor
deficit, as well as word finding difficulty. Neurology was
consulted and felt that he might have spinal cord ischemia
secondary to embolization. An MRI was ordered and showed no
ischemia of the spinal cord. Despite this finding they believe
transient ischemia is responsible for his improving deficits.
His word finding difficulty improved and he was able to speak
clearly prior to discharge.. His leg weakness improved as well
over the next several days. He passed speech and swallow and was
started on a diet. Diet on discharge: Regular Consistency: Soft
(dysphagia); Thin liquids Supplement: Ensure breakfast, lunch,
dinner. Neurology recommends follow up in [**1-11**] weeks and repeat
MRI of T spine with diffusion weighting if deficits remain.
Despite LLE improvment he remains incontinent of stool and
retaining urine. Neurology also recommended wearing a soft
collar for arm tingling.
#Fever: Mr. [**Known lastname 5721**] had a fever on [**10-14**] and spiked again on
[**10-17**]. He was treated empirically for a ventilator-associated
pneumonia although no cultures were positive and there were no
suggestive findings on CXR. He received an 8-day course of
vancomycin and piperacillin/tazobactam. Cultures were negative.
#Anemia: Some anemia, secondary to hemoptysis. Received one
unit early in stay. Hct was afterwards stable.
#Elevated Lipase - patient was noted to have a transaminitis as
well as elevated level of lipase. Most likely secondary to
propofol use for sedation; no evidence of biliary etiology. He
did not complain of abdominal symtpoms. [**10-19**] RUQ US negative.
He has been eating without dificulty. Continued monitoring of
lipase and LFTS biweekly is warrented.
# Tachycardia: Multiple contributing factors, including resp
failure, anemia, and agitation. However with stabilization of
the above factors the patient remains tachycardic to the 110s to
120s. He was orthostatic but remains elevated despite fluid
resusitation. Benzo withdrawal was considered but thought
unlikely given the timeframe and administration of valium
without improvement. He is without onging oxygen requirement
making PE unlikely. Ongoing IVF resusitation is warrented. It is
also hypothesized that the tachycardia is from mild
pancreatitis. Ongoing heart rate monitoring is warrented.
# HTN: After extubation the patient was hypertensive with SBP up
to 190s. This was attribued to aggitation. He was treated with
IV metoprolol, clonidine patch, and IV hydral. With improvement
in his mental status BP improved and he was switch to
monotherapy with PO metoprolol by discharge.
# Delirium: Patient was aggitated for much of his ICU stay
requiring IV Valium, zydis, and IV haldol. This likely
contributed to hypertension and tachycardia. By discharge his MS
had returned to baseline without need for ongoing antipsycotics.
Medications on Admission:
LORAZEPAM 1-2 mg [**Hospital1 **] PRN anxiety/insomnia (around 3 mg a day)
ACAPELLA 20 times in both AM and PM
TESTOSTERONE CYPIONATE [DEPO-TESTOSTERONE] 200 mg/mL Oil - 1.5cc
IM injection Every 14 days
MULTIVITAMIN daily
OMEPRAZOLE 40 mg daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. 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.
7. Acapella Device Sig: Twenty (20) times Miscellaneous
twice a day.
8. testosterone cypionate 200 mg/mL Oil Sig: 1.5 cc
Intramuscular q 2 weeks: currently on hold.
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
hempotysis
presistent tachycardia
LLE weakness and bowel incontinence, bladder retension believed
[**2-11**] to trainsient spinal cord ischemia
Delirium
Anemia
Discharge Condition:
good. A+Ox3, non ambulatory given LLE weakness. HR 110s
Discharge Instructions:
You were admitted because you were coughing up blood. You
required a breathing tube to help you breath while you bleed.
You had three special procedures to help stop the bleeding. We
were able to stop the bleeding and remove the breathing tube.
After the procedure you had some difficulty moving the left leg
and with bathroom control. This is believed to be from
temporarily lack of blood flow to the spinal cord as a
consequence of the embolization procedures. You also remain with
an elevated heart rate which will continue to need treatment on
the rehab. You also had alterations in your mental status and
swallowing ability which have now improved.
The following changes were made to your medication list:
Lorazepam was discontinued
senna and colace were started
heparin sub cutaneous was started
metoprolol was started
testosterone is on hold.
Followup Instructions:
Neurology: Dr [**Last Name (STitle) **] [**Hospital1 18**] [**Hospital Ward Name 23**] [**Location (un) **]. [**Telephone/Fax (1) 5722**]. 1030
am, [**2183-11-5**].
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5723**] [**11-6**], 820 am
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2183-10-24**]
|
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"336.1",
"788.30",
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"275.41",
"401.9",
"287.5",
"997.31",
"508.1",
"E879.8",
"276.3",
"518.81",
"293.0",
"494.0",
"276.2",
"344.89",
"V15.82",
"E849.7",
"300.00",
"997.99",
"276.8",
"285.1",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"39.79",
"96.72",
"33.22",
"88.42",
"96.05",
"96.6",
"38.97",
"88.44"
] |
icd9pcs
|
[
[
[]
]
] |
17116, 17215
|
10935, 13565
|
288, 635
|
17419, 17477
|
3299, 10912
|
18377, 18840
|
2741, 2746
|
16189, 17093
|
17236, 17398
|
15919, 16166
|
17501, 18354
|
2776, 3280
|
13579, 15893
|
238, 250
|
663, 1997
|
2019, 2488
|
2520, 2725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,599
| 139,218
|
17354
|
Discharge summary
|
report
|
Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-17**]
Date of Birth: [**2081-2-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
HCV cirrhosis and HCC
Major Surgical or Invasive Procedure:
[**2137-8-30**]: Orthotopic liver [**Month/Day/Year **]
[**2137-9-5**]: ERCP with stent placement
History of Present Illness:
56 y/o male with chronic Hepatits C and Hepatocellular
carcinoma with MELD score of 28 who has been called in for liver
translpant from high risk donor. Risks and benfefits were
discussed with Dr [**Last Name (STitle) 497**] prior to acceptance.
The patient reports feeling okay lately, with no sick contacts.
Denies fever, chill, nausea or vomiting. He state he does
occasionally have diarrhea. He denies chest pain or difficulties
breathing, cough. He does have occasional slight pedal edema and
feels his abdomen is more distended. He has never had
paracentesis. He did undergo Cyberknife in [**Month (only) 958**] of this year
and
has one lesion recently recharacterized by CT in [**Month (only) 216**] of this
year.
Past Medical History:
Hepatitis C with cirrhosis
Hepatocellular Carcinoma s/p cyberknife
HTN
DM- diet controlled previous to [**Month (only) **]. Post OLT, ss insulin
[**2137-8-30**] orthotopic liver [**Month/Day/Year **]
Social History:
Married. Lives with wife
Family History:
Father died of cirrhosis
Physical Exam:
VS: 98.7, 75, 111/65, 20, 97%, 110.9 kg
General: well appearing robust male, alert and oriented, NAD
HEENT: Scleral icterus noted. PERRLA, EOMI, oral mucosa pink and
moist, no exudate or sores noted. No LAD
Lungs: CTA bilaterally
Card: RRR, no M/R/G
Abdomen: Soft, obese, non-tender, + BS, no scars noted
Extr: 2+ DP and radial pulses, sl lower extremity edema, warm,
well perfused, PIV right arm
MS: Left shoulder previous fracture, well healed, has some pain
w/ ROM
Neuro: alert and oriented, answers appropriately
Skin: warm, dry, no rashes
Pertinent Results:
[**2137-9-17**] 05:37AM BLOOD WBC-5.2 RBC-2.97* Hgb-9.5* Hct-28.0*
MCV-94 MCH-31.8 MCHC-33.8 RDW-17.3* Plt Ct-173
[**2137-9-17**] 05:37AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-140
K-4.6 Cl-101 HCO3-35* AnGap-9
[**2137-9-17**] 05:37AM BLOOD ALT-45* AST-21 AlkPhos-61 TotBili-0.4
[**2137-9-17**] 05:37AM BLOOD Albumin-2.8* Calcium-8.3* Phos-4.7*
Mg-1.2*
Brief Hospital Course:
On [**2137-8-30**], he underwent orthotopic liver [**Date Range **] from a high
risk donor. The donor had extensive history of both oral and IV
drug abuse. The HCV and NAT testing were positive for HCV
indicating active HCV infection. HIV testing was negative. This
was discussed preoperatively with the patient. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative
report for complete details. Standard induction
immunosuppression was given intraop. Due to prior radiofrequency
ablation, his right liver lobe was mobilized off the diaphragm
requiring entry into the right chest. The liver pinked up
immediately and made bile. The arterial anastomosis involved
end-to-end anastomosis to the common hepatic artery just prior
to the celiac artery, just proximal to the takeoff of the left
gastric artery. Two [**Doctor Last Name 406**] drains were placed.
Postop, he was transferred to the SICU intubated. He required
placement of a right chest tube for a right apical pneumothorax.
He was extubated without event and transferred to the med-[**Doctor First Name **]
unit on [**8-31**] with the chest tube on suction. He did well with
diet advancement. Pain was managed with intermittent iv
morphine. This was later switched to iv dilaudid for increased
c/o pain. The lateral [**Doctor Last Name 406**] drain output averaged ~ 2
liters/day. The medial was under 200cc.
On [**9-4**] (pod 5), he received iv dilaudid for complaints of RUQ
pain. The chest tube was placed to waterseal and then he became
hypoxic with desaturation to 84% on roomair with confusion. O2 2
liters NC was placed and O2 increased to 92-94%. A stat portable
CXR showed a small apical pneumothorax slightly larger. It was
also noted that his lateral JP had bilious drainage. A chest CTA
and abdominal CT were then done with the chest negative for PE.
The abd CT showed a peripheral wedge-shaped hypodensity in
segment VII of the liver concerning for ischemia. Perihepatic
fluid surrounding fluid collection was concerning for bile leak.
He was transferred to the SICU given concern for bile leak and
hypoxia. IV hydration was given and he was kept npo. A liver US
showed patent hepatic vessels and left hepatic artery was not
assessed. LFTs continued to trend down. He was pan-cultured and
IV vanco/zosyn were started and continued for 1 week. All blood
and urine cultures remained negative. He had 1 JP culture that
grew staph coag negative, sparse growth. The lateral JP
continued to appear bilious and have high outputs requiring IV
fluid replacements and albumin intermittently.
An ERCP was done on [**9-5**] showing a mid CBD stricture with bile
leak. He had placement of biliary stent. LFTs continued to trend
down and the JP output became sero-sanguinous. He continued to
be mildly confused and pain medication was changed to iv
morphine with less delerium noted. On [**9-6**], a head CT was
negative. TPN was started as he was kept npo due to confusion.
Lungs continue to be coarse on exam with O 2 sats in low 80s
with agitation. A cxr showed minimal apical pneumothorax on the
right with persistent bilateral basilar opacification.
Aggressive pulmonary toilet was done and O2 NC was administered
with improved O2 sats.
Mental status slowly improved and diet was started with good
tolerance. TPN was weaned off. He was transferred out of the
SICU to the med-[**Doctor First Name **] unit where PT followed him recommending
home PT. Mental status continued to improve and narcotics were
minimized.
The chest tube was removed on [**9-9**]. O2 sats were in the high
90%. The medial JP was removed on pod 14. The lateral JP
continued to drain ~ 2 liters of ascitic/serous fluid. This JP
was removed and vital signs remain stable. He was taking
oxycodone for mild RUQ discomfort. Nutrition supplements were
given as kcals were on the low side (639kcals with 33grams of
protein). This improved with supplements. [**Last Name (un) **] was consulted
to assisted with insulin management which was started for
hyperglycemia. He was new to insulin and was taught how to
inject.
Immunosuppression continued with cellcept administered 500mg qid
for c/o loose stool. Stool was negative x3 for c.diff. Steroids
were weaned to 20mg qd, and prograf was adjusted based on trough
levels.
VNA services were arranged and he was discharged home on [**9-17**] in
stable condition with mental status significantly improved and
at baseline.
Medications on Admission:
Citalopram 20 mg daily
Doxazosin 2 mg daily
Mycelex 5 mg QID
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for liver [**Month/Year (2) **].
4. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
taper to 3 [**12-26**] pills on [**9-20**].
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day: Take with breakfast.
Disp:*600 units* Refills:*2*
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Disp:*2 bottles* Refills:*2*
16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-26**] Syringe Sig: One
(1) Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
17. Sharps Container-Ins Syrng-Ndl 0.3 mL 29 x [**12-26**] Syringe Sig:
One (1) container Miscellaneous once a month.
Disp:*1 container* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p orthotopic liver [**Hospital **]
R pneumothorax
cbd bile leak, s/p stent placement
DM
Discharge Condition:
Stable/good
Discharge Instructions:
Please call the [**Hospital **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down food, fluids or medications
Labwork as ordered by the [**Telephone/Fax (1) **] clinic every Monday and
Thursday, labs faxed to [**Telephone/Fax (1) 697**]
No heavy lifting (nothing heavier than a gallon of milk)
Do not drive if taking narcotic pain medication
Monitor incision for redness, drainage or bleeding. Staples will
stay in until your clinic visit
Take all medications as directed
Followup Instructions:
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2137-9-19**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-19**] 2:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-26**] 1:40
ERCP in 6 weeks ([**Month/Day/Year **] office to schedule)******
Follow up with [**Last Name (un) **] [**2137-9-19**] at 11:30 with Dr [**Last Name (STitle) **] at [**Hospital **]
clinic [**Location (un) 1773**]
Completed by:[**2137-9-19**]
|
[
"512.1",
"535.50",
"E878.0",
"571.5",
"250.00",
"E935.2",
"155.0",
"456.21",
"070.54",
"997.4",
"292.81",
"576.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.41",
"00.93",
"38.93",
"45.13",
"51.85",
"34.04",
"51.87",
"40.11",
"99.15",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
8841, 8899
|
2452, 6999
|
335, 435
|
9033, 9047
|
2073, 2429
|
9639, 10360
|
1467, 1493
|
7111, 8818
|
8920, 9012
|
7025, 7088
|
9071, 9616
|
1508, 2054
|
274, 297
|
463, 1186
|
1208, 1409
|
1425, 1451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
546
| 107,882
|
44181
|
Discharge summary
|
report
|
Admission Date: [**2127-4-1**] Discharge Date: [**2127-4-7**]
Date of Birth: [**2045-1-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethoxazole/Trimethoprim / Codeine / Antihistamines
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Weakness, diarrhea
Major Surgical or Invasive Procedure:
left subclavien central line placement
right arm picc line placement
History of Present Illness:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4844**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2425**], [**Company 94804**]
.
.
HPI: Ms. [**Known lastname 68181**] is an 82yo woman with h/o afib, COPD, recent
hospitalization [**Date range (1) 61523**] with shortness of breath, (treated for
pneumonia with levofloxacin for 10d (ended 3d ago) and COPD
flare with prednisone 5d course), and chronic low back pain on
oxycontin who presented to the ER today feeling drowsy and with
diarrhea. very poor historian. She has not had fever at home.
There are several calls to [**Date range (1) **] by her son, after which [**Name (NI) **]
[**Last Name (NamePattern1) 2425**], NP called an ambulance to bring her in today.
.
Per [**Last Name (NamePattern1) **] notes and ER staff there are questions of whether her
son has been giving her more than her prescribed oxycotnin
versus taking it himself (or selling). Per [**Last Name (NamePattern1) **] notes the
patient has been refusing all of her meds except oxycontin all
week, and her son has been giving her extra doses. She has also
been quite sleepy all week. Denies dysuria, cough, sob, abd
pain.
.
In the ER the patient was noted to be afebrile and in afib with
RVR at 160. Cards was called and recommended dilt drip. She
received 3LNS and was given potassium repletion and was started
on a dilt drip, which was able to bring her heart rate to
100-120s with an SBP of 100s. O2 sat 97-100% on 2LNC. She had a
WBC of 28. CXR was performed and revealed her prior pna seen on
CXR 3w ago. UA was negative for infection. Stool was not sent.
Blood cultures were drawn and she was given a dose of ctx and
azithro to cover for possible CAP before it was noted that her
infiltrate was unchanged from prior.
.
ROS: denies HA, states diplopia lasting a few seconds at a time
for last "month or so", lower back pain which is worse since
they lowered her oxycontin dose, not wearing bottom dentures
because gums are swollen and sore. no dysuria.
.
Past Medical History:
- chronic low back pain on oxycontin with oxycodone for
breakthrough
- HTN
- CAD with RCA stent: Pmibi in [**1-29**] showed Mild, reversible
perfusion defects of the apical portions of the inferior and
inferolateral walls. Normal left ventricular cavity size and
systolic function.
- CHF due to valvular disease: mod AR and AS with severely
thickened AV, mild MR [**First Name (Titles) **] [**Last Name (Titles) **] [**First Name (Titles) 151**] [**Last Name (Titles) 20440**] deformity and
annular calcification.
.
- rheumatic heart disease followed by Dr. [**Last Name (STitle) **]: echo [**9-28**]:
left atrium mildly dilated. [**Month/Year (2) 1192**] symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
aortic valve leaflets are severely thickened/deformed. [**Month/Year (2) 1192**]
aortic valve stenosis. [**Month/Year (2) **] (2+) aortic regurgitation.
mitral valve leaflets are moderately thickened. The mitral valve
shows characteristic rheumatic deformity. There is severe mitral
annular calcification. There is [**Month/Year (2) 1192**] thickening of the
mitral valve chordae. There is mild mitral stenosis. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] [**Month/Year (2) 1192**] pulmonary artery systolic
hypertension. Compared with the findings of the prior report
(tape unavailable for review) of [**2124-8-29**], the pulmonary
hypertension is worse, and the mitral regurgitation may be
better.
.
- tachy-brady syndrome s/p dual chamber pacer
- panic disorder
- COPD: last PFTs [**9-28**] showed TLC 2.76 (72%), DLCO 39%pred, FVC
1.61 (75%) with FEV1 1.18 (83%) and FEV1/FVC 111% pred.
- restrictive lung disease with scoliosis
- s/p TAH/BSO
- multinodular goiter
- hyperlipidemia
- chronic leg edema with venous stasis
Social History:
lives with son. his [**Name2 (NI) 802**] [**Name (NI) 41215**] lives upstairs. smokes 1ppd for
about 65yrs. no etoh.
Family History:
siblings with "heart conditions" and "cancer"
Physical Exam:
T 96.0 HR 95, BP 96/33, RR 18, O2 100% on 2LNC
Gen: confused but answers questions
HEENT: NCAT, PERRL, R side of mouth with droop (no photos to
compare), MM dry
Neck: no LAD
Cor: irreg irreg, ii/vi systolic and diastolic murmurs heard
throughout precordium
Pulm: CTA L lung, R base with crackles
Abd: soft, NTND, no HSM, hyperactive BS
Ext: 2+ pitting edema BLE (per pt at baseline), DPs faintly palp
bilat
Neuro: able to move eyebrows bilat, able to puff out cheeks
bilat, pt will not smile for me. [**4-28**] bilat dorsi/plantarflexion,
[**2-26**] bilat hip flexor (cannot raise leg off of bed but can with
bent knee and foot on bed)
GU: foley catheter in place with concentrated brown urine in bag
Pertinent Results:
WBC-28.1*# RBC-4.56 HGB-11.9* HCT-36.1 MCV-79* MCH-26.1*
MCHC-32.9 RDW-15.7* PLT COUNT-380
- NEUTS-93.6* BANDS-0 LYMPHS-2.4* MONOS-3.4 EOS-0.4 BASOS-0.1
PT-29.4* PTT-36.2* INR(PT)-3.0*
GLUCOSE-100 UREA N-61* CREAT-1.3* SODIUM-131* POTASSIUM-3.8
CHLORIDE-94* TOTAL CO2-21*
CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.2
CK(CPK)-1431* ->799
CK-MB-29* -> 20
cTropnT-0.04* ->0.03
LACTATE-1.9 -> 1.1
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR
BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
Markedly limited study. There is still persistent opacity at the
medial right lung base which may be the residual of prior
infection or recurrent disease. No significant edema.
.
EKG: afib at 150, nl axis, ST depression in II, III, F,
downsloping ST depression in V5-6. ST depressions decreased in
size on repeat at rate 123 .
.
Brief Hospital Course:
82yo woman with CAD, rheumatic valve disease, COPD, afib,
tachy-brady syndrome s/p pacer, recent hospitalization [**Date range (1) 61523**]
where she was treated for pneumonia with levo and COPD flare
with prednisone.
.
MICU course:
# SIRS/diarrhea: The patient was admitted overnight to the MICU,
where she was found to be afebrile, in atrial fibrillation with
RVR, hypotensive with systolic BP in the 80s-90s, confused and
clearly dehydrated. She was hydrated with normal saline
aggressively overnight, including 250cc boluses x 3 and a
continuous NS IV drip at 250cc per hour. CXR showed only
persistence of her known prior pneumonia. Blood cultures were
drawn and were pending. Stool cultures were sent for general
bacterial infection as well as C diff toxin and she was started
on Flagyl empirically and placed on contact precautions for
presumed C diff given her recent antibiotic exposure. On the
morning after admission, the patient was much improved
hemodynamically. Her urine output and blood pressure had
recovered to normal values and her acute renal failure as well
as hyponatremia both resolved after overnight hydration with NS.
# afib with RVR: She was continued on her sotalol and was
initially on a diltiazem drip for her atrial fibrillation,
however given her hypotensionand the fact that this was not
adequately controlling her HR this was stopped. Her heart rate
improved somewhat with hydration, dropping from the 140s to the
100-120s. At approximately 4am, the patient spontaneously
converted to NSR and was atrial paced at a rate of 70. After
this time, her SBP remained in the 100-120s.
# CAD: Her initial EKG at rate 150s showed marked ST depression
in II, III, F and V5-6. On repeat EKG at rate of 120s, ST
depressions were still present but smaller. After the patient
converted to NSR and was atrial paced at 70 ST depressions
resolved in II, III, and F but remained (although only 1-2mm) in
v5-v6. Notably the patient has known reversible inferior and
inferolateral defects seen on Pmibi in [**2124**] which were not
intervened upon. She ruled out for MI with cardiac enzymes and
was started on full dose aspirin. Her statin was continued, but
Ace was held and no BB was started given hypotension.
# social: Repeated conversations were had with the patient's
son, [**Name (NI) 4036**], who called the MICU 6 times in 20 minutes from the
time his mother was assigned a bed and the time she was settled
in with nursing staff. He appeared angry and paranoid by phone,
stating that the pt would say he was abusing her, that he
believed his [**Name (NI) 802**] [**Name (NI) 41215**] was overdosing the patient on her
oxycontin and that the two of them were whispering about him and
plotting against him. He also said he had to tell the patient
right away that he was moving out and not paying her rent. The
patient's [**Name (NI) 802**] [**Name (NI) 41215**] also phoned, saying that [**Doctor First Name 4036**] is
mentally ill and becomes more unstable when the patient is
in-house. Social work was called. Plan was to call [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2425**], [**Company 94804**] who is very familiar with the pt and per her
recommendation to contact elder services, as it is likely the
patient is either being given too much oxycontin or that this is
being taken from her. [**Doctor First Name 4036**] called patient relations on the
morning following admission, and [**Doctor First Name **] from our patient
relations office also suggested we involve elder services.
# confusion: The patient was oriented x 1 on arrival ot MICU.
She has an unclear baseline. Possible that pt has MS change in
setting of infection, versus use of oxycontin/oxycodone as well
as valium. Her oxycontin dose was halved and on the day
following admission she was still somnolent. We switched to low
dose immediate release oxycodone only. This raises suspicion of
possible theft of her medications at home. Her valuim was held,
and she displayed no signs of withdrawal while in the MICU.
Mental status was somewhat improved after overnight hydration
and Flagyl, however she remained oriented x 1 only on call-out
to the floor.
# valvular CHF: Due to history of rheumatic heart disease. We
held her home lasix while in MICU due to dehydration and
aggressively hydrated her. On the morning following admission
she was still satting 100% on 2LNC and had developed only mild
crackles at her bilateral bases. Her JVP had increased to about
8 and further hydration was held, as she was felt to be replete
by exam, blood pressure and urine output.
.
MEDICAL FLOOR COURSE
.
# Atrial Fibrillation
The patient converted to NSR in the MICU. She was continued on
sotalol and electrolytes were repleted. She remained in NSR
until her cardiorespiratory arrest and death.
.
# C Diff colitis
She was started on PO Flagyl for presumed c diff colitis in the
MICU. Her C diff toxin was positive. She continued with
profuse watery diarrhea for the first several days while on the
medical floor. Given the fluid losses, she was given volume
resuscitation with normal saline. After 4 days of PO flagyl,
the patient's overall condition was somewhat improved. Though
still with profuse watery diarrhea and diffuse abdominal pain,
her mental status was improved such that she was oriented x 2
(name and location) and her white blood cell count was declining
as well. She was switched to PO vancomycin given her risk for
serious complications and recurrence of c diff per her age, MICU
admission, and co-morbidities. Over the next several days the
patient's white blood cell count increased and her abdomen was
increasingly painful and tender to palpation. She was also
increasingly somnolent. Her stools did decrease as well. On
[**4-7**] her white blood cell count increased dramatically despite
treatment with PO vancomycin. Given further worsening of her
abdominal examination, general surgery was consulted. She was
started also on IV flagyl (in case PO meds were not reaching the
colon). A CT scan was ordered with PO contrast to evaluate for
possible perforation and or pancolitis / megacolon. IV fluids
were also bolused as well given clinically hypovolemic state and
worsening acute renal failure on laboratory studies. The CT
scan was delayed by attempts to have the PO barium contrast for
the study ingested (concerns re: aspiration and risks to place a
NGT in her hypercoaguable state). As the day progressed on
[**4-7**], the medical team was notified by nursing that the
patient's RR was increasing to 30-40s.
.
# CODE BLUE [**2127-4-7**]
When the medical team arrived the patient was confused,
tachypneic, with cool distal extremeties and feet, and weak,
thready pulses. Her blood pressure was systolic 70s / doppler
(despite cuff measurement of systolic 110s). An ABG was
obtained which showed a severe metabolic acidosis. As the team
was preparing for enhanced intravenous access, the patient's
breathing shallowed and then she stopped breathing. A CODE BLUE
was called. The patient's airway was secured open and
venitlated with the Ambu-Bag. After several breaths the patient
vomited and aspirated a large volume of dark brown liquid. This
was suctioned and resuscitation was continued. Soon therafter
the patient lost a pulse and she entered into a PEA arrest. CPR
was initiated, and epinphrine, atropine, bicorbonate,
amiodarone, vasopressin were administered. An ET tube was
placed via anesthesia. The patient was shocked 3 times. Fluids
were being infused as rapidly as possible and dopamine was also
infused. Surgery placed a left subclavien central line for
access. After 25 minutes approximately, the patient's pulse did
not restart and the code was terminated. The time of death was
1:45pm. The chief cause of death was considered cardiopulmonary
arrest from progressive metabolic acidosis, likely from toxic
megacolon and/or bowel perforation. The son [**First Name8 (NamePattern2) **] [**Name (NI) 94805**]) was
present at the beginning of the resuscitation, and left soon
thereafter. He was contact[**Name (NI) **] via telephone approximately 1 hour
after the code was terminated. The patient's grandson [**Name (NI) **]
[**Name (NI) 94805**] also was contact[**Name (NI) **]; he and his wife arrived at the
hospital for viewing. [**Doctor First Name **] could not be contact[**Name (NI) **] again to
obtain permission for the post-mortem examination.
.
# Neglect
Concern regarding neglect was raised during the patient's
initial presentation. Per [**Name (NI) **] records, the [**Name8 (MD) 228**] NP had
several conversations with the son [**Name (NI) **] [**Name (NI) 94805**] about her
deteriorating clinical state. Despite the NP's recommendations,
the son refused to bring her to the hospital. After several
days and no improvement, the NP called EMS herself. Social work
was consulted and eldery services became alerted to the case.
Investigations were ongoing at the time of death regarding
elderly neglect / abuse.
.
# Coagulopathy
The patient presented to the medical floor with an elevated INR.
She takes coumadin at home for atrial fibrillation; it is
possible that the levofloxacin increased her INR. The INR did
not trend down over several days. This was considered secondary
to c diff colitis (overtaking normal bowel flora). It is also
possible that hypotension on the day of death contributed to
hepatic dysfunction. Haptoglobin and fibrinogen were checked to
evaluate for DIC, but were found to be WNL.
Medications on Admission:
- ASA 81 mg po qday
- atorvastatin 20mg po qday
- bisacodyl 10mg po qday prn (per d/c sum bottle not with her)
- citalopram 30mg po qday (per dc summ from 1week ago however
pt's med bottle says 20mg)
- diazepam 2-4mg po q8hrs prn
- colace 100mg po bid
- advair 250-50 1 inhalation [**Hospital1 **] (per d/c sum, not with her)
- furosemide 20 mg po qday
- lactulose 30mL po q8hrs prn (per d/c sum)
- lisinopril 10mg po qday
- oxycontin 20mg po qam, 10mg po qnoon prn, 10mg po qhs (bottle
not with her)
- oxycodone 5mg po q8hrs prn (bottle not with her)
- ranitidine 150mg po bid
- sotalol 120mg po bid
- warfarin 2.5mg po qhs
- ferrous sulfate 325mgpo qday (not on d/c summary but pt has
bottle with her)
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
c diff colitis
copd
s/p pneumonia
atrial fibrillation
Discharge Condition:
deceased
Discharge Instructions:
expired
Followup Instructions:
none
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
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16613, 16624
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15749, 16454
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4430, 4548
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,384
| 160,321
|
9393
|
Discharge summary
|
report
|
Admission Date: [**2137-8-6**] Discharge Date: [**2137-9-2**]
Date of Birth: [**2099-9-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
Trachostomy
History of Present Illness:
The patient is a 37yo woman with end-stage renal disease
secondary to IgA nephropathy s/p replacement of her transhepatic
hemodialysis catheter [**7-14**] after it fell out. She was
discharged from that admission on [**2137-7-30**]. On [**8-5**] she
presented to [**Hospital 1562**] Hosp with a fever of 104 and low oxygen
saturations at her [**Hospital1 1501**]. At the time denied
chills/rigors/nausea/vomiting.
Did complain of diarrhea x 1 day per the admission note. Was
febrile to 102 at the OSH, CXR showed no infiltrates. She
received levaquin 500mg IV x 1, vanc 1gm IV x 1. She was
transferred to [**Hospital1 18**] ICU due to suspicion that her hepatic vein
HD cath was infected. On arrival she was hypotensive.
Past Medical History:
PAST MEDICAL HISTORY:
1. End-stage renal disease (secondary to IGA nephropathy).
2. Schizoaffective disorder.
3. Depression.
4. Chronic anemia.
5. Gastroesophageal reflux disease.
6. Cardiomyopathy.
7. Hypothyroidism.
8. History of GI bleed.
9. Right lower extremity DVT.
10.Seizure disorder.
PAST SURGICAL HISTORY:
1. Status post left upper and lower extremity AV fistulae
(failed).
2. Status post right upper extremity AV fistula (basilic
vein transposition (failed).
3. Status post right forearm AV graft (failed).
4. Status post attempted insertion of a peritoneal dialysis
catheter (failed).
5. Central venous stenosis.
6. Innominate venous stenosis.
7. Status post right brachioarterial to axillary
arteriovenous graft, nonfunctional, status post multiple
thrombectomies and angioplasties.
8. Status post tracheostomy.
9. Status post thrombectomy of AV graft x5.
10. Transhepatic HD catheter placement
Social History:
She denies tobacco, alcohol, or recreational drug use.
Lives at [**Location **] skilled Nursing Facility in [**Hospital1 1562**]
[**Telephone/Fax (1) 32079**]
Family History:
Non-contributory.
Pertinent Results:
[**8-6**] Blood cultures and [**8-8**] hemodialysis line were positive
for:
STAPH AUREUS COAG +
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**8-26**] Culture from hemodialysis tip:
WOUND CULTURE (Final [**2137-8-28**]):
PSEUDOMONAS AERUGINOSA. >15 colonies.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ =>16 R
Brief Hospital Course:
Ms [**Known lastname **] was admitted on [**2137-8-6**] to the SICU hypotensive and
having fevers. It was felt that this was due to line sepsis.
Brief Hospital Course by system:
1. Neuro: She was at her baseline on the day of admission but
was sedated and intubated on HD for most of this admission.
Psych was called to assist with medication management of her
anti-psycotics. Remeron, Ropinirole and clonazepam were stopped
given excessive sedation. Fluphenazine continued. Mental status
improved as infections cleared.
2. Respiratory: On HD 1 she developed acute respiratory distress
and she became stridous. This was after she recieved 2 liter
boluses for hypotension. She was intubated. She continued to
spike temperatures and sputum was sent and grew pseudomonas and
morganella on [**8-7**]. IV cefepime and amakacin were given for 10
days. Due to laryngeal swelling from IV fluids she developed
laryngeal edema and given h/o tracheomalacia, a trache was
performed on [**8-16**] by Dr. [**Last Name (STitle) 17109**]. She was extubated and
recovered well post trache. The trache was down sized to a # 7
cuffless, fenestrated trache. This was well tolerated. A passy
muir valve was applied and well tolerated.
3. Cardiovascular: HD 1 she was hypotensive due to sepsis from
her line which grew MRSA. IV vancomycin was started. She
initially responded to boluses of fluid, but then started
phenylephrine when she was intubated. She initially received
CVVHD then was converted to HD. Pressors were stopped and she
maintained a SBP of 100/63.
4. Renal: Hemodialysis was initially performed through a
transhepatic hemodialysis catheter which was felt to be
infected. HD 3 she had the line removed and replaced with a new
hemodialysis line. Once the hemodialysis line was replaced she
was started on CVVHD to remove fluid. After she was weaned from
her sedation and she was on trach mask, her blood pressure
improved and she was started on her normal hemodialysis regimen
of Tuesday/Thursday/Saturday which she has tolerated. Midodrine
was used post HD.
5. ID-MRSA was cultured from the hemodialysis line and blood
from [**8-6**] & [**8-8**]. She was kept on Vancomycin and with a prolonged
course of 6 plus weeks were recommended with weekly trough vanco
levels. Trough goals are 15-20. She will follow up with ID and
at that time a stop date will be determined.
She continued to spike fevers and a previously placed central
line was removed and grew . Sputum was grew pseudomonas
aeruginosa. Cefepime was started and ID recommended a 7 day
course. Last dose should be given on [**9-3**] and then the central
line in her neck should be removed.
6. Heme-INR was initally 4.2. Coumadin was held. (for
prophylaxis to prevent transhepatic hemodialysis line from
clotting). Of note, she experienced some emesis on [**8-18**] and was
lavaged. Hematocrits had trended down to 20.7 on [**8-22**] from 28.9
on [**8-15**]. She was transfused with several units of PRBC. Epogen
was given during HD. GI was consulted and recommended IV
protonix which was given as a drip in the SICU. This was
switched to po protonix when she was tolerating a soft diet.
7. GI-GI did not feel that an EGD was necessary. Protonix was
recommended. Bloody emesis resolved. Hematocrits stabilized. She
was cleared by speech and swallow for a soft diet.
She remained afebrile prior to discharge with stable vital
signs. She was able to get out of bed with assist to sit in the
chair. The trache and transhepatic catheter site remained c/d/i.
PT evaluated and recommended rehab. She will be transferred to
[**Hospital **] Rehab.
Medications on Admission:
Fluphenazine HCl 5mg'', Levothyroxine 100mcg', Cinacalcet 90
mg', B Complex Vitamins 1Cap', Fluphenazine HCl 10 mg qhs,
Omeprazole 20 mg qhs, Fluticasone-Salmeterol 250-50 mcg 1
puff'', Clonazepam 1 mg'', Docusate Sodium 100 mg'', Senna 8.6
mg'', Calcium Acetate 667 mg''' w/meals, Mirtazapine 37.5mg qhs,
Ropinirole 1.5mg qhs, bisacodyl 10 mg' prn, Acetaminophen 650mg
q6H prn, Warfarin 2 mg'
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
6. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): hold for sbp >90.
7. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): am and noon.
10. 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*
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 1 months: at HD
ID to determine stop date on follow up visit.
12. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 1 days: give on [**9-3**] then d/c
pt has tolerated without side effect.
13. Outpatient Lab Work
weekly labs at Hemodialysis for cbc, BMP, and vanco trough
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (infectious disease)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESRD
MRSA bacteriemia
pseudomonas/Morganella pneumonia
GI bleeding
anemia
tracheomalacia/edema
Schizoaffective disorder
Discharge Condition:
fair
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if fevers,chills,
malfunction of the transhepatic hemodialysis line, shortness of
breath, or problems with the trache
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD (Infectious
Disease)Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-9-24**] 9:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-19**]
9:00
Completed by:[**2137-9-2**]
|
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icd9cm
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[
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|
2159, 2320
|
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